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Norman Swan: So let’s get to this story of the party drug and whether it could help an incredibly disabling psychological disorder. Joel Werner investigated.
Donna Kilgore: It’s a feeling that you’re in a movie and you’re completely detached from yourself, things around you aren’t real to the point where I start touching things to make sure they’re really there. I had migraines, I was passing out, all kinds of physical problems, not sleeping, I was having nightmares. The nightmares that I had would be in situations where I had no control, where I was helpless, where I was going to die and I had a deep rooted fear of death. Or I started having panic attacks and anxiety attacks and when I say anxiety attacks I mean I could be driving down the road and such a feeling of impending doom would come over me that I would have to pull over and I’m looking at the sky for something that is going to fall on my car. I mean it’s horror, it’s overwhelming.
Joel Werner: That was Donna Kilgore describing her life as a person living with post-traumatic stress disorder or PTSD, a disorder that affects around 200,000 Australians each year. Sandy McFarlane, a professor of psychiatry at the University of Adelaide, described the debilitating effect that PTSD has on people’s lives.
Sandy McFarlane: This is a disorder that’s often experienced by people who’ve been exposed to horrific events. We’re talking about war, or victims of crime, or people who have been involved in major disasters. And the event is imprinted in their mind in a way which brings back the distress and extremely vivid sensory memories of what they’ve been through, often in response to triggers.
A second part about it is those sorts of memories drive anxiety and fear, so people have difficulty sleeping, they startle more, they are very vigilant about their environment and then obviously people have got to try and contain that distress. So another dimension of the difficulties where they try and avoid reminders and also become quite shut off emotionally because often they are in this sort of state of high arousal and the secondary mechanisms try and sort of shut off their reactivity, but that of itself becomes a problem because they become withdrawn and emotionally numb.
Joel Werner: The good news is that about two thirds of those who suffer the disorder will respond well to treatment, which usually comes in the forms of talking therapies such as cognitive behaviour therapy or CBT, where thoughts are readjusted as the person is gently re-exposed to the cause of their trauma, or drug therapies, which are more controversial. But for a lot of people with PTSD the fear of re-experiencing the traumatic event prevents them from even attempting therapy in the first place. Sandy McFarlane.
Sandy McFarlane: About a third of people offered cognitive behaviour therapy won’t want to do the treatment because it requires them to talk about the trauma; it requires them to confront reminders. So these psychotherapies, whilst they are effective there is a significant percentage of people who really can’t participate because of the distress they cause. In terms of the drugs we’re really here talking about the classic SSRIs, the typical antidepressants. One of the problems is that no pharmacological agent has actually had a primary indication for PTSD and really these are drugs that have been brought on the market for other reasons and then get trialled in PTSD so that there really is a great need for improved treatments in this field.
Joel Werner: Which brings us to this trial of a drug of abuse, a party drug, one that you might have even tried yourself: ecstasy. In the lab it goes by the name 3,4-Methylenedioxymethamphetamine, or MDMA, but on the street the so-called ‘love drug’ is renowned for producing feelings of empathy and openness in users. And it’s this aspect of the drug’s effect on the brain that led Dr Michael Mithoefer to trial it in the treatment of PTSD.
Michael Mithoefer: The rationale is that because MDMA has been reported to decrease fear and defensiveness and increase a sense of trust it made sense that this might be helpful for people with post-traumatic stress disorder, particularly those who didn’t respond to existing treatment.
Joel Werner: MDMA has been around for a long time but it wasn’t until the late 1960s that people became aware of the unique effect that it has on the human brain. By the late 1970s a bunch of North American therapists had started to experiment with it in marriage counselling but by 1985 the drug had been scheduled as a controlled substance in the US and it would be a quarter of a century before the US Food and Drug Administration, or FDA, gave approval to Mithoefer and his colleagues to run trials of MDMA. Michael Mithoefer.
Michael Mithoefer: It’s not just suppressing symptoms directly but more that it’s helping catalyse a therapeutic experience that gets at the PTSD itself. We set out to study that in a systematic way comparing MDMA to placebo and this was not a take home dose, this was not something that people took every day or even frequently, it was something that was administered two or three times a month apart under direct supervision. People would spend a day with male and female co-therapists, myself and my wife in this case while the MDMA effect lasted then they’d spend the night in the clinic with a nurse and very careful supervision and then a lot of close follow up to help them integrate the experience afterwards. They had that with MDMA or the same therapy with placebo.
