MDMA treatment for post-traumatic stress disorder in veterans: ethical considerations

Post Traumatic Stress Disorder and Addictive Drug Treatments

The two ongoing U.S. military involvements in Iraq and Afghanistan have dramatically increased the numbers of American servicemen and service women returning from overseas service with traumatic physical and psychological injuries and disabilities that complicate their re-assimilation back into civilian society and emotionally stable interpersonal relationships. Among the more difficult conditions to resolve satisfactorily are the long-term conditioned psychological responses to prolonged repeated exposure to threats to one's life and to numerous experiences of losing comrades in combat and witnessing the graphic human carnage of modern warfare.

Post Traumatic Stress Syndrome (PTSS) or Post Traumatic Stress Disorder (PTSD) is a condition caused by warfighting and its symptoms can be highly debilitating. Generally, PTSD treatments have focused on traditional psychotherapy and pharmacological management. There is empirical evidence suggesting that certain psychotropic drug therapy can be beneficial to PTSD patients, among them, methylenedioxymethamphetamine (MDMA) or "ecstasy." However, the use of potentially addictive drugs, especially in populations already vulnerable to depressive and other mood-related issues, also may support legitimate ethical objections. The fact that MDMA is also an illicit drug widely used recreationally and available on the black market is equally of concern in that regard.

Post Traumatic Stress Disorder

Thousands of World War I veterans returned from the battlefields of Europe with incapacitating neurological disorders that caused them to shake uncontrollably or panic at any loud or unexpected noises, or to experience vivid nightmares and waking "flashbacks" for the rest of their lives (Gerrig & Zimbardo, 2008). At that time, those symptoms were collectively described as "shell shock," a reference to the terrifying nature of being shelled by heavy artillery in the trenches of the European theater. A generation later, U.S. veterans experiencing acute and chronic psychological impairment caused by their combat involvement were referred to as suffering from "combat fatigue" (Gerrig & Zimbardo, 2008).

In the last several decades, the psychological (and the entire medical) community has recognized those symptoms as a specific psychological disorder referred to as Post Traumatic Stress Disorder (Frain, Bishop, & Bethel, 2010; Gerrig & Zimbardo, 2008). Generally, PTSD manifests itself in an exaggerated and uncontrollable conditioned set of fear responses. It is linked to clinical depression, societal dissociation, psychological isolation, substance abuse and addiction, violence, spousal abuse, and suicide (Frain, Bishop, & Bethel, 2010; Gerrig & Zimbardo, 2008). In some patients, the disorder is responsive to traditional psychotherapy and pharmacological intervention; however, in other patients the symptoms of PTSD are unresponsive to traditional therapeutic modalities and are, therefore, intractable (Mithoefer, Wagner, Mithoefer, et al., 2010).

Several alternative and adjunctive approaches developed in the last decade that have been used to treat PTSD patients whose symptoms were not resolved by traditional intervention. Among the most promising is based on specific patterns of exposure to various types and intensities of light in a process called Eye movement desensitization and reprocessing (EMDR). The EMDR technique is used in conjunction with psychotherapy and it has proven very effective for statistically significant numbers of patients in controlled studies (Breslau, Lucia, & Alvarado, 2006; Gerrig & Zimbardo, 2008).

Ethical Issues in Treating PTSD in Returning Combat Veterans with MDMA

A much more ethically controversial approach involves the use of low doses of MDMA in conjunction with traditional psychotherapy. That is because MDMA is an illicit drug with a very well-deserved reputation for being notoriously popular with recreational users and addiction. While their may be beneficial therapeutic uses of MDMA in certain patients, the population of U.S. armed services veterans suffering from PTSD are also, demographically and psychologically, at the greatest risk of drug addiction and to mental instability that could be worsened by non-therapeutic use of consciousness-altering substances, particularly in connection with unauthorized and unmonitored or controlled use.