Ketamine & Mental Health: What We Know Already

A very good friend sent me a landmark study surrounding Ketamine a little while ago.  In drug research, big effects and powerful findings are usually accompanied by tiny sample sizes and weird statistics magic to rig the findings. So when I read the meta-analysis and systematic review published in The American Journal of Psychiatry, I was heartened. This is serious science and serious stats, with 167 patients evaluated across multiple studies. Also, the reporting scales (MADRS, HAM-D, QIDS-SR & the BDI) are well understood, robust and respected in the field. All of this adds up to this results abstract being very, VERY important:

Ketamine rapidly (within 1 day) reduced suicidal ideation significantly on both the clinician-administered and self-report outcome measures. Effect sizes were moderate to large (Cohen’s d=0.48–0.85) at all time points after dosing. A sensitivity analysis demonstrated that compared with control treatments, ketamine had significant benefits on the individual suicide items of the MADRS, the HAM-D, and the QIDS-SR but not the BDI. Ketamine’s effect on suicidal ideation remained significant after adjusting for concurrent changes in severity of depressive symptoms.
~The Effect of a Single Dose of Intravenous Ketamine on Suicidal Ideation: A Systematic Review & Individual Participant Data Meta-Analysis (Wilkinson et al)

That’s a dense couple of sentences, so let me explain why it’s so earth shattering. Suicidal thoughts, (known as suicidal ideation in clinical psychology) and depressed feelings are very difficult to get rid of, especially for depressed people. Treatment-resistant depression is a term associated with someone who has attempted multiple types of treatment for their Axis I disorder, but it hasn’t gotten better. After trying multiple types of interventions with no success, people slide quickly into hopelessness and thoughts of self harm. Up until now, depression treatments like SSRI drugs and Cognitive Behavioral therapy take time to work, sometimes more than a month. If you’re not in a good place right now, these things can’t help you. Ketamine infusions help immediately, and the change is apparent both to the patient and to the interviewing physician afterwards. This bit is huge, as most drug research relies heavily on self-report, which leads to bias and distorted findings. But, people are already talking to the press swearing by it, and it’s getting quite a lot of press, so here’s what they’re talking about.

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Cannabis, Decommodification & Brake Lights: Gifting in 2017

Column by Terry Gotham

While the Best Coast has just about legalized the growth & sale of cannabis from the Mexican to Canadian borders, us poor unfortunate souls stuck in New England, the Mid-Atlantic, and what’s traditionally thought of as the Deep South, remain mired in drug reform purgatory. In New York state, medical cannabis laws allow for purchase of concentrates, edibles and, non-plant matter containing products that have THC/CBD, but dispensaries are few & far between, and there is a steep fee to obtain an MMJ license. In Massachusetts, cannabis became legal a full year before dispensaries are allowed to open, providing legal cover to people who can already access the stuff, while propagating the same patterns of arrest and harassment of gray/black market channels as before the law was passed. We’ve seen similar patterns of arrest for dealers who don’t play by the “tax stamp” rules in Colorado, but Washington DC takes the cake when it comes to cannabis market dysfunction.

“Thank you and here’s a gift for you to have as a souvenir.”
~Legal loophole in DC creates bizarre pot bazaar, Ashraf Khalil – Associated Press 9.28.17

In Washington DC, cannabis was legalized, but a congressional committee gets to review all laws the District of Columbia passes. Some asshole named Andy Harris, an anesthesiologist member of the “Freedom Caucus” who opposes the cannabis legalization, got a rider passed that prohibited DC from spending cash on figuring out how to tax or regulate pot. So, it remains legal to possess, but illegal to buy or sell. While this is one of the dumbest things you’ll hear all month, that hasn’t stopped DC. Businesses all over the city have started selling mugs, t-shirts, calendars, and tons of other swag with “a little something.” With DC police in no hurry to stamp out anything but the most in your face abuse of this system, we’re starting to see what happens when something that starts as Mutual Aid or gifting, turns into a market economy.

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There Are No More Heroin Overdoses

Report by Terry Gotham

Enough people sent me the NY Times article about Fentanyl overtaking Heroin that I had to say something about it. If you’ve not seen it and the plurality of think pieces surrounding it, the only piece you need to read on it is by the person who runs The Dose Makes The Poison, Kevin Shanks. He’s been one of my go to sources on novel psychoactive substances for years now, and he, along with a handful of others have been yelling as loud as they possibly can. The point he raised almost a month ago is one I’ve not seen a single mainstream medical journal begin to grapple with in any kind of meaningful way.

