[Psychedelic Science 2013]
[Evaluating the Therapeutic Potential of Ayahuasca for Substance Use Problems]
[Brian Rush, Ph.D. April 20, 2013]
BRIAN RUSH: I'm new to the study of ayahuasca, but not new to the study of addictions.
Thirty-seven years in the field, and I just feel to
make a contribution in this area
by bringing some of that experience into this context.
And I... It's late, so I also wanted to
thank you for being here.
You're either hardcore addiction researchers,
or clinicians, or you're
hardcore ayahuasca researchers,
or clinicians, or both.
So thank you for staying.
So without further ado, let me figure out how to do this.
You can see the title:
I thought a lot about what I could contribute,
and I framed the title this way.
What do the prevailing models and methods of
alcohol and drug treatment and treatment research,
what can they bring to the study of ayahuasca
and its therapeutic potential?
But also I'd like you to think about the reverse of that,
which I've spend quite a bit of time thinking about.
What does the study of ayahuasca - what is the
potential to bring to the study of alcohol
and drug treatment in other contexts?
I think that's a more reciprocal way
to look at the work that we face.
Okay.
Nope.
Help me out.
AUDIENCE MEMBER: Point it at the projector.
BRIAN RUSH: Ah.
HELPER: Maybe the battery's died.
Is there a way to move it forward?
BRIAN RUSH: I guess also by way of introduction,
while we're getting started,
I'm not a psychiatrist, a clinician, a physician.
I'm an epidemiologist,
so I bring a public health perspective to this as well,
which I think is interesting, to see how we can
contribute to something kind of in a clinical context,
but also both aware of the potential risks
in public health contexts, but as you'll see,
I'm going to just raise questions for you about
the role of ayahuasca in treating the full spectrum,
or supporting the full spectrum of substance use
and abuse, including its role in prevention.
I'm from Canada, so this is kind of a Canadian
afternoon with our colleagues. So, I'm from Toronto.
We are on the cusp of being in the Stanley Cup
Playoffs for the first time in the last century, it feels.
So we do play hockey, and
we are a very multicultural society.
I thought I would just point that out,
because everything I'm going to talk about including use
of ayahuasca in its therapeutic context
is really all about cultural context,
so this is a little bit of my cultural context.
So I'm going to start,
just the way the presentation's organized --
What are some of the things we've learned
from the study of alcohol and drugs and treatment,
and then what are some of the implications
of that for the study, for the therapeutic potential
of ayahuasca. So the first thing we've learned
over the last while, is that the treatment system,
and I'll go on to describe what I mean by that,
really needs to address the full spectrum.
It doesn't exist in an either/or phenomena,
not like the good and bad spirits (Jacques?).
Alcohol and drug use in the community exists
along a full spectrum, and we now see the need
to see how the specialized services for the treatment
of addictions actually can be distributed
through the community to address the full spectrum
of risks. And this asks us to look at the relationship
between treatment and prevention.
And, to point out, the afternoon has been about
the use of ayahuasca for treatment, but just as a
reminder, in many cultures it's used in a prevention
context, and we should also have that in mind.
It's not the focus for today, necessarily, but the children
are the future.
This is what's often referred to as a
population health pyramid.
Many people who are coming into
alcohol and drug treatment, and for sure,
my visit to Takiwasi, the people coming to the center
are really very severe, and quite complex,
but we have to recognize that's kind of
the tip of the iceberg.
These people emerge from a history
of use and abuse. And if we think about
Gabor Maté's presentation,
a history of a wide range of trauma.
So there's a personal trajectory, often, here.
But most of the people are here.
If we put some numbers on that,
in the Canadian context,
and if you have the right epidemiological data,
you can do this in most of the developed countries.
This is really a very small percentage of the overall
population, whereas most of the people are here.
And then if we ask what percentage of these
people are actually going for help related to their
alcohol and drugs, here very few people go for help,
but even here most of the people with very,
very severe problems, are not going for help.
The emerging view in the alcohol
and drug treatment literature,
is that this kind of microsystem of alcohol and drug
and mental health services is just not sufficient
to address this population. It's just not big enough,
and not enough people are going for help.
So the emerging view is that these services need to
be working in concert with other health services.
There's a wide range of collaborative care models,
and this is the system of support for those folks:
schools, workplace, um, the social assistance.
I've added spiritual resources.
Most people would not put them there.
I'll come back to that point.
Traditional healing, most people would not
put them there, but I'll come back to that point.
So this is the alcohol and drug treatment system.
That picture looks quite different in many countries.
This is the system of healing, and you can
see I added question marks here, because in some
communities in developing countries,
low-income countries, theres really very little of this,
and there's really only this.
