Neurobehavioral outcomes of infants exposed to MDMA (Ecstasy) and other recreational drugs during pregnancy

A perspective on psychedelic teratogenicity: the utility of zebrafish models

Psychedelic drugs have experienced an unprecedented surge in recreational use within the past few years. Among recreational users, the risks of psychedelic use by pregnant and breastfeeding women are severely understudied and there is little information on the potential teratogenic effects of these drugs. We provide an overview of the previous data on psychedelic teratogenicity from rodent studies and human surveys, discuss their limitations, and propose the utility of the zebrafish as a potential effective model for investigating psychedelic teratogenicity. Recent years have validated the use of zebrafish in the study of fetal exposure and developmental biology; we highlight these properties of the zebrafish for its suitability in psychedelic toxicity research.

Early neurobehavioral outcomes in infants with suspected abusive head trauma: Performance across and relationship between measures

Early neurobehavioral outcomes among infants with abusive head trauma (AHT) have not been well characterized. Though there are standardized measures for assessing infants, the ability of these measures to detect deficits may be limited. The Neonatal Intensive Care Unit (NICU) Network Neurobehavioral Scale, Second Edition (NNNS-II) has been correlated with neurobehavioral outcomes as early as birth but has not been used with this clinical group. There is no strong evidence of the concurrent validity of this measure. The primary goal was to examine the concurrent validity of the NNNS-II in patients with suspected AHT by comparing it to the Mullen Scales of Early Learning, American Guidance Service (AGS) Edition (Mullen). A secondary goal was to characterize early neurobehavioral outcomes among infants with suspected AHT across two measures. This retrospective study included 11 infants who sustained a traumatic brain injury (TBI) around 40 days of age. The sample's performance was variable and ranged from average to below average across measures. Participants experienced the most difficulty with visuospatial processing, attentional abilities, physiologic regulation, and asymmetric reflexes, and data suggested the NNNS-II may be more sensitive to deficits. There was evidence of concurrent validity of the NNNS-II based on strong to moderate correlations with the Mullen. Use of the NNNS-II shortly after the injury is more likely to showcase deficits, which may increase the likelihood that patients receive early intervention. Establishing concurrent validity of the NNNS-II further contributes to the evidence base regarding its criterion related validity, which may promote its more regular use.

Developmental exposure to MDMA (ecstasy) in zebrafish embryos reproduces the neurotoxicity adverse outcome 'lower motor activity' described in humans

The recreational use of MDMA (ecstasy) by pregnant women is associated with impaired neuromotor function in infants, but the Adverse Outcome Pathway behind this effect is not clear yet. We present for the first time the evaluation of developmental neurotoxic (DNT) effects of MDMA in zebrafish embryos. The aim of the study was to determine whether the zebrafish model reproduces the adverse outcome occurring in humans. We have studied the DNT effects of MDMA in zebrafish within a range of 5-250 μM performing different behavioural tests: spontaneous tail-coiling and light-dark locomotor response; after exposing the embryos to 4 different scenarios combining changes in pH, in starting exposure time and exposure duration. In these scenarios we evaluated the effects of MDMA in general embryonic development and compared the concentrations producing them with those inducing specific DNT effects. As a result, we have established the experimental conditions leading to the adverse outcome "lower motor activity" in zebrafish without producing general developmental delay or general toxicity. The experimental condition chosen opens the door to use this model in future mechanistic investigations to better characterize the Adverse Outcome Pathway associated with the adverse effects caused by MDMA prenatal exposure in humans.

Maternal Exposure and Neonatal Effects of Drugs of Abuse

The public health crisis of pregnant women being exposed to drugs of abuse and of its impact on their unborn children continues to grow at an alarming rate globally. The state of pregnancy is unique, with physiological changes that can lead to changes in the way drugs are handled by the body in both pharmacokinetics and response. These changes place the pregnant woman, fetus, and newborn infant at risk, as many of these drugs can cross the placenta and into breast milk. The substances most commonly linked to harmful effects include alcohol, tobacco, cannabis, stimulants, and opioids. The pharmacological and toxicological changes caused by in utero exposure or breastfeeding exposure are difficult to study, and the full extent of the mechanisms involved are not fully understood. However, these changes can significantly affect the risks of substance abuse and influence optimal treatment of pregnant women with a substance use disorder. In addition, newborns who were exposed to drugs of abuse in utero can experience withdrawal syndromes. Pharmacological management in infants is used to guide and treat withdrawal symptoms, with the goal being to improve the infant's sleep, eating, and comfort. Several barriers may prevent pregnant women from seeking help for substance use, including stigma and interactions with the legal system. Understanding changes in pharmacology, including pharmacokinetic changes that happen during pregnancy, is essential for anticipating the extent of maternal exposure and neonatal adverse effects.

