Why San Francisco should give addicts more drugs

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As I wrote recently, drugs aren’t terribly difficult to obtain in San Francisco. Even though I was technically low-income relative to the area median income, I still found a trustworthy dealer and stuck to the safer varieties. But for low-income people who are dependent on riskier drugs, criminalization means what they’re often buying is impure, untested, and unsafe. 

In part to deal with the spike in overdose deaths in recent years, my former city is currently considering a “safe supply” policy of providing clean, tested narcotics and materials to people struggling with addiction. 

Some San Francisco lawmakers are reluctant to offer safe supply without adequate access to drug treatment programs. The hitch is that standard treatments are expensive and largely ineffective. But there’s a class of substances that work better. They’re also cheaper, safer, and have fewer side effects. Ironically, they’re also illegal drugs.

Reams of evidence support harm reduction strategies to reduce drug dependence and ameliorate the negative impacts of drug use. Portugal, for instance, dramatically decreased  overdose deaths and new blood-borne infections after implementing safe supply,  decriminalizing heroin and other drugs, and offering addiction treatment on demand. But the US has the opportunity to go beyond Portugal’s accomplishments by combining evidence-based harm reduction with psychedelic-assisted addiction treatment. 

The trouble with abstinence-only

Growing up, I spent a lot of time in Alcoholics Anonymous meetings. I picked up a lot of wisdom in those rooms. Hearing first-hand accounts of people hitting rock bottom in their drug and alcohol dependence did more to give me a healthy respect for substances and addiction than DARE could ever dream. But, I am writing for Psychedelic Spotlight. So even if you haven’t read any of my other posts, you can probably guess that the total abstinence message didn’t exactly take. 

While each AA group is fully autonomous, I believe most AA groups encourage staying totally “clean and sober” from drugs and alcohol. The trouble begins with trying to define “drugs.” Every meeting I attended the coffee pot was brewing, although caffeine is a stimulant drug. And the white lawn chairs had turned yellow from the cigarette smoke delivering the mood-altering drug nicotine. 

Then there’s the fact that not everyone with alcohol use disorder is best-served by total abstinence from alcohol. Some people really do struggle with addiction and then successfully learn how to drink in moderation. 

The AA model certainly works for many people. I give the program and the people working the steps tremendous credit for helping many people, including many who are near and dear to me. However, abstinence isn’t always the answer. 

Sometimes the answer is more drugs. 

Current approaches to addiction treatment

“It’s impossible to design any new treatment for alcoholism that’s gonna be any worse than what we’ve got,” said Dr. Ben Sessa on a recent episode of the Psychedelic Medicine Podcast. Sessa is an MDMA and psilocybin therapist and Chief Medical Officer at Awakn Life Sciences. “After 100 years of modern psychiatry, and the very best, gold-standard treatments that modern medicine can offer for alcoholism – one-to-one groups, one-to-one therapy, inpatient rehabs, detoxes, anti-craving drugs, social measures, legal measures, licensing restrictions – we have 90% relapse at 12 months. We were better at treating alcoholism in Victorian times than we are today.” 

Opioid addiction treatment generally begins with an opioid replacement like Methadone, the standard treatment for opioid addiction, or the newer Suboxolane. But problems with these treatments abound. First, the DEA makes them incredibly difficult to obtain. If you can get on them, you have to take them daily. Not only that, but you often have to physically go pick them up every day. They work by preventing physical withdrawal. So your options are to stay on them for life, or gradually taper your dosage. 

The key word here is gradual. If you stop suddenly, perhaps because your clinic shuts down or something else gets in the way, “I’ve heard reports that methadone withdrawal is even worse than heroin withdrawal,” Thomas Kingsley Brown, who studies Ibogaine for MAPS in New Zealand, said. Ibogaine is legal there as well as in Finland and Uruguay. Brown said it takes the average person seven to 12 years of daily use to fully taper off these drugs. They also cause many of the same problems as opiates, including brain fog, loss of coordination, and digestive problems. 

And did I mention it’s expensive? The NIH estimates that methadone treatments cost $6,552.00 per year on average. Suboxone seems to cost about the same. 

But wait, there’s more. Standard treatments aren’t just unpleasant, expensive, and inordinately difficult to obtain and maintain. They also don’t work. 

“The existing treatments are very ineffective,” Psychologist Peter Hendricks told the New York Times. Hendricks studies psilocybin and addiction at the University of Alabama in Birmingham. “I’m hoping to go from pretty darn ineffective to not bad or decent.”

Most people don’t stay on opiate replacements for the decade they require to completely taper off. “Most people don't make it more than about three months,” Brown said. 

Dr. Michael Bogenschutz is a psychiatrist at New York University’s Grossman School of Medicine. He began studying psilocybin-assisted therapy as a treatment for alcohol abuse in part because available treatments have such low efficacy. “The old rule of thumb is that one-third of people get better, one-third stay the same, and one-third continue to get worse,” Bogenschutz told the New York Times.

Dr. Ian Rabb, Chief Clinics Officer at Universal Iboga, has spent the last 15 years offering addiction and mental health treatment. He says conventional treatments for substance abuse disorder have about a 10-15% efficacy rate. By contrast, treatments that incorporate psychedelics work between 60-80% of the time. 

