Hallucinogens: An Update
`John H. Halpern, MD
`
`Address
`Biological Psychiatry Laboratory, Alcohol and Drug Abuse Research
`Center, McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA.
`E-mail: john_halpern@hms.harvard.edu
`Current Psychiatry Reports 2003, 5:347–354
`Current Science Inc. ISSN 1523-3812
`Copyright © 2003 by Current Science Inc.
`
`Research of hallucinogen abuse rarely extends beyond epi-
`demiology and observed pathology. Even less research has
`been completed on the special circumstances surrounding
`the religious use of hallucinogens or on potential therapeu-
`tic applications. Rather than offer another basic review on
`the well-known hazards of illicit hallucinogen use, this paper
`provides an overview and practice recommendations on
`compounds the clinician may be less familiar with, such as
`the botanical plant Salvia divinorum, the drug 3,4-methylene-
`dioxymethamphetamine (“ecstasy”) and synthetic hallucino-
`gen analogs. The often-warned, but rarely occurring, hazard
`of hallucinogen persisting perception disorder (“flashbacks”)
`is also reviewed with treatment recommendations provided.
`The current status of clinical research with the hallucino-
`gens is presented, with case vignettes suggesting hallucino-
`gens may have anti-addictive applications. The special
`circumstances surrounding the religious, nondrug use of hal-
`lucinogens as sacred sacraments in the US and elsewhere
`are also presented. It is hoped that the reader will gain a
`more nuanced understanding of how these physiologically
`nonaddictive drugs may offer legitimate benefits in modern
`society. By appreciating that such benefits may one day be
`borne out by careful, methodologically sound research, clini-
`cians should be better armed in raising the topic of halluci-
`nogen use and abuse with their patients.
`
`Introduction
`It is time for a careful re-examination of the hallucinogens.
`These drugs remain widely used and abused, yet are physi-
`ologically nonaddictive. It is also uncommon to diagnose a
`chronic primary hallucinogen-induced or associated disor-
`der. Nevertheless, crimes and adverse events associated
`with acute illicit intoxication are regularly reported by the
`media. Hallucinogen intoxication can be profound to dis-
`turbing and, on rare occasions, induces temporary suicidal-
`ity; offering caution on the dangers of careless use of
`hallucinogens as drugs of recreation is an important com-
`ponent of drug education. These substances are also used
`in settings outside medical practices for nonrecreational
`
`purposes, including as spiritual sacraments, pharmacother-
`apies for dependence on other drugs, and to treat other
`medical and psychiatric conditions. Moreover, hallucino-
`gens actually do have a long history of safe administration
`in legal controlled research settings [1•]. Unfortunately,
`there is still too little formal research on the putative dan-
`gers or benefits of the hallucinogens.
`Substantial literature exists on hallucinogen abuse,
`related psychiatric and medical disorders, and resultant
`strategies for treatment. Clinicians desiring knowledge of
`these basic aspects of hallucinogens are referred to any of
`the excellent reviews contained in general psychiatry and
`substance abuse textbooks [2(cid:127)(cid:127)]. This paper is written to
`inform the psychiatrist and other medical clinicians about
`the current uses of hallucinogens that some patients
`engage in recreationally or with serious, nonrecreational
`intentions. This paper also provides additional informa-
`tion on current trends in hallucinogen consumption, an
`update on the extent and treatment for hallucinogen per-
`sisting perception disorder (HHPD), and observations on
`some of the current clinical research in the field.
`
`Newly Emerging Hallucinogens of Abuse
`Salvia divinorum
`Salvia divinorum is a small plant from the mint family,
`which contains the psychoactive neoclerodane diterpene,
`salvinorin A. Salvia divinorum is traditionally consumed by
`Mazatec Indians of Oaxaca, Mexico by chewing fresh leaves
`or by drinking the juice of the leaves for absorption of
`salvinorin A through the oral mucosa [3].
`The drug is reportedly psychoactive for 15 minutes at
`doses of 200 to 500 µg when smoked [4], and oral absorp-
`tion leads to a less intense intoxication lasting up to 1
`hour. Unlike all other “major” hallucinogens, such as lyser-
`gic acid diethylamide (LSD), salvinorin A has no action at
`the 5HT2a serotonin receptor and, in fact, is the first
`known example of a naturally occurring non-nitrogenous
`kappa opioid receptor agonist [5]. Very little research has
`been conducted on this plant or salvinorin A itself, but it is
`an emerging intoxicant in the US and elsewhere, primarily
`because of Internet-based advertisements and sales, and
`because of repeated articles about this Internet trend
`appearing in the popular media.
