Is there a case for MDMA-assisted psychotherapy in the UK?

Reprint of: Pharmacosex: Reimagining sex, drugs and enhancement

BACKGROUND

The use of drugs in sexual contexts is receiving closer attention in the media, public health bodies and communities than ever before. However, research to date is most often concerned with the sex-related drug use of lesbian, gay, bisexual, transgender and queer (LGBTQ) populations, and particularly men who have sex with men (MSM) engaging in 'chemsex'. Against a backdrop dominated by public health and medical science perspectives, this article seeks to move beyond prevailing sex on drug discourses characterised by risk and harm, or pleasure. Drawing on an expansive notion of enhancement, we explore intersections between drug consumption and sex via the concept of 'pharmacosex': the ways in which wider populations experiment with a range of illicit drugs that modify and enhance their sex lives in the context of broader processes of the pharmaceuticalisation of sexuality.

METHODS

Drawing on two empirical studies comprising a virtual ethnography and 45 interviews with participants across a range of gender and sexual identities who regularly combine sex and drugs, this article contributes to the growing body of research that attends to the materiality of drug consumption practices in relation to the historical and social contexts from which they emerge.

RESULTS

Our participants reported variegated and complex modes of enhancement in relation to a wide range of psychoactive substances. Participants described enhanced emotional connectedness, bodily sensations, disinhibition and desire, but they also discussed how sex enhances drug experiences. As important but currently neglected in research literature were the therapeutic dimensions of drug-taking reported, which cannot be neatly distinguished from purely hedonic motivations. While enhancement was also experienced by participants in more challenging ways in relation to shame, regret, risk and/or harm, these experiences simultaneously afforded space for the emergence of innovative practices of risk-management, safety and care.

CONCLUSION

This study exposes the diversity of practices and meanings sex-related drug use hold for participants, but also demonstrates the paucity of biomedical conceptions of sexual enhancement limited to stamina, function and libido, and the need for a more expansive approach. The study also raises questions about the extent to which contemporary discourses of self-improvement have come to 'inhabit' sexuality in the twenty-first century, and the role drugs might play in this context. By shifting the gaze from pathology to enhancement and exploring the plurality of practice, we can better understand the motivations for engaging in sex-related drug use, thereby circumventing knee-jerk counterproductive enforcement and policy responses.

Pharmacosex: Reimagining sex, drugs and enhancement

BACKGROUND

The use of drugs in sexual contexts is receiving closer attention in the media, public health bodies and communities than ever before. However, research to date is most often concerned with the sex-related drug use of lesbian, gay, bisexual, transgender and queer (LGBTQ) populations, and particularly men who have sex with men (MSM) engaging in 'chemsex'. Against a backdrop dominated by public health and medical science perspectives, this article seeks to move beyond prevailing sex on drug discourses characterised by risk and harm, or pleasure. Drawing on an expansive notion of enhancement, we explore intersections between drug consumption and sex via the concept of 'pharmacosex': the ways in which wider populations experiment with a range of illicit drugs that modify and enhance their sex lives in the context of broader processes of the pharmaceuticalisation of sexuality.

METHODS

Drawing on two empirical studies comprising a virtual ethnography and 45 interviews with participants across a range of gender and sexual identities who regularly combine sex and drugs, this article contributes to the growing body of research that attends to the materiality of drug consumption practices in relation to the historical and social contexts from which they emerge.

RESULTS

Our participants reported variegated and complex modes of enhancement in relation to a wide range of psychoactive substances. Participants described enhanced emotional connectedness, bodily sensations, disinhibition and desire, but they also discussed how sex enhances drug experiences. As important but currently neglected in research literature were the therapeutic dimensions of drug-taking reported, which cannot be neatly distinguished from purely hedonic motivations. While enhancement was also experienced by participants in more challenging ways in relation to shame, regret, risk and/or harm, these experiences simultaneously afforded space for the emergence of innovative practices of risk-management, safety and care.

