What is a Drug?

The Problem with Oversimplification, Stigma, and the Current View of Mental Health

When I say the word drug, you probably think of controlled drugs (marijuana, cocaine) or possibly prescription drugs (penicillin, morphine). You probably do not immediately think of caffeine or sugar. You almost certainly do not think of love, food, or exercise.

In this post I argue that a better definition of drug is “something that causes a change in experience.” Our current view of the word is narrow and problematic.

Caffeine is a drug used by billions of people every day. For some, it gives focus and energy. For others, it causes anxiety and jitters. Many become dependent on caffeine for their daily level of functioning and suffer withdrawal symptoms if they do not have it. Caffeine impacts the way minds and bodies work. The drug alters experience. The drug is defined by the change in experience.

Food is a drug. Some foods make us feel comforted, some give us energy, and some make make us feel bad. Many are addictive.

What about exercise? The endorphin rush, adrenaline surge, and other physiologic effects of exercise have a clear impact on your experience of the world.

What about love? Love is an experience that causes physiological and mental changes. Is love a drug?

Yes. Drugs cannot always be separated from experiences. Love causes the release of the neurotransmitter dopamine and the hormone oxytocin. The experience changes body chemistry, creating a cascade of further changes that affect mood and behavior.

When we view drugs, including marijuana, in an entirely separate category than caffeine, we are making an irrational simplification. The method by which someone changes their experience of the world should not be what we focus on. What is important is the short and long-term effects of that method.

Some illicit drugs, like heroin, are harmful because they are addictive or destructive to the body. Even though these drugs may cause short term positive effects such as euphoria, relaxation, their long term effects on health, behavior, and relationships are extremely negative. Other illicit drugs, like marijuana, do not deserve their criminalized status or stigma. This is where our narrow conception of the word drug is detrimental to society. Soon after being introduced to the United States, marijuana was demonized by authorities for political gain, and categorized with legitimately dangerous drugs. That association stuck with it for generations. Even when marijuana was acknowledged to be safer than cocaine or heroin, it was then called a “gateway drug” to more dangerous drugs. Marijuana ranks closer to caffeine than it does to heroin when the pros and cons are measured. But again, when I say the word drug, you are more likely to think of marijuana than coffee, alcohol, or tobacco. It will call the same associations to mind as heroin, cocaine, or meth.

Whether you’ve ingested something that is labeled as a “drug,” drank a cup of coffee, fallen in love, or read a good book, these activities will have changed the physiology of your body and the neurochemistry of your brain.

Coffee, like prescription stimulants, contains exogenous chemicals that affects our body in numerous ways outside of normal homeostasis. Marijuana and love also change the neurochemistry of ours brain and the way we experience the world. Whether the chemicals that affect experience come from outside or inside the body does not change the result: an altered experience. Some experiences are beneficial and others detrimental, but I want to emphasize that making a distinction based upon how the experience is initiated is not rational. What we currently define as a “drug” is arbitrary. A more nuanced view should be adopted: one accepting that drugs, food, activities, and experiences are all inherently interrelated.

Expanding Definitions, Expanding Minds

Why does this distinction matter? Our society currently has a narrow-minded and negative view of drugs. Drugs are seen as a narrow set of substances, associated with situations like addiction and abuse. This stance is problematic because there are far more drugs that help people than harm them. The pervasive social stigma around taking drugs is unfortunately not nuanced enough to separate harmful and addictive drugs from safe and beneficial ones.

This stigma surrounding drugs is in part because society suffers from the naturalistic fallacy. This fallacy leads people to believe that what is natural is good, and often the opposite claim: what is unnatural is bad. You can see this at the heart of the irrational fear around genetically modified foods and vaccines. The naturalistic fallacy allows for faster, but not more accurate, decision making.

The word natural has no rational definition. Times change. Cultures evolve. The progress of science marches on. What is natural to our species is hatred, ignorance, war, famine, and absolute poverty. Our species had to work for tolerance, knowledge, peace, abundance, and wealth. What is natural for the individual will change with every generation, and so far, those changes are mostly for the better. The status quo will almost always be worse than what “unnatural” progress offers to bring.

