_______________________________________________ Psychedelic Medicine and Interventional Psychiatry
Hallucinogen : Drug that may cause the user to experience visual, auditory, or other types of hallucinations. Neuromodulation therapy : The use of noninvasive or invasive means to stimulate the brain in order to treat serious psychi- atric problems. Psychedelic medicine : The use of mind-altering (typically but not always hallucinogenic or dissociative) drugs by mental health professionals to improve or even provide remission from severe psychiatric problems, such as depression, PTSD, anxiety, and substance use disorders. Set : Refers to the patient’s mindset. For example, a person who is anxious and fearful is less likely to have a positive experience with psychedelic medicine than a person who has an open and positive outlook. Setting : Refers to the overall ambiance in which psychedelic medicine is administered. A pleasant atmosphere that makes the individual feel safe is best. Transcranial magnetic stimulation : A noninvasive form of therapy that uses large magnets external to the patient to stimulate the brain. Vagus nerve stimulation : Invasive stimulation of the vagus nerve in order to treat serious, treatment-resistant psychiatric diagnoses. PONDERING PSYCHEDELICS More than 50 years have passed since the federal Controlled Substances Act first criminalized the use of psychedelics in the United States in 1970. The initial use (and misuse) of psyche- delic drugs in that era was primarily associated with Timothy Leary, a Harvard professor who promoted the nonmedical use of LSD, a practice subsequently adopted by the amorphous “hippie” counterculture movement of the 1960s and 1970s. Dr. Leary was famously noted as advising his followers to “turn on, tune in, and drop out,” scandalizing much of the conservative population of the time. Numerous events led to Leary’s loss of reputation, academic standing, and position, but his impact during this period was indisputable. In response to this movement, drugs such as LSD, DMT, psilocybin, and mescaline were all placed in the Schedule I drugs category under the Controlled Substances Act 1970 ( Table 3 ). The categorization of psychedelics as Schedule I drugs imme- diately halted intense scientific research on psychedelics, which had begun in the 1950s. This prohibition on psyche- delic drug research significantly delayed advances in medical knowledge on the therapeutic uses of these agents. While much of the focus at that time was on Timothy Leary and the counterculture’s recreational LSD use, some researchers had demonstrated beneficial effects with psychedelic medicine in end-of-life care as well as in the treatment of addiction and other severe psychiatric problems [24].
PSYCHEDELIC DRUG SCHEDULING
Drug
Schedule
Ayahuasca/DMT
I I
Ibogaine Ketamine
III
Kratom
Not scheduled
LSD
I I
Mescaline
Nitrous oxide
Not scheduled
Psilocybin
I I
MDMA (“Molly,” “Ecstasy”)
Source: [23]
Table 3
This research did not restart in the United States in any mean- ingful way until the 21st century. In this new wave of research, researchers in Phase 2 and 3 clinical trials of psychedelic medications have found the possibility of remission in diverse psychiatric populations (including in patients with PTSD, depression, eating disorders, and substance use disorders) as well as reduction in end-of-life anxiety and despair in those with terminal diagnoses [25]. At the same time, researchers have explored the use of older drugs (e.g., nitrous oxide, ketamine) to treat unrelenting psychiatric disorders. Another interesting avenue of research has been in the field of addiction medicine. There is some evidence that certain psychedelic drugs, particularly psilocybin, may act as a sort of “anti-gateway drug.” Years ago, there was a belief that some (or all) drugs were “gateway drugs,” leading inevitably to taking other drugs; for example, this perspective holds that people who smoked marijuana would eventually progress to using “harder” drugs, injecting heroin or other opioids. This theory has largely been discredited and devalued. In fact, several stud- ies have indicated that persons who use hallucinogens are less likely to progress to harder drugs. In one study, researchers used data from nearly 250,000 respondents from the National Survey on Drug Use and Health over the period 2015–2019. Respondents were asked about their past use of classic psyche- delics, and these results were then compared to their later abuse (or non-use) of opioids. Individuals who had used psilocybin (“magic mushrooms”) in the past had a significantly lower rate (30% lower than average) of opioid misuse and abuse later. This finding was not replicated with other psychedelic drugs [26]. An earlier study using National Survey on Drug Use and Health data for the period 2008–2013 found that past use of classic psychedelics decreased the risk for past-year opioid dependence by 27% and of opioid abuse by 40% [27]. Both of these studies relied on individuals reporting on their past use of psychedelic drugs, and there are multiple possible issues with this type of retrospective reporting. But the idea that past use of drugs such as psilocybin could be protective against opioid misuse and dependence in the future is promis- ing, given the ongoing opioid epidemic in the United States.
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