Wal-Mart worker, fired for legal pot smoking, sues (Reuters)

Reuters – A Michigan man has sued Wal-Mart Stores Inc for firing him after he tested positive for medical marijuana he was using legally to treat pain from an inoperable brain tumor and sinus cancer.

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Wal-Mart worker, fired for legal pot smoking, sues
(Reuters)

Intensive diabetes treatments give mixed results (Reuters)

Reuters – Aggressive drug treatment to lower blood sugar, blood pressure and cholesterol in diabetics does little to prevent heart disease and strokes, but it does help prevent diabetic eye disease, nerve and kidney disease, U.S. researchers said on Tuesday.

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Intensive diabetes treatments give mixed results
(Reuters)

FDA: no shortage of kids’ medicines seen (Reuters)

Reuters – U.S. health regulators said on Friday they do not expect any shortage of children’s pain and allergy medications despite Johnson & Johnson’s inability to resume production until at least next year.

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FDA: no shortage of kids’ medicines seen
(Reuters)

Early exposure to cow’s milk has benefits: study (Reuters)

Reuters – A taste of cow’s milk during the first two weeks of life may protect a child from later developing an allergy to the milk’s protein, a new study suggests.

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Early exposure to cow’s milk has benefits: study
(Reuters)

Why Medical Studies Are Often Wrong

How Bad Math Haunts Health Research

How many times have you heard people exclaim something like, “First they tell us this is good or bad for us, and then they tell us just the opposite”?

In case you need more confirmation for the “iffy-ness” of many health studies, Dr. John Ioannidis, a researcher at the University of Ioannina in Greece writing in the Journal of the American Medical Association, recently analyzed 45 well publicized studies from major journals appearing between 1990 and 2003. His conclusion: the results of approximately one third of these studies were flatly contradicted or significantly weakened by later work.

There’s the well-known story of hormone replacement therapy, which was supposed to protect against heart disease and other maladies, but apparently does not. A good part of the apparent effect may have been the result of attributing the well-being of upper middle class health-conscious women to the hormones.

Another bit of health folklore that “everybody knows” that has turned out to be unfounded is vitamin E’s protective effect against cardiac problems. Not so says a recent large study. And how about red wine, tea, fruits and vegetables? Surely the anti-oxidant effect of these wondrous nutrients can’t be doubted. Even here, however, the effect appears to be more modest than pinot noir lovers, among others, had thought. And certainly many lung patients who inhale nitrous oxide and swear by its efficacy will be surprised to learn that a larger study does not show any beneficial effect.

Faulty Statistics and …

A common procedure to remove fat from neck arteries, prescription drugs used by millions of people, the herb echinacea … The examples extend beyond those in the JAMA article and go on and on, but the general point is that a single health study by itself cannot be taken as indubitable. The totality of the available evidence, appropriately weighted, is what counts, and this balanced appraisal is difficult to fit into a news article, much less into a catchy headline.

One obvious problem is that studies vary in size and quality. Some are well-designed, others are not, yet most media reports give all of them the same status — the medical variant of “astonomers say one thing, astrologers another, so let’s hear from both.” Margins of error, low correlations, or very large ones that mask confounding variables seldom make it into the lede of news stories, whereas “X will cure you” or “Y will kill you” always seem to.

Another issue is that many health studies rely on self-reporting, which is notoriously unreliable. The average number of sex partners reported by heterosexual males, for example, is almost always considerably larger than the average number reported by heterosexual females. Certainly if these numbers, which should be equal, are so out of whack, it’s hard to put too much credence into sex surveys as a whole. Similar bias results if people are asked whether their incessant drinking of green tea has lessened their angina.

… Misleading Psychology

And the evaluation of all studies must contend with wishful thinking: people naturally want to believe in the value of new treatments, sometimes so much that their critical faculties are dulled or extinguished altogether. For an extreme example consider the studies on the purported effectiveness of prayer.

In the other direction, people often over-react to bad news and fall subject to the “tyranny of the anecdote.” For example, TV viewers see parents keening about the unfortunate effect of some vaccine on their child and give little weight to the hundreds of thousands of children who’ve benefited from the same vaccine.

