Tag: ayahuasca and alcohol use disorder

05/8/18

Ayahuasca Anonymous, Part 2

© martinak |123rf.com – ayahuasca, traditional shamanic plant medicine.

MDMA-assisted psychotherapy has been designated as a breakthrough drug treatment for PTSD by the FDA. Ketamine has been widely touted as a treatment for depression and its biochemical “mirror image,” esketamine, has been designated as a breakthrough treatment for depression. Johnson and Johnson hopes to file an FDA application for the approval of esketamine by the end of 2018. The tide of the alleged therapeutic benefits of hallucinogens is rising. As we saw in Part 1 of this article, another psychedelic known as ayahuasca is being put forth as a potential treatment for alcoholism and drug addiction. So let’s take a closer look at ayahuasca use and its effects.

In Part 1 of Ayahuasca Anonymous we looked at the findings of a study by Lawn et al. published in Scientific Reports on the potential ayahuasca has as a treatment for alcoholism and found its claims questionable. But psychedelics are the newest fad in psychiatric treatments and I suspect we haven’t heard the last of research into the potential benefits of ayahuasca for alcoholism and drug addiction. So what is it, and how does it work?

Ayhuasca is a psychoactive tea brewed from the Amazonian vine Banisteriopsis caapi and leaves of the bush Psychotria viridis. Taken together, the combination allows the hallucinogen in Psychotria viridis, dimethyltryptamine (DMT), to activate. This induces “several hours of a dream-like altered state of consciousness characterized by intense visual, auditory, ideational and emotional effects,” according to Thomas et al. in “Ayahuasca-Assisted Therapy for Addiction.” As a result of increased tourism to the Amazon, ayahausca drinking has become a transnational phenomenon. Itinerant ayahuasqueros (individuals trained to administer ayahuasca in the traditional Amazonian healing ritual) have been conducting rituals in Europe and North America.

According to Fábregas et al. in “Assessment of addiction severity among ritual users of ayahuasca,” Brazilian churches that use ayahuasca in their rituals have faced legal proceedings in recent years as they expanded into Europe and North America. This was due to DMT being classified as a controlled substance in several countries. The US DEA scheduled DMT as a Schedule I Controlled Substance in 2011. It is a Class A drug, along with heroin, LSD and MDMA in the UK and a Schedule III drug in Canada, making it illegal. In Canada you can face up to ten years in jail if you are found guilty of trafficking ayahuasca.

Both Thomas et al. and Fábregas et al. noted that ritual ayahuasca use does not seem to lead to addiction. Fábregas et al. speculated this was due to DMT acting on serotonergic neurotransmitters within the so-called “neural reward circuit” of the brain instead of the dopaminergic neurotransmitters activated by of drugs of abuse. Ethnographic research also challenged the classification of ayahuasca as an addictive substance. “Furthermore, the therapeutic use of ayahuasca in indigenous traditional medicine is socially sanctioned and politically tolerated in Bolivia, Ecuador, and Colombia.” In Peru, it has been declared part of the national cultural heritage.

Thomas et al. noted where ayahuasca is used within a therapeutic community setting in Tarapoto Peru to help overcome drug addiction. Similarly, a treatment program in Brazil combines the ritualistic use of ayahuasca with psycho-social rehabilitation methods. “Although these programs claim improved health outcomes for patients who complete them, neither has been evaluated with sufficient scientific rigor to provide definitive evidence of the success of their approaches.” The researchers sought to apply ayahuasca-assisted group therapy to a population of First Nations and Aboriginal peoples in Canada. “We posited that this novel form of therapy could enhance the ability of participants to make conscious healthy choices and resist unhealthy urges by eliciting improvements in several attributes related to problematic substance use.”

They found that the ayahuasca retreats correlated with improvements with several cognitive and behavioral states, which they hypothesized would be positively related to recovery from problematic substance use. Participation was also related to improvements in quality of life. The findings suggest this novel form of treatment may facilitate reduced cocaine use and other positive health changes.

The changes in substance use reported by participants by the end of the study period—that is, that cocaine, alcohol and tobacco use declined, whereas cannabis, sedative and opiate use did not—may reflect the fact that in some cases the latter substances were medically prescribed. Some participants reported being in a methadone maintenance program (which was not a criterion for exclusion from the study) and others reported using medical cannabis under the recommendation of a physician. Of note is the fact that cocaine and alcohol were identified as the substances of primary concern by the majority of participants.

The authors noted how the limited number of study participants (18) and the absence of any matched controls means it was “impossible to assign direct causality to the treatment or to determine whether the findings may be generalized to other populations.” The study was not designed to assess the relative effects of the various other aspects of the retreats besides the use of ayahuasca. Also, it was possible that the intercultural bridging occasioned by the ceremonies may have introduced a positive, confounding effect to the retreats.  The connection between the Amazonian and North American indigenous peoples within the context of sharing an important ceremonial healing practice “may have had positive therapeutic effects on its own, independent of the ayahuasca drinking.” So it is not possible to generalize the results of the study to other first Nation peoples in Canada or other aboriginal peoples elsewhere.

