3,4-Methylenedioxymethamphetamine (MDMA, ecstasy) has become a popular recreational drug of abuse among young adults, partly because of the belief that it is relatively safe compared with other drugs with the same stimulant and hallucinogenic effects. However, MDMA use has been associated with a wide spectrum of organ toxicities, with the liver being severely affected by its deleterious effects. This article discusses the essential pharmacology of MDMA and describes the effects MDMA has on various organ systems of the body, with particular focus on the liver. The putative mechanisms by which MDMA can cause liver damage are explored, with emphasis on patient-related factors that explain why some individuals are more susceptible than others to damage from MDMA. The incidence of hepatotoxicity related to MDMA use is presented, and the nursing management of patients who develop acute liver failure due to MDMA overuse is explored in light of current evidence.