The Medicine

by Karen Hitchcock

  Universities and medical institutions around the world are now conducting dozens of trials into psychedelic-assisted treatments – mostly funded by philanthropists and not-for-profit groups, as no pharmaceutical company is interested in non-patentable, potentially curative drugs that will only be used a few times by each patient (and research into the benefits of drugs that, according to schedule 9, have “no medical use” are unable to attract government research funding). Psilocybin and LSD are being studied for treatment-resistant depression, for end-of-life anxiety and depression, and for substance use disorders (with some pilot trials showing in the order of 80 per cent success rates). MDMA and cannabis are being studied for PTSD. Most of the trials have protocols that dictate a number of meetings between patient and therapist before the day of the dose, supervised dosing in a private comfortable room under the supervision of the therapist or therapists, and a number of follow-up (“integration”) sessions afterwards, where the experience and any material it generated are examined. Psychotherapists (or guides or shamans) help the subject surrender in safety and afterwards help them make meaning of the experience.

  Ibogaine (a psychedelic plant medicine) has long been used as a treatment for addiction. Ayahuasca (another psychedelic plant medicine) has been used for centuries both ritually and for mental wellbeing and insight. There are countries where people can already access legal (or decriminalised), and sometimes medically prescribed and supervised, ayahuasca treatment (Spain, Peru, Costa Rica, Brazil), ibogaine treatment (Costa Rica, Gabon, Brazil, Guatemala, Mexico, Canada, the Netherlands, New Zealand and South Africa) and psilocybin treatment (Brazil, Bulgaria, Jamaica, the Netherlands). Underground (illegal) trip-treatments, which have existed in the West since the substances were banned, are increasing in popularity and happen worldwide – including in Australia – run by both ethically motivated, highly trained therapists and self-proclaimed (sometimes dodgy) suburban shamans.

  Unlike a tumour, an infection or a kidney stone, affective disorders such as depression, anxiety, fear of death and chronic “non-organic” pain are subjective feeling states. And yet for the past few decades, with the rise of biological psychiatry (and in the case of chronic pain, perhaps since Descartes), they have been treated in much the same way as we treat errant cellular growth. Doctors and psychologists have taken the space left uninhabited by the shamans and mostly failed to fill their shoes. Imagine a shaman handing a man who has lost his wife of fifty years and is “still” stricken with loss and grief three weeks later a five-minute consultation and a script for antidepressants. That this is not uncommon in modern medicine should make us deeply ashamed. The class of drugs known as antidepressants, a miracle of modern marketing, has now been shown in major meta-analyses to have only small benefits beyond placebo for the majority of patients. (The widely publicised meta-analysis by Cipriani and colleagues in The Lancet in 2018 showed that for moderate to severe depression, 40 per cent of patients feel better with a placebo and 50 per cent feel better with an antidepressant – making the treatment effect of the actual drug in the order of 10 per cent.)

  As a clinician (and a human living in the developed world), I’d simply like to have something to offer that might help relieve a person’s suffering, whether that be caused by a chemical imbalance, childhood trauma, poverty, disenfranchisement, ossified patterns of thinking or loss of hope.

  I’ve subscribed to a loose form of the psychodynamic/psychoanalytic paradigm of therapy for most of my career. But I know it is unaffordable for many and not always a good fit for others. And talented therapists aren’t as easy to find as you might think. The broad theories arising from the psychedelic psychotherapy research, both contemporary and pre-1971, seem both sensible and plausible to me: neuroscientifically, behaviourally, developmentally, psychologically, humanistically and historically.

  These prepared, guided and integrated trips seem to offer something closer to the humane and holistic ritual that the ancient shamans used to great effect for centuries. Utilising a therapist and a medicine in conjunction reunites the psychological and biological theories of mental illness.

