The results of this study indicated that the reasons for rejecting ecstasy varied according to interviewee drug perception and experience level. Non-users (NU) and ex-light users (EX-L) more often gave reasons related to moral, family and religious principles as well as to the fear of adverse effects. However, people who stopped after a period of chronic use (EX-M) tended to attribute cessation to physical, psychological and social complications. They also cited maturity and professional concerns that motivated a parallel withdrawal from the context of use. Despite ecstasy cessation for more than 12 months, these respondents reported the possibility of future use in situations of opportunity, such as the electronic scene.
One of the aspects that deserve to be considered is our difficulty to find people who had not experienced ecstasy after having an opportunity to use it; it was easier to find ecstasy users than to find ex-users (abstinent for 12 months). The average age of our sample group was slightly higher than the average found in most ecstasy studies. The prevalence of tobacco use was also higher than in other Brazilian youth samples. These characteristics deserve attention in the interpretation of results [13, 15, 23]. The interviewees' reports did not necessarily include all of the reasons for rejecting ecstasy because the report content was limited to what the respondents were aware of and could verbalize in an interview.
In the non-users group, several subjects reported the use of other drugs, both licit and illicit, which differed from studies with other populations that included higher proportions of absolute non-users [20, 24]. This difference was possibly related to the study’s inclusion criteria, which were aimed at people who had faced genuine opportunities to use ecstasy, particularly in the electronic scene. The active nightlife characteristic might have differentiated the sample. The characteristic could also be interpreted as a study strength because it highlighted people most vulnerable to drug use. To ensure the specificity of the data to ecstasy, care was taken during the interviews to distinguish it from other drugs [12, 25].
The NU group reported using a smaller variety of illicit drugs compared to the wide range of drugs previously consumed by people in the EX-M group. This finding corroborated Scholey et al. who noted a significant difference in the range of previous illicit drugs consumption by ecstasy users compared to non-users .
The results of this study suggested that ecstasy use was associated with parties in general. The possible development of dependence appeared to be connected to the context of use. The sample reported ecstasy use at different types of parties, which demonstrated diversity in the contexts of use. However, all contexts shared common elements, such as music, dance, social interaction and having fun. The effects of the drug can explain the pairing of ecstasy with partying. However, context was a greater risk factor for chronic use. Classical conditioning, for example, is a theory that can be exploited to understand the use of ecstasy in specific contexts .
Cognitive and behavioral models of drug dependence support the idea that environmental events trigger drug use. The reaction to cues associated with the drug might represent an important risk factor for the transition from recreational use to addiction . Given that behavior is learned through classical conditioning and associated with social learning, the strength of the association depends on the frequency of joint occurrence of the stimuli. If context and stimuli do not appear together, the conditioning is reduced or remission occurs . This logic contributed to our understanding of reported cessation that ex-moderate users who had moved away from the electronic scene. Alternatively, it also suggests that withdrawal from the electronic scene is an important choice that supports people who wish to stop using.
Even when they had experienced complications that provoked the cessation of ecstasy use, ex-moderate users reported that they would resume drug use if they started attending raves and similar parties again. Because all participants met the study criterion of 12 months without ecstasy use, the perception of unpleasant symptoms might have diminished. The individual might consequently be more open to new episodes of use. Falck et al. studied 304 ex-ecstasy users (18 to 30 years old) who answered questions about resuming use of the drug. The responses were: ‘no’, 8.3%; ‘probably not’, 16.2%; ‘did not know’, 15.8%; ‘probably’, 37.3%; and ‘definitely yes’, 22.4% . This prevalence suggests that ex-users of ecstasy tend to want to use the drug again. Behavioral models of dependence should be taken into account in association with the context of use.
Singer and Schensul report that some individuals lost control of their ecstasy consumption. The users reported several unsuccessful cessation strategies. These results differ from those in our study. Therefore, more studies should focus on individuals who try to stop using the drug .
The contexts and social networks in which young adults are immersed are also involved in the use of ecstasy. Vervaeke et al. found that it is common for individuals who continue using ecstasy to remain close to other users, maintaining their social networks focused on consumption . Consumption is restricted to certain subcultures and compatible with collective representations of pleasure seeking, feelings of belonging, and transgression .
