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Hayley: Hi everyone. My name is Hayley and you’re listening to another episode of Straight Talk With The Doc, a podcast on addiction, mental health, and treatment. We break down these topics with the help of addiction medicine specialist Dr. Bhatt.
Dr. Bhatt: Hi Hayley, how are you today?
Hayley: I’m doing great and I’m really excited to talk about today’s subject. We’re going to dive into the world of psychedelics, more specifically hallucinogens that in recent years have been used in a medicinal manner or have at least been researched in helping people with certain mental illnesses. But there’s a lot of conflicting opinions on drugs like psilocybin, cannabis, and ketamine, so it’s important to look at the whole picture. The history and realities of using any mind-altering substance. Dr. Bhatt, does psilocybin, cannabis, and ketamine all belong to the hallucinogen class of drugs?
Dr. Bhatt: Yes, they do. Cannabis from a diagnostic perspective, we often talk about it being used in an abusive manner. They’re often separated from the hallucinogen class. But in essence, cannabis, just like ketamine and psilocybin can produce altered perceptions, altered sense of reality. So yes, can technically fall under hallucinogen class.
Hayley: And what’s this altered perception of reality? How do these drugs affect the user?
Dr. Bhatt: Think about this, when we use something that alters our senses, our senses of smell, touch, sight, producing something that hallucinatory. These are things that aren’t real, an altered sense of reality. And these three drugs that we’re talking about is something that can produce something that is a false perception. Now, the unique thing about hallucinogen is that not only can it produce a false perception, but it doesn’t necessarily alter your sensorium. It’s not like you’re necessarily nodding out or falling asleep like an opiate or alcohol. You somewhat stay intact that way often with your alertness to a certain degree. But during that time, your perceptions of what’s real and what’s not are significantly changed, depending on how much you’ve used, what kind of tolerance you have, and the potency of that drug at that time.
Hayley: Okay, could you break down the effects of each drug individually of psilocybin, cannabis, and ketamine? Because they do all produce different types of effects, right?
Dr. Bhatt: Ketamine, let’s talk about that first. Because ketamine, I think, has gotten a lot of attention recently, not only because of its recent medicinal scientific arguments that it could be used for a variety of mental health conditions. The fact that a certain chemical structure resembling ketamine, as ketamine, has been approved by the FDA for the treatment of treatment resistant depression. Let’s just talk about ketamine as the main drug. Ketamine itself is a dissociative anesthetic. It’s a schedule 3, a controlled substance, but it is used in medicine for anesthesia. It’s also used for certain pain control conditions in people who are needing lighter sedation. People who are suffering from significant burns are often given ketamine. And ketamine is used quite a bit in veterinary medicine. But when it’s abused, ketamine often can be used to have a euphoria, a sense of relaxation, a depersonalization, de-realization, a sense of being out of body type of experience. And these often occur similarly with psilocybin, and with cannabis to a certain degree. Just to be more succinct, the point is that these drugs, in essence, change the way you perceive your surroundings. And that’s the commonality behind this. A lot of people are going to have different effects. Some people can have life threatening consequences from ketamine. It can lead to overdose and death. I’ve seen this at the hospital. People enter what we call cave holes and they become totally psychotic. They can be simultaneously having respiratory depression and hyperthermia. They can go through a lot of different medical issues. With psilocybin, we don’t see it to that degree. People do say they have a sense of pleasure, elevation of food. But when we do have altered perceptions we can act differently and act dangerously, because we’re reacting to things that often aren’t there. With cannabis, many people use it recreationally. They tend to feel good. It slows time. It slows space, alters the way we perceive things. And again with tolerance, we can appear less intoxicated. But at the same time, many people who use cannabis get very paranoid, anxious, even psychotic. That question really is unique to each individual and again, how often they’ve used and their tolerance to those drugs.
Hayley: Okay. You mentioned ketamine is a schedule 3 drug. What’s the definition of that for our listeners?
