The Therapeutic Potential of MDMA

Running head: THE THERAPEUTIC POTENTIAL OF MDMA

The Therapeutic Potential of MDMA

Alan Poey

04/01/2010

The Wright Institute

Introduction

THE THERAPEUTIC POTENTIAL OF MDMA

MDMA, short for 3,4-methylenedioxymethamphetamine, is a synthetic

amphetamine derivative better known as the street drug ‘ecstasy.’ Structurally it is

similar to both amphetamines and phenethylamines, a class of mescaline-like

hallucinogens. Phenomenologically, however, MDMA is quite different from both of

these classes of psychoactives, known for evoking a heightened sense of empathy,

comfort, sociality, and closeness to others, while diminishing feelings of fear, anxiety,

and depression. Although sometimes referred to as a ‘psychedelic amphetamine’ or

‘empathogen,’ the pharmacological class that is most widely accepted today is

‘entactogen.’ Coined in 1986 by researcher David E. Nichols, ‘entactogen’ essentially

means “to produce a touching within” (Nichols, 1986). Nichols was one of many

researchers who in the ‘70s and ‘80s were expounding MDMA as an “outstandingly

valuable therapeutic tool,” and coined the term because he believed ‘empathogen,’ which

contained the word ‘pathogen,’ would create a negative impression in the mind of the

psychiatric patient (Nichols, 1986).

Although first used therapeutically in the United States by a small number of

clinicians with selected clients, word of its effects inevitably spread, and over the last

three decades MDMA has gained huge popularity as a recreational drug. In 1981 the

brand name ‘Ecstasy’ was coined by a Los Angeles distribution network, in hopes that it

would sell better than the arguably more appropriate name ‘Empathy,’ the name that had

been used along with ‘Adam’ by therapists (Eisner, 1989). Throughout the ’80s, demand

for ecstasy increased exponentially throughout Europe and the United States, most

notably within the underground rave scene (all night dance parties with electronic music

and light shows). At raves, MDMA is usually sold in the form of colored pressed pills,

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which are notorious for their unreliable dosages and potential for being laced with other

chemicals and street drugs (Erowid, 2010).

Today, ecstasy is among the most popular recreational drugs. In 2008, 5.2% of

the US population aged 12 or older had tried MDMA, and in 2009, 6.5% of 12th graders

had tried MDMA (National Institute on Drug Abuse, 2010). Because of its classification

as a Schedule One banned substance, its infamous ties to the rave scene counterculture,

and all the negative press it has received surrounding reports of neurotoxicity in animals

and ecstasy-related deaths in humans, attention is rarely paid to MDMA’s roots as a

therapeutic tool. In recent years, however, this is beginning to change, as we are seeing a

renewed interest within the research community in the potential use of MDMA in the

treatment of depression and anxiety disorders, particularly Post Traumatic Stress

Disorder. Thanks in large part to private funding and a several decade-long effort by the

Multidisciplinary Association for Psychedelic Studies (MAPS), a non-profit research and

educational organization, permission has been granted by the FDA for several clinical

studies currently underway investigating MDMA-assisted psychotherapy. This paper

will review the history of MDMA research and discuss its potential for use as an adjunct

to psychotherapy.

History

MDMA was originally patented in 1914 in Europe by Merck & Company as an

intermediate chemical involved in the production of new blood clotting agents

(Freudenmann et al. 2006). Its physiological or psychological effects were not

investigated until 1953, when the American Army Chemical Center used it in animal

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experiments as a potential brainwashing agent (Holland, 2001). Its psychoactive effects

on humans were first documented by Alexander Shulgin and David E. Nichols in 1978,

reporting that it evoked an easily controlled altered state of consciousness with emotional

and sensual overtones (Shulgin & Nichols, 1978). Shulgin, who was also a collaborator

in the first published paper on the chemical’s synthesis (Braun, Shulgin & Braun, 1980),

instantly recognized MDMA’s potential as a therapeutic tool, and suggested to a few of

his California-based psychotherapist friends that they try using it as an adjunct to

psychotherapy (Holland, 2001). Among these friends was Dr. Leo Zeff, who in the

1960s had been a psychedelic psychotherapist using LSD (Holland, 2001). Zeff saw

MDMA as far superior to LSD for this purpose, since the MDMA experience was almost

invariably positive, shorter acting, and without perceptual or identity distortions (Sessa,

2007). By the time of his death, Zeff was thought to have given MDMA to over 4000

patients, and was part of a growing movement of West Coast clinicians in the late ‘70s

and early ‘80s using MDMA in their practice (Sessa, 2007). It is estimated that between

1977 and 1985, half a million doses of MDMA were distributed to patients suffering

from a variety of psychological conditions (Silcott, 2000).

