Pharmaceutical Highs and Lows in the Eyes of the Law

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Ecstasy Tablets (photo from Wikimedia Commons)

 Julia: Hello, can you give us a brief description of your background? 

 Dr. Guo: I'm a resident doctor in the (confidential) hospital. I'm in the third year of my training. My specialty is psychiatry.

Julia: Today we're going to talk about the illegal drug MDMA from a psychiatric point of view. Some people call this pill MDMA; others call it ecstasy. Can you tell us the difference between these two names?

Dr. Guo: MDMA is the abbreviation of the chemical name, 3,4-methylenedioxy-N-methylamphetamine. Ecstasy is its street name. The earliest psychiatrists who used MDMA in psychotherapy nicknamed it "Adam" because it gives the user the feeling of returning to Eden... The name "ecstasy" took on later because it sounded more exciting. "X" and "E" became its abbreviation. In Taiwan it's called "Yi" (衣) (pronunciation similar to "clothes" in Chinese.)

Julia: According to my knowledge, this substance temporary transports you to an altered state of consciousness. Can you describe this condition?

Dr. Guo: In a normal situation, you usually perceive sound, light or touch as separate sensory elements. However, after taking E, one is transported into a state of "totality." Your senses are enhanced: auditory, visual, tactile; but the result of enhancement is a state of wholeness. Under that condition, you only sense things in their entirety; you are not able to separate one sensory element from another.

This is built on the premise that you are taking this substance alone, but if you are with another person, the effect is totally different. When you are with somebody, you might find that the boundaries and distance between you and that person begin to soften. But that's only an impression. If you actually take action and participate in conversation, you'd find your interaction to be surprisingly smooth. Communications often turn into brainstorms. Under that situation you can communicate your ideas more freely, and other's responses or questions will in turn inspire new ideas.

But although you might feel that such experiences enable you to let down your guard and soften your boundaries, after the effect declines, the boundaries will still be there, even if you are willing to tear them down.

Julia: But at least you are aware of such a possibility in human relationships.

Dr. Guo: Perhaps its potency is that it makes you become aware of the rigid boundaries you set for yourself, yet I believe to actually dissolve these boundaries, it requires some extra effort.

Julia: Okay, so from a medical perspective, why does MDMA let people attain such a status?

Dr. Guo: That's because MDMA causes the brain to release large amounts of serotonin. When the secretion of serotonin reaches a certain level, it causes serotonin syndrome, which is also a common side effect of anti-depressants. It causes physical tremors and hyperactivity. MDMA stimulates your motor nerves, which coincidentally makes it a great match with the rhythmic beats of electronic dance music. You may feel that your physical movements are in sync with the rhythm. That's why it's so popular in the dance music scene. It's related to the resonance that the sound creates in your body. Metaphorically speaking, you are vibrating on the same frequency with others, which leads us back to the de-territorialization we mentioned before: your body and soul become one with others.

Julia: Is that also why some people experience e-blues or "coming down" – the emotional state of depression that follows the decline of the effect – is that also caused by serotonin?

Dr. Guo: Yes, it's because of the exhaustion of serotonin.

Julia: I see. So it seems like MDMA is in many ways similar to standard psychiatric medicine. So why do you think MDMA is illegal?

Dr Guo: Politics.

Julia: You mean it's entirely due to politics? There's nothing to do with the substance itself?

Dr. Guo: Actually many researches currently reveal how like marijuana, the harmful effects of MDMA on the body are actually less than legal cigarettes and alcohol. So how come cigarettes and alcohol are legal while others are not? This points to other influences...

But when you speak of substances like heroin, sure it can lead to dependence, and can create a lot of damage too – some illegal substances do have that kind of potential. But on the other hand, if you speak of legal medicine such as Stilnox (a kind of sleeping pill) and Xanax (an anti-anxiety medicine), sure they are legal, but they can also easily lead to dependency and can cause damage to the human body. So I think the boundary tends to become a little bit hazy.

To determine whether a drug should be legal or not, whether it is harmful or not, is actually not that simple. It really depends. In my opinion, we should observe how this substance is used and how it affects the user's behavior and attitude.

