SpongeBob DoctorPants

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I have a patient who is a young adult white female, and she has a history of cannabis and alcohol use disorders; she currently denies cannabis use for the past six months but still drinks alcohol about once a week; she says she drinks socially but about half of these times she ends up getting drunk. She and a friend of hers also recently began participating in Native American religious ceremonies about once a month, in which psilocybin is used, and she reports this helps her to feel happier and it helps her to have interesting thoughts about herself and it makes the world more colorful for a few hours. She denied other substance use to me but from a recent PCP note I read, it appears she also disclosed use of acid and Molly. Of course, her participation in the Native American rituals as a purely religious experience is suspect, given her substance use history and the fact that she is not Native American.

During the recent visit to her PCP, it was recommended she talk with her psychiatrist about getting a medication specifically for her anxiety, because she has been having elevated heart rates, which the PCP also considered was due to the illicit substances, but which the patient said she wasn't willing to give up. She said her PCP recommended a medication that "started with C and ended with pam... I think it's pronounced clonpam, or clonzepam, or clonziapam, or something like that." While it may be true that the PCP suggested clonazepam and the patient just didn't know how to pronounce it, this reminded me of classic drug seeking behavior.

I did not end up prescribing her any controlled meds at this time, but this got me thinking about psilocybin and whether its use in a religious practice without any evidence of a substance use disorder should preclude the use of any controlled substances as medications. Let's say this patient had zero substance abuse history and was only using psychedelics in religious ceremonies. Are there any drug interactions or safety concerns I would need to be aware of, before starting a patient on any medication?
 
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Liquid8

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Of course, her participation in the Native American rituals as a purely religious experience is suspect, given her substance use history and the fact that she is not Native American.

Still laughing at this line.

While it may be true that the PCP suggested clonazepam and the patient just didn't know how to pronounce it, this reminded me of classic drug seeking behavior.

My thoughts exactly. OTOH, perhaps the recommendation was for clozapine and she's after weeks of blood tests :p

I did not end up prescribing her any controlled meds at this time, but this got me thinking about psilocybin and whether its use in a religious practice without any evidence of a substance use disorder should preclude the use of any controlled substances as medications. Let's say this patient had zero substance abuse history and was only using psychedelics in religious ceremonies. Are there any drug interactions or safety concerns I would need to be aware of, before starting a patient on any medication?

I think you could probably justify it if you felt a controlled substance was clinically indicated. You'd have to look at how often are these religious ceremonies being undertaken and the amount of drugs being used each time. While I don’t think there’s huge dependency issues with mushrooms, I’d still default to a CBT recommendation for any substance induced anxiety over benzos.

Honestly don't see a lot of patients who use psilocybin regularly, but recall a theoretical risk of serotonin syndrome with SSRI/SNRIs. Also have some vague recollection about it not playing particularly nice with lithium either, but would have to check again on this.
 
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nexus73

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I can only imagine a person pursuing access to psychedelics in this way surely knows what clonazepam is. I'd also wonder if she is getting more anxious since starting to use psychedelics...perhaps touching the face of God does not settle the soul.

But to your question, it would largely depend on the frequency of psychedelic use. Is this something she's doing every 2 weeks or twice a year? The latter I'd be much less concerned about rx of clonazepam (assuming no addiction hx), but would still not be looking at it first line over therapy, SSRIs, etc.
 
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As I understand it, mescaline has serotonergic and dopaminergic properties as well as structural similarities to amphetamines. I would document a discussion as to risks with combining mescaline with psychotropics that have similar mechs of action, in addition to psychoeducation about psychedelics.

Dosage and type of psychedelic need to be ascertained because they have differences in tolerance and potency, in addition to what specific effect the patient is trying to induce. Trying to induce visions is way different than taking a small amount to feel relaxed and spiritual.
 
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clausewitz2

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As I understand it, mescaline has serotonergic and dopaminergic properties as well as structural similarities to amphetamines. I would document a discussion as to risks with combining mescaline with psychotropics that have similar mechs of action, in addition to psychoeducation about psychedelics.

Dosage and type of psychedelic need to be ascertained because they have differences in tolerance and potency, in addition to what specific effect the patient is trying to induce. Trying to induce visions is way different than taking a small amount to feel relaxed and spiritual.

