In Year 12 a new girl joined my class in a school way out west of Melbourne. Her hair was bleached platinum blonde, we liked the same music, and I shared her periodic inclination not to attend school. She came less and less – floating down the halls, speaking in an ironic monotone – but turned up one day bearing tickets to hear Timothy Leary talk. She’d won them from a radio station dial-in. (She won lots of the dial-ins, being at home so often.) It was 1989 and I wasn’t quite sure who Leary was beyond some vague idea he’d been into LSD and was cool.
I don’t remember a word Leary spoke. (I remember feeling like an imposter, sitting in the small lecture theatre full of appreciative sophisticates.) But on our way there my friend told me why she didn’t come to school. She was addicted to Valium and spent many afternoons seeking new doctors to whom she told the same fiction: she couldn’t sleep, her mum and dad had just broken up, and she’d found relief in the past, after her boyfriend died, with a week of Valium. She said the story was very effective. Later that year, a local pharmacy called the school after she presented an obviously doctored script (she’d changed the quantity of pills prescribed from five to 50). The school cut her a deal: a regular, medically supervised supply of the drug on the proviso that she told no one, turned up every day, and went straight to rehab at the end of the year.
The school had also saved my life, many times, in particular by sending me on exchange to the US for a year when I was 15, after I was caught smoking on campus, again. I didn’t want to go. My homeroom teacher looked to the heavens and then back at me. “Hitchcock, you’re going.” And set up a meeting with my parents, to tell them too. By a further miracle I landed at one of the most progressive private schools on the east coast, stayed with a classics teacher, a famous YA author and their two children, and was seamlessly taken under the wing of the artsy hardcore-music crowd. These were kids filled with curiosity about themselves and the world. Thus began my foray into illicit drugs.
I’d smoked tobacco since I was very young and vomited my share of Brandivino (Was it wine? Brandy? Who knew, but it only cost three bucks) into the toilets at blue-light discos all over Melbourne, but that was it. The drug of choice among my new friends was cannabis. I’d been around heavy cannabis users for years – bogan boys with bongs in fist day and night – but had never been interested. My new friends smoked differently. In circles at parties, listening to Led Zeppelin and Black Flag. Or talking. About interesting things. And laughing. I loved cannabis: there was no vomiting and no hangover. Music sounded incredible. Food tasted incredible. A touch, a kiss. Incredible.
About three months before I was due to fly home, one of the senior boys (a guy with an interest in folklore and psychedelics) asked if I wanted to drop acid with him. I did want to. He took it very seriously and spent a few weeks preparing me for the experience. He educated me about the importance of set (my pre-trip emotional state) and setting (where we tripped) and reassured me that the stuff would be high quality and that he’d keep me safe. It was and he did. He said it would change the way I saw the world, blow my mind, change my life. It didn’t. But given my mind had already been well and truly blown by that year in that place, the little square of LSD-impregnated blotting paper had a lot to compete with. We spent the night dancing and laughing. By the time inanimate objects stopped gyrating and trailing and I wanted to sleep, I found I couldn’t. So I was extremely tired the next day. And that was it. I went back to smoking cannabis on the weekends until I came back to Australia and found myself, as before, disinclined to hang with the bogan bong smokers.
In 2017, Australia’s Therapeutic Goods Administration (TGA) rescheduled cannabis from schedule 9 of the Poisons Standard (“prohibited substance”) to schedule 8 (“controlled drug”), which effectively sanctioned doctors to prescribe it for medicinal purposes. We talked about this change in the hospital where I work, but no one seemed to know what we could prescribe it for, or the steps necessary to obtain permission to prescribe it, or the cannabis preparations that were actually available to prescribe. What would we write on our script pad? Weed. 1 ounce. Smoke as needed (via joint or bong)?
I started looking into the matter seriously in April this year. In order to prescribe medicinal cannabis (MC) for a patient, I needed to submit a Special Access Scheme application to the TGA, nominating a specific cannabis preparation, justifying the need for the drug, and documenting that all other available treatments had been unsuccessfully trialled and why they were unsuccessful and that all the patient’s treating doctors agreed with the trial. If approved, I then needed to apply to the Victorian health department for its approval. If the Victorian health department gave me that approval, I needed the patient to sign a consent document and agree to frequent follow-ups. At that point, I could finally write a prescription and send the patient off to the pharmacy of their choice. The pharmacist would (hopefully) order the product and (given MC is not subsidised under the Pharmaceutical Benefits Scheme) it would cost the patient anywhere between $150 and $350 for a month’s supply.
