Thursday, 25 February 2016

Recreational Drugs to Treat Mental Health: Revolutionary or a Synaptic Catastrophe?

A few months ago we were assigned to come up with a topic within medical science and present the legal and ethical implications within that area - Psychopharmacology of course. However the fact that I had to look at it from a philosophical/legal perspective really suppressed a lot of ideas I had, so now that it's over I can write about it freely!

There is a strong correlation between drug abuse and ill mental health, with up to 80% of substance abusers meeting the criteria for at least one psychiatric diagnosis (Armstrong & Costello, 2002), so why should we turn to those very drugs to treat the disorders? A little ironic isn't it? Well firstly, take a look at the motivation for these drugs. It is not unheard of that many people will turn to drugs to get away from the real world and its troubles, the most common and more socially acceptable drug of use being alcohol, so if we took away the negative aspects of alcohol abuse (in this case, binge drinking is classed as abuse and is over the recommended daily limit) such as the hangovers, nausea and dehydration - do your troubles disappear? Of course that is subjective, but in a lot of cases the answer is always yes! Of course! It's not rocket science that after a few drinks you feel confident enough to tell your troubles to take a backseat while you take over the world, so is it plausible to use that same logic and apply it to treating depression, biploar and PTSD?
Now, I'm not suggesting we use alcohol as a type of medication and try to get it on the NHS, it wouldn't work anyway and the fact that something so destructive is so readily available and socially acceptable should be enough! (This is not to say I'm against it, simply stating facts) But recent research has shown MDMA and Ketamine to be relatively successful in the treatment of these disorders and there is a chance we may be seeing them in our pharmacies for therapeutic use if this success continues. Now, firstly lets look at the facts and what the UK thinks of these drugs:
  • MDMA - The original designer drug! Regularly used in a clubbing or party environment as it makes you feel energetic, happy, awake and is a very slight hallucinogen. Risks include impurities, cognitive dysfunction following chronic use, inability to control body temperature and de/overhydration (essentially drowning yourself). There have been 670 MDMA associated deaths in England and Wales between 1996 and 2014. Class A.
  • Ketamine - Very strong general anesthetic and was reclassified to a class B drug following the surge of bladder removal surgeries in 2014 after they were linked to chronic ketamine use. Affects the heart, lack of inhibition can cause harm and in high doses it can cause death.
Notoriously dangerous drugs, so what good can come out of this? What about after effects? MDMA causes you to fire serotonin in quick, vast amounts and therefore the next morning when all the effects have worn off there is a feeling of great depression due to the depleted serotonin levels (a comedown as your friends will know it). How is this controlled for? I don't want to be suffering a comedown every time I take my medication! Or a weird hallucination, or get stuck in a k-hole! So how have researchers accounted for all of these things?

Small doses and assisted therapy. Seems simple and it really is just that. A 2012 study (Oehen et al) found that 125mg of MDMA alongside therapy (music, touch and talk) showed improvement after 3  weeks and a further 62.5mg of MDMA which was repeated again 3 weeks on. Results were encouraged by the active placebo group (given 25mg of MDMA and then 12.5mg supplementary follow up doses - a small but subjectively effective amount) showed no improvement in scores. After a year follow up, patients seemed to still have improved however only 3 of them seemed to be due to the immediate effects of the study as others had either enrolled in therapy once more or started antidepressants so there's no conclusive evidence that a 6 week course of therapy and MDMA (2 doses) is effective for that long. Patients also showed no serious side effects, some were given treatment for headaches and anxiety following the immediate doses but were fine afterwards. Insomnia was a common side effect but again was not severe and most participants refused treatment as they didn't find it distressing. No problems with blood pressure or heart rate were found, nor with temperature regulation. So basically, participants suffered the same side effects you get when you start a new course of antidepressants (minus the suicidality apparently). 

Lets look at this from the perspective of antidepressants, you take them in fairly high doses, once a day, every day. In a lot of cases, they don't work or are even effective and the side effects can range from insomnia and nausea, to full blown migraines and palpitations. Withdrawal effects from these drugs are intolerable and it can take time to find the right type for you. This study administered 3 doses, 3 days of therapy and patients were fine for 6 weeks. Who's the real winner here? There have been several studies exemplifying the benefits of MDMA and has now been moved to a schedule 2 status (misused but useful medicines) showing its potential as a form of medicine for those suffering from severe, treatment resistant PTSD.