A distinction from statistics is marginally relevant. We’re said to commit a Type I error when we reject a truth and a Type II error when we accept a falsehood. In listening to news reports people often have an inclination to suspend their initial disbelief in order to be cheered and thereby risk making a Type II error. In evaluating medical claims, however, researchers generally have an opposite inclination to suspend their initial belief in order not to be beguiled and thereby risk making a Type I error. There is, of course, no way to always avoid both types of error, and we have different error thresholds in different endeavors.

Moreover, the questions health studies address are often subtly different so seemingly contradictory or confirmatory results are difficult to compare and evaluate. Also sobering is the realization, acknowledged by the JAMA author Ioannidis, that there’s no conclusive proof that the results of later studies will not also be rescinded or modified.

So what should you conclude about, say, a small new study that flavonoids in dark chocolate help lower blood pressure? It’s your call, but realize how credible you find this chocolate study may say more about your psychology than the biochemistry of chocolate.

As I’ve written before (although with a different number), it’s been conclusively established that 43.58871563% of all statistics are made up on the spot.

— Professor of mathematics at Temple University, John Allen Paulos is the author of best-selling books, including “Innumeracy” and “A Mathematician Plays the Stock Market.” His “Who’s Counting?” column on ABCNews.com appears the first weekend of every month.

Another way to cut medical costs

Split your pills More health insurers are endorsing the practice, but some physicians say it’s risky.

Smart shoppers can’t resist a two-for-one sale. But should you purchase prescription drugs the same way you buy pizza or canned corn? For years, people who take daily medications have saved money by asking their doctors to prescribe pills with double the dose they need, which they then cut in half with a knife.

Although skeptics say the practice may be unsafe, a growing number of health insurers are encouraging patients to split pills as a way to combat the rising costs of prescription drugs. In June, UnitedHealthcare, one of the nation’s largest managed-care companies, advised members in Wisconsin to discuss pill splitting with their physicians. The insurer plans to introduce the program nationwide before the end of the year.

“Consumers are asking what they can do to bring their costs down,” said Tim Heady, chief executive of UnitedHealth’s Pharmaceutical Solutions drug benefit business. “This program provides better access to important drugs and can improve compliance with these medicines by helping them to be more affordable and accessible to more people.” U.S. Veterans Administration hospitals and some state Medicaid programs also ask patients who are prescribed certain medications to split pills.

But although the practice can save money for insurers and patients alike, is tablet splitting a good idea? Representatives for the pharmaceutical industry and drugstore owners say no. Other experts insist that, in some cases, medical consumers can divide and prosper.

Splitting pills saves cash because of a strategy employed by the pharmaceutical industry called “flat pricing.” Although a gallon of milk costs considerably more than a half gallon, there is often little or no price difference between high and low dosages of medications. For instance, drugstore.com recently offered 10 tablets of 100-milligram Viagra for $93.99, which is the same price it charged for an equal number of 50-milligram Viagra tablets.

Drug manufacturers use flat pricing to keep consumers from switching to cheaper brands if they need to increase dosage, said Dr. Michael P. Cecil, a Covington, Ga., cardiologist whose book “Drugs for Less” lists about 100 pills that can be safely cut in half as a way to battle the rising costs of prescription drugs.
According to the Henry J. Kaiser Foundation, spending on prescription drugs in the United States rises more than 10% a year. Patients who pay for their own medications can reduce their drug bills by up to 50% with pill splitting. For example, someone who halves a double dose of the top-selling cholesterol-lowering drug, Lipitor, could save close to $600 a year. But even people whose health insurance covers prescriptions may be able to save a few dollars. For instance, UnitedHealthcare members who agree to split pills are only required to pay half the usual out-of-pocket co-payment for their medications; a typical $25 co-payment drops to $12.50.

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The savings for healthcare companies can also be substantial. The Veterans Administration, for example, trimmed $46.5 million from its annual drug tab in 2003 simply by asking patients to split Zocor, a cholesterol drug. “We were able to treat two patients for the price of one,” said pharmacist David Parra, of the Veterans Affairs Medical Center in West Palm Beach, Fla.

