Getting off the merry-go-round

Today's post is about the outcome of last week's election -- but a part of it you might not have heard about, given the media furore surrounding the race for president.

Last week Oregon became the first state to legalize psilocybin -- more commonly known as "magic mushrooms."

[Image licensed under the Creative Commons Arp, Psilocybe semilanceata 6514, CC BY-SA 3.0]

The change came about because of a pair of bills, Measure 109 and Measure 110, which (respectively) made the use of psilocybin legal in a therapeutic setting, including for reasons of "personal growth" (i.e. not to treat a specific condition), and decriminalized the possession of small amounts of a wide range of drugs, making it a minor non-criminal offense on par with a traffic ticket.  I'm not going to get into the second measure, by far the more controversial, except to say that Portugal did the same thing in 2001, diverting the money that would have been spent prosecuting and jailing drug users into treatment programs, and saw voluntary addiction treatment rates rise, and drug use amongst adolescents and deaths due to overdose both decline precipitously.

But passage of the psilocybin measure made me say, "About damn time."  Psilocybin was declared a "Schedule I drug" in 1970, meaning it was claimed to have "a high potential for abuse," "no currently accepted medical use," and "a lack of accepted safety."

All of which, in fact, turned out to be false.  It's non-addictive, rarely if ever causes deleterious side effects, and its efficacy for treating depression has been known for years.  Study after study has come out providing evidence that psilocybin works; so many that it's beginning to sound like the studies disproving the vaccination/autism connection, repeating the same protocol over and over, getting the same result, and saying, "SEE, WE TOLD YOU, IT HAPPENED AGAIN.  BELIEVE US NOW?"

In fact, just last week a study came out in the Journal of the American Medical Association showing that one or two administrations of psilocybin, in a controlled setting, triggered remission of the symptoms of treatment-resistant major depressive disorder for months, possibly years.

This kind of thing is a godsend, because the current state of treatment methodologies for depression resembles a blindfolded game of darts.  I went through three years of considerable hell trying to find an antidepressant that (1) actually mitigated my depression, and (2) didn't give me miserable side effects.  The frustrating part is that an antidepressant that works brilliantly for one person might not work at all for someone else, and no one knows why.  The first two I tried, citalopram (Celexa) and escitalopram (Lexapro), both made me sleepy and completely wiped out my sex drive.  The second one, lamotrigine (Lamictal) gave me thermonuclear-level acid reflux.  The worst was sertraline (Zoloft), which I know is a game-changer for some people, but made me feel like I was at the middle of a neural lightning storm.  I couldn't sit still, couldn't sleep, and couldn't stop out-of-control thoughts that included suicidal ideation.

I got off that stuff fast.

I was on the verge of giving up, but my doctor recommended trying one more, bupropion (Welbutrin).  Welbutrin doesn't give me side effects, which is kind of awesome.  I wouldn't say it erases my depression -- none of them really do that, pretty much for anyone -- but it blunts the edge of the worst of it.  On Welbutrin I don't have the crashing lows I used to get, and have experienced with clocklike regularity every four or five months for pretty much my entire adult life.

On the other hand, if psilocybin works for you (which it does for the vast majority), it works.  People report complete remission of symptoms, something I can't honestly imagine.  Best of all, it only takes one dose to get long-term positive effects.  

I take Welbutrin every day; for me it's a maintenance med.  The idea that I could take one dose of something and get off the merry-go-round of self-medication, to be able to throw away the little orange bottle I have to carry around with me when I travel, is incredibly appealing.

I find it somewhere between absurd and appalling that the government has dragged its heels on decriminalizing psilocybin and authorizing its use as a therapeutic.  Okay, fine, regulate it; allow it only under a doctor's orders and a doctor's care.  We can argue about whether recreational drugs should be legal another time.  But here we have something that could dramatically improve the lives of an estimated eighteen million people in the United States -- about seven percent of the population -- addressing the main reason for the sky-high suicide rate, averaging one person choosing to end his/her own life every twelve minutes.

Would I try it?

Damn right I would.  In a heartbeat.

I know whereof I speak about this.  I'm lucky to be alive.  I attempted suicide twice, ages seventeen and twenty, only pulling back from going through with it at the last minute out of fear.  I had another serious period of pretty much continuous suicidal ideation in my mid-thirties, and that time was saved by the knowledge of what it would have done to my kids.  I still struggle some days, but with the love and care of my wife and friends, and a medication that takes away the deepest lows, I'm on an even keel most of the time.  But the worst of what I've experienced I wouldn't wish on anyone, and it's unconscionable that our government is creeping along in addressing a disorder that is a direct contributor to the horrifying statistic that suicide is the second leading cause of death in the United States of people between the ages of ten and twenty-four, and the tenth leading cause of death overall.

