Addiction Medicine Made Easy | Fighting back against addiction

What I Learned When I Went Down The DMT Rabbit Hole

• Casey Grover, MD, FACEP, FASAM

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Join me, Dr. Casey Grover, on an eye-opening journey as we tackle the tough questions surrounding addiction medicine.

We start by discovering why cannabis isn't the harmless plant many believe it to be, especially in the context of recovery. Drawing from a compelling study, we reveal how cannabis use in sober living environments may set the stage for relapse into alcohol and other drugs, challenging the notion that it can coexist with sobriety.

But that's just the beginning. We next do a deep dive into dimethyltryptamine (DMT), a powerful hallucinogen stirring curiosity in addiction treatment circles. From its natural origins to its historical significance in traditional ayahuasca ceremonies, we explore DMT's unique effects and how they differ based on how it's taken.

In our quest to understand hallucinogens in addiction treatment, we discuss hallucinogen use disorder. With no medication-assisted treatment available, we emphasize the need to address underlying mental health issues. As we finish the episode, we explore emerging research on the therapeutic possibilities of hallucinogens like psilocybin in the treatment of other substance use disorders.

References:

Madam Noire link: https://madamenoire.com/1331923/everything-you-need-to-know-about-ayahuasca/

Addiction Medicine Textbook link: https://shop.lww.com/The-ASAM-Essentials-of-Addiction-Medicine/p/9781975107956

To contact Dr. Grover: ammadeeasy@fastmail.com 

Speaker 1:

Hello, my friends, welcome to the Addiction Medicine Made Easy podcast, where we take topics in addiction medicine and break them down into digestible nuggets and clinical pearls that you can use at the bedside. Dr Casey Grover, here as your host once again. Hey there, thanks for joining me today. Dr Casey Grover, here as your host once again. Before we start, I'd like to give my usual thank you to the Montage Health Foundation for their support of this podcast, and I'd also like to thank Central Coast Overdose Prevention, which is my partner organization for this podcast. If you'd like to see some of the great work being done, you can go to ccodporg. All right on to today's episode, but before we start, I wanted to share a recent article that I found.

Speaker 1:

Now, sobriety has many definitions. For some people, being sober is being on medication, but off of drugs and alcohol. For others, being sober is off all potentially mind-altering substances, and there's actually a bit of a controversy here, as some people in NA and AA don't consider taking medication for addiction treatment as being sober. Now, my opinion as an addiction doctor is that being sober involves being off of all drugs and alcohol, and if you need me to prescribe you medication like buprenorphine or naltrexone to help you stay sober. I am 100% in support and I call that sober. However, some people believe that cannabis is so benign that you can use cannabis but not drugs or alcohol and call that sober. This I actually disagree with, as the increasing strength of cannabis has really changed how harmful it is as a drug, and I actually found a study that looks at this. It's called Cannabis Use and Alcohol and Drug Outcomes in a Longitudinal Sample of Sober Living House Residents in California. It's published in the Journal of Substance Use and Addiction Treatment. It came out in 2024 with Meenakshi Subaraman as the lead author.

Speaker 1:

So the authors wanted to look at how using cannabis in sober living affected sobriety. They looked at over 500 people who were in sober living houses in Los Angeles between 2018 and 2021. And they wanted to see how cannabis use affected non-cannabis drug-related outcomes, including drug or alcohol use, days of use and any alcohol or drug-related problems. And they adjusted for other variables that might affect the outcome, such as age, sex, ethnicity, receiving inpatient substance use treatment, 12-step meeting attendance and percent of a person's social network who used drugs and alcohol. So the question really was how does cannabis as an isolated variable affect sobriety? Here's what they found Slightly. Less than 20% of residents of sober living homes used cannabis within the six months prior to when they were in the study. Then they compared those who used cannabis to those who didn't.