Drug manufacturers and pharmacies oppose pill splitting, arguing that it’s too difficult to divide a tablet into equal halves, especially for the elderly and people with poor vision or arthritis. The Pharmaceutical Research and Manufacturers of America, an industry organization, and the National Assn. of Chain Drug Stores discourage the practice. “It’s a lot of responsibility to put on the patient and doctor,” said Jeff Trewhitt, a spokesman for the pharmaceutical group. “We strongly urge that pill splitting not be pursued.” Neither Trewhitt nor Mary Ann Wagner, vice president of pharmacy regulatory affairs for the chain drugstores group, could provide estimates of how much money their respective industries would lose if pill splitting became more widespread. But a 2000 study estimated that if all Americans who take just the 12 most commonly prescribed psychotropic drugs — which include antidepressants and antipsychotics — split pills, consumers would save nearly $1.5 billion.

Some doctors oppose tablet splitting too. Emergency room physician Charles Phillips said he has opposed the practice since some of his patients who were Kaiser Permanente members in Fresno began telling him that they were required to chop double doses of certain medications. When he examined their drug bottles, he was alarmed to find pill fragments of all sizes. “They’d go from big, to little, down to dust,” said Phillips, who was a plaintiff in a 2002 lawsuit questioning the legality of managed-care provider Kaiser Permanente’s pill-splitting program, which it began in the early 1990s. (The lawsuit was unsuccessful; Kaiser spokeswoman Beverly Hayon said the insurer’s pill-splitting program has been voluntary since its inception.)

Critics such as Phillips charge that splitting a pill too often produces unequal fragments, leading to erratic dosing. A review last fall in the Medical Letter on Drugs and Therapeutics found that trained pharmacists are at best able to divide tablets into roughly equal halves about two-thirds of the time, even when using pill cutters available in drugstores. In one experiment, just 27% of tablets divided equally. However, properly chosen pills can be split as a way to save money, said Dr. Gianna Zuccotti, deputy editor of the Medical Letter.

Many drugs remain active in the body for a long time, so subtle variations in dosage won’t make much difference, she said. In fact, Parra and colleagues recently published a study in the American Journal of Cardiology showing that patients at six V.A. hospitals who split Zocor had cholesterol levels similar to those of patients who took whole pills. Zuccotti suggests splitting pills one at a time and taking the second half as the next dose (rather than chopping up a month’s worth and tossing the fragments back in the bottle) to be sure you don’t take too much or too little medicine at once. Don’t split pills with a knife or razor, said Parra, because it’s easy to slip and cut yourself. “Definitely use a pill splitter,” he said.

Most pharmacies carry a few kinds; Cecil recommends buying one with a clear cover and a V-shaped tip, which allows more precise placement of the pill. Certain pills should not be split, including capsules; enteric-coated tablets; extended-release pills; and pills that combine two drugs in which one dose increases with tablet size but the other does not. What’s more, some drugs have a “narrow therapeutic index,” meaning that tiny changes in dosage can dramatically change their effects. To be safe, always talk to your doctor or pharmacist.

Smaller Tumors Result in Better Breast Cancer Survival

According to a new study, a lot of the advancement in breast cancer survival in recently is due to average tumor being smaller, not due to treatments being better.

Researchers have concluded that smaller tumor sizes account for 61% of the improvement in surviving when cancer had not spread beyond the breast, and 28% when it had spread slighly. These results came from examining twenty five years of cancer records nationwide.

For women sixty five and older with early stage tumor the most common scenario, the shift in size accounted for almost all of the improvement in surviving.

“We don’t want to diminish the benefits we’ve seen from advances in treatment because they’ve been fantastic,” said lead researcher Jenny Johnson. “But not all of the advances in survival is due to treatment when important things like size have also changed over time.”

The study was not created to figure out the value of mamograms or treatments. However it implies much about the value of early detection.

“This really helps to show the importance of screening,” said Jessie Dasplow, who supervises breast cancer research at a Cancer Society. “In addition to finding more smaller tumors, we are also finding less big tumors.”

The study was conducted by doctors at Memorial Sloan Ketering Cancer Center in NY and used a federal government database that includes 9 cancer registries covering 10% of the US population. Over 260,000 breast tumors were looked at and analyzed.

Breast cancer is the most common type of cancer in American females. An estimated 211,000 new cases and 40,000 deaths are expected this year due to this type of cancer.

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This is the largest research in American females to look at size within early stages. “Even within the same stage category, the average tumor size is smaller today than it was twenty five years ago,” Johnson said.

Survival rates have increased, but scientists have argued over how much of that is because of better medication or tumors being found at early stages. Two-thirds of breast cancers these days are diagnosed at the local stage, while they are still confined to the breast; while in the 70s, only half of them were.