Dr. Bhatt: The DEA, the Drug Enforcement Agency and the Controlled Substances Act, this was established back in the 70’s to help us classify drugs based on certain addictive potential and medicinal purposes, and safety. Schedule I being the most potentially addictive or having no real clinical medical utility on an everyday basis, all the way to schedule V which has the least addictive potential or the least degree of safety concern. There’s actually eight characteristics. I don’t want to really get into it here, but the bottom line is it is spread out into one, two, three, four, and five. Ketamine being a schedule three, does show a certain degree of addiction potential, but it does have medicinal utility.
Hayley: What is cannabis’ schedule right now?
Dr. Bhatt: Cannabis is actually a schedule one. I think that is often where people can argue, or this is where the controversy lies. I think that being cannabis, marijuana, is used so frequently amongst people around the world. Many people who use it recreationally say, “Wait a minute, this is not causing me harm. I’m actually living and functioning with this. Why is this a controlled substance? Why is it illegal to possess in many places? And why is it ranked so low, or high, depending on how you want to view it, on that controlled scheduling?” It is a one, and it’s a one based on many historical factors that we’re established in the 1900’s all the way into the 1970’s when the DEA classification system was put in place.
Hayley: I’m glad you brought that up because I wanted to talk about that. When I was reading about this, I saw that cannabis was classified as a schedule one drug in the 70’s. And I wasn’t sure actually if it had changed at all since then, but apparently it hasn’t. Can you talk about the history of why that happened? Why it was put in that schedule?
Dr. Bhatt: Cannabis has such an interesting history. Cannabis has been used over thousands of years. It’s a drug, or plant, that basically made it to Asia. It came across to North America with the colonists, and ultimately, it was used in textiles, in fibers, though the hemp plant. There was so many different other non- medicinal or non-intoxicant use to that. It was actually used for something, and it was used for many, many, many years. I believe I saw in a literature somewhere that back in the 1900’s there was an issue where many people coming during the Mexican revolution. They were coming to America. They also used cannabis quite a bit. Unfortunately, during The Great Depression, it was a lot of conflict between people coming and taking American jobs. There was really a lot of retaliation on, a lot of perception of those coming from Mexico and using cannabis at the same time. Things got blended together in banning. “Hey, are other people coming to America to take American jobs?” Societal and political interests twisted and really banned cannabis along with what was happening with the perception of Mexican people coming and taking jobs during that time. It was a very difficult time for America. As we fast forward though, we saw a lot of hallucinogens take a societal role, had a political agenda, especially during the 60’s and 70’s with certain cultures and again at the time of Vietnam with the Vietnam war. People were big into using these hallucinogens, these drugs, to have a spiritual connection. At the same time, those people often had societal and political views. Drug abuse became an issue quite a bit. In the 70’s we saw the aggressive stance by the government, by the executive branch of the government, on controlling substances and marijuana being one of them. They basically saw that as a problem. And for whatever, again I say, political and social reasons, ranked it and put it up there in the schedule one class. Since then it hasn’t been removed. I think that opens up the doors to the debate of why should it be, or why hasn’t it been taken out of there. I think that’s why we’re talking about it today, because it’s a big topic right now.
Hayley: There really is a debate surrounding that, because public perception, and certain laws surrounding that have shifted over time. Can you touch on where we’re at today in 2021 and the laws surrounding medicinal marijuana and recreational use?