That's all well and good but mescaline/peyote and psilocybin are not at all the same thing.

There is a spirited debate to be had in neo-pagan circles about cultural appropriation of religious rites sincerely practiced, but I think dismissing this as a spiritual experience for the patient just because they are not Native American is unwarranted.

Klonopin is not really first line for anything.
 
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wolfvgang22

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That's all well and good but mescaline/peyote and psilocybin are not at all the same thing.

There is a spirited debate to be had in neo-pagan circles about cultural appropriation of religious rites sincerely practiced, but I think dismissing this as a spiritual experience for the patient just because they are not Native American is unwarranted.

Klonopin is not really first line for anything.
I'm not dismissing it because the patient is not Native American. I'm dismissing it because the patient is using religion as an excuse to continue polysubstance abuse. For me, I don't care if most patients uses a substance a few times a year for religious reasons. OP is noting that for this patient, given the overall history, of which ethnicity is just one part, adds up to a clear picture. This patient is clearly not undertaking moderate usage, but is chasing the next high.
 
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clausewitz2

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I'm not dismissing it because the patient is not Native American. I'm dismissing it because the patient is using religion as an excuse to continue polysubstance abuse. For me, I don't care if most patients uses a substance a few times a year for religious reasons. OP is noting that for this patient, given the overall history, of which ethnicity is just one part, adds up to a clear picture. This patient is clearly not undertaking moderate usage, but is chasing the next high.

I think you need to have a lot more information about the pattern of use of the psychedelics to draw the conclusion that this is polysubstance abuse and disordered. We don't know if LSD use means microdosing a few days a month or actually full on tripping as often as humanly possible. Similarly, someone who uses MDMA when they go to Burning Man is different from someone who is rolling on the weekly. Different patterns of use, different motivations, different consequences, different patterns of impairment or lack thereof. Some of those patterns fit nicely into some spiritual traditions and some don't.

I mean at the end of the day, yes, don't start someone Klonopin for their anxiety. So we agree there
 
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oldiebutgoodie1211

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I don’t think klonopin would even be in the discussion for this patient, first line would be “stop using drugs that can cause anxiety,” second line would be therapy then ssri then we can start thinking augmentation but I would not consider klonopin in the case mentioned above
 
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Crayola227

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As far as I know anxiety can be either or both a short or long term result of use of any number of compounds that have hallucinogenic effects. How much anxiety and how much tripping leads to it being variable.

If she's having so much anxiety she needs a drug for it, then she's having enough to consider sobriety. She may not think her monthly or less trips are doing it (let's say), but it could be. What those drugs do to your standard brain chem milieu to unhinge your reality as I understand it, is a lot. I know tons of people who have reported lasting mood effects of weeks in duration of more than marginal severity, from a single E roll, mushroom or acid trip. And cumulatively worse with more.

I'm sure I'm not the only one here who has had people end up with months to weeks of lasting psychosis from what seems like a baby amount of drugs. They're powerful is my point, very very powerful.

If the patient doesn't seem willing to even figure out if the trips are giving them anxiety, and if so how bad, that's a no go for me. If they run the experiment and find that there is a link, I'd actually be more inclined to start considering frequency, severity, and a balance of meds to enable the behavior - but only if the behavior in question is modifiable to begin with.

To me, it's the mark of disordered thinking about drugs/medications when someone is unwilling to run an experiment that includes sobriety or reduction to help pin down the reality of how they are being affected by them.

If they can't live with their anxiety with the amount they are tripping, the answer is to trip less, not add another drug they may try to refuse to modify later as is their pattern.

I'm sure there's a middle ground or exception here, and I'm not against using psychotropics in a patient using these other compounds for spiritual reasons and doesn't want to give up the practice entirely per se. Just my feeling is never good when someone seems fixed about a behavior involving taking substances.
 
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In the state I did residency in, it was illegal to prescribe controlled substances for a patient who you knew was using/abusing illegal or schedule 1 substances. I think most states have something similar. Doesn't stop the 'candy man' doctors from handing stuff out to people though. And I don't think anyone bothers to charge doctors for this. I was also bored enough to be reading DEA regulations in my PGY4 year, and I think there is some federal law that says something similar but I'm not 100% on that.