The Term Newborn: Prenatal Substance Exposure

Care for pregnant patients with substance use disorder must be provided in a nonjudgmental manner with recognition of addiction as a chronic medical illness in order to establish a therapeutic relationship and improve outcomes. All pregnant patients should be screened for substance use during prenatal care. Screening can be accomplished through several validated screening tools. Patients who screen positive need to be evaluated and referred for treatment as appropriate. This article reviews specific adverse perinatal outcomes associated with the use of a variety of substances and provides guidance on exposure with continued breastfeeding.

A Meta-Analysis of Stressors from the Total Environment Associated with Children's General Cognitive Ability

General cognitive ability, often referred to as ‘general intelligence’, comprises a variety of correlated abilities. Childhood general cognitive ability is a well-studied area of research and can be used to predict social outcomes and perceived success. Early life stage (e.g., prenatal, postnatal, toddler) exposures to stressors (i.e., chemical and non-chemical stressors from the total (built, natural, social) environment) can impact the development of childhood cognitive ability. Building from our systematic scoping review (Ruiz et al., 2016), we conducted a meta-analysis to evaluate more than 100 stressors related to cognitive development. Our meta-analysis identified 23 stressors with a significant increase in their likelihood to influence childhood cognitive ability by 10% or more, and 80 stressors were observed to have a statistically significant effect on cognitive ability. Stressors most impactful to cognition during the prenatal period were related to maternal health and the mother’s ability to access information relevant to a healthy pregnancy (e.g., diet, lifestyle). Stressors most impactful to cognition during the early childhood period were dietary nutrients (infancy), quality of social interaction (toddler), and exposure to toxic substances (throughout early childhood). In conducting this analysis, we examined the relative impact of real-world exposures on cognitive development to attempt to understand the inter-relationships between exposures to both chemical and non-chemical stressors and early developmental life stages. Our findings suggest that the stressors observed to be the most influential to childhood cognitive ability are not permanent and can be broadly categorized as activities/behaviors which can be modified to improve childhood cognition. This meta-analysis supports the idea that there are complex relationships between a child’s total environment and early cognitive development.

Of mice and men on MDMA: A translational comparison of the neuropsychobiological effects of 3,4-methylenedioxymethamphetamine ('Ecstasy')

MDMA (3,4-methylendioxymethamphetamine), also known as Ecstasy, is a stimulant drug recreationally used by young adults usually in dance clubs and raves. Acute MDMA administration increases serotonin, dopamine and noradrenaline by reversing the action of the monoamine transporters. In this work, we review the studies carried out over the last 30 years on the neuropsychobiological effects of MDMA in humans and mice and summarise the current knowledge. The two species differ with respect to the neurochemical consequences of chronic MDMA, since it preferentially induces serotonergic dysfunction in humans and dopaminergic neurotoxicity in mice. However, MDMA alters brain structure and function and induces hormonal, psychomotor, neurocognitive, psychosocial and psychiatric outcomes in both species, as well as physically damaging and teratogen effects. Pharmacological and genetic studies in mice have increased our knowledge of the neurochemical substrate of the multiple effects of MDMA. Future work in this area may contribute to developing pharmacological treatments for MDMA-related disorders.

Developmental neurotoxicity of MDMA. A systematic literature review summarized in a putative adverse outcome pathway

The increasing use of illegal drugs by pregnant women causes a public health concern because it is associated with health risks for mothers and their developing children. One of such drugs is MDMA (3,4-methylenedioxymethamphetamine) or ecstasy due to its high consumption in relevant age and sex groups and its adverse effects on human and rodent developing brains. To thoroughly review the current knowledge on the developmentally neurotoxic potential of MDMA we systematically collected and summarized articles investigating developmental neurotoxicity (DNT) of MDMA in humans and animals in vivo and in vitro. In addition, we summarized the findings in a putative adverse outcome pathway (AOP). From an initial 299 articles retrieved from the bibliographic databases Web of Science, PubMed and DART, we selected 39 articles according to inclusion/exclusion criteria for data collection after title/abstract and full text screening. Of these 3 where epidemiological studies, 34 where in vivo studies in mice and rats and 2 were in vitro studies. The three epidemiological studies reported from the same longitudinal study and suggested that MDMA exposure during pregnancy impairs neuromotor function in infants. In rat, postnatal exposure towards MDMA also caused locomotor deficits as well as impaired spatial learning that might be associated with decreased serotonin levels in the hippocampus. In vitro MDMA caused cytotoxicity at high concentrations and effects on the serotonergic and neuritogenic alterations at lower concentrations which are in line with some of the in vivo alterations observed. Considering the adverse outcomes of developmental MDMA described in humans and in rodents we summarized the first putative AOP on developmental compound exposure leading to impaired neuromotor function in children. For generation of this AOP, MDMA exposure was taken as a model compound. In addition, we hypothesized a second AOP involving developmental disturbance of the dopaminergic system. However, further in vitro mechanistic studies are needed to understand the molecular initiating event(s) (MIE) triggering the downstream cascades and obtain consistent evidences causally linking the adverse outcome to effects at the cellular, organ and organism level.

