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Current Abuse Reviews, 2013, 6, 000-000 1 Ayahuasca-Assisted Therapy for Addiction: Results from a Preliminary Observational Study in Canada Gerald Thomas*,1, Philippe Lucas1, N. Rielle Capler2, Kenneth W. Tupper3 and Gina Martin1

1Centre for Addictions Research of British Columbia, University of Victoria, Canada 2Interdisciplinary Graduate Studies Program, University of British Columbia, Canada 3School of Population and Public Health, University of British Columbia, Canada

Abstract: Introduction: This paper reports results from a preliminary observational study of ayahuasca-assisted treatment for problematic substance use and stress delivered in a rural First Nations community in British Columbia, Canada. Methods: The “Working with Addiction and Stress” retreats combined four days of group counselling with two expert-led ayahuasca ceremonies. This study collected pre-treatment and six months follow-up data from 12 participants on several psychological and behavioral factors related to problematic substance use, and qualitative data assessing the personal of the participants six months after the retreat. Findings: Statistically significant (p < 0.05) improvements were demonstrated for scales assessing hopefulness, empowerment, mindfulness, and quality of life meaning and outlook subscales. Self-reported , and use declined, although and use did not; reported reductions in problematic cocaine use were statistically significant. All study participants reported positive and lasting changes from participating in the retreats. Conclusions: This form of ayahuasca-assisted therapy appears to be associated with statistically significant improvements in several factors related to problematic substance use among a rural aboriginal population. These findings suggest participants may have experienced positive psychological and behavioral changes in response to this therapeutic approach, and that more rigorous research of ayahuasca-assisted therapy for problematic substance use is warranted. Keywords: addiction, ayahuasca, cocaine, substance dependence, substance use, .

BACKGROUND and a few Brazilian ayahuasca religions establishing active spiritual communities in countries around the world [6, 7]. Ayahuasca is a psychotropic brew prepared from the The transnational expansion of ayahuasca has been Amazonian vine caapi and leaves of the bush accompanied by growing scientific interest in the brew’s . These plants contain, respectively, potential therapeutic or salutogenic value. Preliminary harmala and dimethyltryptamine (DMT), which research has shown ayahuasca has promise for alleviating when ingested in combination orally induce several hours of some mental disorders and for providing other long-term a dream-like altered state of consciousness characterized by health and social benefits among regular drinkers of the brew intense visual, auditory, ideational and emotional effects [1, in ritualized and religious community contexts [4, 8-11]. 2]. The presumed biochemical mechanism of action for ayahuasca brews includes presence of beta-carboline Importantly, the use of ayahuasca does not monoamine oxidase inhibitors (harmala alkaloids) coupled typically produce health or psychosocial problems such as with dimethyltryptamine, a compound that acts on specific addiction [12-14]. Rather, ceremonial ayahuasca drinking serotonin receptors, particularly 5-HT2A receptors [3, 4]. has been correlated with lower amounts or severities of substance dependence. For example, Grob et al. [9] found Ayahuasca has traditionally been drunk in ritual contexts that among a randomly selected group of União do Vegetal by Amazonian indigenous and mestizo peoples for a variety (or UDV, a Brazilian ayahuasca church) members, a of divinatory, magical, spiritual, aesthetic and other cultural majority reported a prior history of moderate to severe purposes, including as a diagnostic aid and herbal remedy in problems with alcohol or other , but all had stopped folk healing practices [5]. In the late 20th and early 21st using substances other than ayahuasca (including tobacco) centuries, ayahuasca drinking became a transnational after joining the church and attributed their improved health phenomenon through increased tourism to the Amazon, behaviors to ayahuasca drinking. The UDV subjects also ceremonies regularly conducted by itinerant ayahuasqueros reported less excitability and impulsivity, and more (i.e., individuals trained to administer ayahuasca within an confidence and optimism compared with matched-control Amazonian folk healing ritual context) in the global North, community members who did not use ayahuasca [9].