So the implications: alternative healing needs to
be recognized as a legitimate part
of the community treatment system.
And I say that's a fundamental principle,
whether you're in downtown Oakland, San Francisco,
Chicago, Toronto, Inuktituk in our Arctic --
there are community healers there.
They are doing a lot of good work but they are
generally not seen as part of our health care system.
We need to consider the role of ayahuasca and other
plant medicine for prevention and early intervention.
And this one is a big challenge --
we need to see the treatment centers
as part of this system, but they need to be linked.
You heard from Anya, Gabor,
everyone talking today,
that ayahuasca is not a panacea,
but also for the treatment of addiction,
it needs to be connected to some followup.
So it's raising the question:
"what is the relationship of the retreats,"
"of residential centers, even like Takiwasi,"
"what is the relationship, for discharge,"
"where are those people going, and,"
"what's the connection when they go back home?"
So, lesson learned number 2:
the paradigm of treatment.
The paradigm of addicton drives, obviously,
the design of the intervention,
but the design of the intervention
will drive the choice of evaluation.
There is no one paradigm has been shown to be
superior in guiding the development
and evaluation of treatment.
Indeed, these paradigms are essentially
competing with each other.
We don't have time to go into this.
I think this is very similar to this
slide that Jacques showed...
Um, different ways to explain addiction.
These paradigms lead to different kinds
of interventions, different focus,
the structure of the treatment,
the interaction between the person.
The point I'm trying to make
is that the paradigm drives the intervention.
That's not news, but the question is
whether there's enough acceptance here
to accept a spiritual paradigm for treatment
of addictions - to be successful in getting
funding, to be successful in moving the
project forward.
Of course the sentence has 3 errors, because
the sentence itself is incorrect.
In other words, you will see what you
look for. We do have I think,
a Bio/Psycho/Social. But sometimes we have to
whisper the word 'spiritual'.
Bio, Psycho, Social, [whispers] Spritual...
[scattered laughter]
...paradigm for treatment.
It's like putting it in brackets in the grant.
So, the dynamics of a paradigm shift...
...and I won't dwell here, but where this is
leading is that I do not think we can evaluate
ayahuasca - it's therapeutic potential - without
including a spiritual component.
Paradigm shift, when something is not going well.
But we do have a dominant paradigm, and there's
often a competition to get space for
particular models, or measures.
These are the two fundamental goals of the
treatment system: coverage, and remember,
that even the most severe problems,
people do not go for help, so coverage
is a major problem.
But also quality. Even well-funded, well, uh, uh,
resourced programs still struggle to get very
successful rates, especially with the kinds of
people Gabor Maté is seeing in the downtown
Eastside, and what I think is going to Takawasi.
So a competing paradigm must contribute
and improve upon those two goals.
Will a spirituality-based approach grow and
be supported? Yes... if it improves coverage.
In other words, it will not be supported if we
are only seeing a very, very small number
of people, and if the results are not really good.
No one will pay any attention if you don't
solve those two problems.
So, the implications - we need to be open to
multiple perspectives, we need to fit the measures
to the model - spirituality needs a place in the
measurement model, and we don't have time
to go into it here, but almost everything I say
may not be true for the evaluation of
indigenous programs, it needs its own
paradigm, and its own model.
So lesson learned number 3: no one type
of therapeutic intervention has shown to be superior.
It's basically, 'different strokes for different folks'.
What are the factors related to improvement?
40% of the variance in treatment outcome is related
to what the person brings - their severity,
their context, their family, their community.
15% is related to what we will do with them -
and this quite humbling for people.
15% or so is based on expectancy.
And 30% is based on having a good relationship.
So, it's very difficult to find the one best
techique, because you're really only operating
with a small percentage of the variance.
And it's also important to note that
while there's lots of room for new approaches,
there are some common elements that relate to
therapeutic relationship, belief, expectancies,
and so on - and this calls for a holistic
approach to the evaluation, something, I think,
similar to what, um, has been promoted through
all of the presentations today.
It cannot be biological alone, it cannot be
psychological alone, it cannot be social alone,
these things need a holistic model.
So, the implications: treatment with ayahuasca
needs to be seen in a stepped care model,
in some case, it could be the initial stepping stone,
and needing some extended treatment,
back to what Gabor was saying.
It may be a second stage intervention.
In other words, it's not just one approach,
it needs to be part of a continuing care model.
Long-term residential ayahuasca-assisted treatment
may be effective, but it needs to be reserved
for the most severe.
Lesson learned number 5: what actually is
evidence based practice? What standards
of evidence are being held up for us?