Speaker 1:

So if you used cannabis while in sober living, trying to stay in recovery, you were more likely to drink alcohol, with an odds ratio of 3.85 compared to those who didn't use cannabis. You were more likely to have drinking days, with an odds ratio of 1.76 compared to those who didn't use cannabis. You were more likely to have alcohol-related problems, with an odds ratio of 2.74 compared to those who didn't use cannabis. You were more likely to use other drugs, with an odds ratio of 10.41 compared to those who didn't use cannabis. You were more likely to have more days of drug use, with an odds ratio of 1.86 compared to those who didn't use cannabis. And you were more likely to have drug-related problems, with an odds ratio of 14.99 compared to those who didn't use cannabis, compared to those who didn't use cannabis. So, bottom line, trying to stay sober but still using cannabis is not a good idea. It makes people more likely to return to drug and alcohol use.

Speaker 1:

Okay, now we can move on to today's episode, which is on DMT as in dimethyltryptamine. I am the medical director for a residential treatment program here on the central coast of California and I do education every month for the staff on topics in addiction medicine, and this past month, at the request of the staff, I talked about DMT. So I recorded the lecture as I gave it, since it turned out to be a really interesting topic. I was able to edit out most of my filler words and slip-ups to make the audio better, but I wasn't able to get all of them, so the audio isn't perfect, but here we go. Okay, so we will get started.

Speaker 1:

This is going to be on the topic of dimethyltryptamine, which is making a little bit of a resurgence. It was something that I thought was an obscure substance when I was studying for my addiction medicine board exam, but I've come across people asking me about it and I have to give a disclaimer that I've actually not treated anyone myself who's using DMT, but I've definitely had youth ask about it when I go to schools, and then I've had patients ask about it and then, obviously, colleagues in addiction medicine. We've discussed it. So what is DMT? So the chemical name, as you can see on the screen, is NN-dimethyltryptamine and it's a naturally occurring chemical compound. We're going to go over the plants that it's found in and apparently there's a variant of the molecule that it's found in, and apparently there's a variant of the molecule that's made by certain venomous toads, and it's also something that can be synthesized like many drugs in a lab. And in terms of what it does, it's a hallucinogen and we don't fully know how it works. It's a little bit of an unusual one. Most hallucinogens, like mescaline or psilocybin or LSD, work by affecting serotonin receptors, and DMT works through the sigma-1 receptor, and I was trying to remember because this was on my addiction medicine boards the only other substance that I can think of that stimulates this receptor is dextromethorphan, and I looked it up and it's not really clear what this receptor does. It's not as cut and dry as the opioid receptor or GABA, like with alcohol. It's apparently a receptor that facilitates signals between nerve cells and it's involved with our cognition, how we think and also some of our motor skills and some of our behaviors. Kind of a subtle receptor in terms of you can't pin one thing down on how it works, but this is the mechanism of action of DMT.

Speaker 1:

Now, like any other substance, it can be used orally. It can be used orally, it can be snorted, it can be smoked or it can be injected and, just like any other substance, how it is used affects how a person experiences the effects of the substance. So, if you didn't know, the medicinal substance, ayahuasca, the active ingredient in that is DMT, and most often when DMT is taken orally it's in the form of ayahuasca, which we will definitely dig into in just a little bit. And like most substances, when DMT is taken orally, it's absorbed slowly. Effects don't start up until about an hour, sometimes a little bit faster, and it lasts for several hours. When people either snort it or smoke it, it gets absorbed very quickly, it starts working within minutes and the duration is much shorter, only about 20 minutes. And it's the same experience when people inject it it's absorbed very quickly and it starts working within minutes and lasts about 20 minutes. So, again, the pharmacodynamics of this are very similar to other substances like cannabis or opioids, based on the route of how people use it. Now, again, I have not taken care of a patient who uses this substance, but from what I can tell, the oral route is by far the most common.

Speaker 1:

We'll talk about quite in detail about ayahuasca, but I do want to show you some photos of what it looks like when people use it through different routes. So this is a picture of a crystalline form of DMT, and this is a small baggie next to a scale. And again, it's just a small white crystalline compound, and this is how it's prepared for snorting, smoking or dissolving and injecting. And then here's another picture of DMT. This is a little more powder-like, but these are basically very small crystals. Again, both of these are a white color, small crystals that would be used for smoking, snorting or injecting, and I love the fact that, when I'm looking up information on DMT, I found a website that would sell it to me anywhere from $80 to $8,500, depending on how much I wanted to buy. And, as you can see on the screen, it's like any other substance the amount that you use determines the intensity of the effect. Now, that's DMT from the smoke, snort, inject standpoint, but the oral form is actually a lot more interesting.