Dr. Bhatt: I want to touch on that But I want to interject something, because in my last answer I maybe in my mind was bringing a huge picture to this. But I want to say something about these drugs, especially cannabis and psilocybin. I’m not going to talk about ketamine because it’s not a plant-based thing. But, these other drugs, or ingredients, let’s use that, have been used over centuries for rituals and spiritual things. I’m not trying to condone or I’m not trying to be opposed to it. At the same time, I just want to put into context that these were drugs that many, many, many, hundreds of years ago, many cultures, many societies throughout the world were using these things for spiritual, religious, connecting to a higher sense of spirituality to their gods. However you want to say it. Because of the sensations and the symptoms that it did produce when they used it in that way. Also, it was used medicinally, I mean I know the history all the way back to Asia where the hemp and cannabis plants were used for medicinal purposes way back when. I think as we’ve evolved, a lot of times our pharmaceuticals, or science is going back to basics. Medications come from a lot of natural, plant based things. Things are often pushed due to societal and political agendas. And sometimes the science is taken by those who have a societal or political agenda and can prematurely accelerate scientific research or inquiry and use that and jump steps. That leads me to answer your question about the legalization of it. Because the questions come’s to, are we legalizing it based on societal and political agendas? Or has it been legalized due to medicinal and health benefit? That’s something that I think is a bigger question, a bigger platform, and needs to be entertained. Because I don’t know if that’s something we can answer here. Has it become legalized? Yes, many states have legalized it. Is it legal federally? No, but has it been legalized medicinally in many states? Definitely. Has it been legalized recreationally? I think in about 10 states now they have legalized cannabis for recreational purposes. They’re there. It’s here. Where it goes I believe is up to the scientific community to bring that evidence forth to establish its medicinal and scientific utility to get it out of these probably antiquated classifications and not let societal and political agendas abuse the scientific literature in the wrong way. Just because we’re experimenting, we’re researching, we are doing the due diligence that needs to be done, and it shouldn’t be distorted. And that can often be done like it was done before and that led to the scheduling of it in the first place.
Hayley: Right. This might be almost the same question, just a different drug. But psilocybin is currently listed as a schedule one drug. However, it’s decriminalized in some cities and legal for therapeutic use in Oregon. What’s the history of psilocybin? And why has there been a shift towards decriminalization?
Dr. Bhatt: Psilocybin, I want to use it in an analogous way to cannabis. This was something that was used a long time ago for religious and spiritual purposes. And those have low thresholds for certain types of toxicity and overdosing. It’s kind of been looked at as, “How come then it can’t be used when there are other things out there that are legal that can kill us? It’s not that simple though, because things aren’t necessarily standardized. And that’s the problem. We do have a vetting process. People might agree or disagree and I’m not here to get on this podcast so people can be argumentative. I’m trying to keep on open mind at the fact that the FDA is here. We do have to follow certain processes that help save people from getting exposed to things that aren’t good for them. So even though, yes, in Oregon, when we use the term decriminalization, or wherever it’s been decriminalized, that doesn’t necessarily mean it’s not illegal to possess. It’s just that that agenda of that city is not to take out and hunt down people that have psilocybin and persecute to the full extent of the law. These are things that I think people need to put into context. I don’t think people understand that when they use terms like that. Again, if we say psilocybin has been used spiritually and it has been used for religious situations because of its perceptual changes and our consciousness altering characteristics, that doesn’t mean it’s good for you. I don’t want your consciousness to be altered while you’re driving a vehicle. You’re waiting for a red light, and all of a sudden you think that red light is 5 minutes away when it’s literally 5 seconds away. This is where I think people’s agendas manipulate scientific information. Just because you can’t overdose on it doesn’t mean it’s good. Things that are natural, sand is natural, it doesn’t mean I have to put it in my mouth and swallow it. I mean these are stupid things that people often talk about. But at the same time, we’re hoping that we shed light and bring light to the fact that science is moving in the direction where these things should be looked at. Because they have shown in much research to have benefit for certain conditions that I’m sure you’re going to ask me about as we go along.
Hayley: I want to talk about both sides of that, of course. I want to talk about how these drugs are used in a therapeutic setting, but also how they may still be dangerous. I’m under the impression that they are still dangerous. Any mind-altering substance that you take can be dangerous. For example, you mentioned driving a car. But before we touch on that, can you explain a little bit in layman’s terms how psilocybin, cannabis, and ketamine are used in a therapeutic setting?
