https://www.asam.org/resources/publications/asam-weekly/asam-weekly-editorial-comment

W. Haning MD

A recent article by Zsuzsa Kalo and Associates in the International Journal of Mental Health and Addiction* examines the experience of using cannabinoids expressed metaphorically.  They note, “Metaphors are increasingly used to better understand drug user experiences and as medium to inform and guide clinical responses. Participants describe their drug-related experiences and a myriad of metaphors are recognizable in their depictions.”  This is phenomenological research, carefully auditing the experience of the drug user. Metaphors relating to substance use have long surrounded us, but as physicians we tend to concentrate on how the description of drug use fits into diagnostic criteria. While this effort to rationally conceptualize an illness has merit in the practical task of healing, it sometimes does not take note of the experiential gulf between therapist and drug user. Perhaps none of my patients have sustained their drug use for no apparent reason.  An understanding of the perceived benefits or merits of a drug experience is central to motivational interviewing.

Examples of the use of metaphor in describing drug or alcohol use are dispersed throughout literature, lay and medical.  Ann and Alexander Shulgin in their famous 2000 text, ”PiHKAL (sic)”, (phenethylamines I have known and loved), describe both the synthesis of 1000 pages worth of investigational psychoactive chemicals and the subjective experiences of taking them.  In one example,”#41”, 2C-T-4, “…Very rational, benign, and good-humored. The insight and calm common to the 2C-T’s are present with less of the push of body energy which makes 2C-T difficult for some people. There are no particular visuals, but then I tend to screen them out consistently, except in cases of mescaline and LSD and psilocybin, so I can’t judge what others would experience in the visual area. The eyes-closed imagery is very good without being compelling. The decline is as gradual and gentle as the onset. I am fully capable of making phone calls and other normal stuff. Music is marvelous, and the body feels comfortable throughout.”

In an earlier example, Thomas DeQuincey’s Confessions of an English Opium-Eater (1821)  provides descriptions both of the pleasurable aspects and the adverse consequences of using opium.  At one point, he discusses the respective qualities of alcohol and opioids.

But the main distinction lies in this, that whereas wine disorders the mental

faculties, opium, on the contrary (if taken in a proper manner),

introduces amongst them the most exquisite order, legislation, and

harmony.  Wine robs a man of his self-possession; opium greatly

invigorates it.  Wine unsettles and clouds the judgement, and gives a

preternatural brightness and a vivid exaltation to the contempts and the

admirations, the loves and the hatreds of the drinker; opium, on the

contrary, communicates serenity and equipoise to all the faculties,

active or passive, and with respect to the temper and moral feelings in

general it gives simply that sort of vital warmth which is approved by

the judgment, and which would probably always accompany a bodily

constitution of primeval or antediluvian health.

 

I anticipate that an argument against eliciting these descriptions will be that it induces euphoric recall. Balance in accessing such a history is certainly needed, just as it is in taking a history from someone with PTSD. But an unwillingness to explore the individual’s experience of drug usage risks a misunderstanding of that person’s motivations, and may miss an opportunity to connect with the patient.  If psychotherapy truly is an important component of addiction treatment, then more support for phenomenological research is warranted.

*Zsuzsa Kaló, Szilvia Kassa, József Rácz, Marie Claire Van Hout,

Synthetic Cannabinoids (SCs) in Metaphors: a Metaphorical Analysis of User Experiences of Synthetic Cannabinoids in Two Countries, International Journal of Mental Health and Addiction

https://doi.org/10.1007/s11469-018-9970-0

– W. Haning, MD

Comment;

An interesting concept.  I suspect it’ll work better for some folks than for others however.  I also suspect that just as different folks have different “drug of choice”, and reviewing the excerpt of Thomas DeQuincey’s Confessions of an English Opium-Eater (1821), the same drug will be experienced quite differently by two different users, leading to very differing descriptions.

Dr. Raymond Oenbrink
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