In 1985 a meeting was held at the Esalen Institute in California for psychiatrists

and researchers to discuss and debate drug-assisted psychotherapy. Psychiatrist George

Greer documented the meeting in a paper titled Using MDMA in Psychotherapy (Greer,

1985). A number of therapists reported great success using MDMA in treating victims of

child abuse and sexual assault, in helping people work through feelings of hopelessness

and helplessness surrounding terminal cancer diagnoses, and with psychotic individuals

for whom antipsychotic medications had been unsuccessful. A number of therapists also

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reported success using MDMA in couples therapy, the consensus being that MDMA

enhanced communication and reduced defensiveness and fear of emotional injury,

allowing people to express their feelings directly. Also brought forward at the meeting

was the need for blinded and placebo-controlled clinical research into the drug’s safety

and efficacy. But as Greer pointed out in his paper, because MDMA is no longer

patentable, pharmaceutical companies are not inclined to support the expensive research

required.

Another roadblock to this much needed research came later that year, when the

DEA took emergency measures to make MDMA a Schedule One controlled substance,

essentially labeling the drug as having high addictive abuse potential with no evidence

for medical use, ignoring all requests that the case for medical applications be heard

(Sessa, 2007). This decision came in light of increasing numbers of negative reports of

uncontrolled ecstasy abuse outside the clinical environment (Sessa, 2007), combined with

the recent publication of a study showing that MDA, a related compound and MDMA

metabolite, caused lasting reductions in serotonin levels and serotonergic axon terminal

degradation in rats (Shulgin, 1986; Ricuarte et al., 1985). Once banned, the clinical

research needed to prove MDMA’s therapeutic potential was no longer possible, and

MDMA research became for the most part limited to animal toxicology studies.

The toxicology debate

MDMA causes increased levels of serotonin, dopamine, and norepinephrine in the

brain by reversing the action of membrane transport proteins, not only preventing them

from their usual task of neurotransmitter reuptake, but causing them to release their

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neurotransmitters back into the synapse (Green, et al., 2003). Over the years, a number

of animal studies have shown that large or repeated doses of MDMA can cause damage

to serotonergic and dopaminergic neurons, which has led to much negative publicity

surrounding ecstasy use in the popular culture and public warnings from government

agencies. But the reliability of these studies and their applicability to humans has been

the source of much controversy. In 2002, for example, a National Institute on Drug

Abuse (NIDA) funded study, conducted by the same research group that published the

MDA study that led to the banning of MDMA, reported that a single recreational dose of

MDMA, modeled after doses sometimes taken by humans, led to severe dopaminergic

neurotoxicity, and less pronounced serotonergic neurotoxicity in primates, implying that

MDMA users may be putting themselves at risk for developing neuropsychiatric

disorders such as Parkinson’s disease (Ricaurte et al., 2002). The paper was published in

Science magazine, and received a huge amount of government publicity. One year later,

Ricaurte et al. published a much less publicized retraction, admitting that they had

accidentally administered methamphetamine, not MDMA, supposedly as a result of

mislabeled bottles (Ricuarte et al., 2003).

Misinformation such as this aside, MDMA has indeed been shown to cause dose-

dependant serotonergic and dopaminergic neurodegradation, the formation of tissue-

damaging free radicals, and potentially fatal hyperthermia in lab animals (Green et al.,

2003). However, the majority of animal studies use large or repeated doses of MDMA

not necessarily representative of human use. Rats receiving smaller doses of MDMA

have been shown not to show any signs of neurotoxicity (Wang et al. 2005). Monkeys

allowed to self-administer MDMA for 18 months straight showed no reductions in brain

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dopamine, slight reductions in serotonin levels, but no signs of neuronal injury

(Fantegrossi et al. 2004).

Because the results of animal studies are not easily translated to humans, a

number of studies have been conducted examining the cognitive side-effects of

recreational ecstasy use in humans. One such study found that adolescent ecstasy users

have slower reaction times and showed evidence of hippocampal dysfunction during a

working memory task (Jacobsen, 2004). In another study, MDMA users, as compared to

cannabis users and controls, showed verbal memory deficits and impairments in learning,

consolidation, recall, and recognition (Quednow, 2006). A problem with these studies is

that some recreational ecstasy users take MDMA every weekend, or in combination with

other drugs; patterns of use that are much more excessive than the doses proposed for

MDMA psychotherapy (Sessa, 2007). In a study examining the neuropsychological

effects of MDMA in 23 young MDMA users with minimal exposure to other drugs,

moderate users displayed no differences than non-users on a battery of

neuropsychological tests, while heavy users displayed several deficits, particularly in the

areas of mental processing speed and impulsivity (Halpern et al., 2004). Results from the

Netherlands Toxicity Studies research program failed to find any changes in serotonin

uptake sites or chemical markers of brain injury resulting from low to moderate ecstasy

use (de Win et al., 2007). The conclusion that can be drawn from this research is that

while repeated MDMA use can indeed cause neuronal damage, changes in brain

chemistry, and cognitive impairments, the amount of MDMA use being proposed for

psychotherapeutic purposes is not likely to cause significant harm.