Fábregas et al. [13] examined addiction severity among 56

*Address correspondence to this author at the Centre for Addictions people belonging to two different Brazilian ayahuasca Research of British Columbia, Canada; Tel: 250-494-8188; churches (UDV and ), and found higher lifetime Fax: 250-494-8255; E-mail: [email protected] illicit drug use but lower past-month use of alcohol and no

1874-4737/13 $58.00+.00 © 2013 Bentham Science Publishers 2 Current Drug Abuse Reviews, 2013, Vol. 6, No. 1 Thomas et al. use of psychoactive drugs other than ayahuasca and cannabis The retreat team’s work with ayahuasca came to the in the last 30 days, compared with matched controls from the attention of a rural aboriginal First Nations band in community. In interviews with 32 members of a U.S.-based southwestern British Columbia, which invited the team to chapter of the Santo Daime church, Halpern et al. [10] found conduct retreats for community members with substance that, of 24 who reported past or dependence, dependence or other habitual behavioral problems, such as all but two were in sustained remission and all five with problem gambling. The band’s health office was interested prior alcohol dependence attributed their recovery to in exploring whether a traditional indigenous practice from participation in the church’s . However, all these might help address some of the past trauma studies involve subjects who are regular and committed and consequent health issues that its community members members of religious communities, so it remains unclear were experiencing and that Western medical and legal whether fewer reported substance use problems can be approaches have not been reliably effective at curtailing. attributed to the ayahuasca drinking rather than being a Following the decision to provide this treatment to church member. members of the community, the band’s health office offered The use of ayahuasca as a remedy to help overcome drug the authors of this article (the research team) an opportunity addictions is a fundamental aspect of treatment programs at to conduct an observational study of the retreats in order to Takiwasi, a therapeutic community based in Tarapoto, more systematically document and assess the effects of the [15]. The Takiwasi approach incorporates various aspects of treatment. Funding for the study was secured through traditional Amazonian folk medicine (including the use of philanthropic donations to the Multidisciplinary Association various medicinal jungle plants, in addition to ayahuasca), of Psychedelic Studies (MAPS) and through an anonymous communitarian residence and psychotherapy. Similarly, in donor. In February 2011, members of the research and retreat the state of Amazonas, , the Instituto de teams met with the band Council and band Elders to discuss Etnopsicología Amazónica Aplicada (or IDEAA) runs a the retreats and obtained their consent for the study. At the treatment program that combines the ritual use of ayahuasca request of the band leadership, the band’s health office with complementary psycho-social rehabilitation methods agreed to closely monitor participants for any adverse [16]. Although these programs claim improved health psychological or other reactions following the retreats. outcomes for patients who complete them, neither has been Subsequently, two retreats were conducted, one in June 2011 evaluated with sufficient scientific rigor to provide definitive and the other in September 2011. evidence of the success of their approaches. Nevertheless, evidence from members of Brazilian ayahuasca churches, as PURPOSE well as claims of treatment success from Takiwasi and IDEAA, has led researchers to speculate on possible The objective of this research was to assess the impact neurochemical, psychological or transcendent mechanisms that this form of ayahuasca-assisted group therapy may have of ayahuasca’s purported therapeutic action [3, 4, 17, 18]. on several measures of mental and behavioral health related to addiction. The primary outcomes of interest relate to the In Canada, First Nations and Aboriginal peoples have ability of participants to consciously and consistently make been disproportionately affected by illnesses and social choices that promote long-term psychological, emotional, problems that are the legacies of colonialism and consequent and physical well-being rather than acting compulsively on territorial and cultural dislocation [19], including substance immediate urges based on conscious or unconscious dependence (although considerable variation in emotional needs and/or unhealthy psychological patterning epidemiology of addiction exists across this heterogeneous (i.e., addiction) [22]. We posited that this novel form of sub-population) [20]. However, current approaches to therapy could enhance the ability of participants to make treating addictions—especially to alcohol and cocaine— conscious healthy choices and resist unhealthy urges by continue to be of limited success [21], despite decades of eliciting improvements in several attributes related to research. Dr. Gabor Maté, a Canadian physician specialized problematic substance use [21]. in addictions medicine and experienced in working with Aboriginal people [22], became interested in the potential Specifically, we collected data to assess the following value of ayahuasca as an adjunct to group therapy in 2009. propositions: He began conducting occasional multi-day “Working with • that participation in the ayahuasca ceremonies in the Addiction and Stress” retreats in partnership with context of the “Working with Addiction and Stress” ayahuasqueros from Peru and British Columbia (the retreat retreats would be associated with improvements in team), reporting positive outcomes for participants from the mindfulness, emotional regulation, personal general Canadian population with a variety of psychological empowerment, hopefulness and quality of life in health conditions and illness severities. The retreat team study participants; and, refined the structure, pacing and other elements of their approach over the course of several retreats conducted with • that participation in the retreats would be associated mostly non-aboriginal Canadian participants in 2009 and with reductions in problematic substance use. 2010. This allowed the retreat team to establish procedures • Semi-structured interviews conducted six months for enhancing interpersonal rapport and creating a coherent after the retreats provided additional qualitative data therapeutic context prior to the sessions conducted with the from participants’ reflections on the outcomes of their First Nations participants observed in this study. experiences.

