Illicit Drugs and Therapeutic Potential

So I wanted to post late (partially because of break and needing to re-collect my thoughts about the discussion, but partially for the more productive reason of hearing what you all had to say) and provide a little bit of a summary and my response to the above. First, I want to thank you all again for such insightful comments and provocative questions both in our class session and on the boards-- Liz, Elliot, and I really appreciate all your thoughts.

There a couple of topics which we seem to keep coming back to, one of which is this concept of recreational use and legalization. It seems that the general concensus here is that there should be research done using these drugs-- most of us justified this by stating that the possible benefits outweigh the currently understood consequences. I think both Stephanie and Jenna brought up the interesting point at the beginning of the talk about what happens for these patients (talking in a medical context alone for a second) are outside their controlled therapeutic environment. Most studies only look at the effects of these drugs with such controls in place (there is no study where a patient talks it out and trips in a safe place in one condition as compared to just handing someone drugs and saying go for it), so I think it is a very necessary thing to be worried about. We don't know if it might be the COMBINATION of the setting and drug which allow for benefits-- in fact all the drug literature do state that setting/atmosphere are the most likely predictors of the "goodness" of the trip/experience. But then the issue becomes how we go about controlling this, especially if we move outside of the medical context and talk about legalizing recreational use.

In terms of this, Emily A. brought up the idea that many of these studies say that patients would not use/abuse outside of the study (to clarify though: most patients state that they would use again, because of the positive effects, but that the drugs were illegal-- which is worrisome-- and that they liked the environment -- which is good.) Therefore, I still feel that overuse could be a problem, though hopefully if bad trips is what we are working against you would think that anyone who had one would not use recreationally, sort of a self-selecting anti-abuse mechanism. However, if bad trips are not that prevalent then you could see over-use/abuse... but if there aren't bad trips then what is the exact problem?

which brings us to the other topic that seemed to keep coming up in discussion: neurodiversity and drug-use. I really like the way Jenna put it when she said that it would be a "personal choice as to your state of mind." This really makes these drugs exactly like we would consider alcohol-- you can use if you so wish. I also like Kara's point about the "natural" state of things; when she brought up that perhaps drugs are simply allowing us to use our brains in a completely natural, if different, way. I like this idea because if you think about it (and especially as many of these compounds are natural, and those that aren't mimic what we consider to be natural effects) there are a lot of things we do everyday that change our brain chemistry... all of which we have a choice about. what we eat changes our body/brain chemistry. what we do-- i mean adrenaline pumping activities (be it working out or constant stress) have been shown to have significant effects on our brain chemistry. in fact, to put it into what is seemingly a ridiculous example, couldn't we say we should call stress somewhat of an illegal "drug" because it has been proven to have serious negative effects on longterm function? now i realize that homework and job stress are not likely to become schedule I anytime soon, but it makes the interesting point that our everyday actions are a choice. it is only cultural imposition of this negative stereotype that brings up such negative intuition, as Ian put it, about drugs.

now im not saying we should completely legalize all drugs here and now... because I think we do need more information about their safety and actual mechanism of action. It seems to me that these drugs allow our brains to heal themselves (as we talked about with CBT), and alex t put it nicely when he said they allow for "disinhibition and therefore self-reflection." But before i put them on the market I want to make sure we aren't mimicking something with drugs that we dont fully understand...

thanks again for all the interesting ideas!

In keeping with Elliot's post, I think it's important to compare the standards we set for one class of drugs with the standards we set for other classes of drugs. Many people in the forum have addressed the perceived danger of these drugs, which I think ties in nicely with a previous line of discussion we had about culture and science. It seems to me that all objective data suggests that the psychedelics are far less dangerous than people actually think they are. This line of thinking is evidenced by the frequent use of the terms "scary" "hard drugs" etc. I have to admit that I feel similarly... something about these drugs feels dangerous. I think it's precisely that feeling that can be attributed to culture and also all mixed up with observations like what these drugs do, who uses them, why those people use them, etc.

After acknowldeging that this is a cultural thing, it seems important to me to address how this can be changed. For this, I think that the example of cigarettes and nicotine is a great one. In our parent's generation, cigarettes were considered to not have a long-term negative effect on the body, and in some advertising cases, were touted as able to improve health. In one generation, cigarette use went from status quo to stigmatized. It's important to note here that this change happened through research on all levels of organization. Reserach drove this cultural change, even in the face of corruption, concealment, and blatantly unethical decisions on the part of tabacco corportations. This all sounds so similar to the history of psychedelics!