The subjective experience of MDMA

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In 1986, immediately following the DEA’s banning of MDMA, George Greer

published a paper titled Subjective Reports of the Effects of MDMA in a Clinical Setting,

which documented data gathered from the first 29 patients to be administered MDMA, 14

of whom reported psychological problems (Greer & Tolbert, 1986). Using MDMA

synthesized in the lab of Alexander Shulgin, who was present throughout the study for

assistance and consultation, subjects were administered an oral dose of 75-150 mg of

MDMA, depending on the patients’ weight, with instrumental music playing in the

background, and therapists available and attentive to respond to patients’ needs, interact

with patients as deemed appropriate, and record communications. When the effects

began to subside, patients were offered a second dose of 50 mg to prolong the session and

allow for a more gradual return to baseline. Follow-up was conducted verbally soon after

the session, and by written questionnaire much later.

All 29 subjects found their experience quite useful. 22 noted cognitive benefits

such as expanded mental perspective, insight into personal patterns or problems, and

improved self-examination skills. 10 subjects reported greater self-confidence or self-

acceptance, and 10 reported a lowering of defenses. All subjects but one had entered into

the experience with some purpose or goal, and 16 felt their purpose had been completely

realized. All nine subjects with DSM-III diagnoses reported significant relief from their

problems, and two reported full and lasting remissions. The majority of the subjects felt

that MDMA enhanced self-understanding and was useful in their personal and spiritual

growth. Every subject but one reported positive changes in their relationships after the

sessions, 16 reported positive changes in their occupation, 14 reported positive changes in

their spiritual practice or physical well-being, and 14 reported a decrease in their use of

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mind-altering substances. All subjects reported undesirable physical side effects during

or shortly after the experience, including nausea, jaw tension, loss of appetite, urinary

urgency, and insomnia, but no side effects were deemed serious.

In another study reporting on the subjective effects of MDMA, 20 psychiatrists

who had taken MDMA previously were evaluated using a semistructured interview

concerning the drug’s subjective effects and the short- and long-term sequelae (Liester et

al., 1992). 90% reported altered perception of time, 85% noticed an increased ability to

interact with or be open with others, 80% reported decreased defensiveness, 65%

reported decreased fear, and 50% had an increased awareness of emotions. Of the short-

term sequelae, decreased sleep and decreased appetite were the most common. The most

common long-term sequelae were improved interpersonal functioning (50%). Changes in

values and life priorities were common, often involving a shift away from materialistic

values towards interpersonal relationships. 30% reported increased interest in religious

issues and commitment to spiritual practices. All denied any craving to take MDMA

again, but 70% reported interest in taking it again at some point. 17 of the 20 supported

further clinical research utilizing MDMA, and over half stated they believe MDMA has a

high or very high therapeutic potential.

In 1986 Lester Grinspoon and James Bakalar published a paper in the American

Journal of Psychotherapy discussing MDMA’s therapeutic value using anecdotal

evidence from a number of psychiatric patients who had received MDMA-assisted

psychotherapy (Grinspoon & Bakalar, 1986). They concluded that MDMA provides a

“highly controllable experience which invites rather than compels intensification of

feelings and self-exploration.” As one patient reported, “MDMA breaks down

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inhibitions about communication, making it easy to give or receive criticism or

compliments that under normal circumstances are embarrassing.” In another paper

describing individual and group experiences with MDMA, a patient was quoted as

saying, “during the course of a single Adam session, I experienced a deep natural healing

within myself…For the first time in my life I can feel myself consciously and lovingly

aware of the body in which I live” (Adamson and Metzner, 1988).

Mechanisms for therapeutic change

What makes MDMA unique as a pharmacological agent, and another reason why

pharmaceutical companies have no interest in pursuing it, is that it often requires only

one to three sessions to bring about long-lasting clinical progress (Doblin, 2002). By

eliminating fear and anxiety, MDMA allows the patient a unique opportunity to confront

long-standing emotional conflicts (Doblin, 2002). As Greer and Tolbert have pointed

out, once the barrier of fear is removed, “a loving and forgiving awareness seems to

occur quite naturally and spontaneously” (Greer & Tolbert, 1990). What takes place is a

corrective emotional experience, allowing the patient to “reassess any aspect of their lives

and relationships that they choose, from the broader perspective of security and love,

rather than from one of vulnerability and fear” (Greer & Tolbert, 1990).

