Addiction Policy Forum Blog

6 min read

How MDMA might help in therapy and treating PTSD

By Mark Gold, MD on January 9, 2020

In May, in a reflection on her religious upbringing, societal strictures, and individual spiritual development, The New Yorker’s Jia Tolentino wrote that she first tried ecstasy, or MDMA, in college:

“We swallowed pills that had been crushed into Kleenex, and then we slipped into a sweaty black box of a music venue down the street, and I felt weightless, like I’d come back around to a truth that I had first been taught in church: that anything could happen, and a sort of grace that was both within you and outside you would pull you through."

Some individuals who have used MDMA in non-scientific settings claim that it provides them with energy and reduces social inhibitions through mind-expanding spiritual uplift. It is the substance of choice at night parties, one of the major synthesized club drugs, and linked to accidents, dehydration, overheating, and dangerous behaviors.1 Recreational use is certainly not without its risks. 

But what’s the difference between the substance’s purported therapeutic function and its dangerous side? MDMA is ecstasy’s main ingredient, but individuals who use the substance recreationally are sometimes misinformed about levels of adulteration. It can also be harmful in street versions, which may mix or combine other substances with MDMA. MDMA is not perfectly unique in its effects on sociability and human connection — adages about “moderation” in use abound in part because some substances have both relaxing and stimulating properties that can make social engagements more convivial. Yet the substance is often misused, and can lead to substance use disorder (SUD). In a recent Stanford study, researchers note, “It is unknown, however, whether the mechanisms underlying [MDMA’s] prosocial therapeutic effects and abuse potential are distinct.”

Through controlled doses and experimental administration, MDMA is currently being studied for therapeutic benefits. Early reports by some researchers reviewing MDMA as one option for treating post-traumatic stress disorder (PTSD) have been most promising so far. Carefully observed and administered scientific settings dramatically reduce the likelihood of withdrawal, overdose, and diversion.2 This Stanford study tested mice to try to distinguish between MDMA’s beneficial and harmful effects.

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7 min read

What we have learned from stress and addiction research

By Mark Gold, MD on January 2, 2020

Experts and professionals have become increasingly aware of the health effects of trauma and stress. Trauma, sexual, physical, or emotional, can change the brain and increase risks for many psychiatric conditions and diseases. Adverse Childhood Experiences (ACEs), for example, which refer to traumatic events in the lives of people under the age of 18, can negatively affect the brain and lead to addiction, academic problems, heart disease, and depression. A recent study found that ACEs and lifetime adversity exposure were significantly associated with increased risk of substance-related hospitalization, overdose, witnessing overdose, and having a friend and family member who overdosed.1 Similar data have been reported recently for suicide.2 Discussing trauma and stress can be difficult and evoke feelings of depression or shame: they are heavily stigmatized, compounding many of these potential problems and sapping individual reserves of resilience. Science shows us that stress and adversity aren’t just generally irritating aspects of everyone’s lives. In severe forms, they’re also major threats to our health and ability to think clearly and logically.3 

Not all traumatic experiences cause Post-traumatic stress disorder (PTSD) or substance use disorder (SUD). Recent research findings from the Yale group suggest that trauma in the absence of a PTSD diagnosis does not lead to a stronger craving for alcohol. 4 Yet researchers know that the risk of developing mental illness rises because of psychosocial adversity. 5 “These adverse factors,” write the authors of one recent study, “include developmental psychological trauma and adult life events (situations or occurrences that bring about a negative change in personal circumstances and involve threat).” These factors can also increase the risk of developing SUD. Researchers are investigating how various therapies, including mindfulness, modify triggers and traumatic memories. 6 But experts have not clearly identified the ways in which stress and trauma dispose people to later problems. In this recent study, researchers wondered whether stress affects dopamine levels, impairing them over a longer term. They exposed participants to stress and gauged their reactions through state-of-the art PET scans.
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7 min read

Physician substance use disorders: contingency management encourages recovery?