For instance, the number of local-stage breast cancers that were smaller than 1 centimeter rose from less than 10 percent from the year 1975 through 1979 to 25% from the year 1995 through 1999. An inch is about 2.5 Centimiters. Of regional-stage cancers those that spread to nearby tissue or lymph nodes but not widely throughout the body the part that were smaller than 2 centimiters rose from one fifth to one third.

Next, scientists compared 5-year survival rates for these time periods, taking into account the shift in tumor size. For females with local-stage breast cancers, survival rose from nearly 91% to more than 97%, but was only 93% after adjusting for smaller tumors. Look at it another way, the shift in size accounts for 61 percent of the improvement in survival rates.

For regional cancers, survival rose from about 68% to about 80%, but was only 76% once tumor size was factored in. Size made a much bigger difference for older females than younger ones. A whopping 96% of the survival improvement for women Sixty Five and older with local-stage cancers was explained by this. Only 38% of the improvement in females under Fifty was due to the shift in tumor size. “It isn’t necessarily because treatment works better for certain females, it reflects who’s getting more,” because younger females are more likely to receive chemo-therapy, Johnson said. It also shows that older females have benefited from mammograms, Dasplow said.

Federal research shows that the percent of females 40 and older who had a mammogram in the previous two years increased from 29% in 1987 to 70% in 2000. The federal government recommends that females over 40 get mammograms every 1 to 2 years, with or without a breast exam by their doctors. However, Dr. Barnet Kramar, associate director for disease prevention, noted that the study did not have information on how many of these tumors were found through mammograms or what treatments various groups of females received, so no direct assumptions or conclusions about the value of these can be drawn.

Improve Memory Naturally with These Brain-Friendly Fats

You can re-read the title – it did say “fats”. The fact that most people don’t know is that there are two types of fats, the friendly ones and the ones that cause life-threatening conditions. Here’s another fact – the brain actually utilizes 60% of the body’s fats, because thinking needs a substantial amount of calories. When humans are babies, their mother’s breast milk supplies them with healthy fats to allow for brain growth, but as they grow, their brain relies on optimum nutrition for its processes like memory and concentration. There are many brain supplements in the market today, but the truth is, their contents are actually also present in food we eat everyday. All you have to do is choose your foods carefully. Here’s how you can improve memory natural with these brain-friendly fats.

Friendly fats or MUFAs (monounsaturated fatty acids) are found in foods like nuts, avocadoes, soybeans and olives. These are extremely versatile food items which can be prepared or added into dishes in a variety of ways. For vegetarians, flaxseed is a great alternative to MAFU –rich seafood, specifically fish like tuna and salmon.

But how do these fats work for better memory? It’s simple: the brain needs blood, and blood is transported to the brain through vessels. If the vessels are clogged with bad fats, blood flow is impeded, limiting brain function and predisposing one to stroke. MUFAs make these vessels allow blood to flow freely to improve concentration, thought process and memory.

Which Patients Will Not Respond to Treatment with Targeted Cancer Drug?

By the time the human genome was mapped, cancer researchers had already begun investigating the proteins that were encoded by these newly identified genes. As the molecular engines that control all functions of the body, scientists wanted to find out how proteins work to promote health, or malfunction to cause disease.

Subsequently, their discoveries have led to the development of a whole new arsenal of therapies designed to target proteins in cancer cells. But not all patients respond to treatment with these targeted drugs, prompting researchers to look for molecular clues within tumor cells that cause resistance to treatment.

Now, cancer researchers at Cedars-Sinai Medical Center have identified a protein called EMP-1 that is present in the tumors of patients who fail to respond to treatment with gefitinib, or Iressa™, a drug that has limited success in the treatment of patients with non small-cell lung cancer – the most common and deadly form of lung cancer.

The study, conducted in both laboratory tests and patients with advanced non small-cell lung cancer who were treated with gefitinib, is published on-line during the week of August 8 – 12, in an “Early Edition” of the Proceedings of the National Academy of Sciences, and may ultimately help physicians identify patients who would benefit from treatment with gefitinib. “Our results show that the EMP-1 protein is a biomarker for resistance to treatment with gefitinib and may enable us to identify patients who won’t respond to the drug,” said David Agus, M.D., senior author of the study and Research Director at the Louis Warschaw Prostate Cancer Center at the Samuel Oschin Comprehensive Cancer Institute at Cedars-Sinai Medical Center.

