10/8/14

Falling Down the K-Hole

Over the past few years, there has been an increased interest in using ketamine to treat depression and other psychiatric disorders, such as PTSD. It is fast acting relief for symptoms of both depression and PTSD. For depression, it is effective within two hours and was reported to help a greater proportion of individuals than traditional antidepressants.  Sounds like there is tremendous potential here, right? Maybe.

A 2006 study by lead author Carlos Zarate and other researchers found that subjects receiving a single dose of ketamine “showed significant improvement in depression” within 110 minutes after injection. “Robust and rapid antidepressant effects resulted from a single intravenous dose of [ketamine]; onset occurred within 2 hours postinfusion and continued to remain significant for 1 week.” However,  it was reported by Franz Vallenweider and Michael Kometer that: “all but 2 of the patients relapsed within 2 weeks after a single dose of ketamine.”

A 2011 study (and here) confirmed the alleviation of major depressive symptoms within two hours from a single, low-dose of ketamine. Its effects lasted up to two weeks. The researchers suggested that ketamine appeared to work so quickly by increasing the synthesis of BDNF, or brain-derived neurotropic factor. The increase in BDNF is caused by ketamine deactivating a chemical that normally suppresses BDNF production. “BDNF is a nerve factor that helps brain cells grow and develop new neurons.”

A 2012 study by lead author Matthew Sanjay and others reviewed the emerging literature on the potential rapid-onset antidepressant properties of ketamine. They cited data from a 2009 study that ketamine was associated with “rapid reductions in explicit and implicit suicidal cognitions within the first 24 hours.” They also noted a report from the NIMH where patients previously non-responsive to ECT (electro convulsive therapy) “showed significant improvement in depressive symptoms.”

There were acute impairment of working, episodic and semantic memory, but it did not effect the retrieval of previously learned information. The acute impairments were also temporary. There were no residual deficits found 3 days after drug administration. The Sanjay study concluded that enthusiasm for the early ketamine studies should be tempered by concerns for the validity of these studies; that the antidepressant action is short lived; and uncertainty regarding its safety with a depressed population. “Accordingly, ketamine therapy remains a highly experimental treatment approach for MDD and adoption in psychiatric practice settings at this time is premature.”

Another 2012 article, “Ketamine for Depression: Where Do We Go from Here?” said that while adverse effects had generally been mild, some patients experienced brief changes in blood pressure, heart rate, or respiration. They supported further research of ketamine to treat mood disorders. “However, given the paucity of randomized controlled trials, lack of an active placebo, limited data on long-term outcomes, and potential risks, ketamine administration is not recommended outside of the hospital setting.”

A 2013 study reported in the American Journal of Psychiatry was a randomized controlled study. Ketamine again demonstrated rapid antidepressant effects. It added further support to studies showing that NMDA receptor modulation as a potential mechanism for “accelerated improvement in severe and chronic forms of depression.” Reservations on its use in clinical practice were again expressed because of its short action and safety concerns.

Ketamine is not a new drug. It was developed in 1962 by Parke-Davis and is used as an anesthetic in human and veterinary medicine, usually in combination with another sedative drug. It has been used for several decades as a recreational drug under nicknames such as “Special K,” “K” or “Ket.” It makes users feel disassociated or disconnected from their body and can cause hallucinations. The user can feel sleepy, sluggish, confused or clumsy. They may babble, appear drunk, or have trouble remembering who they are.

It comes as a clear liquid and a white or off-white powder. It can be injected, mixed in a drink as a date-rape drug or sprinkled on tobacco or marijuana and smoked.  It is virtually tasteless and causes a person to become disoriented, confused, suggestible, easily manipulated and compliant.

The victim is usually compliant, suggestible, and shows no overt resistance. As a result they can be easily led into a private setting and usually do not resist whatever is done to them. When given in a sufficient dose the victim has no memory of what happened. On the street this period of dissociated amnesia is called ‘being stuck in the K hole.’

The K-hole state can mimic catatonic schizophrenia, out-of-body experiences or near-death experiences. Since it is an anesthetic drug, ketamine could cause vomiting with its use. And “eating or drinking before taking the drug increases the risk of choking on one’s own vomit.” It is addictive, classified as a Schedule III drug by the DEA. Taken with other sedating drugs like alcohol, the effects of slowing or shutting down the central nervous system are increased. It is possible to overdose on it.

The 2014 Global Synthetic Drugs Assessment reported that ketamine is widely misused in East and South-East Asia; more than in the Americas and Europe. “Extensive ketamine use has also been reported in Brunei Darussalam, India, Myanmar and Singapore.” Between 2008 and 2011, 60% of global ketamine seizures occurred in mainland China and Hong Kong.