`Salvia divinorum is a powerful dissociative intoxicant
`with hallucinogenic properties, but so is the atropine-con-
`taining Datura stramonium (“Jimson Weed”) growing
`throughout the US. Although they remain unregulated,
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`Substance Use Disorders
`
`only S. divinorum is being promoted by an increasing num-
`ber of web site shops [6(cid:127)] and local smoke-shops, and is
`now being sold in concentrations two to even 10 times
`greater than found in its natural state. This plant does not
`appear addictive, and few individuals make repeat pur-
`chases. Harm most likely occurs from inadequate prepara-
`tion and understanding of its safe use or from use in
`settings in which it is dangerous to be intoxicated with any
`drug at all (eg, such as driving).
`
`Ecstasy
`3,4-Methylenedioxymethamphetamine is most commonly
`referred to as “ecstasy” on the street. First synthesized by
`Merck in 1912 as a study compound, it often has been erro-
`neously mentioned as a patented appetite suppressant. A
`dopamine-releasing agent, ecstasy is also a potent serotonin-
`releasing agent, as well as a selective serotonin reuptake
`inhibitor, and it is thought that the mood-enhancing, anxi-
`olytic properties of this “empathogen” are primarily caused
`by its intense modulation of serotonin release [7].
`Ecstasy is now widely used in the US, particularly among
`teenagers and young adults who participate in all-night
`dances, or “raves.” The 2001 National Household Survey on
`Drug Abuse (NHSDA) estimated that over 8 million individ-
`uals aged 12 or older had used ecstasy at least once in their
`lives, including 13.1% of young adults aged 18 to 25 [8]. In
`the NHSDA, individuals reporting first use of ecstasy in the
`past year increased from fewer than 80,000 in 1992 to
`almost 2 million in 2000. Similarly, in the Monitoring the
`Future Study, rates of ecstasy use among high school seniors
`have risen 61% since 1996, when this study started tracking
`consumption in-depth [9]. A longitudinal study of students
`at a prestigious college also found a striking rise in ecstasy
`use from 1989 to 1999; approximately 10% of college
`seniors in 1999 had tried the drug at least once [10].
`Ecstasy use is becoming a serious problem in certain
`special populations, such as young gay men [11,12]. In par-
`ticular, some gay men are combining ecstasy with sildenafil
`citrate (Viagra; Pfizer Pharmaceuticals, New York, NY);
`erectile dysfunction is a common side effect of ecstasy, and
`so some men take Viagra to counteract this problem. This
`combination is referred to as “sextasy” [13], but it is doubt-
`ful that most people ingesting these two drugs simulta-
`neously are also cognizant that the vascular effects from
`Viagra may increase the risk of cardiotoxicity from ecstasy,
`which already is known to increase blood pressure, core
`body temperature, and heart rate.
`Ecstasy may lead to neurocognitive deficits in chronic
`users. However, most studies reporting cognitive impair-
`ments are marred by small sample size, inadequate com-
`parison groups, testing of individuals who had used
`multiple drugs other than ecstasy, or those with concomi-
`tant mental disorders [14,15(cid:127)]. Some studies also suggest
`that memory deficits found in users may be better attribut-
`able to premorbid mental illness or may not be as signifi-
`cant as earlier cautionary reported findings [16,17].
`
`Including questions about the use of multiple drugs or
`dosages in one setting are part of the “practice recommen-
`dations” for discussing ecstasy use with patients. Patients
`should also be asked whether they have considered using
`“pill testing kits,” which are specially purchased reagent
`tests that can verify the presence of ecstasy in a pill, but not
`exclude the possibility of contamination with other drugs.
