Classic psychedelics in the treatment of substance use disorder: Potential synergies with twelve-step programs

David B. Yaden, Andrea P. Berghella, Paul S. Regier, Albert Garcia-Romeu, Matthew W. Johnson, Peter S. Hendricks

International Journal of Drug Policy, 2021,

Doi : 10.1016/j.drugpo.2021.103380

 

a b s t r a c t

Several pilot studies have provided evidence supporting the potential of classic psychedelics like psilocybin in the treatment of substance use disorders (SUDs). If larger trials confirm efficacy, classic psychedelic-assisted psychotherapy may eventually be integrated into existing addiction treatments such as cognitive behavioral therapy, contingency management, and medication-assisted therapies. Many individuals seeking treatment for SUDs also join twelve-step facilitation (TSF) programs like Alcoholics Anonymous (AA), which are among the most widely available and accessed treatments for alcohol use disorder worldwide. For such individuals, engaging in clas- sic psychedelic-assisted psychotherapy could be seen as controversial, as members of AA/TSF programs have historically rejected medication-assisted treatments in favor of a pharmacotherapy-free approach. We argue that classic psychedelics and the subjective experiences they elicit may represent a special, more compatible case than conventional medications. In support of this claim, we describe Bill Wilson’s (the founder of AA) little known experiences with psychedelics and on this basis, we argue that aspects of classic psychedelic treatments could complement AA/TSF programs. We provide a review of clinical trials evaluating psychedelics in the context of SUDs and discuss their potential large-scale impact should they be ultimately integrated into AA/TSF.

Keywords : Psychedelics, Harm reduction, Community, Twelve step

 

In 1934, Bill Wilson was on his fourth attempt to recover from al- cohol use disorder (AUD). He was being treated in New York City’s Towns Hospital, undergoing an experimental treatment using an admixture containing henbane and belladonna, plants that contain tropane alkaloids, deliriants that are sometimes classified as hallucinogens ( Julien, 2001 ; Lattin, 2020 ). During this stay, an old friend of Wilson’s, who had become sober, tried to convince Wilson to turn to religion for salvation from his addiction. Soon thereafter, while under the influence of the hallucinogenic admixture, Wilson experienced a bright white light and a feeling of great peace, which he interpreted as a spiritual, self- transcendent experience ( Kurtz, 2008 ). After this moment, he reported remaining alcohol-free for the rest of his life ( Miller, 2019 ). Bill Wilson would go on to found Alcoholics Anonymous (AA), the template for all twelve-step facilitation (TSF) programs, with a mission to heal individu- als with AUD through a spiritual awakening like the one he himself had experienced.

Several years later, in 1956, Bill Wilson would take another hallu- cinogen, this time ingesting the classic psychedelic lysergic acid diethy- lamide (LSD) under the care of Dr. Sidney Cohen and the philosopher and author Gerald Heard. Wilson experienced a deep sense of peace and feelings of connection that, similar to his experience more than 20 years prior, he considered spiritual ( Kurtz, 2008 ). In fact, Wilson later recounted in a letter to Dr. Cohen that through his experience with LSD “all of the assurances of my original experience were renewed, and more ”( Lattin, 2012 , p. 7). Wilson’s positive experiences with LSD (he took the substance several times thereafter) and the similarity it had to his earlier self-transcendent spiritual experience during the henbane/belladonna treatment led him to believe that classic psychedelics like LSD could be used to facilitate transcendent experience and help in the treatment of substance use disorder (SUD).

That the founder of AA believed LSD could be a crucial tool in treat- ing addiction is still often overlooked. This may in part be because Wilson’s promotion of LSD was actively suppressed by AA, the very organi- zation that he founded ( Miller, 2019 ). According to some scholars, the board of AA likely believed that his message would be too confusing for its members, opting instead for a policy that advocated for abstinence without pharmacotherapeutic assistance of any kind in treating substance use disorders ( Miller, 2019 ).

While research interest on the therapeutic potential of classic psychedelics was increasing when Wilson first took LSD, investigation of the topic was subsequently stifled for many years. Although using LSD to help with SUD may have seemed radical at the time, the idea of having a spiritual experience to achieve sobriety was woven into the fabric of AA. The book of AA describes many such experiences, and states that those who have them can go on to have alcohol-free lives (e.g., Alcoholics Anonymous, 2001 ; pgs 56-57). The book of AA suggests everyone is capable of having a spiritual experience, though they may differ in variety (e.g., sudden vs. slowly-developing), and that these experiences allow for a connection to something greater than themselves, relieving them of the burden of self and paving the way for a drug-free life ( Alcoholics Anonymous, (2001) pg 63). The book of AA was written by Bill Wilson well before his LSD experience; however, the parallels to classic psychedelic therapy inducing a mystical experience, which is correlated with better drug-use outcomes ( Garcia-Romeu, Griffiths, & Johnson, 2014 ), are striking.

