Motivations for Using MDMA (Ecstasy/Molly) among African Americans: Implications for Prevention and Harm-Reduction Programs

Prevalence and Correlates of Past Year Ecstasy/MDMA Use in the United States

OBJECTIVES

3,4-Methylenedioxymethamphetamine (MDMA) (also known as "ecstasy" or "Molly") has regained attention in recent years for its efficacy in treating posttraumatic stress disorder, and the drug was granted breakthrough therapy designation for such use by the US Food and Drug Administration in 2017. However, little is known about the current epidemiology of recreational ecstasy/MDMA use.

METHODS

We estimated past-year prevalence and correlates of ecstasy/MDMA use based on a representative sample of noninstitutionalized US individuals 12 years or older from the 2015-2020 National Survey on Drug Use and Health (N = 315,661).

RESULTS

An estimated 0.9% (95% confidence interval [CI] = 0.9-1.0) of individuals used ecstasy/MDMA in the past year. Compared with those ages 35-49 years, all younger age groups were at increased odds for use, while those older than 50 years (adjusted odds ratio [aOR] = 0.14, 95% CI = 0.08-0.23) were at low odds for use. Compared with heterosexual men, those identifying as bisexual women (aOR = 1.32, 95% CI = 1.02-1.72) were at increased odds for use, and compared with White individuals, those identifying as Asian (aOR = 1.92, 95% CI = 1.42-2.59), Black (aOR = 1.70, 95% CI = 1.41-2.06), or multiracial (aOR = 1.61, 95% CI = 1.19-2.16) were at increased odds for use. Past-year use of other drugs (e.g., cannabis, ketamine), prescription drug misuse (e.g., pain relievers, stimulants), nicotine dependence (aOR = 1.21, 95% CI = 1.00-1.45), and alcohol use disorder (aOR = 1.41, 95% CI = 1.25-1.58) were also associated with increased odds for use.

CONCLUSIONS

While use of ecstasy/MDMA continues to be relatively rare, findings from this study can help inform prevention and harm reduction strategies, especially among certain subpopulations that are at high risk for use.

MDMA-assisted therapy for posttraumatic stress disorder: A pooled analysis of ethnoracial differences in efficacy and safety from two Phase 2 open-label lead-in trials and a Phase 3 randomized, blinded placebo-controlled trial

BACKGROUND

Limited ethnoracial diversity in previous ±3,4-methylenedioxymethamphetamine-assisted therapy (MDMA-AT) trials for posttraumatic stress disorder (PTSD) has prompted questions concerning whether Black, Indigenous, and People of Color (BIPOC) also benefit from this treatment.

METHODS

Secondary analysis was conducted using a modified intent-to-treat sample pooled from two Phase 2 open-label trials and a Phase 3 randomized, blinded placebo-controlled trial to compare efficacy and safety of MDMA-AT for PTSD between BIPOC and non-Hispanic White participants. Four subgroups were of interest: MDMA-AT, BIPOC (n = 20); MDMA-AT, non-Hispanic White (n = 63); Placebo-assisted therapy (Placebo-AT), BIPOC (n = 17); and Placebo-AT, non-Hispanic White (n = 27). Planned comparisons tested subgroup differences in changes in Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) scores from baseline to primary endpoint, controlling for study type and baseline scores. Adverse events (AEs) on the day of (day 0) to 2 days post-dosing were reported for each subgroup.

RESULTS

In the MDMA-AT group, no significant ethnoracial difference in CAPS-5 change scores was observed. In the Placebo-AT group, BIPOC participants trended toward greater reductions in CAPS-5 scores than non-Hispanic Whites. Among non-Hispanic Whites, MDMA-AT was accompanied by significantly greater reductions in CAPS-5 scores than Placebo-AT. No treatment difference emerged among BIPOC participants. AEs were mostly rated as mild or moderate across subgroups.

CONCLUSIONS

These findings provide preliminary support for the efficacy and safety of MDMA-AT for treating PTSD across ethnoracial groups. There was also a trend toward greater efficacy with Placebo-AT among BIPOC participants. There was an imbalance in subgroups, highlighting the need for culturally responsive recruitment strategies to diversify future studies.

Subtypes of Bullying and Types of Substance Use among Urban African American Adolescents: Who Is Likely to Use What?