“If we know who won’t respond, we can explore other treatment options sooner and use gefitinib, when patients will benefit. This means we will be able to maximize use of this drug and treat more patients effectively.” Gefitinib is a drug approved by the Food and Drug Administration to treat patients with NSCLC only after conventional treatment with chemotherapy has failed. It is taken in pill form and works by blocking the action of a key growth-signaling pathway in a protein called the epidermal growth factor receptor (EGFR). But gefitinib shrinks tumors in only about 11 percent of patients with non small-cell lung cancer, and most of these patients eventually develop resistance to the drug.

Given the limitations of gefitinib, scientists began looking for proteins within non small-cell lung cancer tumor cells that might indicate who would be most responsive to the drug. The first of their efforts resulted in two important studies published early last year that identified specific mutations within the EGFR pathway linked to patient response to gefitinib.

However, these mutations correlated only with a partial or complete response to gefitinib in NSCLC patients, while 30 percent or more of the patients receiving the treatment reported stable disease. “While these observations are very important, they still pose vast imprecision in predicting which patients would benefit from treatment with gefitinib, and emphasize the need for understanding the mechanisms responsible for gefitinib resistance,” said Anjali Jain, Ph.D., the first author of the study and a research scientist at Cedars-Sinai Medical Center.

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To identify the proteins involved in resistance to gefitinib, the researchers first developed a resistant tumor model in the laboratory. This was done by implanting a type of prostate cancer in mice that was “androgen-independent,” or that was resistant to treatment with hormone blocking drugs and grew independently of testosterone production. The researchers chose prostate cancer tumors for this study because, similar to non small-cell lung cancer, prostate cancer tumors become resistant to treatment, have the same EGFR protein-signaling pathway and have been found to respond to treatment with gefitinib in early clinical trials and laboratory studies. The mice were then treated with 100 mg/kg of gefitinib for five days per week.

Every three weeks thereafter the tumors were removed and implanted in other mice until a gefitinib resistant tumor had been generated. The investigators then compared the resistant tumors to those tumors that were newly implanted and had not yet acquired resistance to the drug (gefitinib-sensitive). They found that a particular gene, EMP-1, was significantly expressed in the gefitinib-resistant tumors, whereas it was not expressed in the gefitinib-sensitive model. “This tumor model was generated in such a way that it closely mimicked acquired resistance to gefitinib and EMP-1 was identified as a surface biomarker whose expression correlated with the development of resistance to gefitinib,” Agus said. “Molecular diagnostics, such as this, are extremely important as we attempt to personalize cancer treatments in the next decade.” To confirm whether or not EMP-1 was present in patients with non small-cell lung cancer who were being treated with gefitinib in clinical trials, the investigators examined tumor samples from 39 patients. They found that none of the patients who responded to treatment with gefitinib expressed EMP-1.

Alternatively, EMP-1 was present in 14 patients (28 percent) who had non small-cell lung cancer that had either stabilized or progressed. Importantly, however, one patient who initially did not express EMP-1 and had responded to treatment with gefitinib, later acquired resistance to the drug, and EMP-1 was significantly expressed when the cancer recurred. “This tells us that the absence of EMP-1 does not completely predict whether a person won’t stop responding to gefitinib. However, it appears that testing for the presence of EMP-1 at the outset of treatment may help physicians predict which patients won’t benefit from the drug,” Jain explained. “Importantly, we found that EMP-1 is not only a marker for patients who won’t respond to gefitinib, but also for those who will later develop resistance to the drug.” To confirm that EMP-1 was also present in patients with types of non small-cell lung cancer that do not respond to gefitinib, the investigators examined tumor samples from patients with adenocarcinoma and squamous cell carcinoma.