Stimulant Use in Pregnancy: An Under-recognized Epidemic Among Pregnant Women

Stimulant use, including cocaine, methamphetamines, ecstasy, and prescription stimulants, in pregnancy is increasingly common. In the United States, stimulants are the second most widely used and abused substances during pregnancy and pregnant women using stimulants in pregnancy are at increased risk of adverse perinatal, neonatal, and childhood outcomes. In this review, we describe the pharmacology, pathophysiology, and epidemiology of stimulants, summarize the maternal and neonatal effects of perinatal stimulant use, and outline treatment options for stimulant use disorders among pregnant women. Development of effective treatment strategies for stimulant use disorders identified among pregnant women are urgently needed.

Recreational 3,4-methylenedioxymethamphetamine or 'ecstasy': Current perspective and future research prospects

AIMS

The purpose of this article is to debate current understandings about the psychobiological effects of recreational 3,4-methylenedioxymethamphetamine (MDMA or 'ecstasy'), and recommend theoretically-driven topics for future research.

METHODS

Recent empirical findings, especially those from novel topic areas were reviewed. Potential causes for the high variance often found in group findings were also examined.

RESULTS AND CONCLUSIONS

The first empirical reports into psychobiological and psychiatric aspects from the early 1990s concluded that regular users demonstrated some selective psychobiological deficits, for instance worse declarative memory, or heightened depression. More recent research has covered a far wider range of psychobiological functions, and deficits have emerged in aspects of vision, higher cognitive skill, neurohormonal functioning, and foetal developmental outcomes. However, variance levels are often high, indicating that while some recreational users develop problems, others are less affected. Potential reasons for this high variance are debated. An explanatory model based on multi-factorial causation is then proposed.

FUTURE DIRECTIONS

A number of theoretically driven research topics are suggested, in order to empirically investigate the potential causes for these diverse psychobiological deficits. Future neuroimaging studies should study the practical implications of any serotonergic and/or neurohormonal changes, using a wide range of functional measures.

Psychomotor Tremor and Proprioceptive Control Problems in Current and Former Stimulant Drug Users: An Accelerometer Study of Heavy Users of Amphetamine, MDMA, and Other Recreational Stimulants

The recreational use of various stimulant drugs has been implicated in the development of movement disorders through dysregulation of the dopaminergic and serotoninergic neurotransmitter systems. The present study investigated psychomotor differences in current and former recreational stimulant drug users compared with nonusing controls. Sixty participants comprised 3 groups: 20 current stimulant drug users (CSUs; 11 men, aged 31.4 ± 9.1 years), 20 former stimulant drug users (FSUs; 5 men, aged 39.1 ± 8.5 years), and 20 nonuser controls (NUCs; 5 men, aged 35.7 ± 6.4 years). Psychomotor arm steadiness for each participant was assessed with a wrist-attached accelerometer during 5 arm positions with eyes open and then eyes closed. Arm-drop of arm position was indicated by the arm longitudinal rotation axis (ALoRA), and tremor was indicated by the overall vector of dynamic body acceleration (VeDBA). Overall, CSUs performed the most poorly on ALoRA (P < .05) and VeDBA indices (P < .05), and FSUs perform almost as poorly on VeDBA indices (P < .05) compared with NUCs. It was concluded that stimulant drug use, primarily MDMA and amphetamines, may result in acute stimulant-induced tremor as well as long-term proprioceptive deficits in terms of arm-droop.

Alcohol Interactions with Psychostimulants: An Overview of Animal and Human Studies

Alcohol consumption with psychostimulants is very common among drug addicts. There is little known about the possible pharmacological interactions between alcohol and psychostimulants. Among most commonly co-abused psychostimulants with alcohol are methamphetamine, cocaine, 3,4-methylenedioxymethamphetaminen, and nicotine. Co-abuse of alcohol with psychostimulants can lead to several neurophysiological dysfunctions such as decrease in brain antioxidant enzymes, disruption of learning and memory processes, cerebral hypo-perfusion, neurotransmitters depletion as well as potentiation of drug seeking behaviour. Moreover, co-abuse of alcohol and psychostimulants can lead to increase in heart rate, blood pressure, myocardial oxygen consumption and cellular stress, and the risk of developing different types of cancer. Co-abuse of alcohol with psychostimulants during pregnancy can lead to fetal brain abnormalities. Further studies are needed to investigate the pharmacokinetics, pharmacodynamics, and neurochemical changes on co-abuse of alcohol and psychostimulants.