At the time, I was working in a busy, bulk-billed, public-hospital specialist clinic with a long waiting list of mostly unemployed patients. I estimated that completing the paperwork necessary to prescribe this treatment to a single patient (one who could afford it) would require at least four hours of my time. Prescribing enough opiates to kill them and their family, by way of comparison, would take me 30 seconds, max.
It was, however, theoretically possible to become an “authorised prescriber” and bypass this administrative load. And so this was what I pursued. I completed a medicinal cannabis course, and conducted and documented a major literature review of the current medical research. My final application to prescribe five different MC preparations for seven clinical indications, following the TGA template, stretched to 52 pages.
In order to submit the application to the TGA I needed an ethics committee to assess and approve it. My specialist college, the Royal Australasian College of Physicians, declined to do this, just as the Royal Australian College of General Practitioners and the Royal Australian and New Zealand College of Psychiatrists declined to assess the applications of two of my colleagues. They suggested we try a university or hospital ethics committee. I heard that the National Institute of Integrative Medicine (a not-for-profit education institution based in Victoria) had an ethics committee composed of doctors and scientists who were willing to assess such applications. I contacted them – they were knowledgeable, rigorous and supportive – and sent it in for their appraisal. (I was granted ethics approval. My application is now with the TGA.)
Studies show that approximately 35 per cent of the Australian population aged over 14 years has tried cannabis. Data from the Australian Institute of Health and Welfare shows that in 2016 approximately one in four adults in their 20s and approximately 10 per cent of people aged over 14 years reported recent use of cannabis. It’s hardly a fringe dweller’s criminal activity. I know more people who take or have taken cannabis than not. You probably do too. Netflix even has a cannabis cooking show.
In July this year, South Australia’s attorney-general, Vickie Chapman, announced that the state intended to get tough on cannabis possession: introducing prison sentences and quadrupling fines. Her rationale was a 2012 shooting murder of a teen by another teen who tested positive for alcohol, ecstasy and cannabis. In response to this proposal, Dr Alex Wodak from the Australian Drug Law Reform Foundation said, “Most people who smoke cannabis crawl into a corner and fall asleep or they eat ice cream. They don’t go around murdering people … This is just nonsense.”
Australia already spends twice as much on the (evidently ineffective) policing of drug supply as it does on health and social services aimed at reducing demand, preventing harm and promoting treatment. Use of illicit substances has risen consistently since prohibition in the 1970s. What are we to do? Incarcerate ever-increasing segments of our population as they’ve done in the US, causing great suffering? To no avail?
Australian Greens leader Senator Richard Di Natale, a trained doctor, has said, “Right now there are many millions of Australians who have made this choice [to use cannabis recreationally] and the question for us is, are we going to make this a safer choice, or are we going to continue to have them exposed to serious harm?” Legalising, regulating and taxing cannabis for recreational use would unclog the criminal justice system and raise billions of dollars in tax revenue, which could easily fund education and comprehensive substance-abuse treatment programs. The Parliamentary Budget Office has estimated that legalising cannabis would generate almost $2 billion per year for the Australian economy. If a government wanted to be “tough on crime”, it could instantly wipe out entire criminal empires by legalising cannabis.
None of the countries that have decriminalised recreational drugs has seen an increase in the use of the substances. Overdoses, criminality and related violence are usually the result of the prohibition rather than of the drugs themselves. Decriminalisation has proven to reduce these things.
There are more than 30 medicinal cannabis preparations available for prescription in Australia. Most are in oil form. They all contain pure delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) in varying ratios. Chemists have isolated and extracted these two cannabinoids from what is a highly complex and diverse ancient plant medicine that contains more than 400 chemical entities and more than 60 cannabinoids. They are the plant’s two most abundant cannabinoids. THC is the major psychoactive substance, whereas CBD acts on cannabinoid receptors in the brain and periphery that don’t make you high but do have psychoactive effects such as decreasing anxiety and psychosis. CBD is also purported to be a potent anti-inflammatory.
I am filled to the brim with facts about the effects and clinical efficacy of these two chemicals in their variety of big pharma–determined ratios. Prettily packaged, they’re indistinguishable from anything else in my pharmacopeia. It’s what we do in medicine. Reduce and control. Package and sell. There are positives to this: accurate dosing, uniformity of preparation for clinical trials. And for those who have cannabis-treatable conditions and don’t have access to their own plants or a dealer, or for those who are cannabis-naive or “anti-drugs”, it’s both literally and figuratively the most palatable way to take medicinal cannabis.
