Editorial Comment 10/1: What isn’t here

Editorial Comment:  What isn’t here

In psychiatric residency training, there is an admonition that every supervisor makes to the trainee, at some point:  listen for what isn’t being said.  There are various interpretations of this – one is simply, “Look for what history you have omitted.”  Another, less obvious translation is to listen for what has been either concealed or repressed.  We don’t give great attention to hallucinogens or psychoactive drugs here in the Weekly, except in their psychopathological role, and it is unsurprising that it should be so. After all, the careers of the editors, the journal authors, and most of the readership have been directed toward getting people to stop using these substances.   Invariably, we examine them for their psychopathological roles.

The links that I have included below refer to psychedelic drugs in their potential for therapeutic effect. It's a scary area to enter, but only if we fail to apply the same standards to investigations of psychedelic drugs, of hallucinogens, as we do to all other conventional medications. And sadly so far, much of such exploration, even at the level of the humble cannabis plant, has been less than rigorous. That hasn't prevented impulsive use, or even impulsive legislation supporting use as a medicinal.  Many states now advocating or actually enabling use of cannabis for opioid use disorders have done so in the absence of good supportive bench or clinical data, and even in the face of contravening evidence.  Patients, their families, and even physicians are great believers; they hope for an effect, particularly when they foresee bad outcomes.  Many will reach for the hopeful rather than wait for the validated.

So it happens that we do not commonly see discussions of possible therapeutic potential for psychedelic substances or hallucinogens, here or in addiction journals, for fear of misleading.  A publication founded by David Smith 50 years ago, Journal of Psychoactive Drugs, has treaded warily but inexorably, in discussing the potential for psychotherapeutic benefit.  The more general absence of a scientific conversation reflects a sense of the caution inherent in a field where psychoactive substances are themselves central to the psychopathology we would  remedy.  It’s the repressed discussion, what isn’t being said, and not without some reason.

I have three citations to serve as examples of the literature .  One is taken from the Journal of Psychopharmacology, the latter two from Journal of Psychoactive Drugs:

1. Kuypers KPC et al., Micro-dosing psychedelics: More questions than answers? An overview and suggestions for future research, 14 July 2019, Journal of Psychopharmacology. This paper provides background on psychedelic use and addresses some of the questions around micro-dosing while offering guidelines for future scientific research.  It includes an examination of the safety and history of experimental psychedelic drug use. 

https://journals.sagepub.com/doi/pdf/10.1177/0269881119857204

1. Doblin RE et al., The past and future of psychedelic science: an introduction to this issue, Journal of Psychoactive Drugs (full text PDF, open access)  https://www.tandfonline.com/doi/full/10.1080/02791072.2019.1606472 ;  and David Smith’s essay on the journal’s role in the evolution of psychedelic medicine (abstract).   https://www.tandfonline.com/doi/full/10.1080/02791072.2019.1589607

The latter two incidentally form the introduction to the 50^th anniversary issue of Journal of Psychoactive Drugs in providing a discussion of the obligation for research.  Dr. Smith, a Past President of ASAM and a founder of the Haight-Ashbury Free Clinics in San Francisco, has been at the spearpoint of addiction medicine throughout his career.

- Editor-in-Chief: William Haning, MD, DFAPA, DFASAM