For example, some people are more prone to anxiety and they need Xanax to relax, so they habitually take Xanax whenever they're anxious. But when they use MDMA, they may avoid using it on workdays and only use it on holidays in order to function properly. They can control these things, but they must take Xanax whenever they have anxiety, so in this sense they are even more addicted to Xanax.

Julia: Because ecstasy can often makes one exhausted after its effects cease. Xanax has less side effects, so one can choose to take Xanax daily but not Ecstasy.

Dr. Guo: True, but if you take Xanax everyday, it's still going to damage your memory. So in a sense Xanax is doing more harm to this person than Ecstasy, since Ecstasy is taken only every once in a while, while Xanax is taken everyday. In this sense, a legal drug like Xanax can do much more harm than an illegal drug like Ecstasy. So I really think it's a matter of degrees, there's no clear-cut distinction to this. Nothing's all good and nothing's all bad. A substance can lead to positive results on one person while causing harm on another. Nothing is absolute.

Julia: But don't you think a part of the legal determination is the degree of the high – the higher a drug gets you the more easily it gets banned?

Dr. Guo: But a lot of people get high on alcohol.

Julia: So you don't believe in such a distinction?

Dr. Guo: Perhaps we can look back to the context under which MDMA was banned. Around the beginning of the eighties, American psychotherapy societies were secretive about their use of MDMA in medical practice, but around 1984, MDMA began to circulate widely in America's recreational drug market. The press started honing in and Reagan's conservative Republican government took rigid actions, banning every type of drug that was used for medical purposes. Even though not much was known about the safety and medical benefits of the drug, the Drug Enforcement Administration (DEA) still decided to list MDMA as a Schedule I drug in 1985. Schedule I means that this substance is highly addictive, has no accepted medical use in treatment and is not safe to use even under medical supervision. That is to say, this drug does only harm and no good.

Of course, after a drug is placed in Schedule I, research on it becomes extremely difficult. According to knowledge accumulated through years of experience, the psychotherapy societies who practiced therapy with MDMA believed that it had high medical potential while causing less harm to the human body than most people think. They felt that it shouldn't be placed in Schedule I and called for a hearing, hoping that their reports upon the benefits could lower the level of control upon MDMA. After the hearing, the judge and juries all advised the DEA to lower MDMA to Schedule III in order to leave more space for the assessment of MDMA's medical properties. However, the DEA did not accept their advice and kept MDMA in Schedule I.

It wasn't until after years of research that the relative harmlessness of MDMA was proven and that clinical trials upon its medical benefits became possible. If MDMA was not placed under Schedule I in the first place, perhaps we could've assessed its safety and medical benefits much sooner. So I think this issue is actually highly related to politics and ideology.

Julia: But it must take a very long time to prove such a substance harmless or otherwise. Take the newly synthesized "legal high" drug bath salt for example; it was already circulating in the market before any assessment could be made, and it soon made its appearance in headlines as a dangerous drug that turns people into face-eaters. Perhaps it would be more cautious to set it as illegal before any more damage is done?

Dr. Guo: Well I guess this is a question of ideology; it depends on the attitude you take towards the situation. You can argue to ban this substance before any assessment is made, that's one point of view. The other stance would be to make sure that a substance is truly harmful before any legal actions are made. Of course there are also others who believe that whether one uses or abuses a substance or not is strictly a personal matter and the option of banning shouldn't even be considered.

A lot of this is a matter of balance. When you're using the law to inhibit something, that influence is enormous. Everyone must act according to this rule. So it is actually a pretty big deal that affects everyone, no matter whether they think of using it or not. The influence is full-scale.

Julia: So how does science decide whether a drug is harmful to a person or not?

Dr. Guo: They do experiments on animals. Usually before a drug is legally approved to be marketable, they must first determine whether this substance is harmful – that it is not harmful within a certain range. Only after the drug passes this step can scientists begin research upon its medical properties. It must be done this way. If it is proven to be harmful, there won't be any next step to test its practicality. For these tests of harmfulness we usually use experimental animals. There are already some animal modules for scientific research, that is if I want to test a specific drug, I first use it on rats and see what dosage causes what percent of rats to die, and from this dosage they get to calculate the equivalent dosage that may cause damage to the human body. Any drug that wants to apply for legal marketing must go through this process.

