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Methylenedioxymethamphetamine Therapy Be Used to Treat Alcohol Use Disorder?

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Methylenedioxymethamphetamine Therapy Be Used to Treat Alcohol Use Disorder? Journal of Psychedelic Studies 1(1), pp. 1–9 (2017) DOI: 10.1556/2054.01.2016.003 First published online December 27, 2016 Can 3,4,-methylenedioxymethamphetamine therapy be used to treat alcohol use disorder? BEN SESSA* Imperial College London, London, England, UK (Received: September 2, 2016; revised manuscript received: November 28, 2016; accepted: December 3, 2016) Treating people with alcohol use disorder has been an important target area for psychedelic research – both in the first studies of the 1950s and during the Psychedelic Renaissance of the last 10 years. To date, most studies have looked at the classical psychedelic drugs as adjuncts to psychotherapy; with attention paid to the psychospiritual aspect of the experience as a central therapeutic process in effecting abstinence from drinking. Psychotherapy assisted with 3,4,-methylenedioxymethamphetamine (MDMA) has never been explored for treating alcohol use disorder. However, MDMA has some unique pharmacological characteristics – particularly its capacity for reducing the fear response and facilitating engagement in therapy around past psychological trauma – that could make it a useful candidate for tackling the core features of alcohol use disorder. This paper briefly describes the burden of alcohol use disorders and the history of psychedelic-assisted psychotherapy in the field of addictions. It gives the theoretical and experimental justification for MDMA-assisted psychotherapy for treating people with alcohol use disorder and introduces a forthcoming study from Bristol and London, UK, exploring the role for MDMA in treating a person with this challenging condition. Keywords: MDMA, alcohol use disorder, dependence, psychedelic, trauma, LSD INTRODUCTION primarily on post-traumatic stress disorder (PTSD). However, MDMA has never been explored as a tool to treat people with At the turn of the 20th Century, the personal, societal, and alcohol use disorder. It could be, however, that delivered in a clinical burden of alcohol misuse reached a historical peak safe setting, after thorough screening of suitable patients, (Wilson, 1940). There followed a move away from the careful scrutiny of physiological measures, and intensive moralistic “Inebriety Asylum” approach, with a reappraisal integrative follow-up, a course of MDMA-assisted therapy ’ of the problem using a medical-/disease-based model can assist a patient s capacity to access, explore, and resolve (Mann, Hermann, & Heinz, 2000). Since then we have seen ingrained negative beliefs about self and others that maintain a plethora of different treatment approaches from the reli- addictive behaviors. This can provide an important opportuni- gious to the pharmaceutical. Despite our current wide range ty for people with alcohol use disorder to maintain abstinence, of pharmacological and psychosocial treatments for patients reduce the harms associated with drinking, and achieve im- addicted to alcohol, the rates of relapse, a return to drinking proved psychosocial functioning associated with recovery. after detoxification, remain high (Miller, Walters, & Bennett, 2001). This perennial problem for medicine and THE CLINICAL, SOCIAL, AND FINANCIAL society deserves an innovative approach. People with alcohol use disorder are often stigmatized, BURDEN OF ALCOHOL DEPENDENCE maligned by society and blamed. However, many of these patients have experienced adverse psychosocial circum- Although drinking alcohol is a widely socially acceptable stances. Their trajectory into alcohol use disorder has often behavior and many people consume alcohol without resulted from childhood trauma into drug dependence that experiencing any problems, approximately 24% of the adult ties them to a lifestyle of emotional, psychosocial and population of England consume alcohol in a way that is financial dysfunction. Because of the complexity of etiology potentially or actually harmful (NICE, 2011). In the UK, the and the resulting psychological and physiological depen- prevalence of alcohol use disorder is about 4%; with 6% of dence that results, treating people with alcohol use disorders men and 2% of women. The disorder is characterized by can be very challenging (Sessa & Johnson, 2014). withdrawal symptoms on cessation of alcohol, or drinking to In the 1950s and 1960s, the treatment of people with avoid withdrawal symptoms, tolerance, and the persistent alcohol use disorder became an important priority for some of desire to continue drinking despite negative consequences the earliest psychedelic drug-assisted therapies with lysergic (American Psychiatric Association, 2013). Patients with acid diethylamide (LSD). And now, after a hiatus of