A study published in the Journal of Psychopharmacology, a British scholarly journal, has been picked up, repeated and amplified by many news organizations. Given the quality of the source research, I’m astonished that the headline, “LSD may help alcoholics to get sober” has been accepted without much reservation. The article is a meta-analysis of 6 studies of the effect of a single dose of LSD on subsequent drinking by people we are told are “alcoholic.” All the studies reviewed and compiled in this paper were performed prior to 1970. So even a cursory glance at this article tells us we’re talking about research that is about a half-century old. Assuming the research is valid and justifies some confidence that LSD is therapeutic for this syndrome, (and that assumption is wrong anyway) why should door-nail dead, 6-feet-under research that is disinterred after more than 42 years make such a splash?
I think the answer is twofold: First—the scourge of alcoholism is significant at a population level and at a deeply personal one. Everyone’s life has been touched usually in profoundly sad ways by problems caused by alcohol. As with many prevalent diseases that are painful and recalcitrant, any news item that purports to provide a solution will be cause for hope, and thus grab attention. (Sadly, all too often, it is a false hope.) Second: This news item resurrects a taboo drug, namely LSD. Only aging baby-boomers or their seniors will know that LSD was once available by prescription. In the early 60s it earned a seat of honor at the high-table of the DEA’s forbidden substances banquet. Because it is associated with the counterculture, and a bygone summer of love, an article about it might be nominated in the category of Best Revival, a la Hair. It’s titillating, so let’s swallow the message hook line and sinker.
The reading public may not know that there is a persistent group advocating for the therapeutic role of mind-bending drugs such as LSD. One online resource on this topic is the Multidisciplinary Association for Psychedelic Studies or MAPS (based in Santa Cruz CA). The authors of the LSD study getting all the attention now were previously funded by MAPS to investigate any potential role of MDMA (ecstacy’) in psychotherapy for post-traumatic stress disorder. So the authors, while not having a commercial vested interest in this topic, may indeed have a professional stake in this subject. I can’t comment on whether support for psychedelic research, or the topic in general, makes up a significant part of the authors’ professional portfolio, but it is worth noting the authors’ involvement in the movement.
What about the intrinsic worth of the article being shouted out to the online news world? Does it demonstrate what all the headlines say? Bottom line: shoddy paper. The authors are limited, as would historians be by the inability to get fresh data. They admit they were “unable to obtain the [research] protocol of any of the trials” included in their meta-analysis, yet they stand by the quality of the research in the individual trials. This is on the face of it absurd.
But we may look at the information provided about the studies included in the meta-analysis. Do the studies deal with “alcoholism” in the first place? Does the word refer to the same diagnosis now as it did 50 years ago when the subjects were recruited? And do we know that the subjects were comparable on important variables, one study to another and one treatment arm to another within individual studies? What about the treatment(s)? Are they relevant to today’s management of people with alcohol dependence? (That is, would the findings apply to today’s system of care and patients?)
The source article is perforce limited by the state of understanding and treatment as it was a half-century ago. At that time the prevalent diagnostic criteria for alcoholism were vague and different from today’s. Since the 1960s, there have been several iterations of increasingly specific diagnostic criteria; the state-of-the-art continues to evolve today: the next Diagnostic and Statististical Manual (DSM–the diagnostic guide in psychiatry) to replace the 4th revised edition, and the diagnoses of addictions are undergoing some significant refinements. The next iteration, DSM V, will permit better sub-categorization of both severity and type of alcohol problems. It is likely there will no longer be, for instance, a seemingly arbitrary separation between alcohol “abuse” and alcohol “dependence.” In any case, there are many discrete criteria for the diagnosis today, and the definition of alcoholism’ in the LSD articles is vague at best.
Today we understand that there is great heterogeneity among people who might share the diagnostic label of alcohol dependence. They vary on pattern of drinking, of severity of consequences, on level of volitional control and other biologic and behavioral parameters. In well-performed studies of addiction today, baseline severity is assessed, and we would like to know that the severity of the problem in the experimental group at baseline is comparable to that of the controls. There is no mention of this in the LSD article. This could be an apples and oranges (and pineapples and kumquats) problem : Without attention to baseline severity, one study might be comparing outcomes in employed, married, wage-earners who meet minimal criteria for the disease to a group of homeless men who meet maximal criteria and have severe biopsychosocial and economic decompensation, while carrying the same diagnosis. The former group will likely do better irrespective of the intervention. We also are not informed of the immediate past drinking history of the subjects. Had they been sober for a day, a week or a month, prior to the LSD dosing?