Speaker 1:

So we're going to talk a little bit about ayahuasca, and ayahuasca is a tea made from a combination of two plants, and we're going to look at them in detail. The first one and I may butcher this, but Psychotria viridis is the plant that actually contains DMT, and it turns out when you drink it it doesn't get absorbed very well. So I don't know who figured this out. I didn't go that far down the DMT rabbit hole, but someone in human history discovered that if you make the tea of this leaf with a second plant, a vine called Benisteriopsis copy, it actually improves absorption of the DMT. And I love human history because I have to just wonder how much trial and error it took to actually figure out that this was the combination that would allow people to use DMT.

Speaker 1:

So here's the first plant, psychotria viridis. Here's a picture of it. It's a large green leaf and it's a plant in the coffee family. And again, this is what contains the actual dimethyltryptamine, and it's native to Central and South America. Now the vine, banisteriopsis copy, also grows in South America. It does not, again, contain DMT, but rather facilitates absorption, and I'll show you some pictures.

Speaker 1:

This vine is absolutely enormous. It can grow up to about 100 feet long. So on the left there's a picture of kind of some small green leaves when the plant is young, and then to the right you can see this just enormous curving vine. That's what it looks like in its adult form. And here's a picture of someone actually going to brew ayahuasca and you can see it's a combination of the green leaves of the first plant and some pieces of the actual vine from the second plant and essentially it's put in some sort of liquid and heated. And here's an actual picture of how it's brewed and again you can see the mixture of the leaves with the vine in this vat that's going to be cooked and when it comes out it's a very dark red liquid and here's a picture of it in an opaque container. You can see it's got dark red color. And then here's a picture of it next to the leaves and vine and again it's like that rich dark red color is what ayahuasca actually looks like.

Speaker 1:

Now, in terms of using ayahuasca, it turns out that the legal status varies country to country. It's legal in you can see the countries here on the screen Costa Rica, brazil, peru and Mexico and it's usually actually not used really recreation by a person, by themselves. It's usually part of a traditional ceremony and it's overseen by a shaman and people, because it's a hallucinogen, are put in a safe place, which we'll talk about in a little bit and essentially you go to a site where one can pay for an ayahuasca experience, again overseen by a traditional medicine shaman. Here's a picture of an ayahuasca ceremony where people are going to be and in this case they're actually preparing some of the vines, but people actually consume it in a ceremonial circumstance. Now, in terms of what does it feel like?

Speaker 1:

Dmt is a hallucinogen, so obviously that's going to distort our sense of reality, and these hallucinations can be visual. So people describe seeing things change in color or things beginning to swirl or things changing shape, and again, the hallucinations can also be auditory. Like most hallucinogens, the experience can be positive. Like most hallucinogens, the experience can be positive. It can be negative and even frightening. And unique to DMT compared to things like LSD or mescaline, there's a lot of specific hallucinations around the body. People can have out-of-body experiences. Certain parts of the body can appear to have injuries, people can perceive pain and there's actually one unique thing with DMT that apparently people sometimes feel like they're not breathing. They hallucinate that they're not breathing.

Speaker 1:

Sometimes it is very pleasurable and euphoric and apparently each time that you use it you can actually get a different experience, which probably makes sense, just because with hallucinogens, a lot of times it's the set and setting that determine the experience that you have. Meaning, if you had a great day and you're with friends and you're in a safe environment and you use a hallucinogen, that's going to be very positive. But if you've just had a fight and you're very fearful there was just recently something traumatic that might be something that would predispose you to a more frightful or negative hallucinogenic experience. In terms of kind of the negative experiences with DMT, as I mentioned, sometimes the hallucinations can be frightening and then sometimes we do see injuries during the experience of not just DMT but all hallucinogens, and I'll talk about that in just a sec.