Julia: Did the research on MDMA go through such a process?

Guo: No. Because there wasn't enough data for such a process to even happen. They just went and banned it. The people who were against classifying MDMA as Schedule I possessed some research data; there wasn't much research upon the medical beneficiary of the drug, but there were some assessments upon the drug's harmfulness. That's also probably why the aforementioned judge felt that MDMA shouldn't be placed in Schedule I. Maybe he took a look at the data and didn't find any strong evidence that pointed towards definite harmfulness. So the judge advised the DEA to place it in Schedule III so that it could be researched for its medical use.

When they placed it as Schedule I, the report showed that their animal experiments involved direct injection of large quantities of MDMA into
rats' brains to prove that MDMA is harmful to the nerves of their brains. Yet some researchers object to this by pointing out that normally one does not inject MDMA; it is orally consumed and passes through through the liver. So the quantity actually consumed is definitely way less than the amount they injected in the rats' brains. That's way too much and it will definitely harm you. But these scientists just turned in this report and say "see? It's proven to be harmful," but actually it's really a matter of degree.

In other words, the legal process in which they classified this drug as Schedule I cannot be described as solid and exact. It hasn't been thoroughly scrutinized and analyzed. They just "wham" and banned it just like that, because it was the era of the War on Drugs. Speaking of which, it was Reagan's wife who chaired the "Just Say No" drug awareness campaign. So it was actually a heavily ideologicallyinfluenced decision.

Julia : So do you think medical psychiatry's attitude towards drugs is still influenced by the law? Are they willing to use illegal substancefor medical use now?

Dr. Guo: Well to talk about it, you must refer to the current research on MDMA. Actually in the mid seventies, doctors were using this substance for medical purposes. It's related to the feature of this drug – MDMA can create a strong sense of empathy – that's one feature. The other is that it lowers the defense mechanism of the user. The empathy effect is often applied in marriage counseling, in couples' therapy.

Julia: But doesn't that make you blurt out all the things that should be kept under the carpet? Perhaps after the effect recedes, one would hold grudge against another...

Dr. Guo: But that's the way to really solve problems, relationship is a mutual issue. Perhaps in the past you've done some wrong things, but you couldn't admit the damage you've done to other people. By taking this drug, you become more willing to listen to the other person and understand the consequences of your actions. That sort of empathy creates a chance to reflect upon one self. That's what improves your relationship.

So that's how MDMA's empathy-enhancing feature can be used in therapy. Its ability to lower self-defense, on the other hand, is practical in treating patients suffering from post-traumatic stress disorder (PTSD). The psychical defense mechanism of those who suffer from PTSD are activate in order to separate the consciousness from traumatic experiences or emotions, so that the subject will not have to face the painful emotions brought on by this trauma. However, the dissociative disorder that accompanies such a repression can destabilize the mental faculties, so that the PTSD patient still continues to suffer from his/her trauma, only in another way.

While one finds it difficult or impossible to articulate his/her own trauma in his/her current mental state, perhaps under the effect of MDMA and the guidance of another person, one could turn this trauma into words. It is only after your defense is lowered that talking about such things becomes possible, which enables you to face the impact of this trauma.

It is under these circumstances that they found out about the features of this drug and how it could be used in therapy. It has been proven to be helpful in the process of working-through, so basically a lot of people were using it. However, they knew that a lot of clubs were using it too, and under the social atmosphere at that time, it could easily be banned under political influences. So they were pretty secretive about this stuff. Due to the secretiveness, they couldn't clinically prove the medical benefits of this drug, so when it was going to get banned, they couldn't prove that it was actually beneficial.