CONCLUSION

This study exposes the diversity of practices and meanings sex-related drug use hold for participants, but also demonstrates the paucity of biomedical conceptions of sexual enhancement limited to stamina, function and libido, and the need for a more expansive approach. The study also raises questions about the extent to which contemporary discourses of self-improvement have come to 'inhabit' sexuality in the twenty-first century, and the role drugs might play in this context. By shifting the gaze from pathology to enhancement and exploring the plurality of practice, we can better understand the motivations for engaging in sex-related drug use, thereby circumventing knee-jerk counterproductive enforcement and policy responses.

"Go Ask Alice": The Case for Researching Schedule I Drugs

The available treatments for disorders affecting large segments of the population are often costly, complex, and only marginally effective, and many have numerous side effects. These disorders include dementias, debilitating neurological disorders, the multiple types of drug addiction, and the spectrum of mental health disorders.Preliminary studies have shown that a variety of psychedelic and similar U.S. Drug Enforcement Administration Schedule I drugs may offer better treatment options than those that currently exist and pose potentially the same or even less risk than do legal psychoactive (alcohol, caffeine, nicotine) and nonpsychoactive (aspirin, acetaminophen, ibuprofen) substances. The pharmaceutical industry and academia, however, have largely avoided this avenue of research.Fairness to the affected populations demands that these drugs be adequately studied and, if they or their congeners are shown to be effective, made available with the proper caveats, instructions, and protections that other potentially abused medications (e.g., narcotics) receive. These substances may prove to relieve patients' struggles with less effective treatments and decrease mortality from nontreatment of some conditions.

Psychedelic Moral Enhancement

The moral enhancement (or bioenhancement) debate seems stuck in a dilemma. On the one hand, the more radical proposals, while certainly novel and interesting, seem unlikely to be feasible in practice, or if technically feasible then most likely imprudent. But on the other hand, the more sensible proposals – sensible in the sense of being both practically achievable and more plausibly ethically justifiable – can be rather hard to distinguish from both traditional forms of moral enhancement, such as non-drug-mediated social or moral education, and non-moral forms of bioenhancement, such as smart-drug style cognitive enhancement. In this essay, I argue that bioethicists have paid insufficient attention to an alternative form of moral bioenhancement – or at least a likely candidate – that falls somewhere between these two extremes, namely the (appropriately qualified) use of certain psychedelic drugs.

Serotonergic neurotransmission in emotional processing: New evidence from long-term recreational poly-drug ecstasy use

The brain's serotonergic system plays a crucial role in the processing of emotional stimuli, and several studies have shown that a reduced serotonergic neurotransmission is associated with an increase in amygdala activity during emotional face processing. Prolonged recreational use of ecstasy (3,4-methylene-dioxymethamphetamine [MDMA]) induces alterations in serotonergic neurotransmission that are comparable to those observed in a depleted state. In this functional magnetic resonance imaging (fMRI) study, we investigated the responsiveness of the amygdala to emotional face stimuli in recreational ecstasy users as a model of long-term serotonin depletion. Fourteen ecstasy users and 12 non-using controls underwent fMRI to measure the regional neural activity elicited in the amygdala by male or female faces expressing anger, disgust, fear, sadness, or no emotion. During fMRI, participants made a sex judgement on each face stimulus. Positron emission tomography with ¹¹C-DASB was additionally performed to assess serotonin transporter (SERT) binding in the brain. In the ecstasy users, SERT binding correlated negatively with amygdala activity, and accumulated lifetime intake of ecstasy tablets was associated with an increase in amygdala activity during angry face processing. Conversely, time since the last ecstasy intake was associated with a trend toward a decrease in amygdala activity during angry and sad face processing. These results indicate that the effects of long-term serotonin depletion resulting from ecstasy use are dose-dependent, affecting the functional neural basis of emotional face processing.

