The Medicine

by Karen Hitchcock

  Despite its continued power in lay parlance, the simple concept of “addiction” has become almost meaningless. Even the latest iteration of the Diagnostic and Statistical Manual of Mental Disorders has scrapped the term altogether and replaced it with “substance use disorder”. The book lists eleven criteria, which include negative consequences on your life, work, relationships and health as a result of taking the substance, desire to stop but not being able, evidence of tolerance (needing more for the same effect) and effects of withdrawal. The number of criteria you fulfil determines the severity of your abuse. If drug law enforcement were a substance, our politicians would score an abuse disorder diagnosis.

  It is not the specific drug that is innately “addictive” or abuse-inducing, but rather it is the person’s history, psychological state, genetic predisposition and social circumstances that lead to substance abuse. This may be demonstrated by the example of alcohol. Most of us appreciate that different people have different relationships with alcohol and don’t all use it in the same way. For some it’s a nightly glass of wine with dinner, or an aperitif or nightcap. Others drink once a week, once a month, only at Christmas, or on Sundays during Mass. Others down two bottles of whatever in quick succession every day at 1 p.m. and pass out because the long stretch of an empty afternoon seems unbearable. Some drink steadily from eyes open to eyes shut. All of these ways of using alcohol have different meanings, precipitants, effects and ratios of pleasure to harm. Prohibition did not help those who abused alcohol. However, social and mental-health supports may. And it is exactly the same with every single other recreational drug. From heroin to pot.

  I know a handful of fully functioning professionals who occasionally use methamphetamine, and they aren’t bashing emergency department doctors and picking face scabs. Many thousands of patients are prescribed weeks-long courses of high-dose opiates after surgery, which they simply cease when their bones or bruised internal organs have healed. (Interestingly, in the US an increase in prescription-opiate overdose deaths has followed the increase in opiate prescription, whereas in the UK, where opiate prescription is also on the rise, there has been no increase in overdose deaths.) Twenty per cent of US soldiers in Vietnam were heavy users of opium while on tour. Ninety-five per cent of those men simply ceased upon their return home (which brought the statistics back to the 5 per cent pre-deployment rate of use). Where, how, why and who are the important things – not what. It’s the context, not the substance. Instead, for a long time we have thought of and treated addiction (and depression) like we treat an infection: the problem is this bug and we need to eradicate the bug.

  I saw a man in my clinic a few months ago who was being treated for alcohol use disorder by an addiction specialist who promotes the idea that addiction is first and foremost a disorder of the brain. The man’s GP sent him to me because he was tired, couldn’t think clearly and suffered insomnia. He handed over the list of ten medications the other specialist had prescribed to treat his “addicted brain”. It was a horrific cocktail of high-dose antipsychotics, antidepressants and anticonvulsants, as well as three or four other things I had to look up. How bad had his alcohol abuse been? He’d been drinking up to six beers a day, had clean clothes, a bank account and a full-time job. His girlfriend had broken up with him a few months prior and his beer drinking followed. The specialist had not asked about that, nor suggested counselling. It didn’t fit his paradigm.

  An oft-cited series of studies conducted by Canadian psychologist Bruce K. Alexander in the late 1970s, referred to as “Rat Park”, challenges the theory that drugs can be innately addictive. The studies showed that rodents kept in empty cages consumed nineteen times more morphine solution than those kept in rich social environments with running wheels, toys and room to mate. And moving the caged mice to Rat Park led to them markedly decreasing their morphine consumption.

  Some people’s lives are much harder than others’: economically, educationally, physically, emotionally. Some people have absorbed unimaginable trauma. I sit in front of patients and hear stories that leave me wondering how they have survived, wondering how they rise from their beds in the morning, put on their clothes and manage to leave the house. People who have suffered this kind of pain in their lives are at a far higher risk for substance abuse – licit or illicit – as well as mental-health disorders such as post-traumatic stress disorder (PTSD), depression and anxiety. Canadian psychiatrist and addiction specialist Dr Gabor Maté says that the drugs aren’t the problem; the drugs are the person’s attempt to treat their problem. And to be perfectly frank, we in the health professions don’t seem to be offering much in the way of effective, affordable, safe alternative treatments for these patients. You can now be euthanised for “treatment-resistant” mental-health disorders (including depression) in Belgium.