  So how do they work? The answer is, no one really knows – which is more common than you’d think when it comes to medical treatments, but even more common in treatments that attempt to alter subjective states. One of the research leads in the New York University psilocybin-assisted psychotherapy trials with patients with terminal cancer diagnoses, Associate Professor Anthony Bossis, has said:

  People come out [of the treatment] with an acceptance of the cycles of life. We’re born, we live, we find meaning, we love, we die, and it’s all part of something perfect and fine. The emergent themes are love, and transcending the body and this existence. In oncology, we’re pretty good at advancing life and targeting chemotherapies, but we’re not so good at addressing deep emotional distress about mortality. So to see someone cultivate a sense of acceptance and meaning, something that we all hope to cultivate over a ninety-year life, in six hours? It’s profound.

  (In response, a critic of the psilocybin trials, Professor James Coyne, a clinical psychologist who holds academic positions at the universities of Groningen, Stirling and Pennsylvania, wrote, “This investigator’s New Age depiction of mechanism falls short of conventional scientific standards.”)

  At one point in his recent book How to Change Your Mind, a participant-observer exploration of trip-therapies, author Michael Pollan fills out a validated questionnaire – the MEQ30 – to ascertain whether or not his 5-methoxy-N, N-dimethyltryptamine (5-MeODMT) trip qualified as a mystical experience. He made it to mystical by one point. Hallelujah …

  When it comes to mechanisms regarding mental illness and distress, “conventional scientific depictions” seem to have led us nowhere particularly useful thus far. Perhaps conventional scientific understandings of the phenomenological experience of being human are inadequate. We are just at the very beginning of anything approaching a sophisticated understanding of human consciousness and our experience of sentience. From where in the wet mass of your brain, with its 90 billion cells, does the sense that you are you arise? Noxious subjective feeling states are in a sense “all in our mind”, or woven from the stories our minds spin about our selves and our world. How can a doctor treat that? Fifteen years on a couch might do the trick. But you can’t merely tell a patient she is not worthless. You can’t merely tell a patient there is nothing wrong with his body that feels pain all over all the time, nor convince a man that every shadow does not hide an attack. Many of our modern afflictions (versions of which we have struggled to understand for centuries) might thus be seen as a kind of disorder (or stuckness) of thought. It is hypothesised that psychedelics relax prior assumptions, beliefs and defences, which can greatly facilitate psychotherapeutic work. As Pollan puts it, psychedelics can help reverse “petrifaction of thought”.

  Of course, it may turn out that the drugs are a kind of spectacularly effective placebo, with their dramatic mental effects and inducement of heightened suggestibility, and the concomitant psychotherapy with someone who has kept you safe as you went on an internal, sometimes scary journey (which surely generates an intimacy of sorts). Subjects come into the treatment with expectations, often reinforced by the therapists. If this does turn out to be the case, then so be it. Given the low risk, the non-toxic profile, the short treatment duration and the seemingly drastic treatment effects, it would be a powerful wielding of the placebo effect (an effect medicine has always used).

  *

  Outside of psychotherapeutic circles, the culture of psychedelic use is as far removed from the 1960s hippie counter-culture as one could imagine. The non-medicinal use of psychedelics is occurring in Silicon Valley and other enclaves of the tech and entrepreneurial worlds. In this realm the drugs are used as tools for optimising cognition and creativity. These high-performers trip in order to come up with new ideas, solve problems, think “outside the box”. They trip because it makes them more productive. Says autho
r, entrepreneur and superstar podcaster Tim Ferriss, “The billionaires I know, almost without exception, use hallucinogens on a regular basis … [They’re] trying to be very disruptive and look at the problems in the world … and ask completely new questions.” (It seems Nixon need not have been afraid.)

  If you are resigned to the idea that governments won’t do much to change anything radically for the good (unless it happens to coincide with corporate interests), then the obvious options are to drop out or to create the change from outside the political system, using your own wealth to invent the future everyone else will live in. Unlike the hippies, these guys have discovered that you don’t need to “drop out” to be free. Wealth buys you freedom. (Who’s the boss on Mars?) And much of the philanthropic support for the trials into psychedelic-assisted psychotherapy and micro-dosing is coming from the tech world. There goes the 1960s counter-culture claim that psychedelics necessarily foster a mystical sense of connectedness and a decrease in individualism.

