MDMA

Introduction

While MDMA is currently on the fast track to legalization, only a handful of years ago, few would have imagined that such a thing could be possible.

For decades, media coverage suggested the non-classical psychedelic drug (most commonly known by the street names ecstasy or molly) was the cause of an epidemic of brain damage and seizures amongst young ravers, which created both fear and stigma.

As research on MDMA began opening up in the 2010s, more and more clinical trials and studies have made it clear that the compound may offer exciting potential benefits for mental health. Some evidence suggests that MDMA’s supposed neurotoxicity in humans may be overblown. In fact, recent neuroimaging studies have demonstrated that MDMA does not appear to cause long-term damage to the serotonin system. Today the growing consensus is that safe, regulated, legal MDMA will reduce harm and may be a valid treatment for conditions such as post-traumatic stress disorder (PTSD).⁽¹⁾

As psychotherapist Charley Wininger explained in Listening to Ecstasy: The Transformative Power of MDMA, “MDMA is a gateway drug. It swings open the gate to tactile, emotional, and spiritual exploration and opens the door to the heart.”

Dr. Wininger discusses how MDMA could be the key to a healthy relationship in this article on how the “love drug” just may save your relationship. In his article, Dr. Wininger speaks with a married couple who have been exploring the use of MDMA in conjunction with couples therapy to take back control of their relationship. Their experience and his findings showcase just how MDMA earned its title as the “love drug.”

The History of MDMA

The pharmaceutical company Merck first synthesized MDMA in 1912. In the late 1970s, Methylenedioxymethamphetamine (MDMA) became known in psychotherapeutic circles. Claudio Naranjo, a Chilean psychiatrist, became one of the most notable MDMA therapists in the United States. Around 1980, Ann Shulgin, the wife of chemist Alexander Shulgin (known as the “Godfather of ecstasy”), began to provide MDMA to patients during therapy. The earliest research into MDMA focused on the ways it could be used to enhance psychotherapy. It showed, and continues to show, promise for the treatment of PTSD, as a tool in couples therapy, and may even have some potential as a treatment for traumatic brain injuries.^{(2, 3, 4, 5, 6, 7, 8)}

In 1985 MDMA was criminalized, which forced experimentation and use underground. Around this time, and through the 1990s and early 2000s, it was primarily associated with the rave culture, which adopted the drug due to its capacity to enhance music appreciation and increase feelings of stimulation, intimacy, and euphoria. However, this medicine has now transcended the club scene and entered the realm of mental health treatments once again.

The MDMA Experience

MDMA is an entactogen/empathogen, meaning it increases feelings of empathy, compassion, affection, intimacy, and emotional openness. MDMA is often considered a non-classic psychedelic because it doesn’t produce many typical psychedelic effects, such as profound perceptual changes or mystical experiences. However, it can create dramatic shifts in emotional and thought patterns. As Allison A. Feduccia and Michael C. Mithoefer stated in a paper on MDMA-assisted therapy for PTSD:

The MDMA experience often helps individuals feel more empathy towards themselves and others, which is why the compound is useful for healing individual distress and interpersonal conflict.

The Efficacy of MDMA Therapy

Some studies suggest that MDMA-assisted psychotherapy can alleviate the symptoms of several hard-to-treat conditions. These include PTSD, alcohol use disorder (colloquially known as alcoholism and substance abuse), eating disorder symptoms, and social anxiety in autistic adults.^{(10, 11, 12, 13, 14)}

It is estimated that 3% to 27% of the U.S. population will have PTSD at some point in their lives, and about 33% of those are said to be treatment-resistant (which means the patient failed to respond to two or more treatments). Before MDMA’s classification as a Schedule I substance (a drug with a supposed high risk of abuse and no medical value), psychiatrists reported that it appeared to help by simultaneously reducing defensiveness and fear, while increasing relaxation and trust. These effects help patients confront their trauma(s), rather than avoid them, and open up more to their therapist.^{(15, 16, 17, 18)}