Dr. Bhatt: Cannabis, medicinal marijuana, like I said, centuries ago there’s been literature and research that has shown that cannabis hemp plant has been used for control of pain. I think there was something to do with how it affects our GI system and has controlled stomach aches and stomach pain. We’ve seen that evolve now where medicinal marijuana is used often for cancer related pain, nausea, people who lose their appetite, anorexia. There’s good indication for it. These are again, in standardized, reproducible dosages where THC and active ingredients are measured and used. At those times, though, when a lot of this was coming about, the level of the psychoactive compound THC was a lot lower. Now we’ve hybridized and used many different formations of cannabis plants where the tetrahybrid cannabinoid, the psychoactive ingredient percentage, and potency is a lot higher. It’s obviously going to give a different effect. So, we can’t compare recreational use that might have a different effect then medicinal use. But, medicinal has been used for anxiety, for depression, for pain, for stomach issues, for appetite issues. There’s a plethora of other neurological stuff that has been opened up where cannabis is used for. Psilocybin, there’s been research that has shown again, for treatment resistant depression, anxiety, obsessive compulsive disorder, trauma, alcohol use, tobacco use disorders. Psilocybin’s being looked at with positive results in research on that side too. With ketamine, ketamine has already been approved by the FDA for treatment resistant depression disorder with suicidal ideations. And that’s because it went through those studies and has shown to be beneficial. Ketamine is used off label by those who are willing to take that opportunity or that chance and have it administered for alleviation of depression, of trauma, of anxiety, and other psyche, psychological and neurological issues. There’s a lot, there’s a wide variety of things that people have in research that are still under way, and now, especially with s-ketamine, that has come to the forefront of actual FDA approval.
Hayley: As somebody in your field, is it a concern that people are going to see some of the research and see the positive effects that it’s had for some people in certain studies and try to self-medicate with one of these drugs?
Dr. Bhatt: If you are suffering with addiction or self-medicating any way with many different things, yes. If we have an agenda, and the agenda is to use for the purpose of getting high, we can misconstrue or we can manipulate the information that’s at hand. And use it to get high under the guise of saying it’s helping me address something. Then in real life, people often become addicted to something because it is helping them with their underlying condition that might not be getting addressed. So, yeah, that is a fair that we have, that people are going to take research and preliminary information. They’re going to take preliminary information and make it into propaganda and make it into fact. I think that can be dangerous, especially because we’ve seen that it still needs to be proven. It still needs proper trials and proper scientific experimentation to ensure that these are not just incidental things. But these are large mainstream reproducible events before we can say in the medical community that this is something that we should apply for a disorder. Look at all the scrutiny that we’ve had with the COVID vaccine. People are like, “Is it good?” “Did we cut steps?” Whatever, because nobody’s getting high off the COVID vaccine. What’s the other agenda somebody could have to say that this is good for you? I don’t see any. That’s not the same to say with a huge addiction problem where cross-addiction and poly-addiction is a fact here in the United States and around the world. Saying somebody might use this with ulterior motives and manipulate the facts, that’s not far-fetched. It’s happening all the time.
Hayley: That happens with other drugs that we see used for treatment, like opioids.
Dr. Bhatt: Definitely, yeah.
Hayley: I want to talk about the dangers of these drugs, too. If I ask you can using cannabis ever be dangerous someone might be listening and be like, “No way, cannabis can’t be dangerous”. But I want to hear your stance on that.