An Ethical Exploration of Barriers to Research on Controlled Drugs

We examine the ethical, social, and regulatory barriers that may hinder research on therapeutic potential of certain controversial controlled substances like marijuana, heroin, or ketamine. Hazards for individuals and society and potential adverse effects on communities may be good reasons for limiting access and justify careful monitoring of these substances. Overly strict regulations, fear of legal consequences, stigma associated with abuse and populations using illicit drugs, and lack of funding may, however, limit research on their considerable therapeutic potential. We review the surprisingly sparse literature and address the particular ethical concerns pertinent to research with illicit and addictive substances, such as undue inducement, informed consent, therapeutic misconception, and risk to participants, researchers, and institutions. We consider the perspectives of key research stakeholders and explore whether they may be infected with bias. We conclude by proposing an empirical research agenda to provide an evidentiary basis for ethical reasoning.

Underground MDMA-, LSD- and 2-CB-assisted individual and group psychotherapy in Zurich: Outcomes, implications and commentary

Underground psychedelic-assisted psychotherapy has persisted in Europe despite the banning of the substances LSD and MDMA in the 1960s and 1980s, respectively. This article describes the work of a Zurich-based psychotherapist providing individual and group psycholytic psychotherapy, whose practice persisted for several years before she was arrested in 2009. The article provides commentary on the psychopharmacological, moral, ethical and legal issues of this case and discusses these issues in the context of the growing medical research of psychedelic substances as mainstream treatments for psychiatry.

Hallucinogen use predicts reduced recidivism among substance-involved offenders under community corrections supervision

Hallucinogen-based interventions may benefit substance use populations, but contemporary data informing the impact of hallucinogens on addictive behavior are scarce. Given that many individuals in the criminal justice system engage in problematic patterns of substance use, hallucinogen treatments also may benefit criminal justice populations. However, the relationship between hallucinogen use and criminal recidivism is unknown. In this longitudinal study, we examined the relationship between naturalistic hallucinogen use and recidivism among individuals under community corrections supervision with a history of substance involvement (n=25,622). We found that hallucinogen use predicted a reduced likelihood of supervision failure (e.g. noncompliance with legal requirements including alcohol and other drug use) while controlling for an array of potential confounding factors (odds ratio (OR)=0.60 (0.46, 0.79)). Our results suggest that hallucinogens may promote alcohol and other drug abstinence and prosocial behavior in a population with high rates of recidivism.

Pharmacological enhancement of exposure-based treatment in PTSD: a qualitative review

There is a good amount of evidence that exposure therapy is an effective treatment for posttraumatic stress disorder (PTSD). Notwithstanding its efficacy, there is room for improvement, since a large proportion of patients does not benefit from treatment. Recently, an interesting new direction in the improvement of exposure therapy efficacy for PTSD emerged. Basic research found evidence of the pharmacological enhancement of the underlying learning and memory processes of exposure therapy. The current review aims to give an overview of clinical studies on pharmacological enhancement of exposure-based treatment for PTSD. The working mechanisms, efficacy studies in PTSD patients, and clinical utility of four different pharmacological enhancers will be discussed: d-cycloserine, MDMA, hydrocortisone, and propranolol.

Harms and benefits associated with psychoactive drugs: findings of an international survey of active drug users

There have been several recent efforts in the UK and the Netherlands to describe the harms of psychoactive substances based on ratings of either experts or drug users. This study aimed to assess the perceived benefits as well as harms of widely used recreational drugs, both licit and illicit, in an international sample of drug users. The survey was hosted at https://www.internationaldrugsurvey.org/ and was available in three languages. Residents reported their experience of 15 commonly used drugs or drug classes; regular users then rated their harms and benefits. In all, 5791 individuals from over 40 countries completed the survey, although the majority were from English speaking countries. Rankings of drugs differed across 10 categories of perceived benefits. Skunk and herbal cannabis were ranked consistently beneficial, whilst alcohol and tobacco fell below many classified drugs. There was no correlation at all between users' harm ranking of drugs and their classification in schedules of the USA or ABC system in the UK. Prescription analgesics, alcohol and tobacco were ranked within the top 10 most harmful drugs. These findings suggest that neither the UK nor US classification systems act to inform users of the harms of psychoactive substances. It is hoped the results might inform health professionals and educators of what are considered to be both the harms and benefits of psychoactive substances to young people.