`One should question patients carefully for claims that
`ecstasy assists with social awkwardness; ecstasy decreases
`shy and self-critical thinking, and increases impulsivity,
`sense of calmness, and acceptance. By inquiring further
`about social anxiety, researchers may be able to diagnose
`individuals with social phobias or social anxiety disorder
`and offer these individuals more long-lasting, effective
`pharmacotherapy [18]. If ecstasy is ingested primarily at
`all-night “rave” dance/music parties, these patients should
`be cautioned that the rave setting may pose special risks;
`heightened empathy and risk taking may make the intoxi-
`cated easy “prey” for abusers; euphoria and heightened
`stamina (ecstasy has amphetamine-like properties, as well)
`may falsely reassure individuals to continue dancing
`despite increasing dehydration, hyperthermia, and tachy-
`cardia; ecstasy also increases vasopressin release [19] and
`so there is also the risk of lethal over-hydration. Finally,
`patients should be reminded that the risk for an adverse
`event from taking ecstasy will increase with dosage. Over
`time, with successive dosing, the desirable effects of ecstasy
`become less intense, and this encourages some users to
`take two, three, five, or even 10 pills in one night!
`
`Hallucinogen “analogs”
`The most common hallucinogen used in the US is LSD
`and psilocybin-containing mushrooms (such as Psilocybe
`cubensis), but a number of synthetic analogs appear on
`the illicit market from time to time. Most of these analogs
`were invented and first characterized by the highly
`regarded forensic chemist, Alexander Shulgin, who has
`published two books on these compounds, much of
`which is also posted on the Internet [20,21]. Two such
`analogs that have made some inroads in the illicit market
`are “2C-T-7” (2,5-dimethoxy-4-(n)-propylthiophenethy-
`lamine) and 5-MeO-DIPT (N,N-diisopropyl-5-methox-
`ytryptamine). 2C-T-7 goes by street names such as “7” or
`“blue mystic,” and 5-MeO-DIPT is associated with names
`such as “foxy” and “foxy-methoxy.” These drugs have
`been placed into Schedule 1 by the US Drug Enforcement
`Agency (DEA) in the past year. These drugs have anecdot-
`ally been reported to have LSD-like and ecstasy-like prop-
`erties. Shulgin and Shulgin’s books [20,21] provide
`excellent references for most hallucinogen analogs men-
`tioned by patients, but, of course, the full profiles of drug
`action have not yet been characterized.
`“Practice recommendations” include asking patients about
`their experimentation with hallucinogen analogs, as well as
`reviewing Internet postings on these and other newly emerging
`hallucinogens (the web site http://www.erowid.com is recom-
`
`

`

`mended as a good starting point). Users should be reminded
`that because there are no clinical or research data on the safety
`of these new drugs, clinicians are unable to offer reassurances
`about potential drug interactions, and, of course, there are no
`guarantees that these pills purely, if at all, contain the stated
`substance. Unlike botanical hallucinogens, such as peyote
`(Lophophoria williamsii), or even synthetic LSD, these analogs
`have been ingested by a much smaller population of users over
`a much shorter period of time, and so the risk for an adverse
`event is much more poorly known. In scheduling 2C-T-7, the
`DEA associated three deaths with its experimentation—one
`overdose after intranasal insufflations and two deaths at raves
`where 2C-T-7 was taken in combination with ecstasy [22].
`
`Hallucinogen Persisting Perception Disorder
`(“Flashbacks”)
`According to the American Psychiatric Association’s Diag-
`nostic and Statistical Manual of Mental Disorders (DSM-IV)
`[23], the diagnosis of HPPD (“flashbacks”) is made if the
`following criteria are met.
`
`1. The re-experiencing, after cessation of use of a hal-
`lucinogen, of one or more of the perceptual symp-
`toms that were experienced during intoxication
`with the hallucinogen (eg, geometric hallucina-
`tions, false perceptions of movement in the periph-
`eral visual fields, flashes of color, intensified
`colors, trails of images of moving objects, positive
`afterimages, halos around objects, and macropsia
`and micropsia).
`2. The symptoms in criterion 1 cause clinically signif-
`icant distress or impairment in social, occupa-
`tional, or other important areas of functioning.
`3. The symptoms are not caused by a general medical
`condition (eg, anatomic lesions and infections of
`the brain, visual epilepsies), and are not better
`accounted for by another mental disorder (eg,
`delirium, dementia, or schizophrenia) or hypno-
`pompic hallucinations.
`
`Hallucinogen persisting perception disorder (“flashbacks”)
`are mentioned because this illness is often presented as a
`common adverse consequence of hallucinogen abuse. A
`recent careful review of the literature on HPPD reports that
`it is a rare disorder that develops in a distinctly vulnerable
`subpopulation of users who also were primarily exposed to
`LSD, in particular [24]. Those afflicted with HPPD may
`experience serious morbidity, but, as of yet, there have
`been no randomized controlled trials assessing the efficacy
`of any pharmacologic agent for HPPD. Improvement has
`been reported with use of sunglasses [25], psychotherapy
`and behavior modification [26], or various pharmacologic
`agents, the most promising of which include clonidine
`[27], benzodiazepines, and selective serotonin reuptake
`inhibitors [26].
