The moderating effect of psychedelics on the prospective relationship between prescription opioid use and suicide risk among marginalized women
Elena Argento, Melissa Braschel, Zach Walsh, M. Eugenia Socias and Kate Shannon
Journal of Psychopharmacology, 2018, 1–7
DOI : 10.1177/0269881118798610
Background/aims : Given high rates of depression and suicide among marginalized women, and increasing calls to integrate trauma-informed biomedical and community-led structural interventions, this study longitudinally examines the potential moderating effect of psychedelic use on the relationship between other illicit drug use and suicide risk.
Methods : Data (2010–2017) were drawn from a community-based, prospective open cohort of marginalized women in Vancouver, Canada. Extended Cox regression analyses examined the moderating effect of psychedelic use on the association between other illicit drug use and incidence of suicidal ideation or attempt over follow-up.
Results : Of 340 women without suicidal ideation or attempt at baseline, 16% (n=53) reported a first suicidal episode during follow-up, with an incidence density of 4.63 per 100 person-years (95% confidence interval 3.53–6.07). In unadjusted analysis, psychedelic use moderated the relationship between prescription opioid use and suicide risk: among women who did not use psychedelics, prescription opioid use increased the hazard of suicide (hazard ratio 2.91; 95% confidence interval 1.40–6.03) whereas prescription opioid use was not associated with increased suicidal ideation or attempt among those who used psychedelics (hazard ratio 0.69; 95% confidence interval 0.27–1.73) (interaction term p-value: 0.016). The moderating effect of psychedelics remained significant when adjusted for confounders (interaction term p-value: 0.036).
Conclusions : Psychedelic use had a protective moderating effect on the relationship between prescription opioid use and suicide risk. In the context of a severe public health crisis around prescription opioids and lack of addiction services tailored to marginalized women, this study supports calls for innovative, evidence-based and trauma-informed interventions, including further research on the potential benefits of psychedelics.
Keywords : Women, psychedelics, hallucinogens, suicide prevention, substance use, moderating effect
Marginalized women, such as street-involved sex workers or women who use drugs, experience a disproportionately elevated risk for suicide stemming from complex and interrelated sociostructural factors (Gu et al., 2014; Roxburgh et al., 2006; Shannon et al., 2015; Ulibarri et al., 2013; Zhang et al., 2016). In North America, marginalized and street-involved women (i.e. women who experience poverty, inadequate shelter, and elevated rates of health and drug-related harms) (Bungay, 2013; Shannon et al.,
2007) continue to face severe forms of stigma, violence, and criminalization, including social exclusion, ongoing trauma from historical experiences of childhood abuse, and concurrent mental health and substance use issues that are known to be key drivers of depression and suicide (Hawton and van Heeringen, 2009; Li et al., 2011; Whiteford et al., 2013). Additionally, Indigenous women in North America are vastly overrepresented among street-based sex workers and experience devastating multigenerational effects as a result of colonialism and racial policies, including a high burden of mental illness and suicide and displacement from land and home communities (Benoit et al., 2003;
Bingham et al., 2014).
Rates of suicide vary significantly across settings and populations, however, global research and evidence demonstrate that nearly half (45%) of marginalized women (injection drug using sex workers) surveyed in China reported suicide ideation in the last six months (Gu et al., 2014); nearly one-fifth (19%) of female sex workers in India reported suicide attempts in the last three months (Shahmanesh et al., 2009); and nearly three-quarters (74%) of street-based sex workers in Sydney, Australia reported lifetime suicidal ideation or attempt (Roxburgh et al., 2006). Among a sample of trans women with a history of sex work, 64% reported ever attempting suicide (Nemoto et al., 2011).
Substantial structural barriers to accessing safe and non-judgmental health and support services exist for marginalized and street-involved women sex workers (Dell et al., 2011; Duff et al., 2014; Shannon et al., 2015), and few evidence-based mental health or addiction interventions are tailored to the needs of such key populations both in Canada and internationally (Benoit et al., 2003; Jeal et al., 2015). Research and intervention efforts have paid inadequate attention to developing addiction supports as part of a complex trauma-informed care package that includes community-driven and structural interventions. In the context of significantly elevated risk of suicide, there remains an urgent need to develop clinical addiction treatments tailored to the needs of marginalized women alongside community/sex worker-led interventions within a trauma-informed care framework.
Re-emerging evidence demonstrates that use of psychedelics – chemical compounds such as lysergic acid diethylamide (LSD), psilocybin, mescaline, methylenedioxymethamphetamine (MDMA), and dimethyl-tryptamine (DMT) – may be associated with improvements in mental wellbeing and addiction issues (dos Santos et al., 2016; Hendricks et al., 2015; Sessa, 2012; Tupper et al., 2015), yet the literature is characterized by large gaps and a paucity of evidence on how psychedelics might influence suicide risk. Findings from early studies conducted in the 1950s and 1960s indicated important utility of psychedelics for treating mental health and substance use disorders, however, political concern over recreational use resulted in a decades-long gap in research (Dyck, 2015; Sessa, 2012).
Renewed scientific inquiry and evidence is now lending mounting support to the therapeutic potential of psychedelics to treat addictions (Bogenschutz et al., 2015; Brown, 2013; Johnson et al., 2014; Krebs and Johansen, 2012), as well as ameliorate treatment-resistant depression, anxiety, and post-traumatic stress disorder (PTSD) (Carhart-Harris et al., 2016a; Gasser et al., 2014; Griffiths et al., 2016; Grob et al., 2011; Osório et al., 2016; Ross et al., 2016). Two large population studies among the US adult population found significantly reduced psychological distress and suicidality associated with non-medical (naturalistic) psychedelic use (Hendricks et al., 2015; Krebs and Johansen, 2013).
Most recently, a longitudinal study by our team demonstrated that naturalistic psychedelic use predicted reduced suicidality among a community-based cohort of marginalized women in Vancouver, Canada, while other illicit drug use and childhood trauma predisposed women to suicidality (Argento et al., 2017b). In the context of these findings demonstrating a significant relationship between psychedelic use and reduced risk of suicide, the present study aimed to further explore the potential moderating effect of psychedelics on the relationship between other illicit drug use and suicide risk among women in this setting.