This is a guest blog post written by fellow nurse, Nick Angelis, CRNA, MSN.
In the 1950’s, promising research showed that alcohol addiction could be treated with the psychedelic LSD. (I planned to define every term I use in this article, but I started boring myself, so instead I’ll answer questions in the comments.) Marked by hallucinations and sensory distortions, lysergic acid diethylamide uncoupled the brain from its habitual processing pattern, sometimes curing addiction permanently. In the decades following, psilocybin from “magic mushrooms,” MDMA (Ecstasy), the anesthetic ketamine, and several other psychoactive compounds also showed considerable promise, especially in treating depression, PTSD, and the ever growing patient population told by physicians, “We don’t know what’s wrong with you, but it’s probably in your head.”
You know the ones- a long list of allergies in their chart, a medical history of anxiety, fibromyalgia, and eventually syndromes with unusual acronyms such as POTS, EDS, CRPS, and MCAS. The challenge is that insurance-based office visits can’t quickly solve the core issues for these complex and desperate patients, so they’re labeled as “non-compliant” when they try to Google search their way to wellness. Oh, and also labeled “criminal addicts” since, with the exception of Schedule 3 ketamine, these psychedelics were all classified as illegal thanks to flawed and sometimes fraudulent government data overstating their risks.
Marketing Influences our Views
But, although I’ve owned a ketamine clinic for about 4 years and have witnessed the healing power of psychedelics on a daily basis, this is a blog post for nurses to identify the risks related to patients using these substances. Despite old stigmas, there are positive stories on every news source about ongoing research studies. This reminds me of years ago when I was a ‘FreshRN’ instead of the ‘WitheredCRNA’ I am now, and everyone obsessed over their cholesterol levels. Generic statins weren’t available yet, so Lipitor and similar drugs were bringing in billions of dollars. Pharmaceutical companies know that good marketing convinces soccer moms, not just physicians, so it’s important to get everyone possible talking about the topic.
Psychedelics vs Marijuana
The same pattern occurred with marijuana. News stories about possible risks decreased once someone other than Derek could make money from weed. Tattoos, wispy mustache, baseball cap at an obnoxious angle–yeah, that’s Derek. Although medical marijuana treats many of the same conditions psychedelics do, the biggest difference is that with weed, the effects fade as the chemicals leave the nervous system, so the user has to retake the substance to keep symptoms at bay. It’s the same issue with chocolate, red wine, and other fun and heavily-researched chemicals that cause problems when not used in “moderation.”
To summarize thus far for those of you who, like me, would fall asleep in the back during nursing school lectures: don’t do drugs. Well, ok, don’t do certain drugs or law enforcement will get sad. Well, maybe they’re ok if you really need them, but not if you take too much. Again with the example of marijuana, how do you take enough to function, without risking addiction, panic attacks or psychosis, hyperemesis syndrome, gastroparesis, or eating cheese balls in Mom’s basement until forcefully evicted? A common response to worsening symptoms is increased dose and frequency, leading to a vicious and expensive cycle that only helps Derek (or your legal dispensary). This tunnel vision is why medical supervision is helpful, especially since we’ve already (unfairly) profiled the ‘Healthcare Puzzles’ who bounce from medical specialists to alternative medicine, to whatever has a chance to return them to the blissful land of Patients Who Don’t React Weirdly to Standard Medical Interventions.
So, complex patients are at risk because they’re at risk from everything they try, so why should psychedelics be any different? Whether or not their reactions are purely psychological isn’t crucial, as psychedelics function to repair the nervous system. PTSD often manifests in physical symptoms. My patients often claim that their heartburn, knee pain, or some other random symptom disappears forever after one ketamine infusion. As the picture above illustrates, the danger lies in thinking we’ve found a cure-all. Because psychedelics are not naturally addictive, in healthy people an isolated trip is not something to write an incident report about. Microdosing avoids many issues as it allows patients to function normally (unless they read the wrong sketchy blog on how to microdose). Ketamine possesses sympathomimetic effects, the way you wish thinking about exercising actually induced aerobic exercise without any of the effort. This can be dangerous in patients with poorly managed heart conditions. The true psychedelics won’t increase heart rate and blood pressure in this manner. They work primarily on serotonin receptors when they light up the 90% of your brain that your 7th grade biology teacher accused you of never using.
(trip looks like this ^)
Of course, if your eyes are seeing patterns like the above while tripping on psychedelics, that could indirectly scramble your vital signs even if you don’t try flying off a building. I haven’t written anything about detecting if a patient is under the influence of a psychedelic, because the nursing care is similar to that of any other patient showing up at the ED–ask good questions and keep them safe. If they can’t confirm what’s in their system, speak in a comforting manner and reduce stimulation. Lower the lights and the sounds they might hear while in an altered state. Set and setting are paramount in finding therapeutic uses for psychedelics. That’s why when I use ketamine in the hospital OR, patients may wake up screaming if I don’t also give sedatives. Surgery is a scary time. Tripling the dose in a quiet clinic with soft music playing offers a time of reflection and meditation for that same patient. Buying some mushrooms from Derek (that guy gets around, let me tell you) while listening for cops is not conducive for an anxiety cure.
