From the Streets to the Rx Pad: Do Party Drugs Have a Place in the Medical Office?

Can drugs be categorized as good (eg, medicinal), bad (eg, recreational with deleterious side effects and addiction issues), or is there a middle ground? That was the underlying theme in the lecture “Perils and Promise of Psychoactive Drugs: A Focus on Harm Reduction Psychiatry” at the US Psychiatric and Mental Health Congress this week in Las Vegas.

To make his point that drugs can have both negative and positive effects, Andrew Penn, RN, NP, APRN-BC, Associate Clinical Professor at the University of California at San Francisco, highlighted 3 drugs that are known to be agents of abuse yet display some therapeutic properties-ketamine, 3-4 methylenedioxymethamphetamine (MDMA), and cannabis.

“Our society takes a simplistic approach to drugs-just say no,” he said, adding it’s time psychiatry takes the lead on this discussion. With the lack of research and good data on the scientific side of things, the anecdotal claims that these compounds may be “cure-alls” make them the snake oil of the 21st century, Penn added. Meanwhile, many patients already use them for recreational purposes and even more are looking to them to cure what ails them.

The newest drug to gain attention for possible therapeutic effects is ketamine, Penn said. A dissociative anesthetic developed in 1963, ketamine is used in medical and veterinary offices. On the streets, people use (usually snort) a processed form of ketamine to obtain those same dissociative “out of body” feelings, Penn noted. Like many substances of abuse, ketamine is not without deleterious effects. Repetitive use is associated with cystitis, dependence, and respiratory issues.

Yet studies have shown ketamine also might have antidepressant effects.1,2 Critics of the early studies claimed maybe people were just getting high and thus feeling better. But investigations showed the antidepressant effects took place sometime after intoxication, Penn told attendees. Clearly there is abuse potential, he added, but should we dismiss the therapeutic potential as a result?

MDMA, known on the streets as Ecstasy and more recently as Molly, has a similar story, Penn noted. MDMA abuse is well known, but recent studies show it may be especially effective in treating PTSD. In 2009, Bedi and colleagues³ conducted an fMRI study of MDMA and found it quieted the fear response in the amygdala, Penn explained. More recently, Mithoefer et al^4,5 conducted MDMA-assisted psychotherapy studies and found that not only did patients respond very favorably (83% response rate in the active treatment group versus 25% response rate in the control group), but that these helpful effects persisted. Penn added that with limited treatment options for PTSD, and the fact that only 30% achieve remission with these options, having another tool could significantly and positively change outcomes for patients. With current studies suggesting MDMA may be curative, Penn asked attendees, is it right to push the drug aside because of its street use?

Cannabis, like MDMA and ketamine, is a drug that holds promise and peril. Meanwhile, Penn noted the country has found itself struggling to find an appropriate place for this recreational drug, with a patchwork of state laws allowing medicinal marijuana. Indeed, there is therapeutic evidence that cannabis can help ease nausea and neuropathic pain as well as help patients with multiple sclerosis and anorexia.⁶

Yet cannabis use is not without risk, Penn added. Some patients can develop a dependence on the drug, he said. And recent studies suggest use among adolescents can lead to the development of depression and anxiety as well as psychosis. For instance, one study found that teen girls were 5 times likely to develop depression and anxiety after weekly use of cannabis.⁷

Unfortunately, lack of consistent product in street drugs and lack of available good data and studies often put psychiatry behind the eight ball in determining the proper place-if there is one-for these drugs, Penn added. For instance, Ecstasy/Molly usually has all sorts of ingredients in addition to the MDMA. Similarly, people purchasing marijuana may not know exactly what they are getting. Anecdotal evidence based on varying product strength makes it difficult for clinicians to determine the benefit versus risk profiles.

As a result, Penn urged clinicians to take a harm reduction approach to these agents, including those who seek the drugs for “medicinal” purposes. Keep an open, nonjudgmental dialogue with your patients, he said. Ask them questions like: What is your intention with this drug? With whom will you use it? Where will you be? What is your state of mind before taking the drug? There are drug testing kits available for Ecstasy/Molly to help patients get a clearer picture of what is in the product they are purchasing/using. He encourages patients to buy only from their regular sources-those who have a vested interested in return visits are less likely to poison their customers. He also encourages patients to use the drugs in a “safe” place and to be careful not to put themselves in compromising positions/scenarios (ie, a bunch of strangers, a strange place, etc.).

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References:

1. Berman RM, Cappiello A, Anand A, et al. Antidepressant effects of ketamine in depressed patients. Biol Psychiatry. 2000;47:351-354.
2. Zarate CA Jr, Singh JB, Carlson PJ, et al. A randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major depression. Arch Gen Psychiatry. 2006;63:856-864.
3. Bedi G, Phan KL, Angstadt M, de Wit H. Effects of MDMA on sociability and neural response to social threat and social reward. Psychopharmacology (Berl). 2009;207:73-83.
4. Mithoefer MC, Wagner MT, Mithoefer AT, et al. The safety and efficacy of {+/-}3,4-methylenedioxymethamphetamine-assisted psychotherapy in subjects with chronic, treatment-resistant posttraumatic stress disorder: the first randomized controlled pilot study. J Psychopharmacol. 2011;25:439-452.
5. Mithoefer MC, Wagner MT, Mithoefer AT, et al. Durability of improvement in post-traumatic stress disorder symptoms and absence of harmful effects or drug dependency after 3,4-methylenedioxymethamphetamine-assisted psychotherapy: a prospective long-term follow-up study. J Psychopharmacol. 2013;27:28-39.
6. Martín-Sánchez E, Furukawa TA, Taylor J, Martin JL. Systematic review and meta-analysis of cannabis treatment for chronic pain. Pain Med. 2009;10:1353-1368.
7. Patton GC, Coffey C, Carlin JB, et al. Cannabis use and mental health in young people: cohort study. BMJ. 2002;325:1195-1198.