I think that you three did a great job of letting the data speak for itself. Clearly, there is a role for further reserach in this field. If that is ever allowed, overcoming the public stigma associated with this drug class will be a very large challenge, but not an insurmountable one, as the case of cigarettes shows. It seems to me that the really important (maybe overly simplistic or optimistic?) message of this account is simply that scientific research has the ability to not only shape the scientific sphere, but the culture that it operates in.

            I have always wondered why we have such strict laws against some drugs that people have never lethally overdosed on, or even very infrequently, when some things like alcohol and tobacco, with very clearly shown lethal effects, are not only legal but only loosely regulated.  I had never really thought about the idea that the type of people using drugs affects the legislature surrounding them.  “Counter-culture” drugs, drugs that hippies, or Goths or whoever little known subculture are associated with, seem to get intensely bad raps.  I do believe it is hard to legalize a drug that has been regulated for so long without people going a little crazy at first, but by legalizing, regulating and even taxing, it seems to me that the government could control these substances more effectively, and even make money off of them.  It also does seem strange when some of these drugs have a) never been overdosed on and b) have mainly positive side effects that they are “schedule 1” drugs.

 The idea of “self medication” through both legal (such as alcohol) and illegal drugs is an interesting one to think about.  Although clinical testing is just starting for many of these drugs, there are lots of people out there whose recreational drug use could probably be considered therapeutic.  Just like we talked about talking to a friend or taking a vacation as therapeutic, many people “self medicate” with alcohol (often with tragic results) and I assume this is true for many illegal drugs. It would be interesting to see, outside of clinical trials, the effects of these drugs on people and their use as a way to handle stress, anxiety, etc.

Although on some level I’m not sure that outlawing benign drugs that simply put one in a euphoric or happy state makes a ton of sense, there is still a part of me that would worry if these drugs were completely legalized.  Although I know it is unlikely, I can still imagine a world where people just pop a pill (or whatever intake method) and zone out; where we are dependent on drugs for happiness and functional lives.  It would scare me if the only way I could find happiness was through substance use. This is probably due to reading too much fiction, but I’m sure that some of these fears aid to the rationalizations behind banning these drugs.  Interestingly I suppose the exact same thing could be said of alcohol and alcoholism.

Overall I think that there is definitely potential in these now illicit drugs, although legalizing them seems like a huge step if it is done appropriately I think that they could in fact help at least some people.  We have yet to find medications for many anxiety and stress related disorders that help everyone who is afflicted.  It seems to me that trying to find ways to help more people is a good thing (though I do personally believe that we should “start with what we’ve already got” in terms of treatment), and that if these illicit but mostly harmless drugs can help some of these people, then let’s give it a shot.

Going further to the idea of legalizing drugs like MDMA for everyday use is where I, and most people, seem to become conflicted.  I understand and support Marissa's argument that it's possible that legalization and subsequent regulation of the production of these drugs will lead to "cleaner" or even "safer" products that may not have quite so large of a possibility for bad hallucinogenic experiences.  I definitely think, that given the qualifications for a schedule I drug (i.e. a high potential for abuse and no currently accepted medical use in treatment), that drugs like MDMA should be reclassified.  It makes no logical sense that MDMA should be more highly controlled than cocaine, methamphetamine, or other highly addictive drugs, given its seemingly much less addictive properties (you can find a list of drugs and their classifications here: http://www.usdoj.gov/dea/pubs/scheduling.html).  A big part of me, for whatever reason (maybe it's DARE and all of those "this is your brain on drugs" commercials when we were little) still isn't ok with the idea of just legalizing MDMA altogether.  My hesitation is definitely something I'll continue to think about; if there's no logical reason for my opinion, I'll have to do some reevaluation.

I hope everyone had a great break! It has been very interesting to read over the comments people have made. I have to agree with Jenna when she says that drugs with therapeutic effects should be made legal, at least for medical useage. However I wonder why only THOSE drugs should be made legal, as opposed to ones that at the moment do not appear to have any kind of medical benefit. What is so "dangerous" about allowing these types of things to be sold in the same way that cigarettes or alcohol are.

We spoke some in class about why these drugs have such a bad reception. I know we talked a little bit about the history of illicit drugs, but I wonder if some of it has to do with historical usage. Many of these drugs were isolated in the lab or used by native American populations, but at least in class it didnt seem like many of them had been used much in Europe, though alcohol and tobacco were. Perhaps it was some kind of us/other concept that remained until the drugs became more popular in the 60's. And then again it was another kind of dichotomy, the upstanding moral citizens verses "those crazy radical kids" which led to them becoming so "wrong" and bad.