Motor delays in MDMA (ecstasy) exposed infants persist to 2 years

BACKGROUND

Recreational use of 3,4 methylenedioxymethamphetamine (ecstasy, MDMA) is increasing worldwide. Its use by pregnant women causes concern due to potentially harmful effects on the developing fetus. MDMA, an indirect monoaminergic agonist and reuptake inhibitor, affects the serotonin and dopamine systems. Preclinical studies of fetal exposure demonstrate effects on learning, motor behavior, and memory. In the first human studies, we found prenatal MDMA exposure related to poorer motor development in the first year of life. In the present study we assessed the effects of prenatal exposure to MDMA on the trajectory of child development through 2 years of age. We hypothesized that exposure would be associated with poorer mental and motor outcomes.

MATERIALS AND METHODS

The DAISY (Drugs and Infancy Study, 2003-2008) employed a prospective longitudinal cohort design to assess recreational drug use during pregnancy and child outcomes in the United Kingdom. Examiners masked to drug exposures followed infants from birth to 4, 12, 18, and 24 months of age. MDMA, cocaine, alcohol, tobacco, cannabis, and other drugs were quantified through a standardized clinical interview. The Bayley Scales (III) of Mental (MDI) and Motor (PDI) Development and the Behavior Rating Scales (BRS) were primary outcome measures. Statistical analyses included a repeated measures mixed model approach controlling for multiple confounders.

RESULTS

Participants were pregnant women volunteers, primarily white, of middle class socioeconomic status, average IQ, with some college education, in stable partner relationships. Of 96 women enrolled, children of 93 had at least one follow-up assessment and 81 (87%) had ≥ two assessments. Heavier MDMA exposure (M=1.3±1.4 tablets per week) predicted lower PDI (p<.002), and poorer BRS motor quality from 4 to 24 months of age, but did not affect MDI, orientation, or emotional regulation. Children with heavier exposure were twice as likely to demonstrate poorer motor quality as lighter and non-exposed children (O.R.=2.2, 95%, CI=1.02-4.70, p<.05).

DISCUSSION

Infants whose mothers reported heavier MDMA use during pregnancy had motor delays from 4 months to two years of age that were not attributable to other drug or lifestyle factors. Women of child bearing age should be cautioned about the use of MDMA and MDMA-exposed infants should be screened for motor delays and possible intervention.

Contributions of a Child's Built, Natural, and Social Environments to Their General Cognitive Ability: A Systematic Scoping Review

The etiology of a child’s cognitive ability is complex, with research suggesting that it is not attributed to a single determinant or even a defined period of exposure. Rather, cognitive development is the product of cumulative interactions with the environment, both negative and positive, over the life course. The aim of this systematic scoping review was to collate evidence associated with children’s cognitive health, including inherent factors as well as chemical and non-chemical stressors from the built, natural, and social environments. Three databases were used to identify recent epidemiological studies (2003–2013) that examined exposure factors associated with general cognitive ability in children. Over 100 factors were evaluated from 258 eligible studies. We found that recent literature mainly assessed the hypothesized negative effects of either inherent factors or chemical exposures present in the physical environment. Prenatal growth, sleep health, lead and water pollutants showed consistent negative effects. Of the few studies that examined social stressors, results consistently showed cognitive development to be influenced by both positive and negative social interactions at home, in school or the community. Among behavioral factors related to diet and lifestyle choices of the mother, breastfeeding was the most studied, showing consistent positive associations with cognitive ability. There were mostly inconsistent results for both chemical and non-chemical stressors. The majority of studies utilized traditional exposure assessments, evaluating chemical and non-chemical stressors separately. Collective evidence from a limited number of studies revealed that cumulative exposure assessment that incorporates multiple chemical and non-chemical stressors over the life course may unravel the variability in effect on cognitive development and help explain the inconsistencies across studies. Future research examining the interactions of multiple stressors within a child’s total environment, depicting a more real-world exposure, will aid in understanding the cumulative effects associated with a child’s ability to learn.

Validated LC-MS-MS Method for Multiresidual Analysis of 13 Illicit Phenethylamines in Amniotic Fluid

A multi-residue analytical method was developed for the determination in amniotic fluid (AF) of 13 illicit phenethylamines, including 12 compounds never investigated in this matrix before. Samples were subject to solid-phase extraction using; hydrophilic-lipophilic balance cartridges which gave good recoveries and low matrix effects on analysis of the extracts. The quantification was performed by liquid chromatography electrospray tandem mass spectrometry. The water-acetonitrile mobile phase containing 0.1% formic acid, used with a C18 reversed phase column, provided adequate separation, resolution and signal-to-noise ratio for the analytes and the internal standard. The final optimized method was validated according to international guidelines. A monitoring campaign to assess fetal exposure to these 13 substances of abuse has been performed on AF test samples obtained from pregnant women. All mothers (n = 194) reported no use of drugs of abuse during pregnancy, and this was confirmed by the analytical data.