I also remember reading that the DEA was considering altering the exception in the Controlled Substances Act for the american indian church to be able to use peyote in these ceremonies (or at least letting people who are not church members do it). I know congress would have to change the actual law but the DEA has a wide range of regulatory power. They're (rightfully so, I think?) upset that these folks are basically selling legal trips to people who are not native americans. Now not every group that has the legal ability to use and cultivate peyote is doing this but a lot of them are. They've also been jacking up the price the last decade and I think it's like several thousand dollars now most places.

Anyway, to answer your question, if someone was using a schedule 1 substance but in a federally approved manner (those VA trials with LSD for PTSD, desert peyote adventures, etc), I don't think you would run afoul of any federal or state laws like I had mentioned above. I sure as hell wouldn't do it though. Also there are definitely non-controlled medications you should avoid in people who take certain sympathomimetic hallucinogens, due to risk of extreme BP elevation leading to strokes and other fun things.
 
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Ceke2002

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I have a patient who is a young adult white female, and she has a history of cannabis and alcohol use disorders; she currently denies cannabis use for the past six months but still drinks alcohol about once a week; she says she drinks socially but about half of these times she ends up getting drunk. She and a friend of hers also recently began participating in Native American religious ceremonies about once a month, in which psilocybin is used, and she reports this helps her to feel happier and it helps her to have interesting thoughts about herself and it makes the world more colorful for a few hours. She denied other substance use to me but from a recent PCP note I read, it appears she also disclosed use of acid and Molly. Of course, her participation in the Native American rituals as a purely religious experience is suspect, given her substance use history and the fact that she is not Native American.

During the recent visit to her PCP, it was recommended she talk with her psychiatrist about getting a medication specifically for her anxiety, because she has been having elevated heart rates, which the PCP also considered was due to the illicit substances, but which the patient said she wasn't willing to give up. She said her PCP recommended a medication that "started with C and ended with pam... I think it's pronounced clonpam, or clonzepam, or clonziapam, or something like that." While it may be true that the PCP suggested clonazepam and the patient just didn't know how to pronounce it, this reminded me of classic drug seeking behavior.

I did not end up prescribing her any controlled meds at this time, but this got me thinking about psilocybin and whether its use in a religious practice without any evidence of a substance use disorder should preclude the use of any controlled substances as medications. Let's say this patient had zero substance abuse history and was only using psychedelics in religious ceremonies. Are there any drug interactions or safety concerns I would need to be aware of, before starting a patient on any medication?

I'm not a hundred percent certain, but I believe some branches of the Native American Church do allow membership & participation in sacred ceremonies by non first nations people. If it wouldn't get you into any sort of ethics trouble you could suggest that if she truly feels her participation in Native American style ceremonies, and the use of pscilocybin, is of benefit to her, then she could contact the Native American Church to enquire about membership & to then learn the proper (and safe) use of psychedelic plants in a ceremonial setting. If it is something genuinely beneficial to her then I'd expect her to welcome the potential opportunity to learn the correct participation in these types of ceremonies; if she's just using it as an excuse to trip balls once a month I'd expect her to reject the suggestion, in which case I'd also highly suspect she still has substance abuse issues & is just conning herself otherwise.

 
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SourceOfDenial

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I have a patient who is a young adult white female, and she has a history of cannabis and alcohol use disorders; she currently denies cannabis use for the past six months but still drinks alcohol about once a week; she says she drinks socially but about half of these times she ends up getting drunk. She and a friend of hers also recently began participating in Native American religious ceremonies about once a month, in which psilocybin is used, and she reports this helps her to feel happier and it helps her to have interesting thoughts about herself and it makes the world more colorful for a few hours. She denied other substance use to me but from a recent PCP note I read, it appears she also disclosed use of acid and Molly. Of course, her participation in the Native American rituals as a purely religious experience is suspect, given her substance use history and the fact that she is not Native American.

During the recent visit to her PCP, it was recommended she talk with her psychiatrist about getting a medication specifically for her anxiety, because she has been having elevated heart rates, which the PCP also considered was due to the illicit substances, but which the patient said she wasn't willing to give up. She said her PCP recommended a medication that "started with C and ended with pam... I think it's pronounced clonpam, or clonzepam, or clonziapam, or something like that." While it may be true that the PCP suggested clonazepam and the patient just didn't know how to pronounce it, this reminded me of classic drug seeking behavior.