Lifestyle changes were noted as reasons for cessation of ecstasy use. Withdrawal from the context of use often followed increasing responsibilities within the professional sphere, fear of diminishing efficiency, changing personal relationships and loss of interest in the drug [10, 32]. This latter aspect could be related to a tolerance that developed through use and/or to a decrease in the quality of the pills ingested . However, cessation could also be part of a transitional phenomenon during young adulthood that reflects lifestyle changes and biopsychosocial alterations that increase the likelihood of withdrawal from the contexts of use and other practices .
Although ex-moderate users less frequently cited family and religious beliefs, the opposite trend occurred in the NU and EX-L groups. Non-users and ex-light users highlighted religious and family values as relevant factors for their ecstasy use decisions. Several studies have emphasized the important influence of moral and/or religious principles, coupled with parental influence, in substance use decisions [20, 24, 34–36]. Moral values seem to be significant factors in the early stages of drug use avoidance. However, for those still using ecstasy, such values are given different meanings that do not seem to represent a barrier to use.
The literature states that loss of interest and legal ramifications motivate the cessation of consumption. Our sample did not mention these reasons [12, 24, 34]. Some of the most common explanations were related to health complications, such as cognitive, physical and psychological problems. A longitudinal study of ecstasy users demonstrated that heavy users had more memory difficulties than newer users [37, 38]. Among psychological problems, other studies stated that symptoms such as depression, anxiety and paranoia occur frequently [39–41]. In the UK, 56% of a sample associated cessation with mental health problems . In a study by Falck et al., individuals who had consumed ecstasy on more than 50 occasions showed a higher incidence of severe depressive symptoms than people who had consumed up to 10 times .
Physical health statements from ex-moderate users in this study were consistent with the international literature. The most commonly reported physical problems in other studies were tremors, weight loss and bruxism [32, 40]. Parrott found that positive use effects diminished, while negative symptoms increased over time among newer ecstasy users .
Individual vulnerability is another aspect relevant to cessation. According to Vervaeke et al., some individuals have a greater vulnerability to drug components and may experience worse sensations during ecstasy consumption. Although respondents from the EX-L group did not make this observation, it could explain their discontinuation of ecstasy consumption . Given this hypothesis, the EX-L group could be more vulnerable to the negative effects of ecstasy compared to the EX-M group.
However, the NU and EX-L groups shared similar fears of the negative effects of ecstasy. These results corroborate studies that cited fear as a major reason for the cessation of ecstasy use, specifically fear of psychosocial compromises, loss of control, dependence and health damage [10, 24, 34]. The two groups additionally had similar views on the role of family values and religious matters. Thus, several factors potentially influence the rejection of ecstasy or the decision to not escalate beyond experimental use. Some of these factors could have practical prevention application, such as the appreciation that ecstasy use is not required to enjoy a party. In this sense, fun without ecstasy is a possible promotional message to dissuade drug abuse.
A review by Peters et al. explored social determinants of the ecstasy consumption and found that many have positive expectations associated with use of the drug . It is important that these aspects are demystified so that young adults can obtain reliable information about the unwanted effects of the drug. One should bear in mind that the negative effects of the drug might be associated with contaminated pills. A Brazilian chromatography study of 25 different ecstasy batches found MDMA variations from 30.9 to 92.7 mg. This information could strategically discourage non-users from experimentation and warn current users . Because users cannot test the pills in Brazilian parties, it is difficult to know actual pill composition.
Most respondents reported that they obtain information about the positive and negative effects of the drug through the Internet and/or users. This response suggested that information enhances perception of risk. Young individuals are searching for further information of the drug, possibly due to media coverage of deaths associated with ecstasy consumption. Ex-users also reported access to harm reduction (HR) information, which has been a widely used strategy for damage reduction during and after the consumption of ecstasy [15, 39, 45].
A harm reduction (HR) strategy should be considered because of the association observed in this study between the use of ecstasy in party environments and the intention of ex-users to resume drug usage in these contexts. Various strategies for HR are discussed in the literature. In some contexts, the vendors show users how to use (e.g., ingesting water, food, visiting the chill-out, etc.) . Non-governmental organizations (NGOs) that practice HR at electronic music festivals assess the purity of tablets and assist users having bad trips. These interventions in loco aim to reduce risky behaviors among ecstasy users and ensure a minimal amount of safety for people who opt to take ecstasy [34, 46]. The lifestyles of ex-light users and ex-moderate users, combined with complications resulting from ecstasy use, underscore the importance of intervention in loco. These users usually do not utilize the health care system, which makes it difficult to understand consumption patterns, complications and spontaneous remission [15, 33, 34, 36].