Greater sexual risk-taking in female and male recreational MDMA/ecstasy users compared with alcohol drinkers: a questionnaire study

AIMS

Previous studies have shown increased sexual risk-taking in experienced MDMA/ecstasy users. The main objectives of this study were to compare levels of sexual risk-taking between a young student sample of predominantly heterosexual MDMA users and alcohol-drinker controls and investigate potential gender differences.

METHODS

Recreational drug use and sexual risk questionnaires were completed by 20 MDMA users (10 females, 10 males) and 20 non-user controls (10 females, 10 males). They were predominantly university students, aged between 20-22 years, mainly heterosexual (n = 37), with three bisexual participants.

RESULTS

MDMA users displayed significantly greater levels of sexual risk-taking than the alcohol-drinker controls. It involved significantly higher rates of casual sex, non-condom use during sex, and penetrative sexual risks. This increase in sexual riskiness occurred to a similar extent in males and females.

CONCLUSIONS

These findings indicate that both female and male ecstasy/MDMA users reported more risky sexual behaviours, than the non-user controls. Further research into the sexual behaviour and sexual risk-taking of heterosexual MDMA users should be conducted because much of the past literature has focused on homosexual participants.

Why all stimulant drugs are damaging to recreational users: an empirical overview and psychobiological explanation

AIMS

Stimulant drugs such as nicotine and Ecstasy/3, 4-methylenedioxymethamphetamine (MDMA) are taken for positive reasons, yet their regular use leads to deficits rather than gains. This article outlines the psychobiological rationale for this paradox.

METHODS

The empirical literature on nicotine, cocaine, amphetamine, Ecstasy/MDMA, and mephedrone are reviewed. A theoretical explanation for why they are problematic to humans is then described.

RESULTS

The acute effects of central nervous system (CNS) stimulants are typically positive, with greater alertness and emotional intensity. However, in the post-drug recovery period, the opposite feelings develop, with lethargy and low moods. All recreational stimulants cause mood fluctuation, although it is most pronounced in drugs with rapid onset and comedown (e.g. nicotine and cocaine), explaining why they are the most addictive. Parallel fluctuations occur across many psychological and neurocognitive functions, with users suffering various off-drug deficits. CNS stimulants also affect the hypothalamic-pituitary-adrenal axis, impairing sleep, disrupting homeostasis, and exacerbating psychiatric distress. Neuroimaging studies reveal altered brain activity patterns in regular users. These problems are related to lifetime usage but commence in novice users.

CONCLUSIONS

Repetitive CNS stimulation is potentially damaging to the organism, both acutely and chronically. The review describes the various psychobiological systems through which recreational stimulant drugs impair human well-being.

Developmental outcomes of 3,4-methylenedioxymethamphetamine (ecstasy)-exposed infants in the UK

OBJECTIVE

This paper aims to review findings from a longitudinal study of prenatal methylenedioxymethamphetamine (MDMA, "ecstasy") on infant development.

METHODS

In a prospective, longitudinal cohort design, we followed 28 MDMA-exposed and 68 non-MDMA-exposed infants from birth to 2 years of age. Women recruited voluntarily into a study of recreational drug use during pregnancy were interviewed to obtain type, frequency, and amount of recreational drug use. Their children were followed for a 2-year period after birth. A large number of drug and environmental covariates were controlled. Infants were seen at 1, 4, 12, 18, and 24 months using standardized normative tests of mental and motor development.

RESULTS

There were no differences between MDMA-exposed and non-MDMA-exposed infants at birth except that MDMA-exposed infants were more likely to be male. Motor delays were evident in MDMA infants at each age and amount of MDMA exposure predicted motor deficits at 12 months in a dose-dependent fashion.

CONCLUSIONS

Prenatal MDMA exposure is related to fine and gross motor delays in the first 2 years of life. Follow-up studies are needed to determine long-term effects.

Developmental consequences of fetal exposure to drugs: what we know and what we still must learn

Most drugs of abuse easily cross the placenta and can affect fetal brain development. In utero exposures to drugs thus can have long-lasting implications for brain structure and function. These effects on the developing nervous system, before homeostatic regulatory mechanisms are properly calibrated, often differ from their effects on mature systems. In this review, we describe current knowledge on how alcohol, nicotine, cocaine, amphetamine, Ecstasy, and opiates (among other drugs) produce alterations in neurodevelopmental trajectory. We focus both on animal models and available clinical and imaging data from cross-sectional and longitudinal human studies. Early studies of fetal exposures focused on classic teratological methods that are insufficient for revealing more subtle effects that are nevertheless very behaviorally relevant. Modern mechanistic approaches have informed us greatly as to how to potentially ameliorate the induced deficits in brain formation and function, but conclude that better delineation of sensitive periods, dose-response relationships, and long-term longitudinal studies assessing future risk of offspring to exhibit learning disabilities, mental health disorders, and limited neural adaptations are crucial to limit the societal impact of these exposures.