They're pretty high, but are they really appropriate?
Um, the literature around 'EBPs', as they're called,
evidence-based practice, is evolving, and are now
distinguishing between practice and the process,
in this case, the actual intervention from the
process of delivering it.
We also hear language coming out of the
study of indigenous practices, in particular here
in the United States, um, formal definitions
of practice-based evidence, and community-defined
evidence. And we're likely to find some support
there in moving work in the area of ayahuasca
forward if we're looking to that literature and
the success that the American Indians, and our
indigenous people in Canada - and in New Zealand
in particular - are being very successful in promoting
their work, in getting funding for their programs,
by redefining evidence.
There's also work underway in the evaluation field,
for some people this is a bit of a no brainer,
but think about it.
Intervention plus context equals outcome.
There's a whole range of new methodologies
being developed for synthesizing literature
and so on.
So for sure, and I guess following up
on the last presentation in particular,
there's a need to build upon the existing
database, our existing knowledge.
There's a need to learn from the progress
being made in other indigenous healing practices.
And, this is something I really had to deal with
myself, we need to resist, or at least
carefully consider, our tendency to deconstruct the
ayahuasca experience. We have a strong therapeutic
relationship there, we have, in a shamanic context,
or a religious context, we have a group experience,
we have belief, we have a biological component --
so our first inclination is to want to kind of
pull that apart. But that's just how our Western
brain kind of thinks.
I've been advised by others to not go there
right now, but to try to study the experience
in it's totality, and also to make sure we're still
focused somewhat on toxicity.
So, bringing it all to bear:
I'm a health services guy, this is natural for me
to say, "okay, small-scale clinical studies are
one thing", but I think it's time,
or maybe time, to kinda kick it up a notch,
and what I describe as a health services agenda,
placing ayahuasca-assisted treatment in a larger
context of a health service.
Not small-scale clinical studies.
So, one approach are really finding people
in the community who are not in contact with any
formal services. There are methodologies available
that we can do this. I think we need to
understand why they're using ayahuasca,
and also, what benefits they're getting,
and how they're complementing that experience.
Secondly, and this is a study I'll describe
very quickly, what we call a panel study,
or some might use the word 'descriptive',
but it's a not-controlled, it's not a randomized
controlled trial, I don't think they're there,
but I think we can do larger scale studies
following people out, looking at a variety
of outcomes, and also understanding the context
in which ayahuasca is being used.
So, we have a project in development,
we are not funded yet.
It's a multicenter study being planned to describe
various approaches, the outcomes being achieved,
and their context.
At present the 3 countries involved are
Peru, Argentina, and Brazil.
A few of us here to keep talking about this.
Um, we are proposing a common
baseline description using validated
assessment tools. At this point it's not likely
to be the ASI, uh, we have another option
that we're looking at. But whatever tool
we use needs to have its outcome measures
embedded in that. So it's a common quote-unquote
'clinical assessment' across a number of centers,
and a number of countries.
Um, one- or two-year followup --
this will depend a lot on funding.
So, it would be a quantitative assessment of
outcomes, this is the tool we're looking at.
We're now translating that into Portuguese and
Spanish, this would be the range of measures.
Some of them in the GAIN, the spirituality-based
outcomes. Um, I've done my own literature review
on that, and I got a stack this high,
so nobody can tell me there's no spiritually-based
research being done -- you have to look in, uh,
social work, and other branches, for example
in cancer care, they're studying, um, end of life kinds
of work, and so on.
There's a qualitative narrative component
that will be needed. We are open to explore
other, uh, innovative evaluation techniques,
but essentially, it's a clinical study
done in naturalistic settings. There's a variety
of challenges - one I've been thinking about here -
I would appreciate kind of feedback on,
and we're gonna be talking about in the group.
Um, some people are coming - I don't know if this
is the right word - but are we talking about the
treatment of local people? Or are we talking
about the treatment of people who have come
from Europe or North America into a Latin American
context, and should we separate them in some way?
Should we have two different samples?
I'm not sure, but I think it's different in some way.
The belief system, the expectancies, everything,
are going to be different for that population.
Um, this is an interesting question.
Jacques was good enough to introduce me to
Sacha [?] in uh, Runa Wasi, in Buenos Aires, uh,
they use ayahuasca in the context of mental health,
generally, not just addiction.
So is our study about addictions, is our study
about something broader?
There are a wide range of infrastructure
requirements to do this. To do this in one center
is difficult enough, but to do it, for example,
in the Amazon, if we find a place, do we need
an infrastructure, for not just paper and pencils?
Computers? Data quality? Monitoring fidelity, of the
interventions, and the, and the data collection?