Donna Kilgore: We didn’t know of course who was given placebo and who wasn’t, so I’d pick the pill and within ten minutes I told Dr Mithoefer that I didn’t get the placebo, I started feeling really funny� not funny, funny ha ha but really strange, comforted, I felt safe. The place that I was at mentally, if you can imagine standing on a mountain top and looking down in a valley that’s covered with fog and you know that you have to go through that valley to get to the other side, but you don’t know what’s in that fog but you know you’re going to die if you go there, what this MDMA did for me was lift the fog. And I could look down in the valley and I could see, it was like OK there’s anger, there’s fear, there’s a lack of control, I was able to label all of these things which were down in this fog that I would not have been able to access without that treatment. I was able to reach places that I had so closed off inside of me because of the hurt and the shame and the guilt — all that was down in that valley, but consciously I did not know that. It wasn’t like I could just say to somebody oh I have a lot of guilt over the fact that I was raped, or that I have a lot of shame. I didn’t know that consciously, sub consciously it was destroying my life. MDMA gave me the ability to see all these emotions without the fear.
Joel Werner: By the end of the trial these brief in-therapy encounters with MDMA had a positive effect. Both MDMA and placebo groups significantly reduced their levels of PTSD. The MDMA group was even better off compared to their sugar pill counterparts. And these improvements were
maintained over time. At both a two months and a three year follow up these patients who previously hadn’t responded to any traditional treatment, maintained significantly lower PTSD levels.
But before you get too excited this study was far from perfect. MDMA is a powerful drug, it’s hard to mistake being under its influence. As you just heard from Donna Kilgore it was obvious to both patients and therapists who was on the drug and who was on placebo. And although the psychologist who rated the levels of PTSD before and after therapy remained unaware of who had taken what, the results aren’t conclusive; the best you can say of these findings is that they look promising.
Make no mistake this research is controversial. In Australia and indeed most part of the world ecstasy is a controlled substance often linked to harm. But there’s a big difference between the street and the lab; what’s sold as ecstasy is often at best only 20% pure MDMA. Sandy McFarlane thinks that we need to look beyond our illicit drug taboo if evidence from clinical trials suggests that certain chemical compounds show a promise that stretches beyond the cheap high.
Sandy McFarlane: The controversy around drugs like this is the potential for abuse and the misuse of them in the broader community. But I think that’s not a reason to shy away from them, I think if there’s good evidence we should look at their use. I mean there’s some very interesting data showing that you know the most probable drug of abuse in PTSD are the stimulants like amphetamines and I think we need to recognise that people with psychiatric disorders abuse drugs often because they do make them feel better.
Now that then presents I think a pharmacological challenge about how can we find medications that target those particular neural mechanisms but without the risk of abuse.
Joel Werner: I asked Michael Mithoefer if there was any indication from his trial that participating in the study had encouraged participants to experiment with ecstasy outside of therapy.
Michael Mithoefer: Well we tracked that in a long term follow-up and what we found was that one person had tried MDMA outside the study and she did it once with a friend to try to replicate the therapeutic setting and she said it wasn’t satisfactory and she wouldn’t do it again. But what the other people told us is they tended to think of it as something that was used in this medical setting, some people did say they thought it would be beneficial if they were allowed to have another session in the same setting in six months or a year but we didn’t see a tendency for certainly most people to want to use it outside the study. I think two people said, at least two people said things like I don’t know why they call this ecstasy because it wasn’t just that people felt great and problem solved, the MDMA helped helping people feel they were not going to overwhelmed by anxiety of fear, it also helps really to connect with emotions. So people had some very frightening and difficult experiences and needed good support and though it was helpful it was not a day of ecstasy.
Norman Swan: Michael Mithoefer was talking to Joel Werner who’s joining us on the Health Report team.
Mithoefer MC et al.The safety and efficacy of 3,4-methylenedioxymethamphetamine assisted psychotherapy in subjects with chronic, treatment-resistant posttraumatic stress disorder: the first randomized controlled pilot study. Journal of Psychopharmacology. DOI: 10.1177/0269881110378371
Reporter Joel Werner finds out about the role the drug ecstasy might play in easing the torment of those suffering from post-traumatic stress disorder (PTSD). Warner interviews Michael Mithoefer, M.D. and his patient Donna Kilgore.