Taking these drugs while alone could result in harm, and it’s naïve to think that a substance meant to help process traumatic experiences could never make it worse. Similar to Reglan or Haldol, patients may appear blissful while panicking (swirling around a “K hole”). Ketamine is medically useful in the ED because it cuts off the limbic system, which helps our brain interpret pain and emotional significance, without causing respiratory sedation. Integration, ideally with a therapist, is crucial once a patient finishes orbiting the Milky Way and returns to their body. The stigma of LSD frying your brain isn’t completely false either, even if most of the research was. In the case of ketamine, memory loss, cystitis, and a generalized disconnection with reality are risks with continued abuse. Patients with underlying addiction issues will simply add psychedelics to the long list of other substances they’ll try whenever they can get their hands on them.
This is the part of my article you should remember, and there are probably much nicer ways to word it. The pharmaceutical industry has convinced us that, at any age, if we have a problem, there’s a chemical we can take to conveniently fix it. We deserve to feel amazing all the time. Lifestyle changes, physical therapy, talk therapy, or paying attention to our spiritual issues seem like too much work compared to popping a pill. Psychedelics grant a profoundly spiritual experience, so patients usually break away from the unwillingness to take charge of their own health. However, once we read anything positive about something we want to do, it eases our conscience so we can indulge in rivers of red wine and dark chocolate and marijuana and psychedelics because “research shows it’s good for you.” That analogy worked really well until you thought, “marijuana can’t flow like a river.”
Do No Harm
The first step when a patient talks about using or wanting to use psychedelics is asking them not to make the decision alone. I’ve mentioned they’re relatively safe compared to other drugs. In part, that’s because they’ve been taken in community with careful rituals. Examples from indigenous tribes on both sides of the Rio Grande include mescaline from the San Pedro cactus or 5-MeO-DMT from toxic toads, thousands of years before scientists started their research. I realize that most nurses might not have the time to engage in long philosophical discussions with their patients, so I’ll close with the following action plan. The goal is harm reduction, not dissuading patients from trying something that could actually help if done properly. “Properly” doesn’t necessarily mean in a research institution with bespectacled men in lab coats nodding gravely–some of the best results I’ve seen were from patients who missed appointments, had multiple additional health problems, and still sustained remarkable improvements.
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So, as a nurse, how can you respond beyond the generic, “Only take what’s prescribed”? The safety profile for psychedelics leads many to advocate for recreational use beyond the confines of the same medical establishment that cheerfully approves of drug classes with horrible long-term risks, such as opioids, steroids, stimulants, benzodiazepines, etc. Here’s a common conversation I have in order to refute excuses.
Patient: “I want to take high doses of LSD or mushrooms for my mental health.”
Me: You can come to a ketamine clinic and be supervised if you’re a good candidate.
Patient: It’s too expensive.
Me: So is jail. Anyway, Spravato, an S-ketamine nasal spray, is covered even by Medicaid plans.
Patient: I live in a log cabin 100 miles away from everything.
Me: Mail-order ketamine lozenges are available from several companies if you qualify.
Patient: Actually, this all sounds shady and I only want what Medicare will cover for mood disorders.
Me: That’s fair. Transcranial Magnetic Stimulation (TMS) is another fast-acting alternative for treatment-resistant depression.
Patient: Nope, I just want a pill that actually works, unlike the 20 I’ve already tried.
Me: Talk to your provider about the new anti-depressant Auvelity–it contains dextromethorphan, which optimizes the NMDA receptor for the neurotransmitter glutamate like ketamine does, but more gently.
Answer 2: If you already dissociate from reality and are at increased risk of psychosis because of schizophrenia or active mania, all of these options can make you worse.
Further reading since I have strong opinions and have merrily stomped all over nuanced, ethical considerations to amuse you. Or you can leave a comment on this article, or listen to this podcast.
Nick Angelis, MSN, CRNA is the author of How to Succeed in Anesthesia School (And Nursing, PA, or Med School) and regularly writes or presents continuing education on a variety of dry and dreary topics, unlike this one. Nick owns Ascend Health Center “Rise Above Emotional and Physical Pain” in Akron, Ohio and enjoys playing several sports poorly. You can connect with him on Twitter or Instagram.
Nicholas Angelis says
I should add, the mail-order ketamine companies are super sus, as the cool kids say. It’s an option the way Taco Bell is an option if you’re hoping Ruth Chris’s Steak House is open for dinner. Much like the Facebook ads for online Adderall, the screening and maintenance process is hi-tech, but not thorough.