  I’ve been educated about alcohol and tobacco my entire life. I had to educate myself about the other recreational substances, because the information I’ve received from the authorities and the media about cannabis, MDMA, LSD and magic mushrooms has, in the main, been unscientific, moralistic bullshit. If a substance gives you pleasure you may seek to forgo food and work and relationships and cease participating in society in order to have it as often as possible – but only if you live in an empty cage (be that internal or external). If your cage is full you might choose to periodically indulge in a burst of chemical pleasure, then get back to the playground. If we’d like to decrease problematic drug use, we need to enrich the struggling person’s life rather than prohibit the drug. This has been demonstrated wherever patients have been prescribed heroin or amphetamines and also been offered mental-health, housing and employment support. They don’t die, crime goes down, they get jobs and their kids back.

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  In March 2018, the findings from a two-year Victorian parliamentary inquiry into drug law reform were presented. The inquiry’s key objectives were to investigate drug control laws and harm minimisation in Victoria as well as in other parts of Australia and internationally. The final report is an impressive and comprehensive document. The team surveyed international literature, travelled the globe and received 231 submissions. (Only one of the submissions, from the group “Drug Free Australia”, supported a focus on criminalisation.) The report points out that in 2016 approximately 8.5 million people in Australia aged fourteen or older (or 43 per cent) had used an illicit drug in their lifetime (including misuse of pharmaceuticals). Approximately 3.1 million (or 15.6 per cent) had illicitly used in the last twelve months, and 2.5 million (12.6 per cent) had used an illegal drug not including pharmaceuticals. The report also points out that criminalising individuals who use drugs contravenes international law, in particular UN conventions governing human rights, and that the World Health Organization “has unambiguously called upon countries around the world to stop criminalising people who use drugs”.

  The inquiry submitted fifty recommendations to the parliament. The first recommendation is that “the Victorian Government’s approach to drug policy be based on effective and humane responses that prioritise health and safety outcomes [and] be in accordance with the United Nations’ drug control conventions”. It would be informed by the following principles: that policies promoted safe communities, were evidence-based, took a supportive and objective approach to people who use drugs and are addicted, were cost-effective, and were responsive and open to new ideas and innovation.

  The Victorian government responded five months later. As I read the response, which was the responsibility of Martin Foley, minister for mental health, I wondered if I had accidentally clicked on the wrong document. It reiterated the minor initiatives and changes to policy the government had already announced (for example, the single supervised injecting room in Richmond), and threw a bit of cash at community and rehabilitation centres. It also promised to be tough on dealers. There was no commitment to decriminalisation or any of the other harm-reduction recommendations in the report. I spoke to MP Fiona Patten of the Reason Party,
one of the key investigators in the inquiry, about the government response. “There was absolutely nothing in it responding to the report or its recommendations,” she said.

  Stephanie Tzanetis, coordinator of DanceWize, a program under the auspices of the independent non-profit organisation Harm Reduction Victoria, agreed that the government response didn’t directly address the recommendations, adding, “I note the word ‘tough’ is used six times, but tough connotes more law and order, which seems at odds with the report’s theme of prioritising health.”

  Recommendation three – ignored along with the rest – is that Victoria establish an independent drug advisory body. As Tzanetis points out, this is important to limit the impact of election cycles on drug policy – as any health policy should be based on evidence rather than popular sway. One of the Coalition Opposition’s election promises was to close down the Richmond safe injecting room – despite the fact that in two months of operation 120 potentially fatal overdoses were treated at the facility. Apparently it sends the “wrong message”. The right message, I presume, is “Just say no”.