The present study examined the types of drugs likely to be used by bullies, victims, and bully/victims. Participants comprise African American adolescents from three high schools, one youth church group, two community youth programs, and four public venues in low-income communities in Chicago's Southside. A series of logistic regression analyses and latent class analyses were employed. Victims are likely to use alcohol, marijuana, and lean/krokodil. Bullies were likely to use alcohol and marijuana. Bully/victims were not at risk of any of the substances. Our LCA findings revealed a lower occurrence of substance use among victims although 30% used alcohol and marijuana; more than half of bullies showed high levels of alcohol, marijuana, and lean/krokodil use; a diverse pattern of drug use was shown among bully/victims although their lean/krokodil and crack/cocaine use was higher than other subgroups of bullying. The drugs of choice for African American bullies, victims, or bully/victims are variable.

Different phases of ATS use call for different interventions: a large qualitative study in Europe

BACKGROUND

Amphetamine-type stimulants (ATS) are globally widely used. Scientific literature generally defines four phases of substance use (initiation, continuation, increase and decrease); however, there is limited understanding of what influences these different phases of ATS use. The ATTUNE study investigated which factors shape individual phases of use, or ATS use patterns. In this article, we report on these phases into and out of ATS use, and propose a set of recommendations for prevention, harm reduction and treatment of the different phases of ATS use.

METHODS

Qualitative, semi-structured interviews (n = 237) were conducted in five different European countries with participants who had used ATS, varying from a few times in a lifetime to daily.

RESULTS

Amphetamine and MDMA were the most commonly used ATS. Yet, types of ATS used differed between the countries. We found that people who use ATS have various motives for and dynamic patterns of ATS use with alternating phases of increase, continuation, decrease and sometimes dependence. Cessation was pursued in different ways and for diverse reasons, such as mental health problems and maturing out. Availability seemed not an issue, regardless of the type of ATS, phase or country.

CONCLUSIONS

These findings demonstrate that tailor-made interventions are needed for the diverse types of people who use ATS and different phases or patterns of ATS use, to reduce possible harms of use. We recommended a set of interventions for the different ATS phases. These include drug checking services, peer-led information, self-management of ATS use, mental health support to help people cope with stressful life events and prevent uncontrolled use, and follow-up support after treatment.

Racial/ethnic differences in prevalence of hallucinogen use by age cohort: Findings from the 2018 National Survey on Drug Use and Health

Background

Few studies have assessed the epidemiology of hallucinogenic substance use among racial and ethnic groups of varying age cohorts. Use of psychedelic substances may differ among people of color (POC), due to factors such as stigma and discriminatory drug enforcement practices against POC. The lack of inclusion of POC in psychedelic research further underscores the importance of identifying differences in use among racial/ethnic groups and age cohorts.

Methods

Data from the 2018 National Survey on Drug Use and Health (NSDUH) was used for this analysis (N = 56,313, unweighted), representative of the non-institutionalized U.S. population. Proportions of lifetime hallucinogen use by race/ethnicity were compared. Proportions of past year rates of use were compared to examine differences by race/ethnicity and age cohort.

Results

Approximately 15.9% of the U.S. population over 12 had used a hallucinogen at some point in their lifetime and 2.0% had used in the past year. Lifetime hallucinogen use was most prevalent among non-Hispanic White and multi-racial individuals, while Black/African Americans reported the lowest rates of use. White and multi-racial groups also reported the highest proportions of past year use among 12–34 year olds, and White individuals reported the highest proportions among 35–49 year olds. Hispanic individuals reported higher proportions of use among the 12–17 cohort, but lower proportions among the 26–49 year old cohorts. Black/African Americans reported the lowest rates of past year use among the 12–25 year old cohorts. 50+ and older cohorts reported the lowest rates of hallucinogen use in the past year.

Limitations

Data is cross-sectional and self-reported. “Race” is a social construction is subject to change over time, and NSDUH ethnoracial categories are limited. Institutionalized populations are not included in the study.

Conclusions

Significant differences in hallucinogen use among ethnoracial groups by substance and age cohorts were observed. Findings from this work may inform education, interventions, and therapeutic psychedelic research.