Grinspoon and Bakalar also point to the increased sense of emotional connection,

trust, and willingness for self-disclosure that the patient feels towards the therapist as the

primary mechanism for positive change: “If, as many believe, the strength of the

therapeutic alliance is the best predictor of a good outcome in therapy, this characteristic

of MDMA would be of very general usefulness” (Grinspoon & Bakalar, 1986). Beyond

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the value of the alliance alone, the role of the therapist in helping integrate emotional

insights into the patients’ lives to provide enduring resolution is also emphasized (Doblin,

2002; Greer & Tolbert, 1990).

Because of its unique ability to temporarily eliminate fear and anxiety, MDMA

has been shown to decrease avoidance behavior and increase tolerance for retrieving and

working through painful memories (Johansen and Krebs, 2009). This makes it an ideal

facilitator in PTSD exposure therapy, by allowing the patient to access and explore their

painful memories and triggers in the absence of fear (Johansen and Krebs, 2009). On a

neurological level, MDMA may achieve these effects by acting on the emotion regulation

circuit implicated in PTSD pathology. “A convergent body of human and nonhuman

studies suggests that the amygdala mediates the acquisition and expression of conditioned

fear and the enhancement of emotional memory, whereas the ventromedial prefrontal

cortex (vmPFC) mediates the extinction of conditioned fear and the volitional regulation

of negative emotion. It has been theorized that the vmPFC exerts inhibition on the

amygdala, and that a defect in this inhibition could account for the symptoms of PTSD”

(Koenigs & Grafman, 2009). In a PET study by Gamma and colleagues (2000), oral

administration of a single dose of MDMA resulted in increased blood flow to the vmPFC

and decreased blood flow to the amygdala, which Johansen and Krebs (2009) suggest

may allow the PTSD patient an opportunity to work on rectifying this defect of

inhibition.

The role of oxytocin is also being examined in MDMA’s potential therapeutic

effects. In addition to serotonin, dopamine, and norepinephrine, MDMA has been shown

to increase plasma oxytocin levels (Thompson et al., 2007). Oxytocin has been shown to

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increase trust in humans (Kosfeld et al., 2005), increase one’s ability to recognize social

cues and infer the mental states of others (Domes et al., 2006), and enhance the encoding

of positive social memories (Guastella et al., 2008). Oxytocin has also been shown to

reduce amygdala activation in humans being shown fear inducing stimuli (Kirsch et al.,

2005), suggesting oxytocin may play a key role in the fear-reducing effects of MDMA.

Johansen and Krebs (2009) suggest that “by increasing oxytocin levels, MDMA may

strengthen engagement in the therapeutic alliance and facilitate beneficial exposure to

interpersonal closeness and mutual trust.”

Conclusion

Despite a substantial body of literature suggesting the positive, life-affirming, and

potentially spiritually and psychologically healing properties of the MDMA experience,

the efficacy of MDMA for treating certain psychological disorders cannot be confirmed

until the results of randomized, double-blinded, placebo-controlled clinical trials have

been published. Until then, questions remain as to whether the benefits do indeed

outweigh the risks involved in implementing a drug that can be damaging to the brain if

used irresponsibly. It is also impossible to prove with anecdotal evidence alone that the

psychological gains afforded by a singular experience, no matter how profound, do

indeed endure over time. What also needs to be considered are the risks involved in the

post-MDMA recovery period, where temporary neurochemical depletion has been shown

to cause depressed mood, irritability, and brooding (Liechti et al., 2001). Further

research is needed to assess whether this hang-over effect could potentially undo or

cancel out emotional insights.

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Although fears and stigma surrounding ecstasy use endure, fears that for years

have served to keep this much needed research from being permitted, the tides seem to be

turning as of late. In the past few years, MDMA has received a great deal of publicity in

a variety of media reporting on its therapeutic potential. There are currently a number of

sophisticated clinical studies underway in the U.S., Switzerland, Israel, Canada, Jordan,

and Spain investigating the use of MDMA in the treatment of PTSD, as well as one study

being conducted at McLean Hospital investigating MDMA-assisted psychotherapy in the

treatment of anxiety secondary to advance stage cancer (Multidisciplinary Association for

Psychedelic Studies, 2010).

But these few studies are only the beginning, considering the amount of research

that will be needed to explore MDMA’s full clinical potential. MDMA has been shown

to be useful for a large number of other therapeutic purposes, including couples therapy,

drug abuse, vocational rehabilitation, and in the treatment of psychosomatic diseases and

schizophrenia (Greer, 1985). Sessa and Nutt (2007) have also suggested its potential for

use in treating suicidal depression in the emergency room as an alternative to

electroconvulsive therapy. It remains to be seen whether the funding for MDMA will

continue to materialize, since pharmaceutical companies have nothing to gain from

MDMA. But if the current studies confirm what seems to be a hugely promising tool for

psychiatric healing in MDMA, perhaps some government sponsorship will start to

materialize in the name of healthcare cost prevention.

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The Therapeutic Potential of MDMA