Depression, anxiety, suicide, infection, and early death are natural. Thankfully, we have drugs and other unnatural technologies to treat them. Yet the stigma surrounding drugs hinders their adoption and detracts from further progress.

There is an especially strong social stigma against taking drugs to alter one’s mental state. This stigma keeps many people from seeking treatment for conditions like depression and anxiety. If you add this to the even more prevalent stigma against having a mental health condition, the situation is dire. People are stigmatized for having a condition, and they are stigmatized if they try to treat the condition. It is a vicious cycle that perpetuates untold needless suffering in the world. I do not know how to best tackle the stigma around mental illness, but I do know that expanding our view of the word “drug” is a vital step in de-stigmatizing treatment for it.

We are at the beginning of what could be a revolution in treatment for mental health issues, including depression, anxiety, Post Traumatic Stress Disorder, Obsessive Compulsive Disorder, and addiction. Psilocybin, the psychedelic compound found in Magic Mushrooms, has recently shown unprecedented efficacy in reducing depression and anxiety in terminal cancer patients. Patients have seen significant long term improvements for up to two years after a single administration. Due to its success in cancer patients, it is now in trials for treatment-resistant depression, which is depression that has failed to improve after treatment with at least two different classes of medication. Early data from these studies, while currently limited by small sample sizes, is very promising.Other psychedelic compounds like MDMA and Ibogaine are showing similar results for PTSD and addiction, respectively. Historically, psychedelic therapy was used to great effect on many mental health issues and addictions before most psychedelics were criminalized and classified as Schedule 1 controlled substances in 1970. Like marijuana, psychedelic compounds such as psilocybin and LSD were stigmatized and controlled for political reasons, not for legitimate concerns about health. These psychedelic compounds are non-addictive, and adverse events are possible (most notably, causing psychosis in some people who are genetically predisposed) but extremely rare. On balance, psychedelics are far safer than many prescription drugs available today.

The Primacy of Experience

Psychedelics are a great example of the blurry and counterproductive lines between drugs and experiences. The researchers working with psychedelics have found that it is not the drug that causes the lasting improvements in participants’ mental health, but the character of the experience while on the drug. The efficacy of psychedelic therapy can be directly correlated to the strength of what the researchers call the “mystical” experience that can occur during a session. The drug is completely gone from the body after a couple of days, but the effects can last for years from a single dose.

This should not be a surprise, because we have all heard stories of a single, life-changing experience that affects the rest of a person’s life. Some people have a near death experience that puts things in perspective, and helps them realize the error of their ways and go down a new path. Psychedelics fit the paradigm of a life-changing experience much better than that of a traditional pharmaceutical. Psychedelics cause a deregulation of the Default Mode Network in the brain, which is responsible for our sense of self, or ego. The source of the concepts of “I” and “Me”. The self is the part of the mind that takes us out of the moment and fixates us on fears of the future (a hallmark of anxiety) or rumination on the past (a hallmark of depression). The mystical experience is strongly related to ego-dissolution, AKA the loss of self. The more completely the ego is dissolved, the better prognosis for the patient.

The analogy to a near-death experience is especially useful, as the experience of the ego dissolution can be very similar to facing death. This can be terrifying, and is one of the reasons that psychedelics are known to be not only nonaddictive, but some say anti-addictive. However, the benefits of this harrowing experience can be extraordinary. For terminal cancer patients, the experience of a “practice death” can take away much of the fear and anxiety surrounding their future departure. For any participant, banishing the ego offers a new way of seeing the world. Humans are creatures of narrative, of story. The self is the center for stories, true or false, to attach to. Without the center, those stories lose their power to control us. “I am an addict,” “I am worthless,” “Things will never get better”… these obsessive and imprisoning thoughts vanish with the ego.

In his new book How to Change Your Mind, Michael Pollan offers a powerful analogy. Imagine someone standing at the summit of a mountain. There are a few well defined tracks for them to ski down. As humans, we get stuck in certain habits, pathways of behavior and thought. Depression, anxiety, and OCD are disorders where those pathways are too structured and inescapable, and people find themselves trapped in these paths helplessly. No matter which way they try to go down the mountain, they end up in those deep grooves again and again. A psychedelic experience lays down a thick blanket of fresh snow, erasing the tracks. Suddenly, the person can choose which way to go instead of being forced in one direction. For some people, this can be the first time they have felt that freedom in years. The pathways will likely come back the next day, but they will not be as deep. And after finally being able to ski on fresh snow, those tracks — those traps — are easier to avoid.