One part of the deal here is that there is this major stereotype that drug use causes a person to not be a productive member of society. While I am sure that happens in some instances, I have met quite a few people at my internship at Prevention Point of Philadelphia, a syringe exchange program, and have met quite a few heroin users that definitely do not fit the stereotypical "drug user" role. They can hold jobs, they pay their taxes, etc, and use heroin too. Why is it not their choice to do so?

Another question is if these drugs were made legal, would they be more "clean" or "safe?" I don't know about how this has works in countries where pot is legal, if the drugs end up being mixed less with other drugs. How many of the bad effects from LSD etc come from their being cut with other drugs?

Also I was wondering if these drugs were able to be used for medical treatments, how should they be tested? How would we be able to ensure safety (should we?) when dealing with these types of pharmaceudicals?

It seems like people have already brought up a lot of interesting questions and topics in the forum, and I’d like to comment on the issues concerning informed consent that have been mentioned by several people above.

I’m not sure how many of us are currently doing research with human subjects, but the significance of obtaining consent for participation, is something that I’ve personally had a lot of opportunities to think about during my project working with elderly patients who have Alzheimer’s. Like with any research, we have to obtain consent from all of our subjects- we give them a form and they sign it (if they still have the ability to write their name; otherwise this step is done verbally and we also obtain written consent from their caregiver). However, to be honest I am quite sure that some of our subjects who are in the severe stages of AD do not have any idea that they are in a study even though we have been working with some of them for over three months, and sometimes this makes me feel uncomfortable. Perhaps the thing that I dislike the most about research is that sometimes I feel like I am forcing people to do things. Most of our subjects seem to enjoy working with us and our computer exercises, but it is not at all rare for subjects to express feeling tired, bored or unhappy about what we are doing. Of course, most treatments have some unpleasant component to it; if we didn’t continue to stick to treatment just because it is a mildly unpleasant, we would probably not get to experience the positive effects. So I know that we can’t let people drop out simply because they complained about some part of the treatment being a little bit unpleasant- after all, people complain all the time and one of our most important roles as experimenters is actually to encourage people to continue and push people when they are in a complaining mood. While I understand this, I find this hard to justify sometimes, because I don’t feel as if I have obtained full consent from the subjects themselves in the first place.

While I do think that research on the possible use of psychedelic drugs is very important, I also think that conducting research on these drugs would be challenging because it could be difficult to monitor the side effects and participant consent. When we are testing substances that could potentially be so dangerous, it will probably be important to stop the administration of the drug whenever physicians see even the slight signs of adverse effects. Granted, most of the effects of the drugs aren’t supposed to be too bad (as Professor Grobstein noted in class) there also have been self-reports from people who have suffered severe dangerous effects after taking these drugs. But if we stopped people in this way, will we really be able to see the full positive effects? Also, what if an experimenter noticed signs of some negative effects and wanted to stop the administration of the drug, but the patient wanted to continue because he didn’t want to go back to suffering from the original disorder (like PTSD)? The informed consent must be composed REALLY carefully, because if the person had perceived that volunteering for the study means getting treatment in return, the subject would probably feel very unhappy that he did not get the full treatment that was promised to him. As Liz mentioned in class, in the end it really is about cost vs. gain. There may be some risks, but if the original condition is so debilitating you might want to take a risk, even if that might mean suffering from some negative effects. The assumption seems to be that these drugs will be used for people who are suffering from really severe forms of depression, fear and anxiety, but can we really depend on such individuals to make judgments about what psychological changes the drugs are promoting and make accurate cost vs. gain judgments? I know that the studies are performed under careful monitoring by professional experimenters, but who gets to choose whether the benefits are outweighing the costs during treatment, the subject or the experimenter?

I enjoyed our topic of discussion on Tuesday- Illicit drugs & their therapeutic potential.  I think our discussion raised many interesting and controversial issues.  Despite the recent evidence (studies we read about) supporting illicit drugs for therapy, I am still a little skeptical.