Teratogenic risks from exposure to illicit drugs

Substance use is prevalent in the United States, especially in the reproductive age population. Even though a reduction in substance use may occur during pregnancy, some women may not alter their drug use patterns until at least pregnancy is confirmed. For these reasons, a large number of fetuses are exposed to illicit substances, including during critical stages of organogenesis. Associating illicit drug use with eventual pregnancy outcome is difficult. This article presents issues pertaining to limitations with published investigations about fetal risks and describes the most current information in humans about fetal effects from specific illicit substances.

MDMA is certainly damaging after 25 years of empirical research: a reply and refutation of Doblin et al. (2014)

Human Psychopharmacology recently published my review into the increase in empirical knowledge about the human psychobiology of MDMA over the past 25 years (Parrott, 2013a). Deficits have been demonstrated in retrospective memory, prospective memory, higher cognition, complex visual processing, sleep architecture, sleep apnoea, pain, neurohormonal activity, and psychiatric status. Neuroimaging studies have shown serotonergic deficits, which are associated with lifetime Ecstasy/MDMA usage, and degree of neurocognitive impairment. Basic psychological skills remain intact. Ecstasy/MDMA use by pregnant mothers leads to psychomotor impairments in the children. Hence, the damaging effects of Ecstasy/MDMA were far more widespread than was realized a few years ago. In their critique of my review, Doblin et al. (2014) argued that my review contained misstatements, omitted contrary findings, and recited dated misconceptions. In this reply, I have answered all the points they raised. I have been able to refute each of their criticisms by citing the relevant empirical data, since many of their points were based on inaccurate summaries of the actual research findings. Doblin and colleagues are proponents of the use of MDMA for drug-assisted psychotherapy, and their strongest criticisms were focused on my concerns about this proposal. However, again all the issues I raised were based on sound empirical evidence or theoretical understanding. Indeed I would recommend potentially far safer co-drugs such as D-cycloserine or oxytocin. In summary, MDMA can induce a wide range of neuropsychobiological changes, many of which are damaging to humans.

Care of Drug-Addicted Pregnant Women: Current Concepts and Future Strategies – an Overview

This review focuses on drug use during pregnancy and the perinatal period, a constellation that is seen more often. Drug use in pregnant women poses an increased risk for adverse health outcomes both for the mother and child. Care is often complicated by social and environmental factors, as well as psychiatric comorbidities. It is, therefore, very important to provide drug-using pregnant women with optimal ante-, peri- and post-natal care. Health professionals should approach them in a nonjudgmental and supportive way, and provide them with the same care and attention as nondrug-using women. Adequate care requires interdisciplinary teams. Ideally, healthcare providers should be specialized in the care of drug-using pregnant women.

Prenatal methamphetamine exposure and neurodevelopmental outcomes in children from 1 to 3 years

BACKGROUND

Despite the evidence that women world-wide are using methamphetamine (MA) during pregnancy little is known about the neurodevelopment of their children.

DESIGN

The controlled, prospective longitudinal New Zealand (NZ) Infant Development, Environment and Lifestyle (IDEAL) study was carried out in Auckland, NZ. Participants were 103 children exposed to MA prenatally and 107 who were not exposed. The Mental Developmental Index (MDI) and the Psychomotor Developmental Index (PDI) of the Bayley Scales of Infant Development, Second Edition (BSID-II) measured cognitive and motor performances at ages 1, 2 and 3, and the Peabody Developmental Motor Scale, Second Edition (PDMS-II) measured gross and fine motor performances at 1 and 3. Measures of the child's environment included the Home Observation of Measurement of the Environment and the Maternal Lifestyle Interview. The Substance Use Inventory measured maternal drug use.

RESULTS

After controlling for other drug use and contextual factors, prenatal MA exposure was associated with poorer motor performance at 1 and 2 years on the BSID-II. No differences were observed for cognitive development (MDI). Relative to non-MA exposed children, longitudinal scores on the PDI and the gross motor scale of the PDMS-2 were 4.3 and 3.2 points lower, respectively. Being male and of Maori descent predicted lower cognitive scores (MDI) and being male predicted lower fine motor scores (PDMS-2).

CONCLUSIONS

Prenatal exposure to MA was associated with delayed gross motor development over the first 3 years, but not with cognitive development. However, being male and of Maori descent were both associated with poorer cognitive outcomes. Males in general did more poorly on tasks related to fine motor development.