It's time to start pushing our leaders into doing something, into following Oregon's lead, and into getting correct information to voters that "decriminalizing drugs" doesn't mean "encouraging everyone to become an addict."  That all current Schedule I drugs aren't the same -- lumping heroin, marijuana, ecstasy, and psilocybin in the same category is somewhere between scientifically inaccurate and downright idiotic.  That people with major depressive disorder should have a choice to try something showing tremendous promise not as a maintenance treatment, but something damn close to a cure.

Please write letters, make calls, get involved.  It could change lives.  Hell, it could save lives.  And I'll end with doing something I rarely do: ask my readers to share this post.  Link it, retweet or repost it, email it.  The word needs to get out there.

If we can get one person out from under the black shadow of depression, help one person to step out into the light, it'll be worth it.

************************************

This week's Skeptophilia book-of-the-week is about our much maligned and poorly-understood cousins, the Neanderthals.

In Rebecca Wragg Sykes's new book Kindred: Neanderthal Life, Love, Death, and Art we learn that our comic-book picture of these prehistoric relatives of Homo sapiens were far from the primitive, leopard-skin-wearing brutes depicted in movies and fiction.  They had culture -- they made amazingly evocative and sophisticated art, buried their dead with rituals we can still see traces of, and most likely had both music and language.  Interestingly, they interbred with more modern Homo sapiens over a long period of time -- DNA analysis of humans today show that a great many of us (myself included) carry around significant numbers of Neanderthal genetic markers.

It's a revealing look at our nearest recent relatives, who were the dominant primate species in the northern parts of Eurasia for a hundred thousand years.  If you want to find out more about these mysterious hominins -- some of whom were our direct ancestors -- you need to read Sykes's book.  It's brilliant.

[Note: if you purchase this book using the image/link below, part of the proceeds goes to support Skeptophilia!]

Voodoo in the brain

I'm sure you've heard about the placebo effect, but have you heard of the nocebo effect?

If you know a little Latin, you can guess what it means.  Placebo is Latin for "I will please;" nocebo for "I will harm."  The nocebo effect occurs when you expect something to cause you unpleasant symptoms, and even though what you've consumed is harmless, you experience the symptoms anyhow.

We've known about the nocebo effect for some time.  It gained prominence due to investigations of "voodoo curses," where someone was cursed through a voodoo ritual, and lo and behold, the cursed individual sickens and dies.  Skeptical researchers don't credit this with voodoo actually working; they have come to realize that when a person thinks they're going to become ill, perhaps even die, the expected outcome manifests in the body.

[image courtesy of photographer Marie-Lan Nguyen and the Wikimedia Commons]

A recent study gives us an even better lens into the nocebo effect, and how the brain influences health.  Any medical researcher will tell you that people in clinical trials of medications will often stop taking the pills they were given, usually citing unacceptable side effects.  What is less well known is that a substantial fraction of the people who end up dropping out of the trial actually were receiving an inert substance.

So the control group, in other words.  They were taking a sugar pill, but because they expected to have side effects from the medication, they went ahead and had side effects anyhow.

The most recent study, which was published in Science last week, was the work of four researchers at the University Medical Center of Hamburg, the University of Colorado, and Cambridge University, and had the unwieldy title, "Interactions Between Brain and Spinal cord Mediate Value Effects in Nocebo Hyperalgesia," and it had a fascinating result:

People in the control group of pharmaceutical clinical trials are more likely to have spurious unpleasant side effects if they're told the medication is expensive than if they're told it's cheap.

Furthermore, they have pinpointed the areas in the brain that are responsible for the foul-up.  The authors write:

Value information about a drug, such as the price tag, can strongly affect its therapeutic effect.  We discovered that value information influences adverse treatment outcomes in humans even in the absence of an active substance.  Labeling an inert treatment as expensive medication led to stronger nocebo hyperalgesia [negative side effects] than labeling it as cheap medication.  This effect was mediated by neural interactions between cortex, brainstem, and spinal cord.  In particular, activity in the prefrontal cortex mediated the effect of value on nocebo hyperalgesia.  Value furthermore modulated coupling between prefrontal areas, brainstem, and spinal cord, which might represent a flexible mechanism through which higher-cognitive representations, such as value, can modulate early pain processing.