Dr. Bhatt: I’ve heard it. I’m an addiction medicine physician. That’s what people tell me all the time because they try to compare it to drugs that are more dangerous. Listen, in my opinion, is cannabis as dangerous as opioids or maybe alcohol? I don’t believe so. I don’t find it to be that way, based on somebody taking one hit of a joint. I don’t think it’s going to have the same affect that I’ve seen, probably if you touch fentanyl or carfentanyl. But, that doesn’t mean though I’m condoning cannabis use for whatever. Recreationally, there is a danger. There’s a lot of studies that do show and do demonstrate how much anxiety cannabis produces in individuals, how much psychosis it can produce in individuals, and I have seen patients. I’m not talking about one, or five, or twenty. I’m talking hundreds of patients over the years that have developed psychotic symptoms with cannabis and no other drugs were on board. Someone could say that they were predetermined, predestined, predisposed, to developing a psychotic disorder. Possibly, but we don’t know. But, there is research that does show that there’s a huge correlation with the development or unmasking of psychotic disorders with cannabis. Not only that, cannabis impairs you. It alters your sense of reality. Maybe for that tolerant individual, it might not be such a big deal. They’ve been accustomed to it. They can manipulate their car or work or do certain things and you wouldn’t even know. But then, you talk to that 18-year-old who might not be using it, whose really having that robust high, getting into a motor vehicle accident or killing somebody because they were intoxicated with cannabis. This applies to all of these. These are mind-altering. They’re called psychedelics because they do alter our mind. They do alter our perception. And it’s just premature to say globally we can apply and let these things run loose. Because there’s a lot of negative outcomes that can happen. Nobody’s saying that there’s not potential positive stuff there. No, I’m not saying that. I’m saying that I can’t say the opposite. Just to let it run loose.
Hayley: Right. I want to jump back to something you said because I just think it’s important to touch on. Are you saying that those people who are predisposed with psychotic disorders, they would’ve never presented if they hadn’t smoked cannabis?
Dr. Bhatt: That’s what we have seen. We have seen that there is a phenomenon there, that there is correlation that cannabis could have an epigenetic type of influence. It can unmask somebody who had a brewing or underlying or somewhat subdued psychotic disorder. And that exposure to cannabis unmasked it. It’s a little Russian roulette there. It’s hard to say 100 %, but it’s a risk that somebody takes. I have seen patients who have used high amounts of cannabis. And again, we’re quantifying and qualifying all of our statements here. I’m sure the counterargument would be quantified and qualified too, but yeah, that’s what I’m saying. We have research that shows that if somebody has some underlying psychotic spectrum disorder, can it be unmasked? Or is there correlation with exposure to cannabis? Yes.
Hayley: What are some of the other long-term effects from abusing any of these drugs?
Dr. Bhatt: It’s hard to answer all of that because they are three distinct drugs that we’re talking about. We’re hoping to say on this podcast that there are- we’re looking at this podcast saying these are historical drugs that are illegal. But look, there’s medicinal value that’s potentially out there. It’s being researched and it might swing. We just don’t want people suffer with addiction going out and using it with medicinal purposes name or other therapeutic purposes name and abusing it. This is the bottom line I think we’re trying to get out here on this show and at the end of the day that’s really there. Long-term effects, we have seen that cannabis often starts out benign, especially in adolescents and young teenage, young adulthood. And it becomes smoking that they smoke and use chronically. And it leads to many different things like anxiety, like depression, like other anti-social type of behaviors. I’m not saying cannabis leads to that and I’m sorry if that’s the sentence I used. But we have seen studies often externalizing, anti-conduct disorder, they tend to have a higher dependency for using cannabis. Also, people becoming unmotivated, not necessarily wanting to do anything unless they smoke, can’t sleep unless they smoke, feel anxious unless they smoke. There’s also these negative consequences from this long-term exposure that affects them psychologically. They become physically dependent on it, because there’s a physical withdrawal to it. There’s an irritability. There’s a stomach problem. There’s GI issues. There’s anxiety. There’s all of these things that can happen and not to mention the psychological withdrawal that happens with cannabis. With ketamine, let me just add to this. I’ve seen people die from this stuff when I was doing training in the ER. I’ve seen many people just psychotically out of control, people who are on life support because of this, because it is an anesthetic agent. It’s a dissociative anesthetic, and psilocybin, to much a less degree I have seen that. The bottom line is there are negative effects that can happen from any of these things. Especially if you’re intoxicated and you get behind a car or are doing some work or some sport, whatever. If you’re using a hallucinogen and try to do those activities given an altered sense of perception, I don’t know how much of that is going to go well when you need to be having an accurate reality testing.
