Understanding Risk

Just Say No’ — Or ‘Just Know’?

My son Johnny, a high school junior this fall, is learning all kinds of new things — academic, social and physical. At 16, he seems fearless. And, as a typical American teenager, he faces two risk-sensitive issues: drug use and sexuality. So I read with keen interest a recent report by the Centers for Disease Control and Prevention that addresses both of these hot-button topics.

Its gist: Teen drug use is up, but fewer young people are having sex, and more of those who do practice ”safe sex.” A decade ago, a third of students surveyed said they had experimented with marijuana. By 1999, almost half had tried pot. But during the same time span, the number of students having sex declined from just over half to slightly under half. Most important: Of those who were sexually active, 58% reported using a condom in 1999, compared with 46% in 1991.

I wanted to know why risky teen sexual activity decreased while drug use rose. A look at our sex and drug education offers an answer: In a nutshell, while we’d all prefer that they abstain from both, we try to reason with teens about sex, but we scare them about drugs.

What Happens When Psychedelic Treatment for PTSD Turns Into a Bad Trip

I lay flat on my back, pouring sweat and heart racing, in a hotel room with a woman who had just overdosed me.

Let’s call her Sarah. To be clear: Neither of us was here to party. Sarah, in fact, was a therapist, a licensed clinician. Outside of her office hours, she offered patients like me psilocybin and MDMA, for PTSD and treatment-resistant depression. She did this at fairly extreme risk to her career, because, as she said, she believed in it. This was my second time trying a guided, high-dosage cocktail of psychedelics to address my ongoing PTSD, a result of my surviving the 2008 terrorist attack on the Taj Mahal Hotel in Mumbai.

The goal with such an experience is to “go inside” yourself, surrender the trappings of the ego, and through that process transcend or soothe damage caused by a fundamental trauma. The idea is fairly simple: By letting go of yourself (commonly known as ego loss, or ego death), you become one with everything else. Put another way, you can experience a sense of wholeness that transcends yourself, and that wholeness can be very healing. In conversations with underground practitioners, I learned this was achieved through taking a combination of “medicines.” (For example: MDMA, the main ingredient in what is commonly referred to as ecstasy, paired with psilocybin, otherwise known as magic mushrooms.) But equally important, they said, was the guided support for the experience itself, followed by integration (processing of the experience) with that same guide. My first trip had been very positive and had resulted in a sense of peace and calm with respect to the particular anguish I had been experiencing for years. Indeed, recent scientific research increasingly supports the potential for MDMA-assisted psychotherapy to be “an innovative, efficacious treatment” for PTSD.

Human Hallucinogen Research: Guidelines for Safety

There has recently been a renewal of human research with classical hallucinogens (psychedelics). This paper first briefly discusses the unique history of human hallucinogen research, and then reviews the risks of hallucinogen administration and safeguards for minimizing these risks. Although hallucinogens are relatively safe physiologically and are not considered drugs of dependence, their administration involves unique psychological risks. The most likely risk is overwhelming distress during drug action (‘bad trip’), which could lead to potentially dangerous behaviour such as leaving the study site. Less common are prolonged psychoses triggered by hallucinogens. Safeguards against these risks include the exclusion of volunteers with personal or family history of psychotic disorders or other severe psychiatric disorders, establishing trust and rapport between session monitors and volunteer before the session, careful volunteer preparation, a safe physical session environment and interpersonal support from at least two study monitors during the session. Investigators should probe for the relatively rare hallucinogen persisting perception disorder in follow-up contact. Persisting adverse reactions are rare when research is conducted along these guidelines. Incautious research may jeopardize participant safety and future research. However, carefully conducted research may inform the treatment of psychiatric disorders, and may lead to advances in basic science.

Manual of Psychedelic Support

The Manual of Psychedelic Support is a comprehensive guide to setting up and running compassionate care services for people having difficult drug experiences at music festivals and similar events. The Manual grew out of the work of its original creators at KosmiCare, the psychedelic care service at the iconic Boom Festival in Portugal. Whilst psychedelic care services have been in operation for decades, and have grown in number and in scope in the past few years, a general guide on how to establish and run them did not exist in the public domain, nor indeed—beyond training manuals for specific organisations—at all. We envisaged a work that would address all aspects of such a project, containing material to guide the care service leader, team leads and care givers, and those fulfilling vital supporting roles (such as psychiatrists and nurses) through the entire gamut of preparation, training, logistics, operations, and the wrap-up of a care service.

The Globalization of Ayahuasca: Harm Reduction Or Benefit Maximization?