The use of the cannabis plant, as a food, fibre and medicine, is estimated to date back anywhere between 5000 and 12,000 years. As such, it’s one of humanity’s oldest cultivated crops. Botanists debate the taxonomy, but in common parlance the two main subspecies are Cannabis sativa and Cannabis indica. Most varieties of cannabis produced in Australia (which is predominantly via illegal hydroponic set-ups) are hybrids of these subspecies, usually ultra-high potency, indica-dominant breeds, as the plants are shorter, bushier and offer a far higher bud yield. It is said that indica is more sedating whereas sativa is euphoria-inducing and cerebral. However, this turns out to be a mythical division. Dr Ethan Russo, an American physician researcher and one of the field’s top scholars, states:
The differences in observed effects in Cannabis are … due to their terpenoid content, which is rarely assayed, let alone reported to potential consumers … Sedation in most common Cannabis strains is attributable to their myrcene content, [while] a high limonene content (common to citrus peels) will be uplifting on mood.
It’s a great pity that research into this plant was halted with the dawn of prohibition. If it had not been, I might, as a doctor, have more tinctures to work with. Or access to a scientifically validated menu of whole-herb preparations. We might have clearer answers about what component works best for what condition. Or know if there’s true benefit from using whole-herb preparations due to the so-called “entourage effect” whereby the numerous other chemical compounds augment the effects of THC and CBD.
The major medical institutions and colleges have been reticent to offer their stamp of approval to the THC/CBD treatment. They have, in the main, cautiously pointed towards the need for larger, more rigorous and standardised trials. (Which is ironic, as the caution and reticence of the major medical bodies have often been a major obstacle to such research.) The Australian Medical Association’s president, Dr Tony Bartone, commented, “Unfortunately, this is a case where the cart came before the horse really significantly because of a considerable amount of political and media interest in pushing this product to the market before it’s gone through its usual channels of preparation and supply and logistical surety.” And to that I’d reply that unfortunately the horse was shot dead in the 1970s and the cart is overflowing with patients who are suffering and have not found relief from currently available treatments.
The main reason patients ask me if I can prescribe cannabis is to treat chronic pain – from arthritis, fibromyalgia, bone or nerve damage. Before medicinal cannabis was legalised I knew three people from separate social circles who were accessing black-market CBD oil to treat their pain. One friend said she got it “from a friend of a friend who gets it from some guy in Sydney”. She wasn’t quite sure what it was.
Pain, according to the International Association for the Study of Pain, is both a “sensory and emotional experience”. The same can be said for pleasure. We are, generally, pain-avoiding, pleasure-seeking animals. That doesn’t describe all of who we are as humans, but it is a major motivating factor in our lives. Joy, comfort, love, euphoria and relief are all pleasurable sensations and emotions. We reap pleasure where we can: sex, sport, conversation, a new dress, a fine meal.
People love to consume substances that bring pleasure, be they alcohol, sugar or illicit drugs. The experience of pleasure, however one manages to get it, and despite puritanical instincts to the contrary, is mostly good. So long as it does not result in harm to others. Life can be painful or dreary, unfair or intolerable. We do what we can to balance the scale. And, given many are willing to take risks to feel pleasure, chasing it can have negative consequences. Most people, to a greater or lesser extent, are readily willing to exchange aliquots of their health or life span to experience pleasure.
We all know that over-eating, smoking tobacco and drinking alcohol (any amount, according to the latest data) will cause harm, and yet the obesity statistics and the widespread smoking and drinking practices of our population tell us that the trade-off is something a majority of people (even when armed with knowledge of the consequences of their actions) are prepared to make.
Medicine has a puritanical streak. We look at the fat and the “substance-abuse-disordered” as weak and greedy, rather than as people just trying to get by in a world that may offer them little else in the way of comfort. We don’t seem to know how to incorporate a human’s need for pleasure or solace and the fact that they’ll take it where they can. A few things have snuck through prohibition: alcohol, tobacco, junk food. As a doctor I’m sanctioned to dull your pain as long as doing so does not cause you pleasure. The euphoria that might arise from the ingestion of cannabis is listed as an “adverse effect”.
You’d think a drug that decreases pain and offers some pleasure would be considered the ideal medicine that a humane doctor could prescribe. The side effects are good feelings! If you break a limb I can saturate you with opiates to stop your pain, but if the pain you seek to ameliorate is emotional (or if the opiates induce in you some form of pleasure) you will be deemed a “drug seeker”. The vast and ever-expanding pharmacopeia of diverse substances that are used illegally for recreational purposes fall under Australia’s schedule 9 of prohibited drugs. Large portions of our population risk legal consequences to partake in them. Given that the production and distribution of these substances has been left in the hands of the illegal underground, the lack of quality control also means it’s difficult to know what else you’re risking.