Speaker 1:

Dmt does affect the motor system, so sometimes people can actually have motor incoordination. With the hallucinations, they can actually be very disoriented and then obviously any hallucinogen is going to distort your reality. So that could put you in a dangerous spot and I love this question. I was at a high school and we basically told the kids like you can ask any question you want around drugs and alcohol, and one of the kids asked the question how can I use mushrooms safely? And of course that got some laughter out of the kids, but it was a really insightful question, right? It's almost like harm reduction for hallucinogens. You know essentially what I told the student is I would recommend against using any hallucinogens. But if you've already made up your mind and you're going to, here's what I would say Use in a safe place and have a buddy again in this case with DMT, a shaman who can help keep you out of danger.

Speaker 1:

Where we see problems with hallucinogens is somebody uses and they're not on the ground floor of a building. They hallucinate something and fall off a balcony or jump out of a window. Or people use near major streets or highways where there's traffic, and then people put themselves in harm's way that way. So that's really the major way that being under the influence of DMT would put a person in danger. And then obviously, like other drugs, the oral route is going to be less intense snorting, smoking or injecting just because it comes on a little bit more gradually. And overall, people apparently describe using DMT as very similar to LSD.

Speaker 1:

As I mentioned, sometimes bad things can happen when people are under the influence of a hallucinogen, and with DMT apparently, the major side effects include nausea and vomiting. At very high doses, people can get seizures, people can have an increased blood pressure and then, as I mentioned, dmt does affect how people move, so sometimes people can almost look like they have Parkinson's. The EPS there refers to what are called extrapyramidal symptoms, which is where certain medications can affect people's ability to move and they end up very stiff and rigid and moving. Their bodies almost feels like they can't move rhythmically, they can't move normally and DMT can do that and consistent with hallucinogens. In general, overdose on hallucinogens is very rare and there's actually no fatal overdoses ever reported in the literature on DMT. So really no known overdose syndrome or experience with DMT that we know of.

Speaker 1:

Now I wanted to ask this question is DMT addictive? And I think this is an interesting question. I can even broaden it to say are hallucinogens addictive? And it's a really good question. There is a DSM-5 criteria for hallucinogen use disorder, but it's a different chemical pathway than other substances. So most of the drugs we know affect the dopamine system. That's the reward pathway of the brain, and hallucinogens don't mess with dopamine. Interestingly, this is reflected in the fact that lab rats will not use hallucinogens. We can train rats to use sugar. There's dopamine with sugar. We can train lab rats to use cocaine, morphine, alcohol. All of those involve the release of dopamine. Again, those pleasure chemicals in our brain that trigger the reward pathways, but hallucinogens don't, and so they tend to be less pleasurable. But some people do like the effects and will use them compulsively. Interestingly, hallucinogens, including DMT, do not have a withdrawal syndrome. You don't get dependence. But interestingly, hallucinogens, including DMT, do show signs of tolerance. So people have to use more to get the same effects as they use more regularly.

Speaker 1:

And from what I was reading in my addiction medicine textbook, hallucinogen addiction, including DMT addiction, is usually related to people trying to manage their underlying mental illness, which leads to repetitive use. So is it addictive? Yes, a hallucinogen use disorder diagnostic criteria does exist, but it's not very common. So let's say somebody does develop addiction to a hallucinogen, including DMT. How do we treat that? Well, regrettably we don't have a hallucinoboxone. I keep joking that we need methaboxone, we need canaboxone. You know we need meds to treat addiction.