In “A Word to the Wise About Ketamine,” Alan Schatzberg noted that the data on ketamine as an antidepressant is still relatively limited. He said that without more data on what ketamine can do clinically, and knowing it can be a drug of abuse, “it is difficult to argue that patients should receive an acute trial of ketamine for refractory depression.” Waiting until there was greater understanding about its effects and risks was his recommendation. Although the recent studies are exciting and open up new avenues for depression research, “until we know more, clinicians should be wary about embarking on a slippery ketamine slope.”

The almost unbridled enthusiasm over the potential of ketamine to treat depression needs to be reined in. We don’t want to find ourselves “falling down the k-hole” instead of exploring ketamine’s potential to treat depression.

 

10/6/14

As Harmless as Aspirin?

The province of Saskatchewan seems an unlikely place to give birth to “psychedelic psychiatry”  (See Erika Dyck’s article, “Hitting Highs at Rock Bottom” and a review of her book Psychedelic Psychiatry), but it’s true. In October of 1951 a British psychiatrist named Humpry Osmond became the deputy director of a Canadian Mental Hospital in Weyburn, Saskatchewan. He immediately organized a biochemical research program in order to continue the work he had begun with hallucinogens while he was at St. George’s Hospital in London.

Not only did Osmond coin the term psychedelic, he seems to be among the first to hypothesize a chemical imbalance theory for both schizophrenia and alcoholism. Initially interested in the therapeutic properties of mescaline, Osmond noticed that mescaline produced reactions similar to schizophrenia. These findings led him to conjecture that “schizophrenia was caused by a chemical imbalance in the brain.” Oh, and he was a pioneer researcher into the psychotherapeutic benefits of mescaline and LSD for alcoholism and various mental health disorders.

Osmond heard of the discovery of lysergic acid (LSD) by Albert Hoffman and tried it himself. He discovered that LSD was more powerful than mescaline and that it produced profound changes in consciousness. By inducing a new level of self-awareness, Osmond theorized LSD could have therapeutic benefits for individuals suffering with schizophrenia. Some of his early volunteers in LSD experiments described this feeling as “a new sense of spirituality.”

According to Osmond’s co-researcher, Abram Hoffer, the idea to try LSD with alcoholics occurred one evening in 1953, when they thought that: “LSD experiences were remarkably similar to descriptions of delirium tremens, or the effects of an alcoholic ‘hitting bottom.’” They wondered if a controlled LSD-produced delirium would help alcoholics stay sober. In 1953, they gave LSD to two alcoholic patients. One person (a female) stopped drinking immediately and the other (a male) stopped six months later. Over the next ten years they tried this procedure on over 700 patients and claimed the results were similar to that first experiment. One of those alcoholics was Bill W., cofounder of Alcoholics Anonymous.

Bill’s involvement with LSD came about through his friendships with Gerald Heard, a British philosopher, and Aldous Huxley, author of the classic novel Brave New World. Bill had been a friend of Heard’s since 1944. He met Huxley through Heard. According to Pass It On, the A.A. book about Bill and the origins of Alcoholics Anonymous, it was Huxley who referred to Bill as “the greatest social architect of the century.”

Under the supervision of Humphry Osmond, Huxley used mescaline for the first time on May 5, 1953. Huxley’s short book about his experience with mescaline, The Doors of Perception, was published in 1954. Through Heard and Huxley, Bill was introduced to Osmond and Hoffman. At first, when Bill heard about Osmond’s work with LSD, he was “extremely unthrilled.” Bill was “very much against giving alcoholics drugs.” He became interested, though, when he heard Osmond and Hoffman were getting results.

Under the guidance of Gerald Heard, Bill took LSD for the first time on August 29, 1956. He was enthusiastic about his experience. He felt it helped to eliminate barriers that stood in the way of an individual’s direct experience of the cosmos and God. According to Nell Wing, then secretary to A.A., “He had an experience [that] was totally spiritual, [like] his initial spiritual experience.” Among the friends and family whom Bill convinced to try LSD was his wife Lois and his spiritual advisor, Father Ed Dowling. Watch a 1950s video of an LSD session and a discussion of its effects by Gerald Heard here.

In a letter he wrote to Sam Shoemaker in June of 1958, Bill said that he took LSD several times and had collected considerable information about it. He felt that the negative information about its “awful dangers” was far from the truth. He thought the experiments by early LSD researchers like Osmond and Hoffman showed it had no physical risks at all. “The material [LSD] is about as harmless as aspirin.” Presciently he said: “It would certainly be a huge misfortune if it ever got loose in the general public without a careful preparation as to what the drug is and what the meaning of its effects may be.”

