Psychedelics and Addiction: Beyond the High

INTRODUCTION

 

Addiction, in its myriad forms, continues to pose a significant challenge to global public health. Recent studies suggest that up to 6% of individuals contend with substance-related issues, with prevalence rates showing an upward trend (Ritchie). In the Netherlands, two million individuals are affected by xxxxx (source). Addiction’s cyclical nature, propelled by shifts in brain chemistry, reinforces compulsive behaviors despite adverse outcomes, contributing to a concerning rise in substance-related fatalities. Legal substances like alcohol and tobacco, as per the World Drug Report (2022), account for the primary contributors to morbidity and mortality associated with substance use, while illegal drugs such as psychedelics, amphetamines, and opiates collectively contribute to 5% of the global addiction burden.

The grip of addiction does not only devastate the lives of those afflicted, but it also has a significant impact on families, communities, and society at large. Despite decades of research and numerous interventions, addiction remains a formidable challenge for healthcare professionals worldwide. Indeed, traditional treatment approaches, such as pharmacotherapy and psychotherapy, have demonstrated limited efficacy (Kan; Hayes; Zafar). Research has shown that the majority of individuals often end up relapsing within six months (Hayes), highlighting the need for more innovative solutions. It is within this landscape of unmet medical needs that alternative therapies, such as PAT, are gaining more and more traction in recent years.

In light of contemporary medicine, there is growing recognition of the need for alternative approaches to addiction treatment, particularly with psychedelics. Psychedelic therapy can be considered a novel therapeutic paradigm as it harnesses the psychoactive properties of certain psychedelic drugs to help facilitate the psychotherapeutic process. Unlike conventional treatments that focus solely on symptom management, psychedelic therapy aims to address the root causes of addiction by inducing transformative experiences that promote introspection, emotional processing, and behavior change, ultimately hoping for long-term recovery. In this article, we will embark on a journey to explore psychedelic-assisted therapy as a novel and promising treatment for addiction.

Defining Addiction

Definition and types of addiction

 

Addiction is formally defined as the continued use of a harmful substance despite adverse consequences. Core features of addiction include the compulsive pursuit of pleasurable stimuli, fixation on substances or behaviors, and continued engagement despite adverse consequences (Koob, all). Decades of research demonstrate that addiction manifests as a deeply entrenched behavioral pattern influenced by alterations in brain function, environmental factors, and psychological dynamics (Koob, all; Heilig). Repeated substance use induces changes in brain functioning, framing addiction as a neuropsychological disorder.

It’s important to differentiate between two distinct aspects of addiction: controlled substance use and the inability to resist the substance or behavior. These represent separate dimensions that collectively encompass the spectrum of addiction, including drug use, dependence, and abuse.

Controlled substance use refers to instances where an individual may regularly consume a substance, but they are able to manage and regulate their usage without experiencing significant negative consequences. This type of use may not necessarily indicate addiction. On the other hand, the inability to resist substance use or behavior signifies a loss of control, where individuals continue to engage in the behavior despite adverse outcomes. This aspect is characteristic of addiction and encompasses both dependence, where the body becomes reliant on the substance, and abuse, which involves harmful patterns of use. By recognizing these distinctions, we gain a clearer understanding of the multifaceted nature of addiction and can tailor interventions and support accordingly.

In the realm of psychiatry research, addiction is typically classified according to either the DSM-5 or the ICD-11 systems. While DSM-5 is prevalent in research contexts, ICD-11 finds broader application in clinical settings. The DSM-5 conceptualizes addiction along a continuum, whereas the ICD-11 delineates between ‘harmful use’ and ‘dependence.’ Consequently, DSM-5 lacks the detail to distinguish between mild and severe dependence. This variance can significantly impact the interpretation and comparison of addiction studies (Hayes). It’s imperative to note that dependence does not inherently equate to addiction, as dependence primarily relates to tolerance and withdrawal, while addiction encompasses complex behaviors involving drug-seeking and craving (Hayes).

Understanding Addiction

 

The field of cognitive neuroscience has recently focused on understanding addiction by looking at its genetic, cellular, and molecular mechanisms. Addiction can be defined by an individual’s biology, which helps explain why someone might initially smoke in social settings but eventually become unable to resist despite the high risk of lung cancer. Addiction makes self-regulation difficult, according to Heilig and Koob (2010). Simply put, addiction makes a person have difficulties with self-regulation (Heilig; Koob 2010).

Chronic substance use or harmful behavior has a significant impact on neural networks involved in reward processing, inhibitory control, stress response, emotional regulation, and learning/memory, among others, as identified by Koob (2010). One of the most notable findings is that the persistent use of drugs can significantly alter the brain’s structure and function. For example, increases or decreases in the reward system (e.g. ventral striatum) perpetuate cravings, while increases or decreases in frontal regions impair self-regulation (Heilig and Koob, 2010).

The disruption of these neural networks has led to several theoretical frameworks that aim to explain how addiction develops over time. Three of the most prominent frameworks include the allostatic hypothesis (Koob, 2005, 2008, 2010), the habit formation theory (Everitt, 2015, 2016), and impaired response inhibition and salience attribution (Goldstein). Despite differing perspectives, all models converge on deficits in reward processing and the hijacking of reward pathways by addictive substances. This leads to prioritizing drug acquisition over non-drug-related pursuits, where the craving for drugs supersedes other goals that are potentially more adaptive for the afflicted individual.

Koob et al.’s (2010) allostatic hypothesis explores addiction through a psychiatric-motivational lens, suggesting that addiction is mediated by cycles of impulsivity and compulsivity delineated in three stages: binge/intoxication, withdrawal/negative affect, and preoccupation/anticipation (craving).