So after the execution of this law, there was even less chance of studying this drug, but gradually they were able to prove that MDMA is less harmful than anyone imagined. So with these evidences they kept on designing rigorous research methods and applying for clinical trial and finally they've attained permission. So far research upon the benefits of MDMA in treating PTSD patients has been done in the United States and Switzerland. They recruited a couple of PTSD patients whose symptoms did not improve after taking anti-depressants such as Zoloft, and gave them small dosages of MDMA while going through psychotherapy.

They divided these people into two groups, one who has taken MDMA and one who hasn't. By the way, the experiment was double-blind, meaning that neither the researcher nor the researched subject knows who has taken MDMA or placebo. This is the most meticulous research method; that way there can be no placebo-effect to mess up the results. The results showed that patients who took MDMA during psychotherapy had an obvious improvement in terms of their symptoms compared to those who didn't. The American research has been completed and is already published in journals. The Swiss research, also completed and published, supports this conclusion to a certain degree. These conclusions are proven through the strictest standardized clinical trials.

Julia: To treat a patient with anti-depressant is to let him take the medication and wait for its effects, but I assume that the treatment with MDMA works differently?

Dr. Guo: Yes. MDMA is used during psychotherapy sessions. It isn't like treatment with anti-depressant, where you just prescribe the pills and wait for its effect. It is used as an adjuvant, as an assistant drug during psychotherapy. So you can say that psychotherapy plays the main role whereas MDMA is its assistant. It catalyzes the interaction and the process of working-through during therapy.

Julia: So is there any study on the relapse condition?

Dr. Guo: Well, nothing has been published yet. The American research has done a follow up study, which has already been accepted by journals, but is still waiting for publication. What they claim is that the follow up results upon these cases (usually a follow up research lasts for three years) shows that after three years, their improvement still continued to sustain. So this research has a statistical significance. It doesn't just last during the sessions.

Julia: I see. So aside from this, are there any other examples that use illegal substances for medical research?

Dr. Guo: In the 80's, an organization called MAPS (multidisciplinary association for psychedelic studies) was established. It is a non-profit organization – their research-funding comes entirely from donations. Aside from research on the combination of MDMA and psychotherapy for treatment on PTSD patients, they've also done research with marijuana and LSD. They use rigorous scientific methods to do experiments with illegal substances.

Let me see, there is currently research on using LSD to lessen the pain of patients with terminal cancer. They try to be as scientific as possible in hopes to prove that substances that are deemed as illegal can actually help mankind. They don't deny that these substances may cause damage, but they want to observe under structural, normalized conditions of treatment whether these substances are really as bad as they seem.

Julia: I see. Do you have anything else you want to communicate with the readers?

Dr. Guo: The discussion on MDMA in Taiwan is often centered upon its negative features, whether from the

Dr. Guo Jia-ying (郭家穎)

light of social commentary, law enforcement or ethical debate. We don't need to talk about that here, the media is always reporting on it. But sources that support MDMA are scarce. In literature we've only go the Chinese edition of Altered State: The Story of Ecstasy Culture and Acid House and Waiting for the Man: The Story of Drugs and Popular Music; as to pro-drug discourse, I know that Pots Weekly had some pro-drug columns that discussed the problem from the view of politics, sociology and substance abuse. There are also some academic papers on this issue, but there are extremely few discussions of this problem on a medical point of view.

According to my knowledge, there was a forum upon this issue following the publication of the Chinese edition of Altered States, probably in 2003. I believe Lung Ying-Tai (龍應台) was also there? She was still head of the Department of Cultural Affairs then. Wang Hao-wei (王浩威) was also there, he's a psychiatrist who is currently promoting psychotherapy and has published several psychotherapy books. There also another forum that invited a psychiatrist, but his opinions upon this issue were also general and reductive. These are the only two events on the internet that involved psychiatric professionals. So in Taiwan's medical field, there really hasn't been much public discussions upon this issue. I hope perhaps this time I can provide some new progress upon the medical knowledge of MDMA in the psychiatric field.

Last modified on Wednesday, 08 January 2014 17:34
Julia Chien (黑玲)

Julia Chien a.k.a 黑玲 is an English/Chinese editor and contributor in eRenlai magazine. She also makes electronic music and DJs under the name of Waywon 味王.

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