Last week, an essay in the Psychologist, a magazine published by the British Psychological Society, called into question the validity of recent research on the effects of Ecstasy. Its publication drew loud and immediate reaction from the British press, which printed stories under headlines like "Ecstasy Not Dangerous, Say Scientists." The study's authors demanded, and received, a retraction from at least one newspaper (the Guardian); but the question the researchers had hoped to raise -- whether MDMA may have medical benefits -- was lost in the din. And not for the first time, according to Dr. Charles Grob, a longtime researcher of MDMA and hallucinogenic drugs and one of the study's three authors.
Grob, the head of adolescent and child psychiatry at the Harbor-UCLA Medical Center in Southern California, is also the editor of a newly published collection of essays, "Hallucinogens: A Reader," which explores the social and psychological worth of such drugs. Speaking from his office, Grob spoke about the essay he coauthored, the current war on drugs, and the history of Ecstasy, which he believes has therapeutic benefit -- not to mention potential as a facilitator of peace in the Middle East.
How did you, and the other authors of the study, end up being described as Ecstasy advocates in the British and American press?
We never said it wasn't dangerous. Clearly, Ecstasy use in today's recreational drug scene is full of risks. There's no doubt about that, and the writer of the specific Guardian article, for example, never bothered to read our article and never bothered to talk to any of us. They just sensationalized without any facts behind them.
It looked like a horrible situation when those newspapers published their articles, but since then there have been corrections. I got ticked off when I saw the Guardian article. I think it looked like a horrible situation at first, but instead it has been an opportunity to get more accurate information about medical applications out there.
You do seem to advocate Ecstasy as a therapeutic tool. What are some of the drug's uses in that setting?
I don't like to use the term "Ecstasy" when I'm talking about medical applications. Ecstasy could be anything. It's a terrible, terrible term. And by the way, do you know how the name came about?
No. How?
By the late '70s, it was being used by underground therapists, mostly on the West Coast. By the early '80s, when the secret had gotten out, there was a small but growing recreational drug scene in Austin [Texas] and California, and an enterprising dealer decided there was money to be made. He decided to market it under its most salient feature.
The most salient feature of MDMA is actually empathy. Which is, of course, why it's so alluring to psychotherapists, because empathy between a patient and a therapist is one of the strongest positive predictive outcome measures you could have, right?
So here's this guy, he's trying to sell this drug, and it's not selling because people who buy drugs don't particularly care for or understand empathy. So he goes back to the drawing board and decides, "I need a better name, one that will grab people's attention." So that's how Ecstasy got its name.
How did you first become interested in MDMA as a potential therapeutic tool?
I had written some articles on hallucinogens, and I thought it was a shame that psychiatry had abandoned research in the area. I started hearing anecdotal accounts about MDMA, so I thought this might be a more accessible area to study.
Ecstasy didn't have the hype at that point, in the mid-'80s, that hallucinogens had, and it perhaps had some advantages over a drug like LSD, in that it was milder, easier to control, and facilitated introspection and articulating feelings. It appeared to be effective on people who were alexithymic -- you know what alexithymic means? It means "without words for feelings." [In "The Sopranos," Tony Soprano is diagnosed as alexithymic, among other things.]
In other words, people like men?
[Laughs.] Right -- engineers. People who just could not connect to the feeling states, who were just cut off from their emotional processes, seemed [under the influence of Ecstasy] suddenly able to access those states and put them into words. And it was thought to be very helpful for relationship therapies.
Were there long-term mental health benefits even after effects of the drug had worn off?
Yes, definitely. Depending on how it was used, and whether there was a skilled therapist on hand who knew how to work within this treatment model, the outcomes were reported to be very impressive.
Now the problem was that by the time these therapists got their act together and started to organize research protocols and tried to get approval, the media had got a hold of it, and it became a sensationalized issue. Kids also started to hear about it, and if anything, the DEA scheduling hearings in 1985, and all the publicity that went along with them, really piqued the interest of young people -- and the marketers of drugs to young people. The whole Ecstasy scene just took off: initially here, and then in Europe. And then it boomed in Europe and came back here, and then it started booming here.
How does this compare with the controversy surrounding the medical uses of marijuana?
Well, I think, as far as medical marijuana is concerned, the charge is that people who support medical marijuana would also support the legalization of marijuana for recreational or personal use. With MDMA, I look at it as a very valuable potential adjunctive treatment, but on the other hand, I would say that there are serious risks involved with recreational use. So I am very reluctant to advocate that this drug be used in a recreational drug scene. It's a problematic drug in how it's used, and people are overdoing it.
You once testified in a congressional hearing about the potential application of MDMA as a therapeutic medication for clinical conditions.
Yes, right, but particularly clinical conditions that are refractory or nonresponsive to conventional treatments. The groups that we thought would be most amenable [to MDMA] would include patients with severe chronic post-traumatic stress disorder who hadn't responded well to conventional treatment. Also people with addictive disorders. And also we were interested in working with a population of people with terminal cancer who had severe anxiety and depression and were not responding to conventional treatment for their anxiety or depression.
What have you seen that might indicate MDMA's medical potential?
Mostly what we're working on is anecdotal accounts by therapists who were able to work with the drug prior to its scheduling in the mid-'80s. They had some very intriguing accounts.
It's a very different model from conventional psychopharmacology. Conventional psychopharmacology talks about treating someone every day for weeks, for months, for years. This involves using the drug on only one or two or three occasions, separated over long periods of time, within the context of psychotherapy. This is a very different model, a model, I might add, that the pharmaceutical industry is not going to be real eager to support because there's not going to be much in the way of profit margin in developing a drug that might only have to be utilized on one occasion.