  *

  Why is Australia being left behind in this global research effort to interrogate the efficacy of psychedelic-assisted psychotherapy? We have catastrophically high rates of depression, anxiety and PTSD. We have clinicians and scientists and patients ready and eager to participate in this research. Australia’s non-profit psychedelic research organisation, PRISM (Psychedelic Research in Science & Medicine), has been working since 2011 to initiate local MDMA/ PTSD and psilocybin/anxiety and depression trials. Approval for one of these studies may be inching ahead, but Dr Martin Williams, president of PRISM, is guarded. Thus far, efforts to run trials in Australia have halted at institutional gates, or if let in have been rejected by ethics committees apparently hesitant to “embroil themselves in controversy”. Is there a brave hospital or university ethics committee out there? We could easily take part in the international phase III trials of MDMA for PTSD, or psilocybin for end-of-life anxiety. Australia generally prides itself on contributing to cutting-edge research.

  There is an emergent idea within geriatric medicine called “the dignity of risk”. This idea proposes that when it comes to limiting an elderly person’s liberty (by, say, forcing them to leave their home and locking them away in a nursing home), the benefit of the doubt should always lie with personal freedom over personal safety. The evidence that they are in imminent danger must be very, very strong. All other options (in-home support, for example) should be trialled first. By this argument, allowing an adult this “dignity of risk” when it comes to the use of “mind-altering” substances is an ethically sound position. Millions of people already use them, and there are ways to allow this and markedly increase the safety of this practice. There are ways for the government to raise revenue from it, and use that to fund our flagging social and health services.

  But are we ready for the blanket legalisation of every illicit substance in Australia? We have a variable (but mostly poor) capacity for restraint, lack of community, wide variance in socio-economic stability and for the moment very few social structures to support harm minimisation. We can’t even curb or minimise the harm caused by food abuse. There are two main conflicting stories about the global “war on drugs”. In the first, the role of government is to protect the individual and society from harm, and drugs are harmful to physical and mental health. Addiction is a disease, drug use a moral failing, prohibition is enforceable, and we should “Just say no”. The alternative view is that the war on drugs is a government-directed policy that exploits the public’s fears and is fertile ground for any politician seeking to demonstrate their toughness.

  The idea that “drugs” are innately bad is a fairytale about the human subject, and about arbitrary divisions of soft and hard, good and bad, tolerated and not, which trace back to our puritanical roots and our rejection of science. And this fairytale conveniently supports various industries, both state-run and private (the police, the military, the prisons, pharmaceutical companies). We swallow it because we believe stories that provide us comfort and the illusion of safety.

  The concept of harm reduction may offer us the foundation for a middle road for reasoned, step-wise drug reform. Almost every major international health and human rights organisation, as well as local inquiries and drug specialists, has found that the criminalisation of users is a harm maximisation strategy. People will always use. In both beachfront mansions and back alleys. Pockets of society (mostly the employed and privileged) have incorporated the occasional use of even “hard” drugs into their culture (such as psychedelics in Silicon Valley and other professional and creative enclaves) – but this cultural incorporation takes time, and perhaps the conditions that make it possible are not widespread. Safe injecting rooms and pill testing save lives and have never resulted in increased use of substances. Supervised prescription of heroin (as is practised in Switzerland, Germany, the UK, the Netherlands, Canada and Denmark) saves lives, decreases criminality, unemployment and homelessness, and also (interestingly) decreases the uptake of heroin use in the population. Cannabis use is so widespread in our society – and the harms so concentrated to particular populations (the heavy-using youth) – that legalisation and robust projects to educate and support those at risk of harm seem sensible. A blind idealism supports both the prohibition and libertarian positions on drug reform. Both ignore what it is to be human (flawed) and the society we live in (unequal).