Addicts generally have to try multiple treatments, often multiple times, to heal. In 2020, more than 40 million Americans struggled with a substance use disorder. And addiction disproportionately impacts low-income populations. Offering expensive treatments that often don’t work to a large group of people who can’t afford them without subsidies is a surefire way to spend a lot of money and end up with little to show for it.

Brief history of psychedelics for addiction

Luckily, recent research is showing there’s a better way to treat addiction. This novel path forward incorporates substances that are anything but new. 

Howard Lotsof was a daily heroin user who also liked to experiment with other various psychoactive compounds to understand their potential psychotherapeutic value. In 1962, at 19 years old, Lotsof got his hands on some ibogaine from a chemist in his social network. 

He didn’t enjoy the trip. He walked home for a nap, vowing to never take it again. After sleeping for a few hours, he woke up totally refreshed and took a walk during which he realized he hadn’t taken any heroin in a day and a half. Yet he wasn’t in withdrawal. He later made it his life’s work to treat addiction, starting a nonprofit and treating heroin addicts in the Netherlands and in New York City in underground locations and hotel rooms. 

None other than Bill Wilson, co-founder of Alcoholics Anonymous, credited LSD with putting him on the path toward sobriety. This certainly challenges the abstinence-only model of addiction recovery. 

The evidence on psychedelics for addiction

After decades of neglect from researchers due to prohibition, recent research is showing psychedelics like ibogaine, psybicilin, and ketamine are more effective than standard treatments at helping people overcome addiction. 

Ibogaine, for example, is a promising treatment for opiate addiction. A MAPS-sponsored study showed that ibogaine is able to deal with withdrawal symptoms as well as methadone. “In our ibogaine study, participants went through treatments over the course of several days: you go to the clinic, you get your treatment, you stay there for a few days, and then you typically go home after that,” said Thomas Kingsley Brown, who studies Ibogaine for MAPS in New Zealand.

Several studies now suggest that ibogaine may be able to quell physical withdrawal symptoms more quickly, permanently, and with more tolerable side effects than opioid replacements. 

In a 2022 study on ketamine-assisted therapy for severe alcohol abuse disorder the treatment group had 10% more alcohol free days over six months than the control groups. 

Researchers say psybicilin is generally effective after just a single session or sometimes several sessions when used alongside psychotherapy or counseling.

Anecdotal evidence also abounds. NBA player Lamar Odom used ibogaine to detox from opioids. 

Jon Kostakopoulos believes participating in a pilot study on psybicilin-assisted therapy for alcohol dependence helped him get sober. He went on to found the Apollo Pact, a nonprofit that advocates for increased federal funding of psilocybin research. 

Patrick Kroupa used ibogaine to overcome his heroin addiction and went on to co-found Clear Sky Recovery to help others do the same.

Getting off problematic substances isn’t the hard part. It’s staying off of them. One thing AA does well is address addiction holistically. There are usually problems underneath the problem of addiction. AA offers alcoholics social support, spirituality, and new ways to see their relationships with substances.

Psychedelics may do some of this as well. Many people report that their psychedelic experiences have a spiritual component. And they’re often able to see themselves, their lives, and their relationship to substances in a new way following a psychedelic experience. 

“People have greater mental flexibility following psilocybin,” Matthew Johnson, a psychologist at Johns Hopkins who leads the smoking trial, told the New York Times. “That increase in openness might be a permanent change that can help in overcoming addiction.”

Here’s how Brown summarized Lotsof after his experience with ibogaine: “He also realized he had a completely different perception of heroin: while it once gave him comfort, he realized it was something that emulated death, and that he preferred life to death.”

Psychedelics also have costs and risks. LSD’s 12-hour duration makes medically supervised trips expensive. At the same time, it’s far faster, and therefore cheaper, than an overnight stint in rehab. Ketamine can itself be addictive and you can overdose, although it’s difficult. 

Side effects like nausea, vomiting, anxiety, pain, and/or loss of coordination are common with psychedelics, although these side effects seem to be better tolerated than the side effects of standard treatments. In extremely rare cases, in predisposed individuals, psychedelic trips can also precipitate a psychotic break. 

Screening is essential before using ibogaine, since it can cause predisposed individuals fatal heart problems. 

A better path forward

Addiction is simply too large and expensive of a problem for society to justify continuing to push treatments that are expensive, unpleasant, difficult to obtain, and largely don’t work. It’s past time to decriminalize all psychedelics in order to speed up research to find out exactly which psychedelics can help which people, and how. Decriminalization will make the treatments that are already working for thousands of Americans more available to low-income people suffering from addiction who can’t necessarily afford to fly to Mexico or New Zealand to get help.

Considering the preliminary and anecdotal evidence on the risks, cost, and efficacy, I believe anyone struggling with addiction who fits the safety profile should consider trying psychedelic-assisted therapy for addiction. 

I don’t regret my many hours spent in AA, although the secondhand smoke probably wasn’t great for me. But I deeply regret watching so many people relapse because the US government said they shouldn’t have access to something that might have worked better, faster. It might be ironic that the best cure for addiction could be another illegal drug. But if that’s what the evidence is telling us, we truly can’t afford to continue to ignore it.