Impulse control disorders involve a surge of arousal preceding impulsive actions, followed by gratification upon execution, driven by mechanisms of positive reinforcement (American Psychiatric Association, 1994). In contrast, compulsive disorders involve anxiety and distress before the enactment of repetitive compulsive behaviors, with relief achieved through their completion, primarily driven by mechanisms of negative reinforcement and automaticity. In other words, addiction is initially driven by the positive effects of drug use, but later people feel compelled to use drugs to alleviate negative withdrawal effects. This ultimately leads to the formation of habits (Koob, 2010). The progression from impulsivity to compulsivity underscores addiction’s complex interplay of psychological and neurological factors, marking a shift from reward-seeking to emotion-alleviating and habitual responses.

Current Treatment Approaches and Limitations

 

Conventional treatment methods, which typically involve behavioral therapies along with medications, have shown only moderate success rates. Studies suggest that a significant number of individuals, particularly those dealing with substance abuse and gambling disorders, tend to relapse within a year of starting treatment (Hayes).

Although pharmaceutical drugs like methadone and naltrexone have been developed to address addiction by reducing withdrawal symptoms and cravings, these interventions may not fully address the underlying causes of addiction, nor do they offer long-lasting solutions for everyone (Peters). For instance, naltrexone, an opioid antagonist, was tested in a double-blind clinical trial on individuals with alcohol dependence and was found to moderately reduce relapse rates. While it does decrease cravings, it did not increase abstinence (Chick). Similar results were observed in opioid dependence, where naltrexone alone did not lead to a decrease in relapses (Gerra).

The chronic relapsing nature of addiction is a significant challenge for clinicians, with limited options available to maintain abstinence. Even for those who have successfully achieved abstinence, the risk of relapse is always apparent, or it seems to never go away. Koob suggests that chronic use eventually leads to increased sensitivity that triggers emotional processes in such a way that encourages drug-seeking behavior. Stress plays a significant role in this relationship and is considered one of the most challenging aspects to address in addiction treatment. Animal studies suggest the role of dopamine and glutamate neurotransmitters in addiction, but craving is difficult to quantify in clinical settings and has not been shown to correlate with relapses (Koob 2008). Nonetheless, further research is required to expand on the knowledge regarding the biological changes in these stages. Understanding the neurocircuitry involved in the progressive stages of addiction lays the groundwork for exploring molecular, genetic, and neuropharmacological adaptations crucial in vulnerability to both the onset and perpetuation of addiction (Koob 2010).

Exploring Psychedelics and Addiction

 

There has been a growing interest in using psychedelic-assisted therapy to treat individuals suffering from addiction. Classic psychedelics such as LSD, DMT, and psilocybin have been combined with psychological therapy such as cognitive behavioral therapy (CBT) and motivational enhancement therapy (MET). These trials aim to explore the therapeutic potential of psychedelics for various addictions, ranging from alcohol and tobacco to methamphetamine and gambling addiction.

The treatment leverages the transformative potential of mind-altering substances when administered in a safe and controlled environment. Early clinical trials and observational studies have shown that psychedelic-assisted therapy sessions can result in notable reductions in substance use, cravings, and relapse rates. Traditional psychedelics may effectively address various addictions, indicating the potential of these substances to target a common underlying mechanism (Yaden).

A pilot study by Bogenschutz (2015) explored the effects of psilocybin-assisted treatment for alcohol dependence. Participants underwent therapy sessions supplemented by psilocybin doses. The results were promising: a significant reduction in drinking days and heavy drinking episodes lasting up to 36 weeks after treatment. Heavy drinking days are defined when participants consumed more than five drinks for males and more than four drinks for females. The standard drink is settled on 14g alcohol which roughly translates to 130 ml of a glass of red wine or 280 ml of beer. Psilocybin also slashed craving scores by half, offering potential for long-term recovery.

Additionally, studies investigating psilocybin’s efficacy in treating tobacco use disorder have also shown promising results. In Johnson’s study (2014), individuals undergoing smoking cessation CBT alongside psilocybin reported an impressive 80% abstinence rate after six months, far surpassing conventional interventions which contrast to the typical 35% abstinence rate observed with current therapeutic interventions (Cahill, 2014).

However, it’s important to exercise caution in interpreting these results, as open-label studies do not permit causal conclusions. The study did not find significant differences between moderate and high doses of psilocybin, underscoring gaps in understanding the mechanisms of psychedelics in addiction.

The findings suggest that psilocybin-assisted treatment has enduring impacts that extend beyond the immediate effects of the psychedelic drug. Participants who ranked their psilocybin encounters as one of the top five most personally significant and spiritually impactful experiences they had ever undergone reported higher rates of success in quitting smoking (Johnson 2014, 2017).

Although the studies did not focus on spirituality, these findings raise the question of the role of spirituality in the effects of psychedelic drugs in addiction. It has been suggested that the emotion of awe plays a crucial role as a mechanism of action in driving mystical experiences during psychedelic-assisted psychotherapy (Kan). Awe nurtures feelings of interconnectedness and unity with others, serving as a primary driver for transformation within the paradigm of psychedelic-assisted psychotherapy (griffifths, 2008).

The enduring psychological and behavioral changes witnessed after psychedelic use may be influenced, at least in part, by the prominent and often subjectively positive immediate effects of 5-HT2AR agonists, which are occasionally described as mystical or transcendent (Griffiths, 2008).

In sum, it seems that PAT demonstrates promising outcomes and could offer hope for individuals grappling with addiction. Despite these promising findings, it is important to note that the topic of psychedelics and its potential for treating addiction remains in its exploratory phase. As the age-old adage reverberates within the halls of academia,  there is a need for future research so we can ascertain both the efficacy and safety of psychedelics for addiction.

By Gwendolyn Drossaert