Hayley: It’s funny you mentioned the physical dependence. In the past I’ve had people tell me they can’t go to sleep unless they smoke marijuana. But at the same time they’re saying that they’re not addicted to it and they can quit whenever they want really. But, if you can’t sleep without it, that’s physical dependence, right?
Dr. Bhatt: Yeah, it’s definitely shown to have those withdrawal signs. People will become tolerant to it. They need more to get the same effect. And although maybe these things are not life-threatening, we do see cravings, and people getting irritable, people becoming depressed, and people having trouble with all of those sleep issues- headaches. Headaches is a big one that I’ve seen with people who stop using. There’s obviously these symptoms that do occur and these symptoms often lead to you wanting to use again. It’s not as benign as people who want to make it as benign say it is. At the same time, as an addiction physician, I could say it’s probably not as pathologic as maybe it’s been made out to be. But like I said I want to be open minded here, that all these drugs and maybe others, we need to look at them. We need research to take its place. We need people to do proper investigations to see how well these previously historically banned agents or taboo agents might be utilized to help people’s lives.
Hayley: Yeah, absolutely. I know we touched on it on if you can actually become addicted to these drugs, can you get treatment? Is that something that you’ve seen, people seeking out treatment for addiction to one of these drugs?
Dr. Bhatt: Yeah, usually they don’t rank it there right on the top. Because often these products- I mean, ketamine, I’ve seen people have a significant addiction and substance use disorder. Cannabis is often by itself or with multiple other stuff. I’ve seen psilocybin depending on the geographical area of the country. We’ve seen it too. Ultimately, when you’re using a substance that you’re using in increasing amounts, you’re failing to keep up with your obligations. You’re having negative consequences. You’re having physical issues as a result of it. And you have to keep upping the ante. You meet the definition for addiction. These are people who suffer with substance use disorders because of those things and they are seeking out treatment for it. But often again, they minimize it because maybe it’s not the drug causing them the most impairment. I’ve seen cannabis with alcohol, cannabis with cocaine, cannabis with opiates, and usually they’ll say cannabis isn’t the bigger problem. But yet, when you tease out the history, it’s a huge problem for them. Because that’s something that they haven’t been able to live without or can’t do anything without, and without it they have a lot of issues. Because of it, they have a lot of issues. This is something that people can get treatment for. If they’re meeting that addiction substance use disorder criteria and have that impairment, they should seek treatment for it. Help is out there at multiple levels of care.
Hayley: Closing out on this topic, Dr. Bhatt, is there anything else that you think people should be aware of?
Dr. Bhatt: Again, I think we need to be educated as a society more and more. As a consumer, as a listener, as a user, whoever someone may be, let’s not jump to conclusions. Based on what we know, there are negative consequences to all of these things. The potential scientific or medicinal or even recreational plus points are usually anecdotal and until we can show and have it go through the proper vetting process to legitimize it and use it. I would let that take its course, before we start singing its praises. But the point is, as I said earlier, I do believe it warrants the exploration and the research that a lot of large medical centers and large research institutes are doing. Because at least in the preliminary studies that we’ve seen, it’s shown benefit and actual practice when it comes to certain things in terms or medicinal marijuana, ketamine, and preliminary psilocybin. We’ve seen preliminary good evidence, as long as it’s not used in the wrong way. That applies to anything. Let’s look out for the potential benefits that come out in the scientific literature in the next many months to hopefully years to come.
Hayley: Thank you for helping me break this down today, Dr. Bhatt. And to our listeners, addictioncenter.com has information on all of the drugs we talked about today, as well as more podcast episodes. You can also listen on SoundCloud, Spotify, and Apple Podcasts, so make sure to go check out some of our other episodes. Thanks for listening to Straight Talk With The Doc.