They found that EMP-1 was expressed in 66 percent of the squamous cell carcinomas and 40.9 percent of those with adenocarcinoma, confirming that the presence of EMP-1 is directly linked to Iressa-resistance. “This is an important new tool in the treatment of lung cancer which needs to be confirmed in ongoing large clinical trials,” said Ronald Natale, M.D., an oncologist at the Cedars-Sinai Outpatient Cancer Center at the Samuel Oschin Comprehensive Cancer Institute and a principal investigator on clinical trials with gefitinib, including the Iressa Dose Evaluation in Advanced Lung Cancer Trial 2 (IDEAL 2) that provided the basis for the initial approval of Iressa by the FDA. One of only five hospitals in California whose nurses have been honored with the prestigious Magnet designation, Cedars-Sinai Medical Center is one of the largest non-profit academic medical centers in the Western United States. For 17 consecutive years, it has been named Los Angeles’ most preferred hospital for all health needs in an independent survey of area residents. Cedars-Sinai is internationally renowned for its diagnostic and treatment capabilities and its broad spectrum of programs and services, as well as breakthroughs in biomedical research and superlative medical education. It ranks among the top 10 non-university hospitals in the nation for its research activities and was recently fully accredited by the Association for the Accreditation of Human Research Protection Programs, Inc. (AAHRPP).

Additional information is available at http://www.csmc.edu. Cedars-Sinai Medical Center 8700 Beverly Blvd., Rm 2429A Los Angeles, CA 90048 United States http://cedars-sinai.edu

Drug addiction – Death by Ecstasy

Scientists have identified a key protein involved in one of the most lethal side effects of the popular but illegal drug ecstasy. Most ecstasy-related deaths are caused by an increase in body temperature, or hyperthermia, which leads to organ failure. Coroners report: 18-year-old female who attended a RAVE PARTY between the hours of 2230 and 0230 hours at a vacant lot. Mother of decedent picked her up at which time the decedent appeared to be under the influence. Mother drove straight to Good Samaritan Hospital where decedent told staff that she had taken 3 Ecstasy pills at the party.

Decedent kept in ER and monitored until about 0800 when she was released with doctor telling the mother that she would probably sleep for 18 hours and wake up with a headache. Decedent unable to get to car on her own and seemed to sleep the entire trip home to Sylmar. Decedent put to bed and checked on every 30 minutes or so by family. When checked on at about 1600 hours she was found not breathing so family called 911. Decedent taken to Olive View Hospital where she was declared dead in the ER at 1701 hours.

In this story the young girl died after being sent home from the hospital. The doctors failed to realize the actual lasting effects of ecstasy and thus were unable to help this girl. If our own doctors don’t even know how to handle a drug like ecstasy, just imagine the state of affairs our youth are in. They need the correct knowledge in order to make the right decisions. As if the drug ecstasy wasn’t bad enough, a lot of times the drug has other things added into it. Things like rat poison, sedatives and other chemical combinations.
While it is the drug ecstasy itself that does the most damage, nowadays kids don’t know what they are taking. They need all the facts and complete understanding about drugs themselves in order to keep from using them. About 8% of high school seniors surveyed had tried Ecstasy at least once in their lives. About 5.5% of 19-22 year-olds surveyed had used Ecstasy in the previous year. Ecstasy-related emergency room incidents increased nationwide from 250 in 1994, to 637 in 1997, to 1,142 in 1998, to 2,850 in 1999. Some of you may be wishing you’d had this type of information when you were growing up doing drugs.

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You know this would have made a big difference. Why? Because you were lied to by friends, who were drug users, and by the drug dealers. This situation is still happening today. What makes things even more horrifying today is that drugs are much more powerful then they were 30 years ago. Combine this with a pure lack of knowledge on the subject of drugs and you can begin to see the uphill battle our youth have in today’s world. “We have an opportunity to reach kids about this drug before they go down the dark side of using Ecstasy. I hope the above story illustrates the importance of this for all of you,” said Young.

For help with overcoming drug and alcohol addiction or to request drug education personnel to your school or group, go to http://www.DrugAddictionHelpLine.com.

What is Ecstacy?

MDMA (3,4-methylenedioxymethamphetamine), most commonly known today by the street name ecstasy, is a synthetic entactogen of the phenethylamine family whose primary effect is to stimulate the secretion of large amounts of serotonin as well as dopamine and noradrenaline in the brain, causing a general sense of openness, empathy, energy, euphoria, and well-being. Tactile sensations are enhanced for some users, making general physical contact with others more pleasurable, but contrary to popular mythology, it generally does not have aphrodisiac effects. Its ability to facilitate self-examination with reduced fear has proven useful in some therapeutic settings, leading to its 2001 approval by the United States FDA for testing in patients with post-traumatic stress disorder.

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