A brief history of oxytocin and its role in modulating psychostimulant effects

Over the past century, the polypeptide oxytocin has played an important role in medicine with major highlights including the identification of its involvement in parturition and the milk let-down reflex. Oxytocin is now implicated in an extensive range of psychological phenomena including reward and memory processes and has been investigated as a treatment for several psychiatric disorders including addiction, anxiety, autism, and schizophrenia. In this review, we first provide an historical overview of oxytocin and describe key aspects of its physiological activity. We then outline some pharmacological limitations in this field of research before highlighting the role of oxytocin in a wide range of behavioral and neuronal processes. Finally, we review evidence for a modulatory role of oxytocin with regard to psychostimulant effects. Key findings suggest that oxytocin attenuates a broad number of cocaine and methamphetamine induced behaviors and associated neuronal activity in rodents. Evidence also outlines a role for oxytocin in the prosocial effects of 3,4-methylenedioxymethamphetamine (MDMA, Ecstasy) in both rodents and humans. Clinical trials should now investigate the effectiveness of oxytocin as a novel intervention for psychostimulant addiction and should aim to determine its specific role in the therapeutic properties of MDMA that are currently being investigated.

Sympathetic system modulation to treat post-traumatic stress disorder (PTSD): a review of clinical evidence and neurobiology

A review of clinical evidence and neurobiology on the effects of modulation of sympathetic system modulation to treat post-traumatic stress disorder (PTSD) is being presented . The review provides an overview of currently available treatments followed by efficacy of orally effective sympathetic blocking agents. The main focus of the review is the application of stellate ganglion blocks (SGBs) or a local anesthetic blockade of the sympathetic ganglion in the neck.

Targeting memory processes with drugs to prevent or cure PTSD

INTRODUCTION

Post-traumatic stress disorder (PTSD) is a chronic debilitating psychiatric disorder resulting from exposure to a severe traumatic stressor and an area of great unmet medical need. Advances in pharmacological treatments beyond the currently approved SSRIs are needed.

AREAS COVERED

Background on PTSD, as well as the neurobiology of stress responding and fear conditioning, is provided. Clinical and preclinical data for investigational agents with diverse pharmacological mechanisms are summarized.

EXPERT OPINION

Advances in the understanding of stress biology and mechanisms of fear conditioning plasticity provide a rationale for treatment approaches that may reduce hyperarousal and dysfunctional aversive memories in PTSD. One challenge is to determine if these components are independent or reflect a common underlying neurobiological alteration. Numerous agents reviewed have potential for reducing PTSD core symptoms or targeted symptoms in chronic PTSD. Promising early data support drug approaches that seek to disrupt dysfunctional aversive memories by interfering with consolidation soon after trauma exposure, or in chronic PTSD, by blocking reconsolidation and/or enhancing extinction. Challenges remain for achieving selectivity when attempting to alter aversive memories. Targeting the underlying traumatic memory with a combination of pharmacological therapies applied with appropriate chronicity, and in combination with psychotherapy, is expected to substantially improve PTSD treatment.

Lost in translation: preclinical studies on 3,4-methylenedioxymethamphetamine provide information on mechanisms of action, but do not allow accurate prediction of adverse events in humans