  Regardless of how we as a society navigate drug reform, the use of and research about the medicinal benefits of illegal substances should not be held back by prejudice and antiquated propaganda. It is one thing to fear losing our minds. It is quite another to turn our backs on what we might discover when taken by the hand and led to places we might never have reached alone.

  * I was granted TGA authority to prescribe medicinal cannabis as this essay went to press.

  In the Body and in the Mind

  Among registrars, Mike’s clinical acumen was legendary: he’d touch his stethoscope to a patient’s skin and hear the heart murmuring secrets that none of us could yet hear. In the first weeks of my physician training, he was scheduled to give us a seminar on chronic fatigue syndrome (CFS). I thought it was a joke; I thought the lecture would turn out to be on heart failure or sleep apnoea or some other disease that renders patients tired. But he walked in wearing pinstriped trousers and started talking about chronic fatigue, the syndrome.

  I couldn’t believe it. Wasn’t he a real doctor?

  “No one knows what’s going on with this,” he said. “Is it a disorder of the immune system, of the autonomic nervous system? Is it a symptom of unexpressed emotion?”

  I searched his face: was he dementing?

  He met my gaze. “Someone has to care for these patients.”

  A few weeks later a pale woman in dark sunglasses named Jane was carried into the emergency department by her mother and father. She claimed to be suffering acute adrenal insufficiency, caused by CFS. She told the triage nurse that if she wasn’t immediately given large doses of intravenous hydrocortisone she would die. The nurse hesitated. The patient’s entire body went flaccid. “I’m crashing,” she cried. “I’m crashing.” Her parents were hysterical. The nurse called a code and Jane was rushed to a resuscitation bay. Her blood pressure was on the low side (but high enough to perfuse her brain); her heart rate was slightly elevated (but slow enough to circulate blood effectively). Despite this haemodynamic stability and the absence of any other hard clinical signs of adrenal insufficiency, Jane’s distress and authority were such that out of pure anxiety the treating team administered the drug she’d demanded – any doctor would have done so, given the dire consequences should she have needed it and the minimal side effects of a single dose. They urgently sent off bloods, the fluid trickled into her vein and everyone calmed down. The intensive care specialist examined the patient, checked the results and hypothesised that she may not have been “crashing” after all. He called me to admit Jane to a ward and help work out what the hell was going on.

  Jan
e insisted that her room be kept perfectly dark, her bed absolutely horizontal. Any noise could set off her symptoms: headache, full body electrification, paralysis, blindness, brain fog, skin pain, stomach cramps or a “crash”. Her mother unpacked Jane’s bag of pills onto the bedside table – there were twenty-five bottles, including three of hydrocortisone, prescribed by three different doctors. Jane sighed gigantically when I asked her for details of her medical history and, without turning her head, handed me a copy of her forty-page “illness diary”. I walked out of the room and called Mike.

  Over the following days I wondered if we’d been transported back in time to Freud’s Vienna. “Let’s get this straight,” Mike told me. “This is not your typical fatigued patient.”

  Jane’s abdomen became the focus of her suffering. I had my interns request notes from specialists and hospitals all over Australia so we didn’t replicate investigations. She’d had gastroscopies and colonoscopies, biopsies and scans. She’d even had her abdomen split and surgically explored. Everything looked and worked like healthy organs should. They just didn’t feel that way to Jane. Her parents grew increasingly agitated: what were we going to do about her pain? When were we going to scan her, scope her, give her monoclonal antibodies? Didn’t she need an operation?

  Jane’s last hospitalisation had ended with the offer of admission to the psychiatric unit for treatment of severe somatisation disorder, the delusional belief that the body is diseased. Our psychiatrists agreed. They came to blows with the patient: Yes, it is. No, it isn’t. Moralism warped the ward: “What she needs is a good spanking,” one nurse said.