  Even the AMA’s Dr Tony Bartone concedes that “countries that have adopted non-punitive responses to drug use have not experienced major increases in the prevalence of drug use, and have reduced the stigma associated with drug use and seeking treatment from doctors”.

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  A few weeks ago I was at a dinner party and a doctor friend asked me what I was writing about. I told her I was working on an essay about illicit drugs such as cannabis and psychedelics, and how they are slowly starting to be studied again and used to treat mental-health problems and symptoms such as pain. She said it all sounded fascinating and she couldn’t wait to read the essay. The woman sitting next to her sat quietly listening, a small knowing smile on her face, until she tapped her fingernail on the table and delivered her fatal blow. “Yes, but what about Charles Manson?”

  “Charles Manson?” I replied.

  She explained, “We can’t allow drugs that make people go around slaughtering each other.”

  Where to start? I was overcome with weariness. I knew that no safety and efficacy data I quoted, no history or science or study results would budge her belief that “drugs” turned people insane and/or murderous. Such has been the power of the unrelenting propaganda since we embarked on this endless war on drugs.

  *

  In early 2018 I read that a phase III trial into MDMA-assisted psychotherapy as a curative treatment for post-traumatic stress disorder had been approved by the US Food and Drug Administration. That made me prick up my ears. PTSD is a condition notoriously resistant to treatment, and its incidence is on the rise. According to the Australian Bureau of Statistics, approximately 6.4 per cent of Australian adults suffer PTSD. In the US alone, approximately twenty veterans kill themselves each day, mostly as a result of intolerable PTSD.

  Prior to US president Richard Nixon’s prohibition of psychedelics in the 1970s, they were researched heavily and widely used within international psychiatry. LSD in particular was being used (apparently successfully, though there were no randomised controlled trials) as a treatment for depression, obsessive-compulsive disorder, schizophrenia, autism, end-of-life anxiety and addiction. More than a thousand scientific papers had been published and more than 40,000 individuals had participated in clinical trials at the time of the ban. Even Bill Wilson, the co-founder of Alcoholics Anonymous, wanted to use the medication as part of the AA treatment program.

  Both the US and the UK militaries tested LSD on their troops in the 1960s. The footage of soldiers attempting to follow drill commands after (unknowingly) being administered LSD can be readily accessed on YouTube: the men gradually cease following their drill sergeant’s orders to march, and instead start to wander randomly, giggling with each other like naughty children. A 1977 Senate inquiry into the CIA-led MKUltra program revealed that the military had tested LSD on more than 1000 soldiers, without a single long-term ill effect recorded. The molecules are non-toxic, non-addictive, have no lethal dose and are generally well tolerated.

  The decades-long global research hiatus, dictated by regulators who suffered – and continue to suffer – anaphylactic shock at the very idea that these suppressed and maligned substances might have medicinal value, is one of the many tragedies caused by prohibition. Science has scant power to inform a public bombarded with decades of grossly skewed reporting and hysterical “alternative facts”.

  Shamans have used psychedelic substances as a treatment and for ceremonial purposes since ancient times, yet our society has banned every perception-changing, mind-altering and mind-expanding drug ever found or produced (besides alcohol). The bedrock argument for these drugs remaining illegal seems to be the belief that they are potentially detrimental to our mental health. But looking at the dire and ever-increasing depression, anxiety and suicide rates, what do we have to fear?

  Our most studied and funded psychotherapy – cognitive behavioural therapy – rejects introspection in favour of behaviour modification. It’s as if we all suffer “psychophobia” – that is, a fear of what’s in our own and others’ minds. As if we’re all but a knife’s edge away from losing, or being lost within, our minds. The UK Psychoactive Substances Act makes novel substances and “legal highs” (even those not yet invented) illegal. Such is the danger of changing our mind. (If only I had a dollar for every time someone told me as a kid, “You think too much.”)

  Whatever its aim, the fear campaign around psychedelic substances has been hugely effective.