3,4-Methylenedioxymethamphetamine (MDMA) induces both acute adverse effects and long-term neurotoxic loss of brain 5-HT neurones in laboratory animals. However, when choosing doses, most preclinical studies have paid little attention to the pharmacokinetics of the drug in humans or animals. The recreational use of MDMA and current clinical investigations of the drug for therapeutic purposes demand better translational pharmacology to allow accurate risk assessment of its ability to induce adverse events. Recent pharmacokinetic studies on MDMA in animals and humans are reviewed and indicate that the risks following MDMA ingestion should be re-evaluated. Acute behavioural and body temperature changes result from rapid MDMA-induced monoamine release, whereas long-term neurotoxicity is primarily caused by metabolites of the drug. Therefore acute physiological changes in humans are fairly accurately mimicked in animals by appropriate dosing, although allometric dosing calculations have little value. Long-term changes require MDMA to be metabolized in a similar manner in experimental animals and humans. However, the rate of metabolism of MDMA and its major metabolites is slower in humans than rats or monkeys, potentially allowing endogenous neuroprotective mechanisms to function in a species specific manner. Furthermore acute hyperthermia in humans probably limits the chance of recreational users ingesting sufficient MDMA to produce neurotoxicity, unlike in the rat. MDMA also inhibits the major enzyme responsible for its metabolism in humans thereby also assisting in preventing neurotoxicity. These observations question whether MDMA alone produces long-term 5-HT neurotoxicity in human brain, although when taken in combination with other recreational drugs it may induce neurotoxicity.

Neuroethics: the ethical, legal, and societal impact of neuroscience

Advances in cognitive, affective, and social neuroscience raise a host of new questions concerning the ways in which neuroscience can and should be used. These advances also challenge our intuitions about the nature of humans as moral and spiritual beings. Neuroethics is the new field that grapples with these issues. The present article surveys a number of applications of neuroscience to such diverse arenas as marketing, criminal justice, the military, and worker productivity. The ethical, legal, and societal effects of these applications are discussed. Less practical, but perhaps ultimately more consequential, is the impact of neuroscience on our worldview and our understanding of the human person.

The role of MDMA (Ecstasy) in coping with negative life situations among urban young adults

This article examines the role of Ecstasy (MDMA or 3, 4-methylenedioxymethamphetamine) as a drug used for self-medication and coping with both short- and long-term negative life situations. We show that urban youth who do not have a specific diagnosed mental illness are more likely than those who have been diagnosed and have received treatment to use Ecstasy to cope with both situational stress and lifetime trauma. Diagnosed and treated youth sometimes self-medicate with other drugs, but do not choose Ecstasy for mediation of their psychological stress. We discuss the implications of self-medication with Ecstasy for mental health services to urban youth experiencing mental health disparities, and for the continued testing and prescription of MDMA for therapeutic use in controlled clinical settings.

Ethanol co-administration moderates 3,4-methylenedioxymethamphetamine effects on human physiology

Alcohol is frequently used in combination with 3,4-methylenedioxymethamphetamine (MDMA). Both drugs affect cardiovascular function, hydration and temperature regulation, but may have partly opposing effects. The present study aims to assess the acute physiologic effects of (co-) administration of MDMA and ethanol over time. A four-way, double blind, randomized, crossover, placebo-controlled study in 16 healthy volunteers (9 male and 7 female) between the ages of 18 and 29. MDMA (100 mg) was given orally and blood ethanol concentration was maintained at pseudo-steady state levels of 0.6 per thousand by a three-hour 10% intravenous ethanol clamp. Cardiovascular function, temperature and hydration measures were recorded throughout the study days. Ethanol did not significantly affect physiologic function, with the exception of a short lasting increase in heart rate. MDMA potently increased heart rate and blood pressure and induced fluid retention as well as an increase in temperature. Co-administration of ethanol with MDMA did not affect cardiovascular function compared to the MDMA alone condition, but attenuated the effects of MDMA on fluid retention and showed a trend for attenuation of MDMA-induced temperature increase. In conclusion, co-administration of ethanol and MDMA did not exacerbate physiologic effects compared to all other drug conditions, and moderated some effects of MDMA alone.

Neuropsychotherapy: conceptual, empirical and neuroethical issues

In this article we suggest a working definition for the concept of "neuropsychotherapy" encompassing three areas: the identification of mediators and targets of psychotherapeutic effects, the determination of new therapeutic routes using neurotechnology, and the design of psychotherapeutic interventions based on neuroscientific knowledge. We review neuroimaging studies of the psychotherapy of depression and discuss some of the methodological limitations inherent in functional Magnetic Resonance Imaging (fMRI) and common fallacies perpetrated in interpreting fMRI studies. Finally, we discuss some neuroethical issues related to this new and active field of research. In sum, we argue that neuroscience harbors great potential and add-on value for improving psychotherapeutic practice and research if applied properly.