Ayahuasca is a tea made from two plants native to the Amazon, Banisteriopsis caapi and Psychotria viridis, which, respectively, contain the psychoactive chemicals harmala alkaloids and dimethyltryptamine. The tea has been used by indigenous peoples in countries such as Brazil, Ecuador and Peru for medicinal, spiritual and cultural purposes since pre-Columbian times. In the 20th century, ayahuasca spread beyond its native habitat and has been incorporated into syncretistic practices that are being adopted by non-indigenous peoples in modern Western contexts. Ayahuasca’s globalization in the past few decades has led to a number of legal cases which pit religious freedom against national drug control laws. This paper explores some of the philosophical and policy implications of contemporary ayahuasca use. It addresses the issue of the social construction of ayahuasca as a medicine, a sacrament and a “plant teacher.” Issues of harm reduction with respect to ayahuasca use are explored, but so too is the corollary notion of “benefit maximization.”

Psychedelic Microdosing Benefits and Challenges: An Empirical Codebook

Background: Microdosing psychedelics is the practice of consuming very low, sub-hallucinogenic doses of a psychedelic substance, such as lysergic acid diethylamide (LSD) or psilocybin-containing mushrooms. According to media reports, microdosing has grown in popularity, yet the scientific literature contains minimal research on this practice. There has been limited reporting on adverse events associated with microdosing, and the experiences of microdosers in community samples have not been categorized.

Methods: In the present study, we develop a codebook of microdosing benefits and challenges (MDBC) based on the qualitative reports of a real-world sample of 278 microdosers.

Results: We describe novel findings, both in terms of beneficial outcomes, such as improved mood (26.6%) and focus (14.8%), and in terms of challenging outcomes, such as physiological discomfort (18.0%) and increased anxiety (6.7%). We also show parallels between benefits and drawbacks and discuss the implications of these results. We probe for substance-dependent differences, finding that psilocybin-only users report the benefits of microdosing were more important than other users report.

Conclusions: These mixed-methods results help summarize and frame the experiences reported by an active microdosing community as high-potential avenues for future scientific research. The MDBC taxonomy reported here informs future research, leveraging participant reports to distil the highest-potential intervention targets so research funding can be efficiently allocated. Microdosing research complements the full-dose literature as clinical treatments are developed and neuropharmacological mechanisms are sought. This framework aims to inform researchers and clinicians as experimental microdosing research begins in earnest in the years to come.

Trends in Drug Use among Electronic Dance Music Party Attendees in New York City, 2016-2019

Objective: Electronic dance music (EDM) party attendees are a high-risk population for drug use and associated adverse effects. We examined trends in past-year drug use within this population to better inform prevention and harm reduction efforts.

Methods: Each summer from 2016 through 2019, we used time-space sampling to survey a cross-section of adults entering EDM parties at randomly selected nightclubs and at dance festivals in New York City. Ns ranged from 504 (2019) to 1,087 (2016). We estimated log-linear trends in past-year use of 16 different synthetic drugs or drug classes.

Results: Between 2016 and 2019, estimated past-year prevalence of use of ketamine increased from 5.9% to 15.3% (a 157.6% relative increase; P=.007), LSD use increased from 9.9% to 16.6% (a 67.7% relative increase, P<.001), powder cocaine use increased from 17.3% to 35.2% (a 103.5% relative increase, P<.001), and GHB use increased from 1.0% to 4.2% (a 311.8% relative increase; P=.002). Past-year use of ≥3 drugs increased from 12.7% to 20.5% (a 61.4% relative increase; P=.013); however, estimated past-year use of unknown powders decreased from 2.0% to 1.1% (a relative 44.7% decrease; P=.038) and ecstasy/MDMA/Molly use was stable across years (at 25.0-28.5%; P=.687). Conclusions: Reports of powder cocaine, LSD, ketamine, and GHB are becoming more prevalent among EDM party attendees. Prevention and harm reduction efforts are needed to address increasing use. Research is also needed to examine whether increasing media coverage of medical use of ketamine and other psychedelics affects prevalence of recreational use.

Adverse reactions to psychedelic drugs. A review of the literature

The use of naturally occurring and synthetically derived compounds for their “psychedelic” effects has been a part of human culture for thousands of years. The basic pharmacology of the major synthetic psychedelic compounds (primarily lysergic acid diethylamide [LSD]-25) is described and reference is made to their potentially beneficial psychological effects. Adverse reactions, defined as dysphoric and/or maladaptive/dysfunctional responses to the use of these drugs, sometimes require careful clinical judgment in order to diagnose. These reactions can be effectively classified along a temporal continuum. Acute, short-lived reactions are often fairly benign, whereas chronic, unremitting courses carry a poor prognosis. Delayed, intermittent phenomena (“flashbacks”) and LSD-precipitated functional disorders that usually respond to treatment appropriate for the non-psychedelic-precipitated illnesses they resemble, round out this temporal means of classification. The question of organic brain damage as well as permanent changes in personality, attitudes, and creativity in patients and normals who have repeatedly ingested psychedelic drugs is controversial, but tends to point to subtle or nonsignificant changes. Future areas for study of the psychedelics’ pharmacological, psychological, and therapeutic effects are suggested.

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