MDMA therapy seems to help where other treatments may fail because of its unique pharmacological effects. MDMA enhances empathy, trust, and cooperation, which is mediated through the release of serotonin, norepinephrine, and oxytocin. Traditional medications prescribed for PTSD, such as SSRI antidepressants, don’t produce these positive subjective effects. In fact, many patients who take SSRIs experience an “emotional blunting” effect: a dampening of both negative and positive emotions.^{(19, 20, 21. 22)}

Individuals who use MDMA (aka the “love drug”) often describe the experience as energetic, comforting, and euphoric. They are also more prone to expressing things they may ordinarily be afraid or embarrassed to discuss. MDMA can also make users feel more connected with the people they love and can increase feelings of intimacy and sensuality. In the context of couples counseling, it may help partners deal with trauma from outside of the relationship that is impacting them. An example would be if one partner had experienced sexual assault before the relationship and is having trouble being intimate as a result.

Is MDMA Legal?

In 2017, the FDA granted Breakthrough Therapy designation for MDMA-assisted therapy for PTSD based on the results of several clinical trials. A breakthrough therapy is a drug that can treat a serious or life-threatening condition alone, or in combination with one or more additional drugs. It also means that evidence suggests the medication may demonstrate substantial improvement over existing treatments.^{(23, 24, 25)}

Breakthrough therapy designation helps expedite drug development and review. Results from Phase III clinical trials (a study that tests a new drug’s safety and efficacy against an existing treatment option) on MDMA have already been published. The FDA requires a Phase III trial before approving a drug. 

For example, the Multidisciplinary Association for Psychedelic Studies (MAPS) just concluded its Phase III clinical trial utilizing MDMA to treat PTSD. The trial showed very statistically significant results, with 67% of participants no longer meeting the qualification for PTSD after three sessions compared with 32% in the placebo group. Additionally, 88% of the participants treated with MDMA experienced a clinically meaningful reduction in symptoms.⁽²⁶⁾

Based on this progress, MDMA therapy (for the treatment of PTSD) will likely soon be legal. The treatment is on track for FDA approval in 2023, at which point patients with the condition (not just those enrolled in clinical trials) will be able to legally access the treatment.⁽²⁷⁾

Accessing MDMA-Assisted Therapy

It is important to remember that MDMA is still undergoing clinical trials, and while the results so far are promising, it is still a controlled substance. However, underground MDMA therapy can be found in some places. This can be practically difficult and carry some safety risks if the therapists/guides are unscrupulous. There are many trustworthy and well-respected therapists, of course, and they may be able to facilitate your MDMA experience in an empathic and beneficial way, but they are not able to do so legally.

It is also possible to join a clinical trial, which you find using this database from Psychedelic.support. By joining one of these trials, you may be able to experience the unique setup of psychedelic therapy and play an important role in helping researchers better understand how the treatment works.⁽²⁸⁾

There are currently no legal retreats involving the use of MDMA. But should the compound be decriminalized or legalized in any cities or countries in the future, MDMA therapy retreats may then arise. For example, MDMA and psilocybin were recently legalized in Australia, with rule-making concluding in 2024. Once the appropriate regulations are in place, this new legal status could open the door for commercial MDMA retreats and treatment centers.⁽²⁹⁾

The Risks and Side Effects of MDMA

Many of the risks of MDMA are associated with recreational use. Some people take MDMA crystal/powder or ecstasy pills without testing the substance. The product may not be MDMA, but a more harmful drug or contain some MDMA and other impurities. 

People using MDMA in a recreational setting may also take high doses of the drug, redosing frequently during a single session. They may spend hours dancing while dehydrated in a hot, poorly ventilated environment. All these factors, in addition to taking MDMA regularly, may increase the risk of neurotoxicity (damage to the brain).⁽³⁰⁾

Research on the link between recreational MDMA use and neurotoxicity is mixed. Heavy MDMA use may damage serotonin receptors, negatively impacting memory, learning, and mood. However, some research has found that moderate MDMA use is unrelated to neurotoxicity.^{(30, 31, 32)}

MDMA therapy involves limited, moderate doses of a pure compound without the risk of overheating. During MDMA-assisted therapy, medical providers are on hand to monitor your session and provide support if you need it. 