Do you feel as if the pharmaceutical industry has been unhelpful?
Well, we could speculate, but they certainly don't go out of their way to attack the model because it hasn't been much of a threat. It's been so out on the margins that for most people, when they hear about this, they are not even aware that at one point it was once perceived as a promising adjunct to psychiatric treatment. To most people, it's just a recreational drug that is out of control among young people.
What about those who would question your motives?
I'm not going to ignore risks! There are serious risks with recreational Ecstasy. But those risks are compounded by an illegal and illicitly produced drug being marketed in massive quantities and utilized in an adverse environment.
What are the dangers that you associate with Ecstasy?
Let's talk about how it's used today. There are a number of problems. First of all, there is rampant substitution going on. The reliability of the drug Ecstasy is very poor. Whereas 10 years ago you could be pretty sure that all Ecstasy was MDMA, today that is not the case at all. Things have changed radically. Surveys are indicating that often more than 50 percent of surveyed Ecstasy turned out to be drugs other than MDMA.
Some of these drug substitutes are relatively innocuous, like aspirin or caffeine. Some are moderately dangerous like methamphetamine, PCP, dextromethorphan. Some are potentially lethal like paramethoxyamphetamine, or PMA, and you really have no idea what you're getting. In fact, that's the strongest argument I can muster when I talk to young people about the dangers of the youth recreational drug scene. Drug substitution with Ecstasy is like no other drug that I've ever seen. You really have no idea what is in the pill. So right off the bat, that makes it very problematic.
Other issues have to do with the fact that you can get into trouble with drug interactions. Not only illicit drug interactions, but you can also have interactions with prescription medications that people take to treat medical conditions.
What about the aftereffects of taking Ecstasy -- suicide Tuesdays?
You have to distinguish between how it might be utilized within a strict treatment setting: hypothetically, since it's not happening legally. If you take MDMA in a treatment context, you're talking about taking it only one time, or perhaps twice over several months, all within the context of an ongoing psychotherapy.
You would also be taking it in a relaxed environment: You wouldn't be dancing in a hot, stuffy nightclub. You'd be lying or sitting comfortably. You'd be taking fluids. So the context is key. And you're also talking about a very modest dose and one time only. I think in situations like that you are far less likely to have a dysphoric reaction a couple days later.
However, when you're talking about recreational Ecstasy users, one issue is that they are often taking a lot of different drugs -- it's kind of a poly-drug-use scene. They often take high dosages. They're up all night, they're sleep deprived, they're nutritionally deprived, they're basically taking the drug in the most adverse environment you could possibly imagine: Hot, stuffy, crowded clubs, not replacing fluids, exercising all night. That will accentuate the likelihood of an adverse response.
The only environment I can think of that's worse would be taking it in a hot tub.
So you are saying that MDMA could be safe if regulated.
When I talk about safe, judicious use, I'm talking about an approved treatment context. I'm not at all talking about recreational use. If I could have my way, I would call for a moratorium on use of this drug at raves.
Why?
Because, number one, they've made it excruciatingly difficult to get a fair hearing on [Ecstasy's] potential treatment benefits. Number two: I think there's nothing wrong with people who are taking a lot of a drug often to take a break and reflect on their lives, and on whether this is having a positive or negative effect on them.
What do you think of laws that seek to penalize clubs where patrons are thought to be using Ecstasy?
It's certainly unwise. What are they doing? Identifying that chill-out rooms and water are evidence of felonious conduct on the part of the proprietor? All you're going to do is drive the phenomenon further underground, and you're going to make harm-reduction efforts even more difficult to implement than they already are. And you're going to get more severe adverse phenomena occurring among young people.
I mean, if we follow to the letter this "Just Say No" mandate, and then if the kid isn't wise enough to follow the "Just Say No" edict, are we saying he deserves whatever adverse effects he experiences?
I think the drug war has yielded catastrophic laws. The laws are compounding the problem because they do not allow for human nature.
How is your opinion looked at by the rest of the medical community?
Oh, it's hardly looked at all -- it's not even on the board. There's hardly a dialogue on this. Even with hallucinogens, the dialogue has eroded seriously over the last few decades. But the feedback I get when I write, when I give talks, and now that I've published a book, has generally been very positive.
I'm not out to be part of a raging controversy. I just think this is a very important issue that has gotten very little attention, with a tremendous misunderstanding. And I think the medical profession and the people we are supposed to be serving are being deprived of a potentially valuable treatment model. I'm not convinced that our conventional treatment models in psychiatry are ideal models.
Such as the psychopharmaceutical revolution?
[Laughs.] Yes, SSRIs for everybody. But think about the Middle East for a minute. I mean you couldn't do this with Ariel Sharon and Yasser Arafat because I'm sure they are in terrible medical shape, but what about taking their children, who are adults, and get them together and provide a sanctioned, medically facilitated MDMA session? Let them have a mutually emphathogenic experience, get in the shoes of the other, feel the pain and the suffering that the other has gone through, and then take a few steps toward feeling what a mutual understanding could be like?
And have you yourself ever taken Ecstasy?
My response to that sort of question is usually along the lines of "I'm damned if I have and I'm damned if I haven't." If I have, then my perspective would be discounted due to my own personal use bias, and if I haven't, it would be discounted because I would not truly understand the full range of experience the drug can induce.
So does that mean you're not answering the question?
[Chuckles.] Exactly.
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