What’s next for MDMA

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MDMA, sometimes called Molly or ecstasy, has been banned in the United States for more than three decades. Now this potent mind-altering drug is poised to become a badly needed therapy for PTSD.

On June 4, the Food and Drug Administration's advisory committee will meet to discuss the risks and benefits of MDMA therapy. If the committee votes in favor of the drug, it could be approved to treat PTSD this summer. The approval would represent a momentous achievement for proponents of mind-altering drugs, who have been working toward this goal for decades. And it could help pave the way for FDA approval of other illicit drugs like psilocybin. But the details surrounding how these compounds will make the transition from illicit substances to legitimate therapies are still foggy.

Here's what to know ahead of the upcoming hearing.

What's the argument for legitimizing MDMA?

Studies suggest the compound can help treat mental-health disorders like PTSD and depression. Lykos, the company that has been developing MDMA as a therapy, looked at efficacy in two clinical trials that included about 200 people with PTSD. Researchers randomly assigned participants to receive psychotherapy with or without MDMA. The group that received MDMA-assisted therapy had a greater reduction in PTSD symptoms. They were also more likely to respond to treatment, to meet the criteria for PTSD remission, and to lose their diagnosis of PTSD.

But some experts question the validity of the results. With substances like MDMA, study participants almost always know whether they've received the drug or a placebo. That can skew the results, especially when the participants and therapists strongly believe a drug is going to help. The Institute for Clinical and Economic Review (ICER), a nonprofit research organization that evaluates the clinical and economic value of drugs, recently rated the evidence for MDMA-assisted therapy as insufficient."

In briefing documents published ahead of the June 4 meeting, FDA officials write that the question of approving MDMA presents a number of complex review issues."

The ICER report also referenced allegations of misconduct and ethical violations. Lykos (formerly the Multidisciplinary Association for Psychedelic Studies Public Benefit Corporation) acknowledges that ethical violations occurred in one particularly high-profile case. But in a rebuttal to the ICER report, more than 70 researchers involved in the trials wrote that a number of assertions in the ICER report represent hearsay, and should be weighted accordingly." Lykos did not respond to an interview request.

At the meeting on the 4th, the FDA has asked experts to discuss whether Lykos has demonstrated that MDMA is effective, whether the drug's effect lasts, and what role psychotherapy plays. The committee will also discuss safety, including the drug's potential for abuse and the risk posed by the impairment MDMA causes.

What's stopping people from using this therapy?

MDMA is illegal. In 1985, the Drug Enforcement Agency grew concerned about growing street use of the drug and added it to its list of Schedule 1 substances-those with a high abuse potential and no accepted medical use.

MDMA boosts the brain's production of feel-good neurotransmitters, causing a burst of euphoria and good will toward others. But the drug can also cause high blood pressure, memory problems, anxiety, irritability, and confusion. And repeated use can cause lasting changes in the brain.

If the FDA approves MDMA therapy, when will people be able to access it?

That has yet to be determined. It could take months for the DEA to reclassify the drug. After that, it's up to individual states.

Lykos applied for approval of MDMA-assisted therapy, not just the compound itself. In the clinical trials, MDMA administration happened in the presence of licensed therapists, who then helped patients process their emotions during therapy sessions that lasted for hours.

But regulating therapy isn't part of the FDA's purview. The FDA approves drugs; it doesn't oversee how they're administered. The agency has been clear with us," says Kabir Nath, CEO of Compass Pathways, the company working to bring psilocybin to market. They don't want to regulate psychotherapy, because they see that as the practice of medicine, and that's not their job."

However, for drugs that carry a risk of serious side effects, the FDA can add a risk evaluation and mitigation strategy to its approval. For MDMA that might include mandating that the health-care professionals who administer the medication have certain certifications or specialized training, or requiring that the drug be dispensed only in licensed facilities.

For example, Spravato, a nasal spray approved in 2019 for depression that works much like ketamine, is available only at a limited number of health-care facilities and must be taken under the observation of a health-care provider. Having safeguards in place for MDMA makes sense, at least at the outset, says Matt Lamkin, an associate professor at the University of Tulsa College of Law who has been following the field closely.: Given the history, I think it would only take a couple of high-profile bad incidents to potentially set things back."

What mind-altering drug is next in line for FDA approval?

Psilocybin, a.k.a. the active ingredient in magic mushrooms. This summer Compass Pathways will release the first results from one of its phase 3 trials of psilocybin to treat depression. Results from the other trial will come in the middle of 2025, which-if all goes well-puts the company on track to file for approval in the fall or winter of next year. With the FDA review and the DEA rescheduling, it's still kind of two to three years out," Nath says.

Some states are moving ahead without formal approval. Oregon voters made psilocybin legal in 2020, and the drug is now accessible there at about 20 licensed centers for supervised use. It's an adult use program that has a therapeutic element," says Ismail Ali, director of policy and advocacy at the Multidisciplinary Association for Psychedelic Studies (MAPS).

Colorado voted to legalize psilocybin and some other plant-based psychedelics in 2022, and the state is now working to develop a framework to guide the licensing of facilitators to administer these drugs for therapeutic purposes. More states could follow.

So would FDA approval of these compounds open the door to legal recreational use of psychedelics?

Maybe. The DEA can still prosecute physicians if they're prescribing drugs outside of their medically accepted uses. But Lamkin does see the lines between recreational use and medical use getting blurry. What we're seeing is that the therapeutic uses have recreational side effects and the recreation has therapeutic side effects," he says. I'm interested to see how long they can keep the genie in the bottle."

What's the status of MDMA therapies elsewhere in the world?

Last summer, Australia became the first country to approve MDMA and psilocybin as medicines to treat psychiatric disorders, but the therapies are not yet widely available. The first clinic opened just a few months ago. The US is poised to become the second country if the FDA greenlights Lykos's application. Health Canada told the CBC it is watching the FDA's review of MDMA with interest." Europe is lagging a bit behind, but there are some signs of movement. In April, the European Medicines Agency convened a workshop to bring together a variety of stakeholders to discuss a regulatory framework for psychedelics.