`
`Hallucinogens: An Update (cid:127) Halpern
`
`349
`
`Hallucinogen Therapy?
`Drug and alcohol treatment with hallucinogens
`Clinical research on the possible medicinal use of halluci-
`nogens occurred primarily in the 1950s through the early
`1970s. Much of this research focused on using LSD to treat
`alcoholism and, to a lesser extent, the pain and depression
`of patients with cancer. More recently, anecdotal reports
`appearing in the popular press and on the Internet have
`endorsed the use of the hallucinogen ibogaine, especially
`to interrupt the withdrawal effects and cravings associated
`with heroin dependence. Ibogaine, extracted from the root
`bark of the west African shrub Tabernanthe iboga, is listed as
`a Schedule 1 drug in the Controlled Substances Act, but
`this has not stopped its growing clandestine use to treat
`addiction in the US, as well as its legal administration in
`several Latin American countries and Canada. (The Journal
`of the American Medical Association recently reported on this
`use of ibogaine in their Medical News and Perspectives sec-
`tion, which the reader is encouraged to obtain [28].)
`Ibogaine intoxicates much like LSD, except that the
`duration of intoxication extends for 8 to 12 hours or more,
`depending on dose. It has traditionally been used in the
`initiation rites and ceremonies of the Iboga cults, which
`have existed for centuries [29] and continue to this day in
`several west African countries, most especially Gabon. Two
`purported nonpsychoactive metabolites of ibogaine, nori-
`bogaine and 18-methoxycoronaridine, have also been
`shown in preclinical studies as promising anticraving
`agents [30]. Ibogaine has reduced cocaine intake in
`cocaine-dependent rats [31], attenuated naloxone- or nal-
`trexone-precipitated withdrawal in chronic morphine-
`dependent rats [32], and has reversed behavioral disinhibi-
`tion and neuroendocrine system stimulation in rats also
`exposed to methamphetamine [33].
`However, the use of hallucinogens to treat drug addic-
`tion in humans has been inadequately evaluated and, like
`ibogaine, is deserving of closer scrutiny [34(cid:127)(cid:127)]. Two case
`vignettes, which were reviewed and approved by the
`patients, are presented herewith. Only potentially identify-
`ing information has been altered and the patients have
`stated they are comfortable with the level of confidentiality
`contained within the text.
`
`Case vignette 1
`Patient 1 is a 38-year-old single white man with a 12-year
`history of heroin dependence and current nicotine and caf-
`feine dependence. Medical history is significant for a sple-
`nectomy, “on and off” psychotherapy over many years, and
`multiple admissions to detoxification centers. One of three
`siblings also has a history of heroin dependence. This indi-
`vidual began smoking cannabis at age 15 and started abus-
`ing cocaine and heroin at age 18. By age 25, the patient was
`a daily heroin user, resulting in multiple arrests for simple
`possession of heroin over the ensuing years. Though
`dependent on illicit heroin, the patient built a successful
`career within the entertainment industry and achieved
`
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`

`350
`
`Substance Use Disorders
`
`abstinence once for 6 months in his late 20s with the aid of
`therapy, support groups, and threat of re-arrest. Despite
`these efforts, relapse occurred during a period of extra
`demands from work and in his personal life. Essentially,
`the patient has been addicted to heroin throughout his
`entire adult life and had resigned himself to remaining
`opiate-dependent, despite wanting to stop. At age 37, the
`patient heard of the use of ibogaine for the treatment of
`heroin dependence. Broaching the subject of ibogaine with
`his physician, he was discouraged from seeking it out
`because research is incomplete, ibogaine remains illegal in
`the US, and there are “more traditional” therapies that he
`could turn to again. Not wanting to switch to agonist ther-
`apy (methadone), frustrated with a “culture of submission
`to my illness” at anonymous 12-step groups, and observ-
`ing that detoxification, individual and cognitive behavioral
`psychotherapy, and run-ins with the law, at best, help
`achieve abstinence for up to a few months, this patient,
`like many dependent on heroin, wanted to find “another
`way…a way that really could help heal me from what I’ve
`been doing to myself; a treatment that could stop my crav-
`ings cold.” The patient decided to explore ibogaine treat-
`ment further without physician guidance. Compared with
`the limited information furnished by his physician, the
`patient discovered a wealth of postings on the Internet.