The thing is with MDMA, it's not the drug itself - it's the way it's used and abused that makes it dangerous. Just like LSD - there have been no links to psychological, cognitive or physical damage in regards to LSD, it is simply the vulnerability and danger caused by such an altered state of mind that has made the drug illegal, and yet still less dangerous than alcohol and tobacco yet we still allow those to be used openly. Why? Because the government (and ourselves) believe that the current laws on alcohol are controlled, but how controlled is an age limit and telling us to drink responsibly when the lady over the counter at Tesco knows full well you're going to shot about 10 units of the Russian Standard in your shopping basket? The only "control" is an age restriction in this country, and it clearly doesn't seem to be working because alcohol and tobacco related damage are costing us billions! Compared to all the related deaths that occur in a year alone, it makes the 670 MDMA related deaths seem like nothing, but is that just due to the fact that MDMA is illegal? Personally I think that's made only a small difference, because legal or not, someone's always going to find a way to get some/make some/sell some.

Other treatment resistant disorders have seen benefits from illegal drugs - Bipolar disorder and Ketamine. Anhedonia is that feeling you get when you find no interest or joy in things you used to, or anything at all really - a helpless, endless feeling of despair towards things you once loved no matter how hard you try - a common phenomenon in bipolar disorder and it is usually resistant to any treatment given. A single sub anesthetic (0.5mg/kg) dose of Ketamine was given twice over a period of 4 weeks and found to immediately have an effect on the participants feelings of pleasure (the very feeling lost due to anhedonia) and this lasted for almost 2 weeks where a second dose was then needed. It was supported by the placebo group showing minimal to no improvement and a PET analysis was also conducted to show that these anhedonia is related to glucose metabolism in the dorsal anterior cingulate cortex (area responsible for reward and decision making in the brain) and is completely independent of depressive symptoms (Lally et al, 2014). As anhedonia is usually clumped under a depressive symptom this is huge news as it's just proven that it's completely independent of it and tiny doses of ketamine can improve on that - which could subsequently improve the overall quality of life. This same amount of Ketamine (0.5mg/kg) showed a significant improvement of depressive symptoms in anxious bipolar depression - a branch of bipolar disorder which suffers from more alcohol abuse and suicide attempts - and lasting for up to 14 days (Ionescu et al, 2014).

Tiny amounts of ketamine in a controlled environment - significant improvements in those who have no responded to treatment no matter what - amazing! Right? What could go wrong? These studies are very recent and currently we have no idea of any long term side effects, however is that a risk we can afford to take? The pros seem to outweigh the cons here it seems because it promises a better quality of life, but are we taking the easy way out for this? Using drugs that already exist that are known for horrific effects on society?

Well because of these studies we have moved forward in the understanding of areas involved in certain symptoms (anhedonia and dACC) and been able to find novel treatments for treatment resistant disorders that doctors were scratching their heads at and wondering what to do with these very patients. There is already a problem with the way mental illness is treated within the system and the NHS, and I fully support the NHS don't get me wrong, but the way many patients have been treated has been disgusting, mainly due to funding cuts and the lack of understanding and treatment only adds to that, so these findings are making it more bearable for those who are already being stepped on by the system. However this opens up a whole new debate in relation to drug use and stigma!

If we start using these drugs that are popularly sought after for medical use then does that not mean it'll create a market for prescription recreational drugs similar to modafinil or codeine? Will it allow social acceptance of these drugs or their misuse? What about the fact that you'll get labelled a junkie the minute you tell your sisters husband's brothers step daughter? Those that use cannabis even for medicinal reasons still have to deal with close minded people letting them know of their disappointment that they've had to turn to "hard drugs" to deal with their life threatening illness. Will we be labelled a nation of drug abusers? And will this slow down pharmaceutical research in regards to these disorders because we've currently found a temporary solution - will we become lazy with the research that we so desperately need? 

Well I can say with fair confidence that you wont be finding these on the black market, simply because these people will be the worst of the worst and desperate to have them rather than make enough to buy them a cheap bottle of wine to drown their sorrows in. I'm also sure these drugs will be administered in a safe/controlled way so that there is no chance of misuse - similar to the way that heroin users are administered methadone (it's very strict and impossible to take away and sell basically), not to mention these doses are so small they'll have no effect anyway. But as Nick Clegg and Richard Branson stated that we've been losing the war on drugs for four decades! Is this the perfect excuse to make them more acceptable? Like Amsterdam and their more relaxed drug policies. If we implement these policies alongside these drugs for medicinal use will we become a nation of druggies? Are these findings revolutionary or just going to cause a huge mess for us in the future medically, scientifically and socioeconomically? Personally? No. If anything, it'll bring in revenue for the pharmaceutical companies, people will be feeling better and therefore an increase in quality of life can result in so many benefits, and if properly controlled (which is debatable with a tool like Cameron running the country. but I digress) then a lot of real good can come from this. 

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