Quantifying Maternal and Paternal Disease History Using Log-Rank Score with an Application to a National Cohort Study

Both maternal and paternal disease history can be important predictors of the risk of common conditions such as heart disease or cancer because of shared environmental and genetic risk factors. Sometimes maternal and paternal history can have remarkably different effects on offspring's status. The results are often affected by how the maternal and paternal disease histories are quantified. We proposed using the log-rank score (LRS) to investigate the separate effect of maternal and paternal history on diseases, which takes parental disease status and the age of their disease onset into account. Through simulation studies, we compared the performance of the maternal and paternal LRS with simple binary indicators under two different mechanisms of unbalanced parental effects. We applied the LRS to a national cohort study to further segregate family risks for heart diseases. We demonstrated using the LRS rather than binary indicators can improve the prediction of disease risks and better discriminate the paternal and maternal histories. In the real study, we found that the risk for stroke is closely related with maternal history but not with paternal history and that maternal and paternal disease history have similar impact on the onset of myocardial infarction.

Psychiatric profiles of mothers who take Ecstasy/MDMA during pregnancy: reduced depression 1 year after giving birth and quitting Ecstasy

BACKGROUND

The recreational drug MDMA (3,4-methylenedioxymethamphetamine) or 'Ecstasy' is associated with heightened psychiatric distress and feelings of depression. The Drugs and Infancy Study (DAISY) monitored the psychiatric symptom profiles of mothers who used Ecstasy/MDMA while pregnant, and followed them over the first year post-partum.

METHODS

We compared 28 young women whom took MDMA during their pregnancy with a polydrug control group of 68 women who took other psychoactive drugs while pregnant. The Brief Symptom Inventory (BSI) was completed for several periods: The first trimester of pregnancy; and 1, 4 and 12 months after childbirth. Recreational drug use was monitored at each time point.

RESULTS

During the first trimester of pregnancy, MDMA-using mothers reported higher depression scores than the polydrug controls. At 1 year after childbirth, their BSI depression scores were significantly lower, now closer to the control group values. At the same time point, their self-reported use of MDMA became nearly zero, in contrast to their continued use of Cannabis/marijuana, nicotine and alcohol. We found significant symptom reductions in those with BSI obsessive-compulsive and interpersonal sensitivity, following Ecstasy/MDMA cessation.

CONCLUSIONS

The findings from this unique prospective study of young recreational drug-using mothers are consistent with previous reports of improved psychiatric health after quitting MDMA.

MDMA and heightened cortisol: a neurohormonal perspective on the pregnancy outcomes of mothers used 'Ecstasy' during pregnancy

OBJECTIVE

The illicit recreational drug 3,4-methylenedioxymethamphetamine (MDMA) or Ecstasy has strong neurohormonal effects. When taken by recreational users at dance clubs and raves, it can generate an 800% increase in the stress hormone cortisol, whereas drug-free users show chronically raised levels of cortisol. The aim here is to critically debate this neurohormonal influence for the children of pregnant MDMA-using mothers.

METHODS

High levels of cortisol are known to be damaging for neuropsychobiological well-being in adult humans. MDMA can damage foetal development in laboratory animals, and the prospective Drugs and Infancy Study was established to monitor the effects of MDMA taken recreationally by pregnant women.

RESULTS

The Drugs and Infancy Study revealed that young mothers, who took MDMA during the first trimester of pregnancy, gave birth to babies with significant gross psychomotor retardation. These mothers would have experienced high levels of cortisol due to Ecstasy/MDMA use, and since cortisol can cross the placenta, this is likely to have also occurred in the foetus.

CONCLUSIONS

In terms of causation, the developmental problems may reflect a combination of neurotransmitter and neurohormonal effects on the hypothalamic-pituitary-adrenal axis, with serotonergic activity being influenced by the high levels of cortisol.

Neuronal reorganization in adult rats neonatally exposed to (±)-3,4-methylenedioxymethamphetamine

The abuse of methylenedioxymethamphetamine (MDMA) during pregnancy is of concern. MDMA treatment of rats during a period of brain growth analogous to late human gestation leads to neurochemical and behavioral changes. MDMA from postnatal day (P)11–20 in rats produces reductions in serotonin and deficits in spatial and route-based navigation. In this experiment we examined the impact of MDMA from P11 to P20 (20 mg/kg twice daily, 8 h apart) on neuronal architecture. Golgi impregnated sections showed significant changes. In the nucleus accumbens, the dendrites were shorter with fewer spines, whereas in the dentate gyrus the dendritic length was decreased but with more spines, and for the entorhinal cortex, reductions in basilar and apical dendritic lengths in MDMA animals compared with saline animals were seen. The data show that neuronal cytoarchitectural changes are long-lasting following developmental MDMA exposure and are in regions consistent with the learning and memory deficits observed in such animals.