Which is kind of amazing.  People who experience unexpected side effects are often labeled as hypochondriacs -- i.e., that they know perfectly well they feel fine, and are making up or exaggerating their symptoms out of fear or a desire for attention.  What's really happening appears to be far subtler.  Because of an expectation of harm, the brain actually manifests the symptoms the person feels they're likely to have.  Labeling the medication as expensive increases the subject's sense of having put something unusual into their bodies, resulting in more anxiety and worse side effects.

For me, the most interesting thing about this is the interaction of the brainstem and spinal cord, two parts of the central nervous system that are usually regarded as controlling completely involuntary responses, with the prefrontal cortex, often considered the most advanced part of the human brain -- the part that is associated with reasoning, decision making, and logic.  The fact that a freakout (to use the scientific terminology) in the prefrontal cortex activates a response in the brainstem is astonishing -- and also explains why people who experience the nocebo effect can manifest actual measurable medical symptoms.

And why some of them die.

All of which brings home once again how incredibly complex the brain is.  We're living at an exciting time -- the point where we're finally beginning to understand the thing in our heads that artificial intelligence pioneer Marvin Minsky called a "three-pound meat machine."  And, apparently, how easy it is for the machine to get fooled.  Kind of humbling, that.

Anti-smirk spells

Most of you probably know the name of Martin Shkreli, the pharmaceuticals executive who became notorious for raising the price of an anti-HIV drug his company manufactures from $13.50 per tablet to $750.  Once caught, he was completely unrepentant, claiming that the price hike resulted in cash that could be put into additional research, which would be "a great thing for society."  Not so great a thing for people who are HIV-positive, of course, but he doesn't seem unduly bothered by that.  Morals don't seem to be Shkreli's strong suit; besides his dubiously ethical practice of jacking up drug prices so as to squeeze the maximum profit from the ill, he was also arrested for securities fraud last year and is currently out on bail pending trial.

He is also notable for having a cocky, self-satisfied smirk so infuriating that it would probably induce the Dalai Lama to punch him in the jaw.

The trouble is, his arrest and upcoming trial have nothing to do with his practice of pricing life-saving drugs out of the reach of all but the very rich.  Worse, he's certainly not the only one in the pharmaceuticals industry doing this, he's just the most visible (and irritating) face of the problem.  Whatever happens apropos of his trial for securities fraud, Shkreli and his profit-above-everything-else motive are going to be difficult to eradicate, given that it's not illegal to sell products at an exorbitant rate in a capitalist society, however unethical it might be.

Which is why a group of Brooklyn witches have taken matters into their own hands, and put a curse on Shkreli.

The spokeswitch for the group, who goes by the name  "Howl," said that she doesn't hex people lightly.  "If I do go to this extreme, it’s to ensure that someone who is doing wrong is held accountable and pays for their wrongdoing, rather than because I just don’t like someone," Howl said in an interview with The Daily Dot.  "Like, this person will get away with doing so much harm.  And I can’t do anything in a financial way, the systems of capitalism alienate the poor from any measure of justice or assertion of voice and power, so what can I do?  And this is one method."

Howl and her friends aren't messing around, either.  They made a wax statue of Shkreli, and then let each of the witches take a shot at hexing it.  "We sent the effigy around the circle and each person anointed a different part of the effigy and expressed their desire for the type of hex they’d like to enact,” Howl explained.  "For example, someone anoints the head and says they hope the ego dies, that Martin Shkreli gets over his ego and realizes the damage that he’s done and makes amends.  Or they’d hex where you’d keep your wallet and says they hope he pays financially for the financial damage he’s done to other people."

Me, I'd like to see a spell that would freeze his facial muscles into a permanent scowl, so I'd never have to see him smirking at federal prosecutors again.  Others have suggested that it might be more appropriate to magically teleport HIV into his bloodstream, and then charge him $750 per tablet for his medication.

Unfortunately, I don't think any of this will work, for as Tim Minchin put it, "Throughout history, every mystery that has ever been solved has turned out to be... not magic."  But I have to say, skeptic though I am, if it comes to a choice between Howl and Martin Shkreli, I'm siding with Howl.  However ineffective her methods almost certainly are, her heart is in the right place.  "Some folks I know live with AIDS, and others rely on the medication, so that price tag is absolutely uncalled for and ridiculous," she said.  "I know systemically it’s not only him.  But he is a very visible part of this."