almost half a century, this research is being revisited with a number * Corresponding author: Ben Sessa, BSc, MBBS, MRCPsych, of contemporary studies examining the medicines psilocybin, Consultant Addictions Psychiatrist and Senior Research Fellow; ketamine, ibogaine, and ayahuasca as potential treatments Department of Neuropsychopharmacology, Division of Brain for people with various drug dependence, all which are Sciences, Imperial College London, Burlington Danes Building, described later. To date, 3,4,-methylenedioxymethampheta- Du 160 Cane Road, W12 0NN; Phone: +44 (0)20 7594 7047; mine (MDMA)-assisted psychotherapy research has focused E-mail: [email protected] © 2016 The Author(s) Unauthenticated | Downloaded 09/28/21 07:46 PM UTC Sessa alcohol use disorder frequently have a past history of psycho- by 44% at 3 months and by 50% at 12 months. There were logical trauma and there is an association between alcohol use no significant differences in effectiveness between the disorder and PTSD (Brady, Back, & Coffey, 2004). Patients groups (UKATT Research Team, 2005). commonly present with high levels of depression, social Mindfulness techniques, originally derived from Vipas- anxiety, and social exclusion and use alcohol as a form of sana meditation, that encourage awareness and acceptance self-medication (McDevitt-Murphy, Murphy, Monahan, of moment-to-moment thoughts to interrupt responding to Flood, & Weathers, 2010). The impact of alcohol misuse is stress with alcohol, have also been increasingly explored as widespread, encompassing alcohol-related illness and injuries a potential approach for treating people with alcohol use and significant social impacts to family, friends, and wider disorder (Marcus & Zgierska, 2009). In terms of psychoso- community. In 2012, there were around 7,000 alcohol-related cial interventions, the best approaches are those that foster deaths in the UK and the Department of Health estimates that good relationships and are delivered by the most experi- alcohol misuse is now costing around £20 billion a year in enced, highly trained therapists. The Mesa Grande system- England alone (HM Government, 2012). atic review looked at 361 controlled studies of treatments for alcohol use disorder in 2002 and identified 46 possible interventions (Miller & Wilbourne, 2002). Interventions A BRIEF REVIEW OF THE CURRENT were ranked according to the rates of abstinence achieved. TREATMENTS FOR ALCOHOL DEPENDENCE The brief intervention approach ranked highest and MET, which is a counseling approach that helps individuals There are many different sorts of treatments for people with resolve their ambivalence about engaging in treatment and alcohol use disorder; with big overlaps between treatments stopping their drug use, ranked 2nd. The MET aims to evoke and large differences between patients’ presentations, severi- rapid and internally motivated change rather than guide the ty of disease, and multiple confounding psychosocial factors. patient stepwise through the recovery process. Pharmaco- Licensed pharmacological options for treating alcohol use therapy with acamprosate and the opiate antagonist, nal- disorders include acamprosate, disulfiram, naltrexone, and trexone ranked 3rd and 4th, respectively. The lowest ranked nalmefene. Acamprosate, a glutamate antagonist, reduces approaches were designed to educate, confront, shock, or N-methyl-D-aspartate activity associated with alcohol with- foster insight regarding the nature of alcoholism. From this drawal and reduces relapse rates (Rösner et al., 2010). systematic review, psychotherapy produced the best Disulfiram is used as an agent to deter relapse by preventing outcomes. the elimination of acetaldehyde. This results in an unpleasant However, the efficacy of current available treatments is physical reaction if alcohol is used in combination with this far from satisfactory, with long-term relapse rates up to 80% medication (Krampe et al., 2006). Naltrexone, a competitive (Finney, Moos, & Timko, 1999). opioid antagonist, which decreases cravings from alcohol (Soyka & Rösner, 2008). Nalmefene is opioid antagonist, A BRIEF HISTORY OF PSYCHEDELIC similar to naltrexone but with a longer half life and lower risk of toxicity than naltrexone. This can be given to patients while THERAPIES FOR ALCOHOL USE DISORDER still drinking alcohol in order to reduce cravings (Paille & AND OTHER ADDICTIONS Martini, 2014). Benzodiazepines are prescribed most com- monly as a time-limited course as part of alcohol detoxifica- There are cross-cultural examples of the naturalistic use of tion program (Lingford-hughes, Welch, Peters, & Nutt, 2012). psychedelic plants to treat people with alcohol use disorder. Several large systematic reviews and prospective studies These include the West African use of the iboga root (contain- have reviewed the efficacy of both medication and psycho-
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