Increased oxytocin concentrations and prosocial feelings in humans after ecstasy (3,4-methylenedioxymethamphetamine) administration

MDMA (3,4-methylenedioxymethamphetamine or "ecstasy") is a recreationally used drug with remarkable and characteristic prosocial effects. In spite of abundant attention in the scientific literature, the mechanism of its prosocial effects has not been elucidated in humans. Recently, research in animals has suggested that the neuropeptide oxytocin may induce these effects. In a double blind, randomized, crossover, and placebo-controlled study in 15 healthy volunteers we assessed blood oxytocin and MDMA concentrations and subjective prosocial effects after oral administration of 100 mg MDMA or placebo. MDMA induced a robust increase of blood oxytocin concentrations and an increase of subjective prosocial feelings. Within subjects, the variations in these feelings were significantly and positively correlated with variation in oxytocin levels, and the correlations between these feelings and oxytocin were significantly stronger than those between these feelings and blood MDMA levels. MDMA induces oxytocin release in humans, which may be involved in the characteristic prosocial effects of ecstasy.

Ecstasy and other club drugs: a review of recent epidemiologic studies

PURPOSE OF REVIEW

This review highlights the epidemiologic research on club drug use in the past year, with a focus on clinical epidemiology, social epidemiology, new methodological approaches, and alternative explanations for drug use behaviors.

RECENT FINDINGS

Although 3,4-methylenedioxy-N-methylamphetamine (MDMA) or ecstasy is currently classified as a type of hallucinogen and its withdrawal is not recognized in the Diagnostic and Statistical Manual of Mental Disorders, there is evidence for the association of withdrawal symptoms with MDMA abstinence. Findings from latent class analysis indicate that MDMA users have a significantly higher risk of dependence than lysergic acid diethylamide users. Research on sociodemographic factors associated with club drug use continues to be a main focus worldwide. New epidemiologic research methods have been developed to enable researchers to monitor real-time drug use behaviors and to conduct surveys on sensitive issues in public places. In addition to traditional behavioral models, researchers began to examine the club drug phenomenon in the context of economic environment.

SUMMARY

Recent findings on MDMA use further question the current drug classification in the diagnostic systems. Despite the continuous growth in the club drug research literature, there is no study on the influence of genetic factors on club drug use. More research in this area is needed.

The dark side of ecstasy: neuropsychiatric symptoms after exposure to 3,4-methylenedioxymethamphetamine

3,4-Methylenedioxymethamphetamine (MDMA, ecstasy) is a known neurotoxin in animals. This review discusses the history, pattern of use, pharmacology, acute and long-term effects of MDMA. Emphasis is given to the concern that MDMA may induce long-term cognitive and psychiatric effects. MDMA is an illegal substance, and investigations of the effects of exposure in human beings have limitations and weaknesses. There are numerous studies suggesting a correlation between MDMA exposure and psychopathology, and that the psychotropic effects may be long-lasting or permanent. However, it is not possible to conclude that there is a causal relationship between exposure and the increased psychopathology observed in MDMA users. Longitudinal studies are needed to assess whether MDMA causes persistent cognitive impairment and/or psychiatric symptoms in human beings.

Neuropsychiatric Effects of Prescription Drug Abuse

Prescription drugs have become a major category of abused substances, and there is evidence that the prevalence of prescription drug abuse may soon overtake that of illicit drugs. Study of prescription drugs has been hampered by vague terminology, since prescription drugs are only separated from other drugs of abuse by social and legal constructs. Reviewed herein is published literature on the abuse of four major categories of abused prescription drugs: sedative-hypnotics, stimulants, anabolic steroids, and anticholinergics. The review emphasizes evidence regarding the effects of these drugs on neural systems. Other abused prescription drugs that fall outside of the major categories are also briefly addressed.