Which is it exactly.  So as far as the Brooklyn witches go, my response is: carry on.  I'd also encourage the Dalai Lama to take a crack at Shkreli, if he's feeling up to it.

"Big Pharma" and the package-deal fallacy

My post from a couple of days ago about the fraudulent psychic who convinced Latina singer Jenni Rivera's family that she had survived a plane crash (she didn't) elicited a curious comment from a reader.

I had prefaced my comments about Rivera and the psychic with a statement that woo-woo beliefs cause a lot of harm -- and I cited homeopathy as one example.  The commenter ignored the main gist of my post, and leaped upon the homeopathy comment, responding, "Does this (harm) include fraudulent behaviour by clinical scientists who are paid by the big pharmaceutical companies to fudge their data?  Typical double standards by pseudosceptics!"

Well.  I could call "red herring" on this and be done with it, but I thought it might be more interesting to look at the question a little more closely.

First, let me say at the outset that I am neither a medical professional nor a specialist in corporate law.  I am, however, trained to do biology, and I understand anatomy and physiology pretty well.  And whatever else you might say about most medications, they do, for the most part, what they're intended to do, and we understand how they do it.  To take two examples from my own health: (1) I am currently recovering from a sinus infection, and have been taking amoxicillin; and (2) I have moderate chronic high blood pressure, and am on two medications (nifedipine and hydrochlorothiazide), and I am pleased to report that at my last checkup my blood pressure was a healthy 118/80.  And all three of those drugs have mechanisms of action that are thoroughly researched and well understood.

So, here's the deal.  While "Big Pharma" is composed of a group of huge corporations, which (like all corporations) exist to make money for stockholders, they do have one thing going for them; the drugs they make seem to work pretty well.  It's kind of funny, don't you think?  All the fraudulent, on-the-take clinical scientists fudge their data, and evil old "Big Pharma" continues to churn out medications that have made us one of the overall healthiest societies ever.  We have virtually eradicated childhood infectious diseases because of vaccination; we have nearly eliminated deaths from bacterial infections because of antibiotics; cancer survival rates have improved significantly because of chemotherapy.  I know personally at least a dozen people who owe their lives to "Big Pharma."

Now, of course, the commenter was right in one sense; when corporate interests and the profit motive get mixed up in anything, there is always going to be some degree of corruption.  Human greed is as insidious, and harder to cure, than human disease.  And while the survival rate from most of the ills that have plagued humanity from the get-go has increased, there are a few conditions that have become more common since the advent of modern medicine, for reasons unknown (allergies, asthma, and autism come to mind).  But the idea that because we haven't cured everything, and because there have been some examples of bad science, fudged data, and coverups, all pharmaceuticals should be avoided, is blatant foolishness.  This is the "package-deal fallacy" in a particularly dangerous guise.

Because, after all, what does the alternative medicine crowd propose as a replacement?  Homeopathy (which I beat on frequently enough that the phrase "'nuff said" comes to mind).  "Colorpuncture," about which I wrote last week.  Crystals, smudging, aromatherapy, flower essences, chakra manipulation.  Oh, yeah, and one other one, that I just found out about last week because of a student in my Critical Thinking class: "Auto-Urine Therapy."  Yes, folks, this is exactly what it sounds like; improve your health and cure disease by drinking your own urine.  What's it supposed to do, you might ask?  I know that's what I asked, after I finished gagging.  "This diet minimises toxins and further enhances the power of the immune system. Ojas [the essential energy of the body] is increased and thus the urine contains more valuable biochemicals," the website says.  "Urine can also be used to cleanse the stomach, lungs, sinuses and nasal passages in the Yoga practices of Neti and Kunjal Kriyas."

Apparently it can also be used as a "skin tonic."   Um, yeah.  I'll just stick with lotion, okay?

Now, don't get me wrong; there are some "natural medicines" that have shown efficacy in treating human diseases.  Digitalis, aspirin, atropine, vincristine, the opiates, and a variety of other medically-useful compounds, now found routinely in standard medicine, are plant compounds.  Others are still being investigated -- the jury is still out on echinacea and turmeric, for example.  Others still (such as ginkgo biloba, supposed to be useful to improve memory) have been shown in controlled studies to be useless.

The point is, doctors and medical researchers are constantly looking for new ways to approach treatment, and they have nothing against herbals as a source of new, more effective drugs.  But, as Tim Minchin said, in his wonderful piece "Storm" (you should all watch it, but be forewarned -- there's some inappropriate language, should you be sensitive to such things), "There's a name for alternative medicine that's been proved to work.  It's called... medicine."