Speaker 1:

There really isn't any MAT or medication for addiction treatment for hallucinogen addiction including DMT. So really, what it is understanding why the person is using and then trying to manage that. So let's say they're depressed and they're using dimethyltryptamine compulsively to try to improve their depression. We need to get to mental health services, we need to get them on an antidepressant If they do not have a significant mental health condition and it's more compulsive use because they like the experience. That would be something where we would focus on behavioral interventions by going to group meetings and then going to therapy as well, so really much more of a behavioral treatment than an MAT treatment. If someone were to come to me and told me that they were using hallucinogens, including DMT, again it'd be assessing the mental health and in terms of medication, it's whatever symptom they have If it's anxiety, starting them on an SSRI and trying, you know, gabapentin or hydroxyzine. If it's, you know, underlying bipolar disorder, it's referring them to psychiatry for a mood stabilizer. So I know we were going to talk about MAT today, but unfortunately there's not any real MAT for DMT. Now the last question that I wanted to move on to and then we can discuss the topic and see what people's experiences have been if they've treated a patient who uses DMT is could DMT be used to treat addiction itself? And that's a really interesting question.

Speaker 1:

We are seeing that there's a move towards using hallucinogens to treat addiction, and where this comes from is, you know, when the war on drugs got declared in the 1970s, a lot of hallucinogens were made schedule one substances that were illegal and research on them essentially stopped. So one of the reasons that there's so many controversies about cannabis as a medicine is that we don't have a lot of data on it, because it was federally criminalized and hallucinogens, including DMT, fall into that same category. But what we're starting to see at large academic medical centers is that they're starting to use hallucinogens to treat various psychological conditions and then significant mental illness and substance use and kind of. The way it works is not that dissimilar to ayahuasca. So when we talked about ayahuasca, that's again the oral form of DMT. And the way that it's set up is you go to this experience, you meet people and then only when you're ready do you, you know, have the shaman administer this to you and then the shaman guides you through the experience. And what I hear from a lot of patients is they think, oh, I can do acid or mushrooms and that'll help me quit fentanyl. Turns out it doesn't really work that way. The idea would be is you do intense therapy with a therapist who has experience in using hallucinogens to treat addiction and you might do like five to 10 therapy sessions just to get ready for the hallucinogen and then it's a several hour process. You are in a clinical setting, like in a hospital bed or in a clinic. You use the hallucinogen it's a very specific dose and then the therapist guides you through the experience and supposedly what it's meant to do is to allow you to actually, like in the hallucination, find your addiction or find the roots of your addiction and be able to confront it and talk to it. And there's some interesting stories about this, not just addiction. One person was afraid of dying at the end of life with ovarian cancer and they used hallucinogens with a therapist to be able to visualize their fear of death and confront it. And then they were able to die peacefully.

Speaker 1:

And there is actually some research that we can use psilocybin to treat alcohol use disorder. This was actually an interesting study where they randomized people to either get psilocybin so those are mushrooms or Benadryl as a placebo, because they wanted people to feel something and see, you know, can we actually treat addiction by taking people on trips with hallucinogens in a very specific therapeutic approach? And again, this is the same thing. People get therapy, they get psilocybin a few times, they get guided through the experience and what they found is actually psilocybin with therapy really helped reduce the incidence of alcohol use disorder and help people stay sober. And you know, people were actually most often able to tell whether they got Benadryl or psilocybin. So there may have been some bias there. But interestingly, there's probably some signal here that hallucinogens can be used to treat addiction and again it's not just like okay, I use fentanyl, I'm ready for shrooms. It's a very specific approach to this in a clinical setting. So I'm going to say I'm going to wrap up here because I want to save about five minutes for questions.

Speaker 1:

But interestingly, there's not a lot of really good descriptions about ayahuasca, and so I looked in my addiction medicine textbook.

Speaker 1:

That had some pretty good data. I really couldn't find in the medical literature a good overview of how it works, how people use it, how ayahuasca is made. So I actually turned to just a general internet search and I found this blog called Madame Noir and it's basically an online magazine around society and culture targeted for Black women. I was really. They had some really interesting stuff on there and that's actually where I got most of the stuff about ayahuasca. I guess one of their authors went and checked it out. So kudos to Madame Noir for some great coverage. And then this is my addiction medicine textbook that I used to study for my boards and that's what I used to get a lot of the information for this, and that is the end of this episode. I hope you found learning about DMT and ayahuasca helpful and informative. Please consider sharing this podcast with a person interested in learning about addiction and addiction medicine. Thank you so much for listening and thank you for what you do, and don't forget treating addiction saves lives.