I did not end up prescribing her any controlled meds at this time, but this got me thinking about psilocybin and whether its use in a religious practice without any evidence of a substance use disorder should preclude the use of any controlled substances as medications. Let's say this patient had zero substance abuse history and was only using psychedelics in religious ceremonies. Are there any drug interactions or safety concerns I would need to be aware of, before starting a patient on any medication?

It strikes me as strange that out of all the substances described, you pick psychedelics, which are the least likely to harm the pt or society out of all the drugs described in your pose, to be the most concerned about.

Why are you not focusing on the alcohol?

If you are really concerned about the psychedelic use, point her in the direction of some guidelines for safe use. Or consider how some of the things that come up during those experiences might benefit her therapy and could be processed with you.

psychedelic use in a ritualized group setting seems way less harmful than other things youve described.

Edit to add: the LD50 or psilocybin or LSD is ungodly high. All serotonergic psychedelics work through the serotonin system of course, so interactions with SSRIs possible. Existing studies require those on SSRIs to taper off before enrolling.

If someone was taking MDMA, on an MAOI, and then using psilocybin/LSD I’d be worried, but typical doses of LSD or psilocybin used with an SSRI are going to be pretty safe, and maybe decrease the enjoyment from psychedelics. Id have more concern if she was taking ibogaine or ayahuasca and on other medications. I’d first get more curious about the use and nature of it first. Eating a mushroom? Fresh or dried? Made into a tea? Powdered into capsule? How is it dosed? What else is mixed with it? Is she sure? How does the group create safety, are there sitters, guides, buddies, etc.
 
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SpongeBob DoctorPants

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Thank you, everyone, for your thoughtful replies. This is very helpful.

It strikes me as strange that out of all the substances described, you pick psychedelics, which are the least likely to harm the pt or society out of all the drugs described in your pose, to be the most concerned about.

Why are you not focusing on the alcohol?

I agree that her alcohol use is a problem. But my question isn't about the alcohol because I'm more familiar with it, and I am less familiar with prescribing in the context of psilocybin use. My question, as stated in the last paragraph of my opening post, pertains to safe and appropriate prescribing for patients who use psychedelics occasionally as a religious practice.

I did not end up prescribing her any controlled meds at this time, but this got me thinking about psilocybin and whether its use in a religious practice without any evidence of a substance use disorder should preclude the use of any controlled substances as medications. Let's say this patient had zero substance abuse history and was only using psychedelics in religious ceremonies. Are there any drug interactions or safety concerns I would need to be aware of, before starting a patient on any medication?
 
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SourceOfDenial

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Thank you, everyone, for your thoughtful replies. This is very helpful.



I agree that her alcohol use is a problem. But my question isn't about the alcohol because I'm more familiar with it, and I am less familiar with prescribing in the context of psilocybin use. My question, as stated in the last paragraph of my opening post, pertains to safe and appropriate prescribing for patients who use psychedelics occasionally as a religious practice.

Gotcha, that makes sense. My question is, what is the importance of the religious experience? Would that be different than once a month going for hike in the woods and eating mushrooms? Dropping acid before a Phil Lesh show?

I am not seeing how using a substance would automatically preclude someone from being prescribed a controlled substance, apart from education on potential drug/drug interactions.
 
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oldiebutgoodie1211

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Gotcha, that makes sense. My question is, what is the importance of the religious experience? Would that be different than once a month going for hike in the woods and eating mushrooms? Dropping acid before a Phil Lesh show?

I am not seeing how using a substance would automatically preclude someone from being prescribed a controlled substance, apart from education on potential drug/drug interactions.

If the substance use can cause anxiety I think it’s wiser to stop the substance use and see if the anxiety goes away rather than starting a controlled substance, same goes for alcohol, caffeine etc
 
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SourceOfDenial

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If the substance use can cause anxiety I think it’s wiser to stop the substance use and see if the anxiety goes away rather than starting a controlled substance, same goes for alcohol, caffeine etc
Agreed, if only it were so easy to just stop. Persistent anxiety tachycardia from substance use is probably least likely to be related to the psilocybin compared to the cannabis, alcohol or MDMA in this situation.

