Introduction
The entactogen MDMA overlaps with the chemical structure of methamphetamine and mescaline and has biological effects similar to epinephrine, dopamine, and serotonin.
It increases the release of monoamines through the reversal of transporter proteins and reuptake inhibition specifically serotonin and norepinephrine. Not only does it block reuptake of serotonin and norepinephrine it enhances the release as well and inhibits VMAT preventing the packaging of monoamines into vesicles making more available for release. It also modulates glucocorticoids through the HPA axis, decreases amygdala and hippocampal activity, increases oxytocin, and increase prefrontal cortex activity.
Medical Use
MDMA started out as a therapeutic agent to enhance blood clotting for surgical procedures and trauma. Turns out it does not work very well for that indication, who would have thought. It’s currently listed as a schedule I substance (defined as having no accepted medical use, high abuse potential, and lack of accepted safety).
It was later discovered to have “empathogenic effects” helping individuals who use the medication to feel more connected to their fellow human beings. After all isn’t that what we are all after? A deep connection to others and people who truly understand us. The original name for the drug was empathy, but that has changed over the years to molly and escstcy. Personally, I like names that describe what a drug does, and empathy or empath is just so much more marketable don’t you think?
Why PTSD is a Big Problem
With several recent wars in both Iraq and Afghanistan, America has a PTSD problem with many combat veterans returning home and requiring treatment. If you ever treated patients with PTSD than you know it’s difficult and the therapy can be intense. Many patients are unable to sit with the discomfort required to reconsolidate these memories. Having worked at the VA for one year I was surprised by the number of vets with non-combat related PTSD. Honestly, they the vast majority of my cases were people who had accidents while working or in training and subsequently developed PTSD.
The idea is we need methods to enhance the efficacy and speed of trauma focused psychotherapies. What better way to do that than with empathy a medication that enhances feelings of connection. The basic idea being the patient would be given MDMA and then undergo psychotherapy and by using the medication it can influence fear extinction and memory reconsolidation. There are many mechanisms at play including effects on dopamine, serotonin, BDNF, cortisol, and oxytocin.
The concept of using a psychedelic drug to enhance the effects of psychotherapy is not a new concept, and was done for years using LSD and other compounds. What is different now, is we are trying to put the scientific rigor behind the studies to prove that it works better than placebo, and to learn more about the mechanism of action.
I want to point out that the main benefit of all these psychedelic medications seems to be enhanced neuroplasticity and the ability to form new connections in critical neurocircuits much easier than would otherwise be possible.
Benefits of MDMA Assisted Psychotherapy
-Increase blood flow to the vmPFC decreasing activation of the amygdala largely responsible for the fear response
-Enhance the production of BDNF which improves the long-term potentiation and memory consolidation
-Elevate the stress hormone cortisol which interacts with glucocorticoid receptors in the hippocampus to improve memory
-Elevates the prosocial neuropeptide oxytocin which decreases activation of the amygdala and enhances connection with the therapist
-Increased levels of dopamine which can destabilize the old memories and help with reconsolidation of new ones
-Increased serotonin levels resulting in prosocial and positive affective states.
The goal of PTSD treatment is to prevent the patient from being held hostage by these memories. We want to destabilize the old memories, modify them, and reconsolidate the new memories. The trauma still occurred, but the patient no longer has the same fear reaction to the traumatic memories.
MDMA-Assisted Therapy proved to be highly effective in individuals with severe PTSD.
-In this study investigators gave patients with PTSD 120-180 mg of MDMA along with a trauma focused psychotherapy. There were significant rates of both response and remission compared to placebo.
-MDMA was well tolerated
-It was granted breakthrough status by the FDA
-This was a big deal in the news and media outlets
-It needs to be replicated to confirm the results
Potential Adverse Effects of MDMA
-Potential for abuse and diversion (probably no take homes)
-Possible hyperthermia or hyponatremia (more common in the recreational use environment than clinical)
-People often engage in prolonged physical activity in hot environments and do not consume enough water this results in dehydration and possible hyperthermia (think large dance party)
-In the opposite case the person overcompensates and overconsumes water diluting their blood and causing hyponatremia. Excess of anything can cause problems and water is no exception.
Blue Monday and Black Tuesday
-Use of MDMA can cause low mood, irritability, and fatigue. It can occur for days after recreational use.
-In the clinical setting, fatigue, anxiety, low mood, headaches, and nausea can occur in the week after treatment