`After reading positive testimonials on one web site, http://
`www.ibogaine-therapy.net, the patient decided ibogaine
`was worth a try. Further Internet research led him to a treat-
`ment center operating in Latin America. Though he flew
`down heroin-dependent, after a brief stay at this center in
`which he had a single, medically supervised ibogaine ses-
`sion, he returned home claiming a total absence of drug
`cravings or desires to reuse. Subjective experience of
`ibogaine was described as “brutal and unpleasant; it felt
`like God was telling me to shut up and then to accept
`myself.” The patient remains drug-free (10 months sobriety
`to-date), has steadily rebuilt connections to family mem-
`bers, and finds himself enjoying work: “I feel like my feel-
`ings are my own finally. I am amazed that I feel free of drug
`cravings rather than trying to fight off those demons to re-
`use. What’s the difference between ibogaine and the other
`things I’ve tried before? Ibogaine has worked.” This
`patient’s opiate-dependent sibling is also now drug-free
`since ibogaine treatment.
`Though the patient is currently in his longest period of
`abstinence, it must be remembered that heroin depen-
`dence typically has a chronic, relapsing cycle. Apparently a
`treatment responder, the patient acknowledges that he
`would seek out another ibogaine session should he ever
`ingest heroin again. Unsatisfied with the approved treat-
`ment options available, this patient typifies individuals
`who increasingly research health questions on the Internet
`and then act on their own. Because there are no large-scale
`studies of ibogaine in the US, this particular patient
`accepted extra risks not typical of patients seeking experi-
`
`mental therapy, including ingestion of a non–US Food and
`Drug Administration approved medication manufactured
`by unknown means from physicians offering ibogaine in a
`third-world country.
`
`Case vignette 2
`Patient 2 is a divorced, white woman in her 50s with a PhD
`in biology. While an undergraduate, she developed pyelone-
`phritis and other chronic kidney and bladder ailments.
`Corrective surgeries and postsurgical treatments resulted in
`the patient also developing sedative-hypnotic dependence.
`After healing from the last procedures, her physician stopped
`prescribing seconal, phenobarbitol, and diazepam without a
`proper taper, which resulted in severe withdrawal symptoms.
`Fearing that the rebound insomnia would harm her
`school and work performance, the patient purchased seconal
`and methaqualone illicitly, continuing her sedative-hypnotic
`dependence for approximately 2 years. Confiding in a friend
`about her illicit use of barbiturates, she was encouraged to try
`psilocybin-containing mushrooms as an addiction cure.
`After seven treatments, she successfully stopped using barbi-
`turates and ceased taking these mushrooms. Her sessions
`with hallucinogens also kindled a lasting interest in faith and
`spirituality; she states, “I actually read the Holy Bible (cover
`to cover) for the first time in my life.... To make a long story
`short, I didn't really go through any 'religious conversion' per
`se, but decided I wanted to do something more positive with
`my life.” This patient also credits her psilocybin use with
`“getting my head straight” about childhood sexual abuse,
`depression, and thoughts of suicide, for which she had
`received several years of individual psychotherapy. The
`patient continued on to graduate school and has had a sub-
`sequent successful career teaching at the university level,
`working at nonprofit groups, and now is a senior university
`administrator. This patient has remained drug-free for 24
`years and contacted the author recently to relay her story that
`hallucinogens aided her recovery from barbiturate depen-
`dence and deepened her work in psychotherapy. She cur-
`rently receives replacement therapy for hypothyroidism and
`suffers chronic neck pain from a motor vehicle accident 2
`years ago.
`This individual was sexually abused in her youth,
`developed sedative-hypnotic dependence postsurgery for
`chronic kidney and bladder ailments, and experienced
`symptoms of severe depression and post-traumatic stress
`disorder during her 20s. In other words, she was a “dual-
`diagnosis” patient with drug abuse, as well as chronic phys-
`ical and emotional problems. During the same period of
`successful work in individual psychotherapy, the patient
`was able to taper off of sedative-hypnotics in conjunction
`with the introspective insights that she feels were gleaned
`from her experimentation with psilocybin-containing
`mushrooms. She also credits her brief hallucinogen use
`with decreasing drug cravings, as well as contributing to a
`subsequent interest in faith and spirituality.