Sample size - Jacques wil be the first to admit -
Takiwasi is, how many people a year? Fifty?
So, we need three or four times that.
The power in these studies is in the numbers, and
for statistical controls, and statistical manipulation.
It's how you can kind of, get away, sort of,
without a control group.
But you need numbers to do that.
We will be able to compare the data,
depending on the measure we choose,
to international benchmarks of outcome.
So, it's not completely uncontrolled,
it's not completely observational.
Um. And the other one, I think I should've, uh,
thought to put on, is that only in Peru
is it really wide open and legal,
unless we did include Colombia I suppose.
So, is there some risk to the centers to be involved?
Um. How are we going to get approval?
If we looked at the Canadian example
that was presented today, it's uh... observational
studies, so maybe we don't need all those approvals.
But, in each case, we have people associated
with university. We need an ethics review.
So it's a little complicated - the logistics about it.
And I had lunch with Anya today to talk about that,
and some of the pros and cons, maybe,
of involving Mexico,
which we'll talk about as a group.
So I think that's it. Um, right now,
it's a staged approach. We are... we got caught up
in trying to get funding from Senado [?] in Brazil...
which ran into its own problems,
and its own kind of drug wars at the moment.
So we are still unfunded, but, uh, I think
we've got a variety of funding options
we'll now pursue. Um, either in Brazil, or Peru,
through kind of traditional
government research funding.
Especially for the first meeting, which is not
going to be super expensive,
we just need to come together to really
finalize the protocol. We may have other
philantropic options, and I'm starting to consider
using crowdfunding through the internet, cause
it's really not that much money.
If the 1600 people enrolled in MAPS each
contributed 10 bucks, we're halfway there!
[scattered laughter]
Thank you, and good luck in your own
personal work. Thank you.
[Applause]
CHAIR: Thank you, Brian. Uh, question.
AUDIENCE MEMBER: Yeah. I have two questions.
First question: Being in Canada, are you aware --
I'm from Arizona -- and in New Mexico they're having
like a traditional healing consult team, in, in Gallup, New Mexico, in the Navajo area, in the hospital.
Does that kind of thing exist in Canada?
BRIAN RUSH: Um. Not to my knowledge. An indigenous healer working in the context of the center?
AUDIENCE MEMBER: Yeah. That's what I've, uh, come across.
That they have like a hogan, you know, in the back, and they can, the patient can ask to participate.
So, I'm just wondering, that's an interesting kind of thing that's happening...
BRIAN RUSH: Not in Ontario... Canada's a big country...
AUDIENCE MEMBER: Sure.
BRIAN RUSH: ...and if it's happening, it would be happening probably in Saskatchewan, or Alberta, where the indigenous population is larger.
Um, we were close to hiring an indigenous, very spiritually oriented psychiatrist at our center, but at the end it didn't...
... I think they were just not brave enough. But, so I think the answer is not.
AUDIENCE MEMBER: Okay.
BRIAN RUSH: There's good relationships, but not in-house indigenous support.
AUDIENCE MEMBER: Okay. And then the next thing is... you know, I have my center there in [garbled] in the middle of Peru, with the MD,
we have computers, and stuff, and we'd love to participate.
BRIAN RUSH: Yeah, I was happy to meet you. We have to talk, and I'm sure you have...
AUDIENCE MEMBER: Yeah, you guys are gonna schmooze me, you know, and take me out, or, you know...
[laughter]
...yeah, but we want to participate. I do. Yeah.
BRIAN RUSH: By the way, it was during your presentation that I started to wonder about the challenges including,
are we talking about local people? Mestizos or indigenous people, from Peru, for example?
Or, your family from Norway? It's a different context, but, we should talk, yeah.
AUDIENCE MEMBER: Well, uh, I mean, just so you should know, I mean, our focus is neurotourism.
You know, we're treating foreigners, because that's how we can run a sustainable business.
BRIAN RUSH: I understand.
AUDIENCE MEMBER: And, I think it is an intriguing model, because that would apply here... to the individuals.
BRIAN RUSH: Yeah.
CHAIR: Next question.
AUDIENCE MEMBER 2: Thanks a lot, Brian. Um. When we finished our study with Canadian First Nations,
we started thinking about what the challenges might be in moving on to clinical research,
and I'm so glad to hear that you're looking at those challenges,
but one of them that was tough to work around, was whether... how to deal with, um, dose response issues, a standardized dose, et cetera.
It was clear that none of the ayahuasceros that we worked with wanted to use the freeze-dried version of ayahuasca.