First, during the presentations, I remember Liz talking about the 'crashing' following using the drug- for example, Ecstasy users who use the drug on the weekends, experience "suicidal Tuesdays" and bad, serious "mid-week blues."   These effects occur days after taking the drug- so, when considering using these drugs for therapy, I think it is very important that we consider the effects the drug may have after being ingested, even a week later- not just the effects for the 8 hour therapy session where the drug's main effect is being experienced by the patient and supervised by a therapist- but what about a few days later when the patient is not with the therapist and is feeling these "suicidal Tuesdays"??  I think this could pose many problems especially for patients with PTSD and other disorders who may even have more intense feelings of "suicidal Tuesdays" and "mid-week blues" than the normal, healthy recreational Ecstasy user.  I think we need to think about the crashing or coming off of these drugs when we are considering them for potential treatments.  Would the effects during the eight hours of the therapy & drug session outweigh these after-effects of the drugs like "suicidal Tuesdays"?  I'm not too sure myself, but I think we must consider these things when investigating these drugs for therapeutic use. 

The potential harmful effects of these drugs need to also be investigated before we begin to use them- might these drugs have long-term effects on memory?  I think we need to do more studies investigating the effects of these drugs on the brain- and this most likely means using fMRI methods- which can be helpful, however, some of the smaller more micro changes occurring in the brain cannot be seen using brain imaging, so maybe in the future we will have better ways of investigating the effects of these drugs on the brain, cognition, and behavior.   Maybe the changes or damages these drugs are inflicting on the brain are too small for us to "see" right now with our current technology- I am still skeptical that using these drugs does not have any harmful or long-lasting side effects on your body or brain. 

Also, some people for example with the congenital heart defects have very bad reactions to some of these drugs, even death- so I think if we decide to use these drugs for therapeutic purposes a list of "exclusionary" criteria need to exist so people with these defects who may easily be harmed by the drug are excluded from taking it. 

I think that the evidence shows that MDMA has treatment potential for people diagnosed with anxiety “disorders”. While I understand the value of pursuing further research for the treatment of different anxiety “disorders” with MDMA, I do not understand why we cannot make use of the prescription drugs we currently use to help people with these “disorders”. If MDMA works directly by mimicking serotonin and working through serotonin pathways, why cant we use SSRIs to treat anxiety related disorders? Also, I think research should focus on the similarities between SSRIs and MDMA, and specifically compare the effectiveness of both drugs in treating people with anxiety disorders. I think that in order to make people more accepting of MDMA as a treatment for anxiety, studies need to prove why MDMA treatment would be more effective than SSRIs or SSNRIs.

I wonder if MDMA would make a person diagnosed with anxiety more functional. I think that before these drugs can be used for treatment, the pathways by which they function and interact need to be further elucidated. People who have taken these drugs recreationally all report very different symptoms and react to situations very differently under the influence of these drugs. The action of these drugs within the brain and other bodily systems is still very unpredictable. In order to convince the public to accept these drugs as a treatment option they need to be completely understood. At this point I understand that research on the method of action of these drugs is limited, but if given a chance I think that some very interesting information could come out of these studies.

I would just like to reiterate Liz’s feelings – thanks for a fun and interesting discussion Tuesday night. Psychedelic drugs certainly provide enough controversy; they deal with everything such as their proposed medical benefits/harms, how they should be used, how they affect our bodies, how history has affected our ideas concerning these drugs, and much much more.

I also have some discussion topics that we touched on in class, but may be beneficial to further analyze through this forum. The first general idea concerns patient selection. Informed consent is an ethical standard considered extremely important in our medical environment. It is sometimes defined as “understanding, appreciating, reasoning, and expressing a choice.”

Can it truly be provided by patients suffering from psychiatric illnesses? How about from children or the elderly?

What if there are other options (such as holotropic breathing – basically induced hyperventilation) that could generate similar effects as these drugs? Should these psychedelics only be considered last resort options?

Should parents or family members be able to make decisions for others? Should the courts? Should doctors? If so, in what circumstances?

Phase trials are crucial for obtaining more research and learning how these drugs work in the human body. However, how should patients be selected and the trials be run, especially when we’re not sure how the drugs work and cannot necessarily predict their outcomes?

The second topic deals with the socio-cultural aspect of these drugs – parts of this topic were definitely discussed in class. Some more questions…

How much are our views today concerning these drugs affected by the hippie/techno backlash? Are we ready to change? Should we change? In what ways (e.g. make psychedelics generally legal or restrict them solely to medical settings)?

Are these drugs really much different than, say, morphine? What about as compared to alcohol?

What is the potential/risk for abuse? Is this likely?

How could their use be regulated safely and effectively?

Would allowing these drugs potentially promote other drug use that may not be so beneficial?

I know those are a lot more questions, but just find something that interests you and run with it! Excited to see what others have to say about this broad spectrum of ideas.

Thanks!

- Elliot