By Mark Gold, MD on December 26, 2019

“Imagine if,” write the authors of a review in The New England Journal of Medicine, “the medical profession barred anyone being treated with pharmacotherapy for depression from returning to practice, insisting that only physicians who had achieved remission with cognitive behavioral therapy were fit to practice.” Why might readers imagine this? Physicians and nurses with opioid use disorder (OUD) are encouraged or required to participate in physician health programs, or PHPs, state-based treatment programs studied by experts like McLellan, Dupont, and Merlo, among others.1 These programs are often focused on abstinence and have defined 5-year outcomes, including fitness for duty and return to work. This New England Journal of Medicine article makes a case for lifting bans on medication-assisted treatment (MAT) in some PHPs and orienting the programs around structural health challenges faced by medical professionals. 

It is certainly true that PHPs have a history of successful recovery, return-to-work rates, and premorbid function outcomes for physicians who are monitored and active in such programs. But all physicians are not the same. Substance Use Disorders (SUDs) are not the same, either, and physician specialties have different risks.2 Before the public heard of fentanyl, for example, it was a dangerous substance for anesthesiologists.3 And health care professionals and business executives can become political footballs in the MAT vs non-MAT dichotomy. 

I like to frame this discussion around personalized medicine. We do not currently have tests or other predictors gauging which person with OUD will best recover at 5 years, and with which treatment. Some studies on PHPs suggest that health care professionals have the best 5-year return-to-work and premorbid function outcomes reported. This may be due to the generally late onset of SUDs in physicians. It could be that a given PHP works because of contingency management—follow the program and you can continue to be a physician. Contingency management is one of the most effective behavioral interventions for OUD and used much more frequently in PHPs than in non-PHP treatment settings. But few psychiatrists or addiction specialists understand the overall utility and efficacy.4 

We need more research to figure this out, but physician intervention, treatment, and recovery has been a model for successful 5-year outcomes and multidisciplinary treatment.5 Some programs are strictly oriented around a non-medication approach, but others are more flexible. Some programs have mandated MAT, like those requiring naltrexone for anesthesiologists6 returning to work, but others may prohibit MAT. Merlo has reported on outcomes and on MAT utilization in this population. She found that “individuals with opioid use disorders managed by PHPs can achieve long-term abstinence from opioids, alcohol, and other drugs without opioid substitution therapy (OST ) through participation in abstinence-based psychosocial treatment with extended, intensive care management following discharge.”7

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7 min read

Alcohol use disorders are complex, but new research should improve practice

By Mark Gold, MD on November 14, 2019

 

Alcohol use disorders (AUDs) are one of the most common and least-treated health conditions in the world. Some AUDs decline in severity or even get better without treatment.1 AUDs often accompany depression, anxiety, fears and phobias, sleep disorders, liver problems, and other diseases. They may be caused by shared genes underlying other psychiatric conditions, especially depression.2 And while there’s a strong genetic component in many AUD cases, there are a host of contributing factors, from cultural and regulatory environments to psychological disposition to brain circuitry and anxiety, that can play important roles in the development of the condition—or, at least, that can play anything from a substantial role to a very limited one. It all depends. 

As any patient, involved health care practitioner, and/or expert would be quick to point out, AUD is a highly complicated condition, sometimes frustratingly so. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), 6.2 percent of adults over 18 in the U.S. have an AUD, including over 9 million men and 5 million women.3 These numbers can be difficult to gauge in part because of the condition’s complexity—if we had a blood test that a physician could perform or a throat culture that could be sent to the lab, it would establish a diagnosis to everyone’s satisfaction. AUD is the most prevalent substance use disorder in the world, and from a public health perspective, it’s important not to let the complexity of AUD get in the way of sound policies and treatment practices. A comprehensive seminar recently published in The Lancet offered an updated discussion of the state of research on AUD, covering diagnosis, treatment, epidemiology, risk factors, environmental issues, and other considerations, as a guide to what we’ve learned about the condition.

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2 min read

How to be 'On Your Side' for Employees

By Mark Powell on October 30, 2019

 

It’s a question Kathleen Herath hears a lot. As associate vice president of wellbeing and safety at Nationwide, colleagues and professionals often ask, “Why does your company have such a generous Substance Free Workplace program?” 

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3 min read

Turning a House Into a Home

By Mark Powell on October 30, 2019

 

It plays out over and over and over. A woman, desperate to overcome her addiction, is forced to endure a long wait before she can begin treatment. The situation is even worse for women who are homeless. 

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