The use of central nervous system active drugs during pregnancy

CNS-active drugs are used relatively often during pregnancy. Use during early pregnancy may increase the risk of a congenital malformation; use during the later part of pregnancy may be associated with preterm birth, intrauterine growth disturbances and neonatal morbidity. There is also a possibility that drug exposure can affect brain development with long-term neuropsychological harm as a result. This paper summarizes the literature on such drugs used during pregnancy: opioids, anticonvulsants, drugs used for Parkinson's disease, neuroleptics, sedatives and hypnotics, antidepressants, psychostimulants, and some other CNS-active drugs. In addition to an overview of the literature, data from the Swedish Medical Birth Register (1996-2011) are presented. The exposure data are either based on midwife interviews towards the end of the first trimester or on linkage with a prescribed drug register. An association between malformations and maternal use of anticonvulsants and notably valproic acid is well known from the literature and also demonstrated in the present study. Some other associations between drug exposure and outcome were found.

Human psychobiology of MDMA or 'Ecstasy': an overview of 25 years of empirical research

AIMS

This paper aimed to review how scientific knowledge about the human psychobiology of MDMA has developed over time.

METHODS

In this paper, the empirical findings from earlier and later studies will be reviewed.

RESULTS

When MDMA was a 'novel psychoactive substance', it was not seen as a drug of abuse, as it displayed loss of efficacy. However, recreational users display a unique pattern of increasing doses, deteriorating cost-benefit ratios, and voluntary cessation. MDMA increases body temperature and thermal stress, with cortisol levels increased by 800% in dance clubbers. It can be extremely euphoric, although negative moods are also intensified. MDMA causes apoptosis (programmed cell death) and has been investigated for cancer therapy because of its anti-lymphoma properties. Recreational users show deficits in retrospective memory, prospective memory, higher cognition, problem solving, and social intelligence. Basic cognitive skills remain intact. Neuroimaging studies show reduced serotonin transporter levels across the cerebral cortex, which are associated with neurocognitive impairments. Deficits also occur in sleep architecture, sleep apnoea, complex vision, pain, neurohormones, and psychiatric status. Ecstasy/MDMA use during pregnancy leads to psychomotor impairments in the children.

CONCLUSIONS

The damaging effects of Ecstasy/MDMA are far more widespread than was realized a few years ago, with new neuropsychobiological deficits still emerging.

MDMA, serotonergic neurotoxicity, and the diverse functional deficits of recreational 'Ecstasy' users

Serotonergic neurotoxicity following MDMA is well-established in laboratory animals, and neuroimaging studies have found lower serotonin transporter (SERT) binding in abstinent Ecstasy/MDMA users. Serotonin is a modulator for many different psychobiological functions, and this review will summarize the evidence for equivalent functional deficits in recreational users. Declarative memory, prospective memory, and higher cognitive skills are often impaired. Neurocognitive deficits are associated with reduced SERT in the hippocampus, parietal cortex, and prefrontal cortex. EEG and ERP studies have shown localised reductions in brain activity during neurocognitive performance. Deficits in sleep, mood, vision, pain, psychomotor skill, tremor, neurohormonal activity, and psychiatric status, have also been demonstrated. The children of mothers who take Ecstasy/MDMA during pregnancy have developmental problems. These psychobiological deficits are wide-ranging, and occur in functions known to be modulated by serotonin. They are often related to lifetime dosage, with light users showing slight changes, and heavy users displaying more pronounced problems. In summary, abstinent Ecstasy/MDMA users can show deficits in a wide range of biobehavioral functions with a serotonergic component.

One-year outcomes of prenatal exposure to MDMA and other recreational drugs

OBJECTIVE

A widely used illicit recreational drug among young adults, 3,4-methylenedioxymethamphetamine (MDMA) or ecstasy, is an indirect monoaminergic agonist/reuptake inhibitor affecting the serotonin system. Preclinical studies found prenatal exposure related to long-term learning and memory impairments. There are no studies of sequelae of prenatal MDMA exposure in humans, despite potential harmful effects to the fetus.

METHODS

A total of 96 women in the United Kingdom (28 MDMA users; 68 non-MDMA) were interviewed about recreational drug use during pregnancy. Their infants were seen at 12 months using standardized assessments of cognitive, language, and motor development (Preschool Language Scale, Bayley Mental and Motor Development and Behavior Rating Scales [Mental Development Index, Psychomotor Development Index, Behavioral Rating Scale]). Mothers completed the Child Domain Scale of the Parenting Stress Index, The Home Observation of the Environment Scale (in interview), the Brief Symptom Inventory, and the Drug Abuse Screening Test. Women were primarily middle class with some university education, in stable partner relationships, and polydrug users. MDMA and other drug effects were assessed through multiple regression analyses controlling for confounding variables, and analysis of covariance comparing heavier versus lighter and nonexposed groups.

RESULTS

Amount of prenatal MDMA exposure predicted poorer infant mental and motor development at 12 months in a dose-dependent manner. Heavily exposed infants were delayed in motor development. Lighter-exposed infants were comparable to nonexposed infants. There were no effects on language, emotional regulation, or parenting stress.

CONCLUSIONS

Findings document persistent neurotoxic effects of heavier prenatal MDMA exposure on motor development through the first year of life.