Bill was aware of the potential dangers to A.A. that his participation in the LSD experiments could have. “I know that I must not compromise its future and would gladly withdraw from these new activities if ever this became apparent.” By 1959 Bill had withdrawn from the LSD experiments.

Despite Bill’s assertion that LSD is about as harmless as aspirin, evidence now suggests there are several potential problems with LSD. It can temporarily impair your ability to make sensible judgments and understand common dangers. So you are more prone to accidents and injuries. It may cause temporary confusion, give you problems with abstract thinking, memory and attention span.

It can also trigger panic attacks or feelings of extreme anxiety. There have been some cases of LSD induced psychosis in seemingly healthy people. Individuals with schizophrenia and depression can see their symptoms worsen under the influence of LSD. Chronic use of LSD “alters gene expression profiles in the medial prefrontal cortex.” Many of the processes altered by chronic LSD use have also been implicated in the pathogenesis of schizophrenia.

The recreational use of LSD was entirely unexpected to Albert Hoffman, the discoverer of LSD, who said:

I had no inkling that the new substance would also come to be used beyond medical science, as an inebriant in the drug scene. Since my self-experiment had revealed LSD in its terrifying, demonic aspect, the last thing I could have expected was that this substance could ever find application as anything approaching a pleasure drug.

10/3/14

A Daily Reprieve

Our Father who art in heaven, (help me not to take a drink today), Hallowed be thy name, (yes, let your name be thrice hallowed for the sobriety you have given me.) Thy kingdom come, (my part in your kingdom is sobriety), Thy will be done on earth as it is in heaven, (for me, let your will be that I do not drink today),Give us this day our daily bread, (your bread is your good will to me, an alcoholic), And forgive us our trespasses as we forgive those who trespass against us, (we are forgiven only if we forgive others as our inventory shows), Lead us not into temptation, but deliver us from evil, (my chief evil is the use of booze), (Keep me sober today), Amen.

The above paragraph was from “Grass Roots Opinion,” an article in the January 1952 edition of the Grapevine, the journal for Alcoholics Anonymous. A previous post, “Our Pappa Who Art in Heaven,” reflected on honoring God and His kingdom in the first part of the Lord’s Prayer. In what follows, we petition the Lord for our daily needs: bread, debt forgiveness, and protection from temptation.

Give us this day our daily bread.” Biblical scholars have had a lot to say about the Greek word usually translated “daily” in the Lord’s Prayer, epiousios. This is often the case when there is only one occurrence of the word in the New Testament, as with the word here. Werner Forester, in The Theological Dictionary of the New Testament, suggested that the meaning of the phrase “daily bread” is adequately given as: “The bread which we need, give us to-day (day by day).”

In Alcoholics Anonymous Bill W. wrote that the alcoholic is never cured of alcoholism. “What we really have is a daily reprieve contingent on the maintenance of our spiritual condition. Every day is a day when we must carry the vision of God’s will into all of our activities.” This is also the spiritual condition of the believer in Christ. In this life, we are never “cured” of sin. Yet we may have a daily reprieve when we ask daily how we can best serve God: “Thy will (not mine) be done.”

A little further on in Matthew 6, Jesus elaborates on how we should not be anxious about our daily life—what we eat, drink or wear: “Your heavenly father knows you need them all,” so take one day at a time (Matthew 6:32, 34). Verse 6:34 actually says: “Sufficient for the day is its own trouble”, but the paraphrase “one day at a time,” commonly heard in 12 Step recovery, clearly fits in both verses, 6:11 and 6:34.

“And forgive us our debts, as we also have forgiven our debtors.” The word translated as debt here refers to a moral obligation or sin, as the Lord’s Prayer is given in Luke 11:4, “and forgive us our sins, for we ourselves forgive everyone who is indebted to us.” Whether sin or debt, the principle here is that our forgiveness by God is correlated to how we forgive others. Verses 14-15 repeat the thinking of verse 12 and add the negative consequences of failing to forgive others, your Father will not forgive you.

Unforgiveness in recovery is understood as holding on to resentment. Alcoholics Anonymous, the A.A. Big Book, says that resentment, “destroys more alcoholics than anything else. . . . It is plain that a life which includes deep resentment leads only to futility and unhappiness. . . . We found that it is fatal. . . . If we were to live, we had to be free of anger.” The people who wronged us were spiritually sick—like we were. So we asked God to help us show them tolerance, pity and patience. “God save me from being angry. Thy will be done.”

“And lead us not into temptation, but deliver us from evil.”  God does not tempt us, as James 1:13 teaches, so the original meaning here was more like “don’t allow us to succumb to temptation” or “don’t abandon us to temptation.” The parallelism of the second clause here—deliver us from evil—reinforces the sense that we are pleading for God to protect us from temptation.