  In 2008 the Dutch government banned psilocybin mushrooms and gave farmers ten days to clear their stock. A French teenager had jumped to her death from a bridge after allegedly eating the “magic” mushrooms, which she’d had someone purchase for her from a “smart shop”. Television and newspaper reports quoted the girl’s mother as saying, “She wanted to live. The drugs have killed her.” Psilocybin-containing truffles are still legal and have filled the void left in the market after the mushrooms were removed. The truffles contain the same psychoactive substance and have the same effect. No doubt the regulators are as aware of this as the consumers.

  Officially, the psilocybin mushrooms were banned to protect the vulnerable. But given the drug remains available and legal (albeit in a slightly different fungal form), how does banning the mushrooms protect anyone? The poor girl was underage, had been illegally supplied and was tripping alone; the media and government did not use this tragedy as an opportunity to educate the public about the safe ingestion of psychedelics (in the way my teenage friend did for me in the US); there was no talk of suicide prevention or how we might help those around us in distress. Who did the change of law protect?

  There are, without doubt, people who are vulnerable to psychosis (for a variety of reasons). These people may experience psychotic episodes if exposed to a variety of stimuli, including but not limited to extreme distress or trauma, sleep deprivation, alcohol, prescription medications such as benzodiazepines, over-the-counter medications such as antihistamines and cough syrups, and inhalants such as petrol. An increased risk of psychosis caused by heavy cannabis use, particularly in adolescence, has been documented in longitudinal studies for decades. (This risk is small, and a recent study from the University of Bristol estimated that 20,000 individuals would need to cease consuming cannabis in order to prevent one case of schizophrenia.) Interestingly, there is emerging evidence that certain components of cannabis (especially CBD) may have antipsychotic properties. Most of the currently circulating illicit varieties of cannabis have been specifically bred to contain very high concentrations of THC and have had most of the CBD content bred out (more bang for your buck). Have black-market forces led to the development of more harmful strains? The emergence of highly potent forms of illegal substances is a common theme in the history of drug prohibition. It was seen with alcohol and more recently in the appearance of the high-potency opioid drug fentanyl on the black market, which has caused an epidemic of overdose dea
ths around the world.

  Terence McKenna, ethnobotanist and author, said that psychedelics were dangerous only due to the possibility of “death by astonishment”. None of the thousands of people who have had LSD administered in clinical trials has had any lasting negative mental-health effects. (The psychotic breaks attributed to LSD in the 1960s are now thought to be mostly misdiagnosed anxiety attacks.) If concern over the mental health of vulnerable Australians were truly a motivating factor for government policy, perhaps the funding of some decent mental-health services might be a good place to start. It would certainly improve mental-health outcomes far more than making a group of seemingly random, mostly non-habit-forming, low-risk and wildly diverse substances a reason for incarceration. Listening to its own health advisers and expert-panel recommendations would also help. Australia is experiencing a mental-health crisis. We are the second-highest users of antidepressants in the OECD. A recent study indicated that approximately 50 per cent of women reported being anxious or depressed. Currently, approximately eight people suicide daily in Australia. Prohibition of these substances won’t stop mental illness. Blaming mental illness on these substances allows us to elide the psychosocial causes, which require far more complex solutions.

  There is a long history, perhaps starting with Timothy Leary, for advocates of psychedelic therapy to be caught up in a kind of zealotry, whereby these medicines are believed to be the answer to all of Western society’s problems (rampant consumerism; lack of connection to self, others or nature; existential distress and meaninglessness). There’s an interesting binary in a story that abounds with binaries (good/bad, hard/soft, legal/illegal): psychedelics are the cause of madness/psychedelics will cure us of madness. It may well be the case that we as a society, in the midst of a mental-health crisis, are not ready to incorporate blanket recreational use of many of the illicit substances. One thing is clear, though: the legal and institutional barriers to studying substances that may help us treat many of our epidemic-level afflictions are, at best, unethical.