As I’ve said for a while now, this ain’t your father’s heroin. At what point do we stop calling it heroin and refer to the standard “heroin” product on the street as fentanyl?
~Kevin Shanks (9/2/17)

While drug overdose deaths are up 22% from 2015 alone, fentanyl deaths doubled. That’s not including the fact that cases are severely under counted, given the volume of fentanyl analogs in circulation right now. I previously reported on the report coming out of Ohio with 24 analogs & active metabolites being identified. That, combined with the increased cost in testing for analog substances, we’ve arrived at a place where medical staff have no idea how many chemicals they’re not testing for. How many rural communities are testing for acrylfentanyl or butyrylfentanyl? How many rural communities are seeing analogs that we don’t even know about yet? Communities along the migratory arc that fentanyl takes from China into Western Canada or Mexico into border communities, that see these substances first, are they still getting the same analogs, or is there already something new? At this point, it’s likely the unknown unknowns are already on the ground and slowly being consumed for the first time.

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Why It’s So Important MDMA Has Been Designated a “Breakthrough Therapy” By the FDA

Report by Terry Gotham

At Burning Man 2006, at the Entheogen Camp on the Esplanade, I watched someone ask Shulgin how many times a year he thought it was safe to take MDMA. He said “do you really want to know?” The guy who asked the question wasn’t so sure, being confronted with the possibility of a real answer. On August 26th, 2017, the Multidisciplinary Association for Psychedelic Studies announced that the FDA had granted MDMA the Breakthrough Therapy Designation for its treatment of post-traumatic stress disorder. After decades of demonization, lies, bad science and straight up villainy by the powers that be, MDMA is being given its time to shine. This victory in a long road that MAPS & MDMA have traveled is a long time coming and absolutely pivotal. “Breakthrough Therapies” are seen as crucial, high-value drugs that the FDA wants to assist through development and review. To receive this designation, a drug must qualify in two ways:

  1. The drug treats a serious or life threatening disease or condition.
  2. Preliminary clinical evidence indicates the drug may demonstrate “substantial improvement over existing therapies” on “one of more clinically significant endpoints.”

This designation is a victory, but if you only know MDMA as something to take at parties, you might not know why. From its use as a legal alternative to alcohol in the club/house music scene in 80’s Chicago/Dallas/NYC to its current iteration as the much maligned “Molly,” MDMA has gotten a pretty bad rap over the years. To understand why this news is being celebrated in harm reduction, drug policy and legalization advocacy circles, we need to look back at how MDMA took hold of America & how it became illegal, because a lot of what you think you may know about its history is wrong. For example, most believe Alexander Shulgin invented the compound for the first time in 1965 for Dow Chemical, while it was actually first synthesized in 1912 by Anton Köllisch, a German chemist working for Merck. The chemist was studying substances to stop bleeding but without bumping into the patent held by Bayer for hydrastinine, so in a bit of 20th century novel psychopharmacology, they developed an analogue, methylhydrastinine. MDMA was actually only synthesized as an intermediate step in the methylhydrastinine synthesis process. One of the most important drugs of the 20th Century was created accidentally, just like Hofmann producing LSD accidentally 36 years later.

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Fentanyl, Toxicology, Healthcare Costs & Estate Planning: Strange Bedfellows in 2017

Report by Terry Gotham

This week’s edition of “Why We Can’t Have Nice Things” is a look at a couple of different secondary effects of the opiate overdose epidemic that I don’t think are being given enough scrutiny. With Donald John Trump Jr. declaring a “state of emergency” but not promising any tangible resources, I thought it would be best to do the opposite. Dive into the nitty-gritty of two facets of the opiate epidemic that are so far out into the policy weeds that our president has probably never thought about them.

One of the more complex problems caused by the flood of fentanyl and fentanyl analogs is the difficulty in investigating overdose deaths. This is somehwat related to the explosion in complexity that ER staff are forced to cope with when it comes to determining what someone is overdosing from exactly. I spoke about this a while ago but only touched on the difficulties Emergency Rooms and hospitals are dealing with while working with the patient in vivo. But the work doesn’t stop there.

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