Of all the drugs reported to induce feelings of joy and pleasure, MDMA (“ecstasy”) is perhaps the most prominent. Yet in all the years I’ve worked in hospitals, I have never seen a patient admitted because they have ingested MDMA. In 2017, 20 people were hospitalised and three people died after consuming a drug, distributed around Melbourne that weekend, that they believed was MDMA. This received major news coverage, mostly claiming the harm was caused by “super-potency”. The fact that toxicology reports subsequently ascertained that the drug was not MDMA at all but rather contained the novel and largely unknown research chemicals NBOMe and 4-FA apparently wasn’t newsworthy. Studies show that the media pays little attention to deaths resulting from prescription medications (other than opiates) or alcohol or tobacco, but they go nuts over the few deaths that are in any way linked to amphetamines, ecstasy or heroin. They can’t report deaths due to cannabis, because you cannot die of a cannabis overdose.
Victoria Police decided not to warn the public about the particular compounds in the fake ecstasy, and instead urged the public not to take illicit substances, full stop. Job done.
In September this year, two people died and a number of others were hospitalised after consuming pills or caps containing unknown substances at the Defqon 1 dance festival in Sydney. After walking back her initial promise to shut down the festival, the NSW premier, Gladys Berejiklian, has established an expert panel on how to make music festivals safer, but it will not consider pill testing. “The last thing we would want to see is people getting a false sense of security,” Berejiklian said.
In 2013, after a similar incident in which a young man died, Barry O’Farrell, Berejiklian’s predecessor, said to reporters, “How many times do people have to be told that these things can kill?”
If by “things” he meant the lack of access to pill testing, he was dead right.
In 2009 psychiatrist and academic Professor David Nutt was forced to resign from his appointment as chair of the UK Advisory Council on the Misuse of Drugs. Five other scientists quit the council in the wake of his sacking. He was sacked because of a conflict between the science and government policy. Nutt collated reams of international scientific and epidemiological data and came to a number of conclusions that the UK government didn’t want to hear, the most inflammatory of which was that alcohol and tobacco were more dangerous than cannabis, magic mushrooms, LSD or ecstasy. Describing the “illegality-logic loop” that was common among his detractors, Nutt wrote:
This is an example of a conversation I’ve had many times with many people, some of them politicians:
MP “You can’t compare harms from a legal activity with an illegal one.”
Professor Nutt “Why not?”
MP “Because one’s illegal.”
Professor Nutt “Why is it illegal?”
MP “Because it’s harmful.”
Professor Nutt “Don’t we need to compare harms to determine if it should be illegal?”
MP “You can’t compare harms from a legal activity with an illegal one.”
As a teen, I dropped some stats about the low toxicity and non-addictive properties of cannabis on my dad. We were at the dinner table, Channel 9 news blaring in the background, and he’d just cracked his second VB for the night. He hit the roof. “I don’t want to hear any more of that bullshit. You start with marijuana, you’ll end up on heroin.” The old “gateway” drug hypothesis is false, proven both by rigorous studies and the rates of use quoted above. Most people who use non-prescription cannabis do so occasionally, socially, happily, or to “self-medicate”. Another urban myth from my youth was that “drug pushers” were injecting people with amphetamines against their will, rendering them hopelessly addicted. One dose was all it took, and you’d be a helplessly loyal customer for the rest of your life. Scary. (As if a dealer would give anyone anything for free.)
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 (psychiatry’s bible) has scrapped the term altogether and replaced it with “substance use disorder”. The book lists 11 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 1pm 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 10 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”, challenge the theory that drugs can be innately addictive. The studies showed that rodents kept in empty cages consumed 19 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.
In March, 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 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 (or 43 per cent) of people in Australia aged 14 or older 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 12 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 Heath Organization “has unambiguously called upon countries around the world to stop criminalising people who use drugs”.
The inquiry submitted 50 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 in August this year. 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. The Coalition Opposition has already declared that it will close down the Richmond safe injecting room if elected in November – despite the fact that in two months of operation 120 potentially fatal overdoses have been 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”.
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.
Earlier this year 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 20 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 10 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 deaths 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.
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 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 50 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 this year 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 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 90-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-MeO-DMT) 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 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. Psychedelics are thought to 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, non-toxic profile, short treatment duration and 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 author, 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 very 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 socioeconomic 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 traces 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 offer 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. The idea that the criminalisation of users results in a strategy of harm maximisation is a finding of almost every major international health and human rights organisation, as well as local inquiries and drug specialists. 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 back on what we might discover when taken by the hand and led to places we might never have reached alone.
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