Karen Hitch­cock on drug le­gal­i­sa­tion and plea­sure Ge­orge Me­ga­lo­ge­nis on chang­ing lead­ers

“You’d think a drug that de­creases pain and of­fers some plea­sure would be con­sid­ered the ideal medicine that a hu­mane doc­tor could pre­scribe.”

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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

He said it would change the way I saw the world, blow my mind, change my life. It didn’t.

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 Par­lia­men­tary Bud­get Of­fice has es­ti­mated that le­gal­is­ing cannabis would gen­er­ate al­most $2 bil­lion per year for the Aus­tralian econ­omy.

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

They can’t re­port deaths due to cannabis, be­cause you can­not die of a cannabis over­dose.

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 week­s­long 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 high­dose 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

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.

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” men­tal­health 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 mil­i­tary had tested LSD on more than 1000 sol­diers, with­out a sin­gle long-term ill ef­fect recorded.

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-the­counter 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-habit­form­ing, 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 meta­anal­y­ses to have only small ben­e­fits be­yond placebo for the ma­jor­ity of pa­tients. (The widely pub­li­cised meta­anal­y­sis 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 no this 5- meth ox y-N, N-di methyl try pt a mine (5-MeODMT) trip qual­i­fied as a mys­tic al 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 psy­cho ther­a­peu­tic 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 non­medic­i­nal 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. M

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