Fábregas et al. studied members of several Brazilian ayahusaca churches from individuals living a community within the Amazon rain forest and from those living in an urban setting. The Addiction Severity Index (ASI) was used to assess potential drug abuse-related problems. Follow up studies were conducted after one year. The ayahuasca-using groups scored significantly lower on the ASI Alcohol Use subscale. At the one-year follow up those differences were still significant for the Amazon rain forest community of ayahuasca users, but not the urban group.

As with the Thomas et al. study, the cultural context of these ayahuasca users, all who were members of ayahuasca churches, limits the generalization of the reported positive results beyond the population studied. Significantly, the failure of the urban group of ayahuasca users to have a significantly lower ASI score after the follow up year was hypothesized to have been due to the member’s involvement with the church. This can be understood as suggesting the more isolated community of the Amazon rain forest group facilitated behavior leading to lower ASI scores. If so, the ayahuasca use could have simply been incidental to the findings of lower ASI scores. It could be that the ability to foster a closer community of church members within the Amazon rain forest group was the significant factor in maintaining lower ASI scores over the year, not the use of ayahuasca.

An addendum to the Thomas et al. study indicated the Canadian physician who initiated the ayahuasca-assisted group therapy in Canada was reprimanded and threatened with legal action by Health Canada if he continued his work with ayahuasca as an addiction treatment. An article in The Globe and Mail said the doctor would reluctantly comply with the order, as he didn’t want to break the law. He hoped to get permission to use it in a therapeutic context, but he did not receive it. The Health Minister ruled the Amazonian brew was “an illicit preparation of controlled substances” and even approving it for ceremonial use within a religious context would not be in the public interest.

Ayahuasca is illegal in the US, the UK and Canada. It’s positive effects were reported in two studies done with populations where the context of the healing ritual in which the drug was given likely had a significant placebo effect on its results. An international survey reviewed in Part 1 of this article found that alcohol consumption was reported to be minimally lower than Psychedelic [drug] Users—less than one point on the AUDIT, the Alcohol Use Disorders Identification Test. Its perceived lower potential for addiction is at least partly based on the likelihood of a participant in the ayahuasca ritual becoming nauseous and vomiting. I don’t think we’ll be seeing its widespread use in addiction treatment any time soon.

04/27/18

Ayahuasca Anonymous, Part 1

© ammit | 123rf.com; shaman during a real ayahuasca ceremony.

Researchers at the University of Exeter and University College London investigated whether a psychedelic drug traditionally used in religious rituals in the South American Amazon could be a treatment for alcoholism and depression. Previous studies had suggested a potential therapeutic benefit from ayahuasca. However, this was “the largest survey of ayahuasca users completed to date,” according to Joe Mellor for The London Economic. His TLE article concluded, as did the researchers, that this “Amazonian shamanic psychedelic brew” was a safe psychiatric medicine to treat alcoholism. But ayahuasca is an illegal psychoactive substance in the UK, Canada and the US.

The British study by Lawn et al. was published in the journal Scientific Reports. The researchers used data from the Global Drug Survey and found that ayahuasca users reported lower problematic alcohol use than individuals who took psychedelics like LSD or psilocybin. But both groups reported higher rates of problematic drinking than other respondents to the survey; and both groups would be considered to be hazardous drinkers according to AUDIT—the Alcohol Use Disorders Identification Test. “Importantly, all three groups [Ayahuasca Users, Psychedelic Users and Other Respondents] would meet the hazardous drinking criterion.”

AUDIT is a ten-item screening tool developed by the World Health Organization to assess alcohol consumption. Scores above 8 are considered to be hazardous. The Ayahuasca Users in Lawn et al. had a mean score of 9.41. The Psychedelic Users had a mean score of 10.33; and the Other Respondents had a mean score of 8.45. While ayahuasca users reported less problematic drinking over the past year than Psychedelic Users, they were higher than the Other Respondents.

Problematic drinking, as measured by the AUDIT, was less prevalent in ayahuasca users than the group using classic psychedelics. This is an interesting finding, as classic psychedelic users were similar to ayahuasca users in many other respects, and is concordant with previous observations of a reduction in substance use with regular ayahuasca use. However, ayahuasca users did show greater problematic drinking than non-psychedelic using respondents in the sample. Moreover, although the groups were statistically different on this variable, the mean differences were relatively small.