And otherwise, if you're doing a long-term clinical study with, with hundreds of participants, you almost need to make one huge dose,
and have that either frozen or otherwise, to be able to make sure that everyone's getting a similar product.
Not because we think it makes a difference in bioavailability,
but because for the scientific community, it will, and so... what are you thoughts on that?
BRIAN RUSH: Well, there may be some of those things we need to try.
I don't think for this project we'd go there. I think it's part of the descriptive thing. Where's it made? What is the dosage? Uhh. Et cetera.
How is it being used is more of interest right now. I think at another stage, is more of a controlled kind of research thing.
And then, as many people in the room will know, you can have the same tea, in the same cup, in the same room, with 5 different people, and it's all different.
And it's gonna be different tomorrow. So even controlling the substance is not controlling the experience.
But, I think it's... for the credibility of the work, in another stage, I think we do have to go there.
AUDIENCE MEMBER 2: Thank you.
AUDIENCE MEMBER 3: Thanks. Uh... very interesting talk. So... trying to think about the cultural context in Canada,
with the work with the First Nations, I mean this is a context in which addiction is intimately linked with ongoing colonial violence,
with dispossession, and with questions of sovereignty. And... to talk about translation, [indistinct] to translation of, of outcomes.
How can we kind of think about that, and also kind of complicate the way in which spirit is being deployed... in this context?
I mean, to kind of echo Max Weber, even, and Slavoj Žižek--
the relation between liberal capitalism, and spirit, and the way in which that's being deployed, in this context,
where really, what we're trying to heal from is an ongoing colonization.
BRIAN RUSH: Yeah, these are all good issues, and we wouldn't dream to go too far without a lot more consultation with our First Nations population.
We have the one project in BC, where they've followed a really good process.
But that's, um, one small community in Western Canada. I'm working with a group at a more national level,
uh, reviewing culture-based, uh, intervention. We're going through a systematic review of culture-based intervention for indigenous people.
I've put your... it was nice to have the publication in press, at least put that there, so the issue of indigenous plants from the South, being used
in a cultural context in the North, it's emerging as a discussion point, but it's not, not quite there yet.
I think it's a very serious topic. Um, you can have a lot of perspectives.
My own is that it's maybe too early. And, and, it's not the right time to introduce it. But it's there anyway.
[Brian chuckles]
So, I appreciate the question a lot.
AUDIENCE MEMBER 4: I'm just curious. In regards to substance abuse, what are the 3 top addictions that you treat normally?
BRIAN RUSH: I'm sorry. Just do it one more time for me?
AUDIENCE MEMBER 4: In regards to substance abuse, what are the 3 top addictions that you normally treat? Like is it heroin, cocaine, alcohol...
BRIAN RUSH: In... In Canada? It depends a little bit on the province and the, and also urban versus rural.
Uh, alcohol is still top of the list. Prescription opiates are emerging as number 2.
In our treatment centers in Ontario, it's sixty, seventy thousand people per year. Um, prescription opiates have now outpaced cocaine,
as the drug of use coming into treatment. So if you just get your head around that it's a little bit scary.
Um. Cannabis is also very high, but we look a little bit suspiciously at the statistics, because many are young people that have been kind of...
...moved there, either from the criminal justice system, or, uh, the school system. So it's not necessarily 'in treatment'...
... the kind of, 'in the treatment program'. But, there are still, there are many people in treatment for cannabis-related problems. Seriously.
So, alcohol, cannabis, and now prescription opiates would be the top 3.
But that's kind of on a large scale. In Vancouver, crystal meth and opiates, and you name it. It's a pharmacy, downtown Eastside.
CHAIR: Okay, we're right at six o'clock, so I'd like to thank Brian again.
BRIAN RUSH: Okay. Thank you all!
[Applause]
[Ciência Psicadélica 2013]
[ Avaliação do Potencial Terapêutico da Ayauasca nos problemas de uso abusivo de substâncias]
[ Brian Rush, Doutorado 20 de Abril de 2013]
BRIAN RUSH: Sou novo no estudo da ayauasca, mas não sou novo no estudo dos vícios.
Trinta e sete anos no campo e senti a necessidade
de contribuir para a área
trazendo alguma dessa experiência para este contexto.
E eu... É tarde, por isso também gostaria de
agradecer o convite para estar aqui.
Vocês devem ser ou investigadores incondicionais do vício,
ou clínicos, ou talvez
investigadores incondicionais da ayahuasca,
ou ambos.
Então, obrigada por permanecerem.
Sem me alongar demasiado, deixem-me ver posso fazer isto.
Vocês podem ver no título:
Pensei bastante sobre o que poderia ser o meu contributo,
e enquadrei o título desta forma.