Perspectives on the therapeutic potential of MDMA: A nation-wide exploratory survey among substance users

Substance use disorders commonly co-occur with post-traumatic stress disorder (PTSD), and each condition increases the risk and treatment refractoriness of the other. Previous epidemiological work cited by Jones indicates elevated PTSD prevalence in several minority racial and ethnic groups and lower treatment engagement and completion among these groups. Existing pharmacotherapies have limited trans-diagnostic efficacy for combined substance use and PTSD, and interest has grown in psychedelic-assisted treatments for their putative trans-diagnostic effects. MDMA, which received FDA Breakthrough Therapy designation in 2017, has been studied in multiple Phase II and Phase III trials for PTSD and produced large symptom reductions in at least one Phase III trial (reported reductions in diagnostic status and remission rates compared to placebo), while secondary analyses have suggested potential reductions in alcohol use severity but mixed findings for drug use severity. This study set out to describe patient-level opinions about the research and clinical potential of MDMA-assisted therapy among people with probable substance use disorders, and to examine whether those opinions vary by race and ethnicity. Specifically, the investigators assessed (1) support for further clinical trial research into MDMA-assisted therapy, (2) belief that MDMA-assisted therapy could be a beneficial treatment (for disorders such as PTSD and addiction), and (3) individual willingness to try MDMA-assisted therapy if it were proven safe, effective, and appropriate. The survey also asked about specific concerns participants might have about psychedelic-assisted therapies and explored demographic differences in responses.

Jones and colleagues conducted a cross-sectional, anonymous online survey targeting individuals who self-identified as struggling with alcohol or drug use. The study was declared exempt by the Medical University of South Carolina IRB; submitting survey responses was treated as consent and IP-based controls prevented duplicate entries. Recruitment used internet advertisements (for example, Craigslist) that invited people to take a short REDCap-hosted survey about psychedelics in addiction treatment. Eligibility required being 18 or older, having used a substance of abuse at least once in the past month, and endorsing at least two of the following: wanting to cut back or stop using a substance, prior treatment for alcohol or drug use, or current treatment for alcohol or drug use. Individuals who failed to meet these self-report criteria, did not use a substance monthly, denied wanting to cut back, or did not consent were excluded. The full survey, taking about 20 minutes, collected basic demographics (age, gender, race/ethnicity) and substance use, and presented participants with a brief information paragraph summarising prior MDMA-assisted therapy findings before asking three core questions about support for research, belief in therapeutic benefit, and willingness to try MDMA-assisted therapy if proven safe and appropriate. Participants who completed the survey were eligible for a US$15 Amazon gift card sent by email; providing an email was optional. All data were collected in REDCap and analysed in SPSS. Descriptive statistics summarised the sample and the three primary attitude outcomes. Group comparisons by race/ethnicity used Kruskal-Wallis H tests (a non-parametric test for differences in distributions across groups), with pairwise follow-up using Dunn's procedure and Bonferroni correction when appropriate. The survey also asked a list of specific concerns about psychedelic-assisted therapies and reported counts and proportions for these items.