Another technical problem with the studies is the difficulty blinding the subjects. In any “blinded” study, it is usual and expected to perform a “test of blinding” to see if the study and control subjects were indeed ignorant of the treatment provided. Several of the studies clearly did not successfully blind the subjects, and none of the studies were noted to have performed tests of blinding. It is astonishing to see relatively primitive research design in the 1960s papers included: not only was blinding not assured, but the subjects receiving LSD were educated about the drug and received extra counseling compared with the controls in several studies. It is bizarre to accept the outcomes of these studies as resulting from the LSD intervention rather than from other aspects of the treatment such as counseling or knowledge of having received the study drug.
It seems that the treatments the various groups of subjects were administered are not comparable one to another nor to the present day treatment milieus. The subjects were inpatients, and some stayed on in intensive treatment for months. Such long stays are virtually nonexistent today.
In contemporary (2012) research on drinking, the outcomes are measured in several ways, triangulating in on several issues. There are validated interviews for evaluating drinking, (for instance the “time-line follow back” method) where in cues are given to remind the subject of recent drinking. There are validated scales for social adjustment and global well-being. The drinking outcomes themselves (e.g. return to heavy episodic drinking, number of drinks per drinking day, duration of total abstinence & etc) are usually collected in fine detail. There is little specificity about what the outcome measures are in the LSD study. The authors have chosen to include several global outcomes even in instances when the drinking was not well characterized.
A casual investigation of LSD online yields predominantly sympathetic and highly detailed articles. The drug-fancier’s website EROWID and Wikipedia both emphasize how benign LSD is. Whoa, there, boy: LSD is clearly associated with prolonged periods of stress, might precipitate new or underlying psychosis, and can presage a prolonged period wherein psychosis recurs at variable severity (so called “Hallucinogen persisting perceptual disorder”) I’d hate to see desperate alcoholics self-administer street hallucinogens to sober up. By under emphasizing the real risk of harm, we gloss over a basic ethical and scientific tenet of human research that we respect today. If significant harm is observed in the absence of benefit, a study is terminated before it has a chance to yield conclusive results. For a drug with known negative side effects to be studied today, the disease studied would need to be both 1) severe and 2) refractory to other less harmful interventions. Alcoholism meets the 1st criterion but not the 2nd. There are 3 approved pharmacologic interventions for alcoholism (acamprosate, naltrexone, and disulfiram), a smattering of effective but non-approved drugs, and several behavioral interventions know to be effective. It is a shame that the blogosphere and the buzzing news outlets emphasize enthusiasm about the exciting LSD headlines and undersell the cogent available and established treatments.
The authors of the LSD study explain that the experience of altered reality can be helpful in treating psychiatric disease. The harmful pattern of drinking in severe alcoholics is deep seated. The dogged repetition of the harmful, shaming and disempowering drinking and relapsing might beg for a “press reset” sort of cure. Such is the unscientific explanation given for LSD. Take just one dose, and like Aldous Huxley in “The Doors of Perception” (although I think his nectar was psilocybin or peyote), you will achieve a salutary and liberating new perspective on your life and habits. I don’t want to belittle the transformation that sometimes occurs in recovery from addiction: indeed it is among the most inspiring, courageous and spiritual parts of Medicine I have the privilege to experience. But it does not always occur in a flash. Touting the “control-alt-delete” version of growth, the “drop a blotter on your tongue to gain enlightenment” method, seems misplaced. The work of recovery is pick-and-shovel work. It is a daily grind. Only after living sober, one-day-at-a-time, using whatever effective, on-balance helpful tools at our disposal, do we look back and grasp the new reality we have built. Can LSD provide a window onto that new reality? Maybe. But the news bouncing around the internet isn’t shedding much light on this.