`
`

`

`Other medical treatments with hallucinogens
`Despite the clear abuse liability and potential adverse
`effects of most hallucinogens used outside the medical set-
`ting, tantalizing evidence—albeit uncontrolled or anec-
`dotal—suggests that these drugs may prove useful
`therapies for conditions inadequately treated by other
`means. Before placement in Schedule 1, ecstasy, for exam-
`ple, was quietly used by some American psychiatrists in
`couples psychotherapy as an aid to enhance communica-
`tion and empathy [35].
`Past research also suggests that LSD and dipropyl-
`tryptamine (DPT) reduce the intensity of chronic pain in
`the terminally ill and may assist in coping with the special
`circumstances raised within the family during that time
`[36–39]. Several investigators in the US are planning to
`renew research with the terminally ill, offering synthetic
`psilocybin or possibly ecstasy.
`Treatment of alcohol dependence is also being investi-
`gated in Russia, where one research team has administered
`the anesthetic agent ketamine to several thousand individ-
`uals now [40]. In subanesthetic doses, ketamine is a disso-
`ciative agent with hallucinogen-like properties. These
`investigators have suggested that ketamine therapy
`improves length of abstinence; they have recently
`expanded their protocol to treat opiate-dependent individ-
`uals, as well [41].
`Synthetic psilocybin is currently being investigated for
`treating severe obsessive-compulsive disorder that has
`failed to respond to at least one accepted therapy. This
`project comes after a recent positive case report of such
`treatment [42].
`Finally, clinical research is actively underway or in the
`planning stages for the treatment of post-traumatic stress dis-
`order with ecstasy (in the US, Spain, and Israel) [43] and for
`eating disorders with psilocybin (in Switzerland) [44].
`
`Hallucinogens Sometimes Are
`Genuine Religious Sacraments?
`Every so often media reports appear of a defendant claiming
`his drug use or drug trafficking is protected by the First
`Amendment right to freedom of religion. Courts generally
`take a dim view of such defenses because, although the Con-
`stitution does protect religious belief, it cannot be used as a
`loophole to commit illegal acts. However, this First Amend-
`ment protection of religious belief can prove quite powerful
`in opposing the will of the government. For example, Jeho-
`vah’s Witnesses can refuse to accept blood transfusions, even
`if they risk death by doing so. Christian Scientists can seek out
`their own health practitioners for their families and avoid the
`medications and other recommendations of a family physi-
`cian (although courts have intervened in some cases where
`death was imminent and a potentially life-saving medical
`procedure was available). A number of small religions have
`even been formed to aid families who wish to refuse state-
`mandated vaccination of children. Though surprising, there
`
`Hallucinogens: An Update (cid:127) Halpern
`
`351
`
`are bona fide, credible religions in the US and elsewhere that
`ingest as holy sacrament substances that, in other circum-
`stances, are regarded as Schedule 1, dangerous hallucinogens.
`The largest such faith in the US is the Native American
`Church (NAC), which reveres the cactus peyote as their “sac-
`rament” and “medicine.” Full protection from any harass-
`ment or prosecution has been granted only to members of
`federally recognized Native American tribes through the
`1994 Amendments to the American Indian Religious Free-
`dom Act (AIRFA) passed by Congress and signed into law by
`President Clinton. Although some states allow for the reli-
`gious use of peyote by anyone, regardless of race or ethnicity,
`the federal government’s protection is not based on religious
`freedom, but instead on the special custodial relationship
`between the government and these tribal members who
`have limited sovereignty out of treaty obligations. The gov-
`ernment is obliged to protect and promote the survival of
`traditional custom, culture, and ritual of these peoples;
`AIRFA was passed to ensure that the long-standing religious
`use of peyote by Native peoples cannot be obstructed by a
`blind application of drug control laws. Though peyote and
`its psychoactive constituent, mescaline, are listed as Sched-
`ule 1 drugs of abuse, each year over 2 million “buttons” (the
`above-ground crown of the cactus) are legally distributed
`throughout the US and Canada under the supervision and
`licensing of the Texas Department of Public Safety and the
`DEA. The NAC, in fact, is the largest faith among Native
`Americans, with over 300,000 members. Without needing
`“medical supervision,” these American citizens safely con-
`sume their sacrament in all-night prayer vigils. The use of
`any drugs of abuse, including alcohol, is expressly forbidden
`in the NAC. Psychiatrists and anthropologists have also
`reported that NAC members attribute this “Peyote Way”
`with saving them from the ravages of alcoholism and drug
`abuse [45,46]. Many members are also quite successful; the
`current elected President and Vice President of the Navajo
`Nation, for example, are life-long adherents to the NAC.