Culture and psychedelic psychotherapy: Ethnic and racial themes from three Black women therapists

Psychedelic medicine is an emerging field of research and practice that examines the psychotherapeutic effects of substances classified as hallucinogens on the human mind, body, and spirit. Current research explores the safety and efficacy of these substances for mental health disorders including anxiety, depression, and posttraumatic stress disorder (PTSD). Although current studies explore psychotherapeutic effects from a biomedical perspective, gaps in awareness around cultural issues in the therapeutic process are prominent. African Americans have been absent from psychedelic research as both participants and researchers, and little attention has been paid to the potential of psychedelics to address traumas caused by racialization. This paper examines cultural themes and clinical applications from the one-time use of 3,4-methylenedioxymethamphetamine (MDMA) as part of an US Food and Drug Administration (FDA)-approved clinical trial and training exercise for three African American female therapists. The primary themes that emerged across the varied experiences centered on strength, safety, connection, and managing oppression/racialization. The participants' experiences were found to be personally meaningful and instructive for how Western models of psychedelic-assisted psychotherapy could be more effective and accessible to the Black community. Included is a discussion of the importance of facilitator training to make best use of emerging material when it includes cultural, racial, and spiritual themes. A lack of knowledge and epistemic humility can create barriers to treatment for underserved populations. Implications for future research and practice for marginalized cultural groups are also discussed, including consideration of Functional Analytic Psychotherapy (FAP) as an adjunct to the psychedelic-therapy approaches currently advanced. As women of color are among the most stigmatized groups of people, it is essential to incorporate their perspectives into the literature to expand conversations about health equity.

Prescription Drug Misuse among African Americans and Afro Caribbeans: Results from the National Survey of American Life

BACKGROUND

The misuse of prescription medications is an understudied topic among the non-Hispanic Black population in the U.S. Even less is known about the prevalence and correlates of misuse among African Americans and Afro-Caribbeans, despite documented differences in their substance use behaviors.

OBJECTIVES

We aimed to examine the prevalence and correlates of lifetime prescription drug misuse among African Americans and Afro Caribbeans using data from the National Survey of American Life.

METHODS

A national household probability sample of non-institutionalized African Americans and Afro Caribbeans from the Collaborative Psychiatric Epidemiology Surveys was used. Pooled and ethnicity-stratified logistic regressions were estimated.

RESULTS

Findings showed no significant differences between African Americans (6.36%) and Afro-Caribbeans (5.71%) in lifetime prescription drug misuse. Several correlates were found to be associated with misuse among only African American or Afro-Caribbean respondents.

CONCLUSIONS

While research has shown prescription drug misuse is an issue among Blacks overall, our results show that the role of ethnicity must not be overlooked, especially when tailoring prevention and intervention programs. Limitations of this study are discussed.

Sexual Risk Behaviors among African Americans Who Use MDMA (Molly/Ecstasy): Implications for HIV Prevention

Numerous studies have linked sexual risk taking to recreational use of MDMA. Questions remain, however, regarding the extent and type of sexual risk behaviors that occur among MDMA users, especially African Americans who use the drug. Because the MDMA literature has historically relied on samples with little minority representation, little is known about Black MDMA users and their sexual risk taking. The primary goal of this study, therefore, was to describe patterns of sexual risk behaviors among African Americans who use MDMA. This study used survey data to identify (a) which sexual risk behaviors occurred among Black MDMA users and (b) the prevalence of each behavior. Qualitative interview data are also presented to contextualize the role that MDMA and the club/nightlife environment might play in contributing to these behaviors. Results show that sexual risk taking (e.g., sex without a condom, "hooking up," sex on MDMA, and group sex) was prevalent and that the mind-set and context in which MDMA was consumed are contributing factors. The current study adds to the limited amount of data on African Americans who use MDMA and is a step toward better understanding the link between MDMA and sexual risk taking. These data can be used to inform social workers in their efforts to prevent HIV in this population.

Race as a component of set and setting: How experiences of race can influence psychedelic experiences

Background and aims

Set and setting function both as a concept that guides research and practice with psychedelic drugs and as a meme aimed at reducing harm among psychedelic users. Referring to non-pharmacological factors that shape drug experiences, the concept of set and setting was popularized in the West during the mid-20th century. However, little theoretical development has occurred regarding what falls under the umbrella of set and setting since its conception.

