Molly Talk Therapy: How MDMA-assisted therapy can be used to help reduce alcohol consumption and hazardous drinking in people with PTSD
/You may have heard of 3,4-Methylenedioxymethamphetamine (also known as MDMA, ecstasy, Molly, and other names before (DEA-1). Maybe it was in a conversation with someone who trusts you (MDMA is currently criminalized in the US (DEA-2)) telling you about how they felt when they took some “ecstasy” at a party and suddenly understood the meaning of life. Maybe they told you that they have been feeling sad lately but after taking Molly they finally “understand what joy is” (Jee) or what love really feels like (Colbert et al., 2023). These accounts are common when people experience psychedelic substances. Psychedelics (Kelmendi et al., 2022) are substances that produce altered states of mind and consciousness sometimes leading to hallucinations. They can be naturally derived like psilocybin extracted from mushrooms, or they can be developed in a laboratory like Lysergic acid diethylamide (LSD). MDMA is a synthetic compound that was developed in a laboratory and has stimulant and psychedelic effects, currently classified by the U.S. Drug Enforcement Administration as a Schedule I controlled substance (meaning it has “no currently accepted medical use and a high potential for abuse” (DEA-3)). MDMA use can alter sensory and emotional processing in the brain easing pro-social interactions (Wardle et al., 2014), making you more likely to want to spend time with others and share your deep feelings with them (Heifets et al., 2019). Because MDMA can have the effect of increased empathy, it is sometimes referred to as an empathogen. Sometimes people can struggle with mental illnesses that cause them to withdraw from human interaction or engage in unhealthy behaviors such as alcohol and drug use to cope with their mental illness. An example of a mental illness that can lead to social isolation and unhealthy behaviors is post-traumatic stress disorder or PTSD.
Post-traumatic stress disorder (PTSD) is a debilitating psychiatric illness afflicting over 20 million people in the United States. Various events can cause someone to develop PTSD, including experiencing mental harm from someone else, surviving an environmental disaster, and the accidental death of a loved one. PTSD’s symptomatology has a wide range, with a few symptoms occurring more often such as pervasive feelings of helplessness, intense fear, trouble sleeping or staying asleep, and constant reminders of the traumatic event. Based on a 9-item scale on a PTSD assessment (APA), PTSD can be determined to be severe and in need of more urgent treatment, making this type of PTSD important to study. Many people with PTSD also have alcohol and substance use problems mostly accounted for by attempts to cope with PTSD symptoms (Thakur et al., 2022).
The authors of this study wanted to understand the nuanced and possibly reinforcing interactions between PTSD and substance use. Just for context, this and other similar studies (MAPS-1) have been funded by the Multidisciplinary Association for Psychedelic Studies (MAPS). MAPS has been educating the public and sponsoring comprehensive and advanced psychedelic research since 1986 (MAPS-2). The authors of this study knew based on a MAPS-supported multi-site, placebo-controlled, Phase 3 trial (Mitchel et al., 2021) of MDMA-assisted therapy that using MDMA and therapy at the same time was a safe and effective treatment for decreasing the symptoms of severe PTSD. In this study, Nicholas et al. (2022) wanted to explore how MDMA-assisted therapy affects alcohol and substance use for participants who also have severe PTSD.
To accomplish their goal, the authors recruited 90 participants from 15 different institutions in the US, Canada, and Israel (mostly white (80.3%) and female (64.6%) with a mean age of 41.4 years old; 8 participants withdrew) and randomly assigned them to two groups; one group received MDMA and therapy sessions and the other group received a placebo and therapy sessions. For the dosing portion of the study, participants partook 3 treatment sessions of 8 hours long each where they received one initial dose and one later supplemental dose of MDMA unless they declined or experienced tolerability issues (although the authors did not define “tolerability” in the context of this study). In the dosing sessions, participants were placed in a comfortable environment with a bed, calming music, a mask to put over the eyes if needed, and support from therapists. The MDMA or placebo sessions were followed by 3 weekly 90-minute therapy sessions that focused on helping participants integrate their MDMA or placebo experiences with their lives. To analyze the effects of the treatment on alcohol use and other substances, the authors administered two surveys to all participants at baseline and at 2- and 12-month follow-ups: the Alcohol Use Identification Test (AUDIT) to assess hazardous drinking, alcohol use disorder, or at-risk use, and the Drug Use Identification Test (DUDIT) to identify patterns of substance use or drug-related issues such as drug cravings and harmful use. To correlate substance and alcohol use and PTSD severity, the authors asked that participants fill out a PTSD symptom severity measurement (CAPS-5 or Clinical Administered PTSD Scale for the DSM-5).
Based on participants’ responses to the alcohol use survey (AUDIT), the authors observed a decrease in alcohol use for people in the MDMA-assisted therapy group versus people in the placebo+therapy group. It is important to point out that alcohol use was not different between participants at the start of the study or in between treatments. This finding shows that MDMA-assisted therapy could help decrease alcohol consumption for people who have severe PTSD and struggle with excessive use of alcohol and its consequences. The authors also found that using MDMA, a criminalized substance in the United States, did not increase participants’ use of illicit substances in general, showing that this treatment can be safe and effective. Based on participants’ responses to the drug use survey (DUDIT), the authors did not see effects of MDMA-assisted therapy on use of substances other than alcohol. They did find that for individuals who received MDMA-assisted therapy, alcohol consumption changes were correlated with PTSD symptoms, but they did not explain whether this relationship led to improvement in symptoms or it made them worse.
As no scientific study is perfect, it is important to point out a few issues with this one. Normally, participants in a randomized study do not know if they received a sugar pill (placebo) or a treatment pill. In the case of psychedelics, it’s easy to determine if you took a pill that made you hallucinate versus a sugar pill, which will not make you feel any different. This is a big issue in psychedelic studies (Muthukumaraswamy, 2021) and to this day has not been solved. In other studies, scientists have tried using an active placebo that leads to superficially similar effects as the drug being assessed (Griffiths, 2016), but this was not addressed in this study. Having a clear distinction between the treatment substance and the placebo can decrease the reliability of blindness in the study. Blindness is when scientists hide from themselves and/or the participants the information on who is receiving the treatment and who is being given a placebo. Blinding is important (Day et al., 2000) to reduce biases that can affect the findings. Furthermore, participants in this study had the option of refusing doses of MDMA or placebo, but the authors did not clearly differentiate between participants who did and did not refuse when sharing results.
The overall conclusion of the paper is that MDMA-assisted therapy can reduce alcohol use and the consequences of misusing alcohol for people who also have severe PTSD. MDMA-assisted therapy could be used in the future to help treat people with severe PTSD who also struggle with misusing alcohol.
Edited by Sedona Ewbank.
References
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DEA-3. Drug Scheduling. Department of Justice/Drug Enforcement Administration – Drug Information. https://www.dea.gov/drug-information/drug-scheduling
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