Research on classic psychedelics has reemerged in the past two decades, and has shown that these substances —LSD and psilocybin (the psychoactive substance in ‘magic’ mushrooms) in particular —have low toxicity and abuse potential ( Johnson et al., 2018 ; Nichols, 2016 ; Nutt et al., 2010 ) and reliably induce experiences often described as ‘self-transcendent,’ ‘peak,’ or ‘mystical,’ which are characterized by a sense of unity, sacredness, ineffability, transcendence of time and space, and deeply felt positive mood ( Barrett, Johnson & Griffiths, 2015 ; Griffiths et al., 2006 ; Griffiths et al., 2011, 2016, 2018 ; Johnson et al., 2019 ; Yaden, Haidt, et al., 2017; Yaden, Le Nguyen, et al., 2017 ). These classic psychedelic-induced experiences have been linked to lasting benefits such as improved well-being in healthy volunteers ( Griffiths et al., 2008 ; 2018), as well as reduced anxiety in people with life-threatening illness ( Grob et al., 2011 ; Griffiths et al., 2016 ; Ross et al., 2016 ; Gasser et al., 2014 ), reduced depression ( Davis et al., 2020 ; Carhart- Harris et al., 2016 ; Carhart-Harris et al., 2018 ; Carhart-Harris et al., 2021 ; Osório et al., 2015 ; Sanches et al., 2016 ; Palhano-Fontes et al., 2019 ), and, most notably for our interests here––improvements in substance use disorders ( Bogenschutz et al., 2015 ; Krebs & Johansen, 2012 ; Garcia-Romeu, Griffiths, & Johnson, 2014 ; Johnson et al., 2014 ; Savage & McCabe, 1973 ). This suggestive body of work comes as we face a na- tional and global mental health crisis that necessitates improved treatment options ( SAMHSA, 2019 ; WHO 2018 ) . Although contemporary published studies on classic psychedelics in the treatment of SUD have thus far constituted small, open-label trials, they have demonstrated no- table therapeutic potential for additional ongoing and future research to confirm.

While the use of classic psychedelics for SUDs has shown potential, a number of established treatments have become available in medical settings since Wilson’s time. These include cognitive behavioral therapy (CBT), contingency management (CM), and medication assisted treat- ments (MAT), none of which would preclude the integration of classic psychedelics on philosophical or other grounds, as suggested by suc- cessful adoption within classic psychedelic-assisted interventions in pi- lot studies (e.g., Johnson et al., 2014 ). However, many people experience substantial barriers to receiving SUD treatment, and dropout rates in SUD treatment average approximately 30% ( Lappan et al., 2020 ; Priester et al., 2016 ). Many individuals seeking treatment for SUD there- fore also engage with AA/TSF, which have shown to be at least as ef- fective as other psychosocial treatments for AUD ( Kelly, Humphreys, & Ferri, 2020 ). Though AA/TSF is often criticized in academic and clinical settings for its philosophical tenets, it has been widely disseminated and is highly accessible. Indeed, according to AA, there are over 120,000 AA groups across 180 countries and over 2 million members ( www.aa.org ). Compared to established treatments such as CBT, CM, and MAT, the peak, self-transcendent, or mystical experiences that so often result from classic psychedelic therapy seems especially compatible with AA/TSF. Yet, unlike these other treatments, AA/TSF appears unique in its opposition to pharmacotherapy in favor of a clinically controversial ‘cold turkey’ approach. This raises the question, could classic psychedelic treatments for SUD fit within AA/TSF programs? In this review, we present findings to support the use of classic psychedelics as a treatment option for SUDs, and argue that despite the historic resistance from AA/TSF programs to any psychoactive drug as an adjunct to SUD treatment, classic psychedelics may represent a spe- cial, more compatible case than conventional medications. We argue that the founder of AA/TSF advocated for the use of classic psychedelics as an adjunct to AA/TSF, and that classic psychedelics may operate in part through a subjective experience (see Yaden & Griffiths, 2020) of the kind described in the AA/TSF literature, which would make classic psychedelic administration uniquely well-suited to AA/TSF treatment goals. We conclude by suggesting that classic psychedelic treatments can be seen as complementary in many ways for those who are involved in AA/TSF.

Classic Psychedelics for Substance Use Disorders

We will focus on the so-called ‘classic psychedelics’, or those that act primarily on the serotonin system, particularly as agonists at the serotonin 2A (5-HT 2A ) receptor. This particular group of psychedelic substances has received the most research interest in recent years, and it includes psilocybin (the active constituent in psychedelic mushrooms), LSD, mescaline, and dimethyltryptamine (DMT), as well as the DMT containing admixture ayahuasca. These compounds have been shown to be extremely low in physiological toxicity ( Strassman, 1984 ; Gable, 1993 ; Halpern et al., 1999 ) and non-addictive (Johnson et al., 2018 ; Nichols, 2016 ; Nutt et al., 2010 ) and typically induce only mild, transient physiological changes, such as modest increases in blood pressure and heart rate ( Griffiths et al., 2006 ; Johnson, Richards, & Grif- fiths, 2008 ). Although some risks remain with recreational use —such as cardiac events in those at high cardiovascular risk, destabilization of those with psychotic disorders or predisposition, and high levels of anxiety or dangerous behavior while under the influence ( Carbonaro et al., 2016 ) —these are strongly mitigated in a clinical setting through screen- ing, preparation, monitoring, and follow-up care, to a risk/benefit ratio that compares favorably with many accepted practices in medicine ( Johnson, Richards, & Griffiths, 2008 ).

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