Methods

By bridging set and setting theory with research from the fields of social psychology and sociology of medicine, this review calls attention to how race can contribute the set and setting for a psychedelic experience.

Results

I argue that psychosocial factors influencing racial differences in mental health also constitute meaningful differences in set. Furthermore, I suggest that the character of race relations in the United States provides a distinct cultural setting for racialized psychedelic users, both in therapeutic and naturalistic contexts. In turn, racial identification may contribute to the variation in framing and interpretation of psychedelic experiences.

Conclusion

These considerations have important implications beyond understanding non-pharmacological influences on psychedelic experiences, including developing protocols for clinical applications of psychedelics, educating future practitioners, and meeting the needs of diverse patient populations.

Intersectional insights from an MDMA-assisted psychotherapy training trial: An open letter to racial/ethnic and sexual/gender minorities

The road to the current psychedelic renaissance in research on ±3,4-methylenedioxymethamphetamine (MDMA) – the active ingredient of the drug Ecstasy – for addressing treatment-resistant post-traumatic stress disorder has been fraught with political and academic bias, as well as cultural stigma among underserved populations, all of which serve as barriers to minority inclusion and participation. In this open letter to ethnic/racial and sexual/gender minorities, the author details intersectional insights from his own experience being administered MDMA legally as part of a therapist training trial for MDMA-assisted psychotherapy, in hopes of radically destigmatizing this treatment approach for marginalized populations. Themes covered include: set and setting; cultural pride; LGBTQIA+ pride; acceptance of intersectionality; and patience, perspective, and strength in retrospection. This letter concludes by tasking current investigators of MDMA-assisted psychotherapy to emphasize issues of intersecting identities (e.g., in terms of race, ethnicity, sexual orientation, and gender identity) in their research agenda, attempt to improve minority participation in a culturally attuned manner, as well as increase minority stakeholdership in this field.

The psychedelic renaissance and the limitations of a White-dominant medical framework: A call for indigenous and ethnic minority inclusion

In recent years, the study of psychedelic science has resurfaced as scientists and therapists are again exploring its potential to treat an array of psychiatric conditions, such as depression, post-traumatic stress disorder, and addiction. The scientific progress and clinical promise of this movement owes much of its success to the history of indigenous healing practices; yet the work of indigenous people, ethnic and racial minorities, women, and other disenfranchised groups is often not supported or highlighted in the mainstream narrative of psychedelic medicine. This review addresses this issue directly: first, by highlighting the traditional role of psychedelic plants and briefly summarizing the history of psychedelic medicine; second, through exploring the historical and sociocultural factors that have contributed to unequal research participation and treatment, thereby limiting the opportunities for minorities who ought to be acknowledged for their contributions. Finally, this review provides recommendations for broadening the Western medical framework of healing to include a cultural focus and additional considerations for an inclusive approach to treatment development and dissemination for future studies.

Nonmedical prescription drug use among African Americans who use MDMA (ecstasy/molly): Implications for risk reduction

Recent data suggest that both nonmedical prescription drug and MDMA (ecstasy/molly) use have risen among African Americans. However, studies investigating these two forms of drug use among African Americans are rare. As a result, very little is known about African-American MDMA users and their nonmedical use of prescription medications. The primary goal of this study, therefore, was to describe patterns of nonmedical prescription drug use among African Americans who use MDMA. We also assessed alcohol and illicit drug use among the sample. Surveys (n=100) and in-depth interviews (n=15) were conducted with African-American young adults in Southwest Florida between August 2014 and November 2015. Survey results show that a significant proportion of the sample used MDMA in conjunction with prescription medications (benzodiazepines=59%; opioids=35%; stimulants=13%). Qualitative findings suggest that benzodiazepine medications were used to alleviate MDMA comedown symptoms, opioids were used to achieve a different quality high, and stimulants were used to provide added energy throughout the night. These results suggest that treatment practitioners and harm reduction professionals should pay particular attention to informing users of the potential hazards of combining MDMA with prescription medications. Although additional research is clearly needed, these findings are an important first step towards understanding both nonmedical prescription drug and MDMA use among African Americans, and could be used to tailor treatment and risk reduction interventions to this population.