Not long ago I attended a conference at which a speaker expressed some reservations regarding the use of hallucinogens— such as ketamine, MDMA, psilocybin, and LSD—as treatment options for patients with mental illness. The speaker’s reservations stemmed from an apparent discomfort with the idea of prescribing substances that before now had been known primarily as substances of abuse. Without any hint of irony, the speaker went on to comment that he viewed benzodiazepines as one of the most effective treatments for patients struggling with anxious depression.
The irony is that benzodiazepines, like hallucinogens, are substances that can be abused. In fact, the morbidity of benzodiazepine use appears to be significantly higher than that of hallucinogens. For example, in 2011 an estimated 152,179 patients had a benzodiazepine-related emergency department visit in the US, compared with 22,498 visits related to MDMA. Of those presenting for benzodiazepine-related visits, 42,314 (27.8%) required hospital admission. By contrast, only 2144 (9.5%) of those with MDMA-related visits required hospital admission.1
Despite the aforementioned discomfort with writing prescriptions that can lead to addiction, the use of potentially abusable substances has long been a staple of mental health care. The purpose of this article is to review some of that history, placing current discussions within a broader historical context, and to briefly examine ethical questions that such treatment raises.
Sigmund Freud was an enthusiastic proponent of cocaine as a mental stimulant and as a treatment for morphine addiction. In 1884, Freud noted that the euphoria brought about by cocaine “in no way differs from the normal euphoria of the healthy person” and that “no craving for the further use of cocaine appears after the first, or even after repeated taking of the drug.”2 Not long after Freud penned those words, the medical community became more aware of the addictive nature of cocaine. Freud later admitted that his advocacy for cocaine use “had brought serious reproaches down on me.”3 Cocaine fell out of favor and is currently not utilized in the treatment of psychiatric disorders. Cocaine is a schedule II drug in the US, but it can still be prescribed as a topical numbing agent.
Before the advent of antidepressant medications in the 1950s, opioids had been used in the treatment of depression and anxiety. Once tricyclic antidepressants and monoamine oxidase inhibitors provided a more specific, nonaddictive pharmacologic option to treat depression, the use of opioids fell to the wayside.4
In the 1990s, tramadol, an opioid with a high degree of serotonergic activity, was studied as a treatment option for OCD.5 More recently, the lack of sufficient results from psychotropics focused on monoamine transmitter modulation has resulted in a renewed interest in opioids and opioid system modulation for the treatment of depression and suicidality.6 Time will tell whether this enthusiasm for opioids is tempered by the current opioid crisis.
Dr Weber is Psychiatry Department Chair, Intermountain Healthcare Logan Regional Hospital, Logan, UT.
Dr Weber reports no conflicts of interest concerning the subject matter of this article.
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