There was also a general pattern for ayahuasca users to have used recreational drugs in their lifetime and in the last month more than the Other Respondents. See Table 2 in the Lawn et al. study for data on eleven drugs for all three groups in the study. Comparing Other Respondents to Ayahuasca Users in Table 2 indicated significantly higher percentages for lifetime or past month use for cannabis, ecstasy, cocaine, amphetamines and heroin. The study suggested there was a lower potential for abuse with ayahuasca, “which speaks to its safety as an emerging treatment for depression, anxiety and drug addiction.” However, ayahuasca use produced a low urge to use the drug again and to take more of the drug while using.

Ayahuasca was rated as having stronger negative effects while high than LSD or magic mushrooms, and these differences were the largest observed. This may well be related to the well-known vomit-inducing effects it has. Interestingly, ayahuasca was rated as being stronger, but also less pleasurable. One might speculate that the ayahuasca experience is cultivated to be less about ‘pleasure’ and more about meaning, spirituality and learning, than LSD and magic mushrooms, which are frequently taken in a recreational way.

In a press release on the Lawn et al. study Dr. Lawn of University College London said their study lent some support to the notion that ayahausca could be “an important and powerful tool” in treating alcohol use disorders. He noted recent research demonstrated ayahausca’s potential as a psychiatric medicine, “and our current study provides further evidence that it may be a safe and promising treatment.” Senior author Celia Morgan of the University of Exeter agreed. She pointed to observational studies that “suggest that ayahuasca use is associated with less problematic alcohol and drug use.” She went on to say: “If ayahuasca is to represent an important treatment, it is critical that its short and long-term effects are investigated, and safety established.”

I don’t think the Lawn et al. study lends even limited support to the notion that ayahuasca has the potential “to be an important and powerful adjunct for the treatment of … alcohol use disorders” as the authors stated in their conclusion. In my article I am concentrating on the application of the study’s findings to alcohol use disorders and not depression, which it also examined.

First, look at the reported mean difference in AUDIT scores between Ayahuasca users (9.41) and Psychedelic Users (10.33) and Other Respondents (8.45). Their results met their original hypothesis, namely that Ayahuasca Users would have less problematic drinking over the past year than the Psychedelic Users. Their findings were statistically significant, but the difference was less than one point on the AUDIT!  Looking at the AUDIT self-report version linked above. That one point difference could reflect individuals reporting they drank alcohol 2-3 times a week versus 4 or more times a week; or drinking 7 to 9 drinks on a typical day of drinking versus 10 or more. It could also reflect a mean difference of individuals reporting they never drank six or more drinks on one occasion versus less than monthly—the next lowest option. The data gathered with self-reported AUDIT scores does not support the authors’ conclusion that ayahuasca could be an important or powerful treatment for alcohol use disorders.

If ayahuasca is used more widely to treat alcohol use disorder, its safety profile does need to be established. But it seems I have a different understanding of how ayahuasca use produced a “low urge” to use it again than was discussed in the study. The authors said this finding suggested ayahuasca has “a very low-abuse potential,” thus speaking to its safety as an emergent treatment for drug addiction. However the reason for its low abuse potential was apparently because of its adverse effects. Lawn et al. stated: “Ayahuasca was rated as having stronger negative effects while high than LSD or magic mushrooms, and these differences were the largest observed.”

I don’t see adverse effects like its “well-known vomit-inducing effects” as speaking to the safety of ayahuasca as an emergent treatment for drug addiction. I see vomiting as the logical reason why Ayahuasca Users in the study said it was less pleasurable and why they had a lower desire to use the substance again. The authors seem to be grasping at interpretive straws with their findings when they say: “One might speculate that the ayahuasca experience is cultivated to be less about ‘pleasure’ and more about meaning, spirituality and learning, than LSD and magic mushrooms, which are frequently taken in a recreational way.” The context of ayahuasca use is typically more about “meaning, spirituality and learning,” than pleasure. But the same would be likely to occur with a guided, healing experience of other psychedelic drugs like LSD. The simple, reasonable explanation for Ayahuasca Users in Lawn et al. having less pleasure and a lower desire to use the substance again is the greater experience of negative, adverse effects with ayahuasca.

Ayahuasca as a therapeutic agent in healing rituals is a novel approach to treating alcoholism and drug addiction. But investigating the potential for psychedelics like LSD as a treatment for alcoholism began back in the 1950s and even involved a cofounder of Alcoholics Anonymous, Bill W. Although Bill was enthusiastic about the therapeutic potential of LSD, he eventually withdrew from the research over concern his participation would compromise the future of A.A. Look at “As Harmless As Aspirin?” for more on this topic.

Nevertheless, as this study by Lawn et al. illustrates, the use of psychedelics like ayahuasca, LSD and MDMA are being explored and lauded as potential treatments for alcoholism, drug addiction, PTSD and other psychiatric/mental health issues. In part 2 of this article we will look closer at ayahuasca use and its effects.