`Over the past several years, the author’s research team
`has conducted the first study to screen for any residual neu-
`rocognitive deficits from exclusive peyote use versus an
`exclusive history of alcoholism versus comparisons who
`never abused alcohol or drugs and were never members of
`the NAC. All individuals were recruited from Navajo
`Nation. Although the final results of blinded neuropsycho-
`logic testing of over 200 individuals is in preparation for
`publication, the author’s team do not expect these findings
`to differ from earlier reports on partial data that failed to
`find differences between the comparison and NAC groups
`[47,48]. Though anecdotal, none of the several hundred
`NAC members interviewed by us reported HPPD-like com-
`plaints or other harmful effects from their participation in
`their ceremonies.
`Indigenous use of hallucinogens extends throughout
`the Western Hemisphere, as well, with psilocybin-contain-
`ing mushrooms and, as mentioned, S. divinorum being
`used ceremonially by Mazatecs in Oaxaca. There is at least
`
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`Substance Use Disorders
`
`3000 years of peyote use by some tribes in northern Mex-
`ico, most notably the Huichol. In Central and South Amer-
`ica, traditional and shamanic use continues with other
`mescaline-containing cacti, dimethyltryptamine (DMT)
`containing snuffs and potions from seeds and barks, and
`with ayahuasca. Ayahuasca is a tea brewed from the leaves
`of Psychotria viridis and the vine of Banisteriopsis caapi, with
`Psychotria containing DMT and Banisteriopsis containing
`reversible monoamine oxidase inhibitors that are neces-
`sary for making DMT orally active.
`Physician familiarity with ayahuasca is gaining impor-
`tance in the US and other countries, because this brew is
`the sacrament of several religions that originated in Brazil
`over the past 100 years or so and are expanding to other
`countries. The two largest of these non-Native faiths are the
`Santo Daime and the União do Vegetal (UDV), which pos-
`sess a syncretic blending of Christian and Native beliefs.
`There are members of these churches living in Europe,
`Japan, and even the US. These faiths are recognized by the
`Brazilian and Peruvian governments as genuine and are
`protected there. This permission drives some spiritual seek-
`ing tourists into the Amazon River for ayahuasca sessions
`and also results in ayahuasca being shipped out for cere-
`monies in third countries.
`In 2001, The Netherlands recognized the Santo Daime
`as an accepted, legal religion, and the State of Oregon
`Board of Pharmacy also acknowledged, in a November 8,
`2000 opinion, that “the sacramental use of the Santo
`Daime tea in the context of a bona fide religious ceremony
`by practitioners of the Santo Daime religion as described
`does not constitute abuse of a controlled substance.” In
`2002, the UDV even won a preliminary injunction against
`the DEA and the Department of Justice concerning govern-
`mental policies preventing their access and right to ingest
`ayahausca. This injunction has been stayed pending review
`by the US Court of Appeals for the Tenth Circuit. Right
`now, then, America’s drug war pits religious tolerance and
`freedom against the need for drug control.
`Whether or not the federal government prevails in its
`current quest to squelch these religions, some Americans
`will continue to use hallucinogens as religious sacra-
`ments. When these individuals, Native or not, become
`patients, clinicians must be mindful of their special cir-
`cumstances, or risk alienating such patients from seeking
`follow-up care. The author of this paper has listened to
`Native Americans, for example, relate how some doctors
`blamed their peyote use as the cause of diseases or birth
`defects, even though the medical literature does not sup-
`port such accusations [49(cid:127)]. If physicians are devoted to
`the well being of their patients, then, yes, they must be
`among the first to extend their hands in help across any
`of the cultural and religious beliefs that may separate
`patients from good care. To act within the highest ethical
`traditions of medicine, it is important to learn about the
`set and setting within which patients use hallucinogens,
`as well as maintain vigilance toward cultural preconcep-
`
`tions that may bias against what may ultimately be rea-
`soned lifestyle choices.
`
`Conclusions
`Alcohol, co