Of 935 individuals who initiated the survey, 918 (98.2%) completed it and were analysed. The sample was predominantly male (70.9% male; 28.2% female; 0.4% transgender or non-binary; 0.4% other/prefer not to answer). Self-reported race/ethnicity distribution was: American Indian or Alaska Native 4.4%, Asian 2.4%, Black or African American 20.6%, Hispanic or Latino 13.6%, Native Hawaiian or Other Pacific Islander 0.7%, White 56.2%, Multi-racial 1.7%, and Other/Prefer not to answer 0.4%. Across the entire sample, a majority expressed positive attitudes toward MDMA-assisted therapy: 68.1% reported supporting or strongly supporting medical research of MDMA, 70.1% reported that they strongly or very strongly believed MDMA could be useful for treating mental health disorders such as addiction and PTSD, and 58.8% said they would be willing to try MDMA-assisted therapy if it were shown to be safe and appropriate for them. Analyses by race and ethnicity found no statistically significant group differences in level of support for further clinical trial research (Kruskal-Wallis H = 9.198, df = 7, p = 0.239) or in belief that MDMA-assisted therapy could be beneficial (Kruskal-Wallis H = 2.763, df = 7, p = 0.906). However, willingness to try MDMA-assisted therapy did differ between groups (Kruskal-Wallis H = 24.699, df = 7, p < 0.001). Pairwise comparisons with Dunn's test and Bonferroni correction indicated that Asian respondents were less willing to try MDMA-assisted therapy than White respondents (p = 0.029) and less willing than Hispanic/Latino respondents (p = 0.002). American Indian/Alaska Native respondents were less willing than Hispanic/Latino respondents (p = 0.041). Reported proportions of definite or probable willingness were 68.0% for Hispanic/Latino respondents, 57.5% for White respondents, 47.5% for American Indian/Alaska Native respondents, and 40.9% for Asian respondents; no other pairwise differences reached significance. Concerns about psychedelic-assisted therapies were widespread: 96.2% of participants endorsed at least one concern and the mean number of concerns reported was 2.94 (range 0–10). Specific concerns and their endorsement rates included fear of going crazy (39.9%), fear that it would change them (35.4%), fear they would no longer enjoy using substances (35.4%), fear of guilt during the experience (32.8%), fear of a bad trip (31.8%), fear of losing their sense of self (31.5%), fear that family, friends or neighbours would find out (27.3%), and fear that it would affect employment (26.7%). Only 4.8% of respondents denied having any concerns, and the proportion with no concerns did not differ significantly by race/ethnicity (p > 0.05). A Kruskal-Wallis test indicated statistically significant differences in the mean number of concerns between racial/ethnic groups (χ2(3) = 14.468, p = 0.002). Pairwise comparisons showed Asians reported fewer concerns than Whites (p = 0.018) and African Americans (p = 0.004), and American Indian/Alaska Native respondents reported fewer concerns than Whites (p = 0.019) and African Americans (p = 0.003). The extracted text references figures and tables for more detail; those visuals were not included in the provided extraction.

Jones frames the findings in the context of documented disparities in engagement with PTSD and substance use disorder treatments among minority racial and ethnic groups and the under-representation of those groups in psychedelic research. The primary descriptive results indicate broad support among people meeting self-report criteria for substance use disorders for further MDMA clinical research and belief in its potential usefulness, with a majority also indicating willingness to try MDMA-assisted therapy if deemed appropriate for them. Although aggregate support and belief did not differ by race or ethnicity, the study identified small but significant differences in willingness to try the treatment: Asian respondents were less likely to report willingness compared to White and Hispanic/Latino respondents, and American Indian/Alaska Native respondents were less willing than Hispanic/Latino respondents. Jones suggests that cultural factors, perceived risks, and prior experience with MDMA (which was not measured) could influence willingness and that differences in general belief about therapeutic benefit versus personal willingness may reflect assessments of personal risk or perceived personal applicability. The authors note strengths of the study including a relatively large and demographically diverse sample of 918 completers. Important limitations are emphasised: self-selection bias from online recruitment, reliance on self-reported screening questions that are not validated diagnostic instruments, absence of assessment for PTSD or other psychiatric symptoms, lack of measurement of prior MDMA exposure or baseline knowledge about MDMA-assisted therapy, and that the study was descriptive and not intended to assess clinical efficacy. Jones also acknowledges that concerns about psychedelic-assisted therapies were common and varied, and argues these concerns point to areas for targeted education, outreach, and engagement strategies to improve equitable research participation and future clinical access. Finally, the discussion reiterates that while MDMA and other psychedelic-assisted therapies show promise for refractory and comorbid mental health conditions, substantial work remains to understand and address barriers to diverse research participation and equitable clinical implementation as these treatments advance toward clinical use.