I do think it’s strange that a pcp would see a person with tachycardia and then jump to saying ‘see a shrink and get some clonazepam’
 
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hallowmann

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...I do think it’s strange that a pcp would see a person with tachycardia and then jump to saying ‘see a shrink and get some clonazepam’

Do you genuinely believe that is what was said? In this context, it really doesn't matter what the PCP said from a treatment standpoint, but I'd be surprised they said "go to a psychiatrist to get clonazepam", something they could easily prescribe if they were so inclined. Obviously they didn't want to walk down that road, so they referred.

If I were to guess, the conversation probably went something like this, but maybe I'm giving the PCP too much credit:
PCP: You have anxiety and a substance use issue, you should see a psychiatrist
Pt: What's the psychiatrist going to do for me?
PCP: They could probably recommend treatments, including some meds
Pt: What meds?
PCP: Oh maybe an SSRI like sertraline or a benzodiazepine like clonazepam
Pt hears: "Go to a psychiatrist so they will give you clonazepam"
 
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Crayola227

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Gotcha, that makes sense. My question is, what is the importance of the religious experience? Would that be different than once a month going for hike in the woods and eating mushrooms? Dropping acid before a Phil Lesh show?

I am not seeing how using a substance would automatically preclude someone from being prescribed a controlled substance, apart from education on potential drug/drug interactions.
I see your point here. Just anytime you have someone with a history of substance abuse (really the "best" although still poor predictor of future abuse), using centrally acting substances in a non-medical fashion, possibly seeking more of the same, this time in the form of a script from their doc, I think one needs to have some big picture concern beyond just what we think the list of drugs is going to do physiologically.

While in theory what is being described is occasional plant hallucinogenic (was it mushrooms? Peyote? I have no idea), no alcohol, and possibly clonazepam at some other than during trips, what ends up happening can be very different.

Keep in mind that many of the many psychedelics cause significant nausea and often vomiting. This leads many to add in marijuana almost as a matter of protocol, as well as for being an "enhancer." A beer or two to wash down nearly anything, seems harmless to many. And anxiety during a trip is common, clonazepam is great for that and also nausea even. Easily we're up to 4 compounds at once, not even counting the fact that the main hallucinogenic could be a number of things.

Keep in mind that any hallucinogenics besides mushrooms or weed can easily be just about anything. I've also heard of shrooms being spiked with other compounds to make them "better" or just to sell other hallucinogens as them.

The patient may deny doing any sort of cocktail, having any plan to do it, and may acknowledge what a bad idea it is when you counsel them, and yet when the acid's dropped the cocktail begins.

People who enjoy the novelty of trips and drugs for fun often like the novelty of mixing things up. Clearly.

It could all be quite innocent and I for one tend to be pretty liberal about a lot of things. But this patient doesn't need clonazepam to add to this mix like they might insulin or something else.

Clonazepam is enough trouble by itself sparingly, and we know how bad it is in a mix.

And the why and how of how people do anything centrally acting from gambling to screwing to popping shrooms is hugely relevant to their behavior and dangers.
 
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NickNaylor

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In general, my approach with illicit substance use of any kind - irrespective of the reason - is to simply talk with the patient about how their substance use is likely playing a role in their symptomatology (assuming that it is) and allow them to make the choice from there. I am personally very reluctant to prescribe controlled medications in someone who admits to other substance use and has no interest in stopping. I try not to be "judgey" about it, but I am very up-front with patients that if their goal is to feel as well as they can be from a psychiatric perspective, their substance use is unlikely to support them in that goal. What they want to do with that information is up to them. I'm pretty candid with them that I will not prescribe controlled substances in someone who is actively using drugs and explore other options with them.

Whether or not this is a "religious ceremony" is immaterial to me. If the patient recurrently develops anxiety after using psilocybin, then the answer is to stop using psilocybin and try and identify another way to participate in the community's religious liturgy. If she doesn't want to do that then that is fully her choice, but it is also fully your choice to not prescribed controlled substances to manage the sequelae of her substance use if you do not feel comfortable doing so.
 
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