Also, according to a 2021 study published in the Journal of Psychopharmacology, participants didn’t experience the notorious MDMA ‘comedown’ (negative effects on mood and cognition) when they took MDMA in a clinical context. Instead, the participants had the experience during the day, which ensured their sleep wasn’t affected. Dr. Ben Sessa, the study’s lead author, said this helps explain why there was no hangover.^{(33, 34)}

While some studies suggest that MDMA therapy is relatively safe, it’s still possible to experience some side effects, regardless of the context in which you take the drug. One study showed that the most common side effects of MDMA include bruxism (jaw clenching), sweating, thirst, nausea, accelerated heart rate and breathing, tense muscles, and blurred vision. These MDMA side effects only occur during the treatment.^{(35, 36, 37)}

MDMA and You, How “Molly” Impacts the Mind and Spirit

MDMA does not typically impart what researchers have defined as a “mystical experience,” which is one of the ways it differs from some classic psychedelics like LSD and psilocybin. This is not to say that it does not impact users in a spiritual sense. Anecdotal evidence suggests that MDMA can deliver a powerfully spiritual experience, though it tends to be distinct from the dramatic “breakthrough” experiences delivered by other psychedelic drugs.

If drugs like LSD and DMT offer mystical experiences pertaining to the nature of reality, the experience derived from MDMA has more to do with the nature of relationships, whether to ourselves or to others. As an empathogen, MDMA’s capacity to increase empathy, compassion, and intimacy may dramatically improve one’s personal or interpersonal connections, which could, in turn, profoundly impact consciousness. Many users have also anecdotally reported that MDMA inspires a stronger connection to the natural environment or the arts—particularly music. This is why MDMA is so commonly associated with dancing and music.

“Setting” describes the social and material circumstances under which you’ll take the drug. That means being in the right place, populated by the right people and things. 

A few suggestions:

The establishment of set and setting for personal use is relatively straightforward. However, many studies do not seem to cover set and setting in a clinical or trial environment. According to Charley Wininger, LP, LMHC, and author of Listening to Ecstasy: The Transformative Power of MDMA, some key ways exist to establish set and setting in the medical environment. 

Furthermore, the MAPS Manual for MDMA-Assisted Therapy has similar recommendations. Many of these align with preparatory actions that one would take if using MDMA for personal use. However, there are some key differences:⁽³⁸⁾

These are just a few examples from the MAPS Manual for MDMA-Assisted Therapy. Whether you plan on participating in a clinical trial, utilizing MDMA recreationally for self-growth, or undergoing MDMA-assisted therapy when it becomes more widely available, reviewing their entire manual may be a good idea. You can find it at MAPS.org. It is available as a free, downloadable PDF. You may also find it by following the link provided in the works cited.⁽³⁸⁾

What to Expect During the MDMA Experience

While other psychedelic drugs can deliver unpredictable psychological content accompanied by dramatic emotional shifts throughout their journeys. Most users report that the MDMA experience is fairly consistent.

The progression usually goes something like this:

While “bad trips” are rare when it comes to MDMA (one study indicates that only 3.9% of MDMA users experience challenging events), the emotional comedown can inspire some negative feelings like exhaustion, sadness, or even a hangover. Part of this may be because it can feel somewhat disappointing to return to normalcy when you were feeling so ecstatic, but much of it is due to your body being depleted of its stores of the neurotransmitter serotonin throughout your journey. Lack of sleep, overexertion, and underhydration can all amplify the emotional comedown.

You can do a few things to offset the downturn^{(38, 39)} :

After your MDMA journey, it’s time for integration. This is the process of analyzing your experience to determine how it can be applied to your everyday life. In a therapeutic setting, some light integration will likely be performed immediately after the journey, though you may feel too drained for deep discussion. This is partially why many psychedelic therapists schedule an integration session for the following day, sometimes with follow-ups a week or even a month afterward. Integration really is the most dynamic work done when using psychedelics for healing purposes. It can yield incredible results, particularly if you keep with it for the days, weeks, and months following a journey. This is the beautiful work of a lifetime in order to create lasting change. 

Integration comes in many forms, but a few common examples include:

Whatever form integration takes, remember that this is your opportunity to document and later return to the feelings of elation, openness, acceptance, and love that MDMA may open your mind to.