There is a dispute as to whether or not the Greek word for “evil” here should be translated “the evil one” (the devil) or just plain old impersonal “evil.” Either one is grammatically possible. But functionally, the point is moot. Whether there is an “evil one” or simply just “evil” we need God to keep us from it. There is also something to be said for sometimes praying to be delivered from “evil” and at other times praying to be delivered from the “evil one.”

The struggle of resisting temptation to sin or to drink and/or use drugs can often feel experientially like we struggle against a personality; an evil one. There is a malevolent force that plots against us; a roaring lion who seeks to devour us (1 Peter 5:8). If we submit ourselves to God and resist the evil one, he will flee from us (James 4:7).

I was intrigued to discover that in the second issue of the Grapevine, July of 1944, was a recommendation for other A.A. members to read the Screwtape Letters by C. S. Lewis. “Readers will laugh at the shrewd portrayal of soft spots, alibis and rationalizations suggested by Screwtape in the battle between His Father, Satan, and The Enemy, God.”  Both A.A.s and followers of Christ can relate to the battle illustrated there.

Please Lord. Deliver us this day from the evil one—whether that is alcohol or another drug; Satan or our own evil desires.

Where in your life are you in need of a reprieve?

This series is dedicated to the memory of Audrey Conn, whose questions reminded me of my intention in seminary to look at the various ways the Sermon on the Mount applies to Alcoholics Anonymous and recovery. If you’re interested in more, look under the category link “Sermon on the Mount.”

10/1/14

The Rise of the Stimulation Junkie

image credit: iStock

image credit: iStock

Do you think your child has ADHD? Are they oppositional, petulant, prone to major tantrums when they don’t get their way? In school, are they inattentive, disruptive, unfocused? Does their teacher essentially have to stand over them to get their work finished? Do something radical—remove television and other electronics from their life!

In The Diseasing of America’s Children, Family psychologist John Rosemond indicated that in most cases, these kids will go through a “withdrawal period”—moodiness, irritability, obsessing about watching TV. “Typically, and depending on the age of the child and the strength of the addiction, after a withdrawal period of one to two weeks, parents begin seeing the signs of recovery.” Within two or three months, the child is better behaved at home and there can be evidence of academic improvement in school.

Rosemond related that within three months of taking his son off of TV and implementing a traditional model of parenting, Eric was one of the best-behaved children in his class; and his reading skills had improved one grade level. Today Eric is a corporate pilot with four boys of his own.

Without doubt, the most glaring difference between the environment of a young child fifty years ago and the environment of today’s child is the prominence of electronic media—television, video games, and computers.

Rosemond isn’t the only person reporting an association between TV and attention problems in children. In “A Generation of Stimulation Junkies,” Allen Hsu reported that according to Neilsen ratings, the average American watches 34 hours of television a week. Children 2 to 11 watch 24 hours a week, translating to 3.5 hours per day. Remember that these statistics don’t account for the time spent on smart phones, video games and computers. Both Hsu and Rosemond cited an important 2004 study in the journal Pediatrics.

In that study, Dimitri Christakis and others found that: “early exposure to television was associated with subsequent attentional problems.” The authors noted that their study did not prove a causative association between television and clinically diagnosed ADHD. Nevertheless, “Early television exposure is associated with attentional problems at age 7. Efforts to limit television viewing in early childhood may be warranted, and additional research is needed.” Hsu said the Christakis study reported that television increased the chances of a child developing attention problems by 28%.

Hsu also said the negative impact of television carried over to video games as well. The more time children spent playing video games and the more violent the video game was positively correlated with increased attention difficulties. A 2010 article by Edward Swing and others in the journal Pediatrics, reported that exposure to both television and video games was associated with attention problems in childhood. This continued in late adolescence and early adulthood: “It sees that a similar association among television, video games, and attention problems exists in late adolescence and early adulthood.”

The increased societal dependence on electronics is affecting how we do things. Hsu thought it was making us more stupid. This is not so outrageous of a thought. In a short story titled “A Feeling of Power,” Isaac Asimov described a future time where people were so reliant on pocket calculators, that they had forgot basic math skills. Then one of the scientists “reversed engineered” mathematics, and demonstrated to his fellow scientists that the same results could be done with paper and pencil.

Our society is becoming a generation of stimulation junkies. We click from website to website, change television channels as we please, while relying on an external stimulation. Viewing fast paced video games, fast paced movies, and addicting television is leading to a population who chooses to quit activities just because they are too hard or not entertaining enough and our need for instant gratification.

Do you think that our dependence upon electronics has altered our neurological networks?