The Perils of Oversimplification

Psychedelics create a new paradigm in research because it is impossible to isolate and test a single variable of the psychedelic experience. It is the entire experience that matters, with the set and setting of the trip being just as important as the dosage or patient expectations. This treatment straddles the border between psychotherapy and pharmaceutical, making it both revolutionary and difficult to standardize. This is an enormous step forward for our understanding of mental health. It should be obvious that we cannot simplify something as complex as the human experience down to a single variable. If we want to make progress on issues of mental health, the traditional simplifications need to be thrown out the window.

What does it mean to be mentally healthy? Mental health is a continuum of experience, just like being alive. There is no “normal” mental state. We create classifications like depression and anxiety to try to recognize patterns and help people find that balance. Those classifications are useful tools, but they are painfully oversimplified, and often interrelated. Our mind is the product of its inputs (which change every second) interacting with the physical structure of the brain and the configurations the brain was previously in. There are infinite potential states of consciousness, and every day each one of us is trying to find the right balance of food, exercise, sleep, social interaction, pharmaceuticals, etc. that lets us lead happy and fulfilling lives. Sometimes the balance cannot be found through the drugs that are uncontrolled (food, exercise, caffeine, love) and something else is needed.

This brings us back to the problem of drug stigmatization, and the narrow and inaccurate view of the word drug. Again, a drug is best classified by the experience it produces, and the short and long term effects. Substances are just one of the thousands of stimuli that can alter our experiences, and maintaining a distinct and stigmatized category for these substances is irrational. A useful example here is the potential uses of virtual reality. What if we can closely recreate the experience of a psychedelic substance with virtual reality? Will that experience be stigmatized if it is removed from the chemical compound? Virtual reality is already being studied in those suffering from PTSD and anxiety disorders to help decontextualize traumatic experiences. By reliving those experiences in controlled settings, it is possible to break the crippling associations of fear and anxiety. The example of virtual reality further strengthens the message: the experience and its effects matter, the way we get to the experience does not.

In the United States, it is important to realize the decisions that make a substance controlled or uncontrolled are often arbitrary, or put into law by a subset of people who do not represent the views of the whole. Many states have legalized recreational marijuana while it remains federally illegal. Some countries have completely decriminalized substances of all kinds. Mexico and Canada both use Ibogaine, a psychedelic, to treat addiction very successfully, though it is illegal in the US. Many countries have drugs available over the counter that you would need a prescription for in the US. If you are from the United States, you grew up with a status quo that is in no way the optimum state for our society to be in. It is simply the way that it was in for a variety of reasons, some scientific, some political, and some just matters of chance. Our society is evolving. Our culture is only one of many throughout the world. No view that places the norms we grew up with as optimal is likely to be right. It is easy to cling to what we know, but that is a dangerous and regressive form of thinking. When we hinder the progress of science because it is not what we are comfortable with, real people suffer.

Here is a brief and incomplete list of alternative therapies for anxiety and depression that have shown some level of efficacy:

Meditation

Cognitive Behavioral Therapy

Mindfulness Based Cognitive Therapy

Transcranial Magnetic Stimulation

Electroconvulsive Therapy

Virtual Reality

Psilocybin

LSD

Ibogaine

MDMA

Ketamine

PCP

Ayahuasca

DMT

Pet Therapy

Music Therapy

Art Therapy

Intermittent Fasting

If we maintain our narrow and outdated views of mental health, many of the treatments on this list will remain difficult for researchers to obtain and study. Others will be underutilized or stigmatized because they are not “normal”. The World Health Organization estimates that 1 in 5 people suffer from anxiety and depression worldwide. Current therapies are not adequate for everyone, and many come with burdensome side effects. It is time that stigma and “normal” are cast aside and a nuanced and open view of mental health is accepted.