Ayahuasca-Assisted Therapy for Addiction Current Drug Abuse Reviews, 2013, Vol. 6, No. 1 3

METHODS A total of seven post-retreat follow-up assessments were conducted, most in person in a group setting at the band’s Observational Study Procedures health office. In cases where the participant was not living in Ethics review and approval was provided by the the community or otherwise unable to attend the in-person Institutional Review Board Services (IRBS), an independent follow-up session, follow-ups were conducted by telephone, research ethics review board. The band’s health office and occasionally the instruments were completed by the notified the community of the retreats and recruited participant on their own time and returned to the research potentially eligible participants. Twelve participants were team. A $20 gift certificate to a grocery store was offered to recruited for the first retreat in June 2011 with six new every participant for each follow-up session, and meals were participants recruited for the September retreat; all were provided at in-person sessions. members of the same coastal First Nations band and most were residents of the community. Approximately two weeks Observational Study Instruments and Rationales for prior to each retreat, a member of the research team their Use contacted registered participants and asked if they would be willing to participate in the research study. After expressing Difficulty in Emotion Regulation Scale (DERS) is a interest, all potential participants were informally screened validated 36-item questionnaire designed to assess the for inclusion criteria (voluntary attendance and the ability to degree to which subjects are able to engage in goal directed communicate in English), and exclusion criteria (under age behavior and refrain from impulsive behavior when 18; have drunk ayahuasca in the past; taking selective confronted with negative emotion and that has acceptable serotonin reuptake inhibitor or monoamine oxidase inhibitor test/retest reliability; therefore, it is suitable for use in medications; currently experiencing psychosis or have evaluations of substance dependence treatment [23]. experienced a psychotic break in the recent past). The latter Rationale: Desires to regulate both positive and negative two exclusion criteria pertained not to the research emotional states have long been recognized as important methodology per se, but to safety precautions relating to motivating factors for substance use [24]. More recently, potential medical contraindications from the research has illuminated details about the process of pharmacokinetics of ayahuasca, and so had already been emotional regulation and in particular the role of emotional initially screened by the retreat team. dysregulation in various forms of psychopathology, Those who met the criteria for participation (n = 18) were including substance dependence [25, 26]. In recent decades, invited to attend a group orientation session at the band’s evidence-based approaches that focus on improving emotion health office several hours before the start of the retreat. At regulation have emerged as forms of treatment for substance the group orientation, inclusion/exclusion criteria were dependence. For example, Dialectic Behavior Therapy formally verified, written consent (after further explaining (DBT) is a treatment modality that has been shown to reduce purpose, procedures and potential risks/benefits of the problematic substance use in some clients by teaching them research) was obtained, and initial self-administered surveys basic skills related to the healthy regulation of emotions [27]. were conducted to collect baseline data on a number of Also in recent years, scholars have documented that reduced psychological and behavioral factors related to problematic emotional intelligence, a concept developed to assess various substance use. The particular psychometric instruments used aspects of emotional functioning, is associated with more in this study—the Difficulty in Emotion Regulation Scale intensive , alcohol consumption and illicit (DERS), the Philadelphia Mindfulness Scale (PHLMS), the drug use [28]. As is the case with most of the factors Empowerment Scale (ES), the Hope Scale (HS), the McGill assessed in this study, healthy emotion regulation is viewed Quality of Life survey (MQL), and the 4 Week Substance as a protective factor while emotion dysregulation (e.g., Use Scale (4WSUS)—all measure aspects of psychological chronic and automatic self-distraction when experiencing health that relate in some way to problematic substance use; negative emotions such as fear) is considered a risk factor for more explicit rationales for their inclusion are discussed in problematic substance use. detail below. Philadelphia Mindfulness Scale (PHLMS) is a 20-item Immediately following the end of the retreats, the State of validated instrument that assesses the two components of Consciousness Questionnaire (SOCQ) was administered to mindfulness posited to have salutary effects on substance participants to assess the nature and intensity of their dependence (awareness of the present moment and ayahuasca experiences. Two weeks after the completion of acceptance) and that has been used with various clinical and the retreat, the six baseline instruments were re-administered non-clinical subjects [29]. (for the first follow-up at two weeks, the 4WSUS was Rationale: Long-term substance use has been shown to modified to assess substance use during the previous 14 negatively affect certain psychological and behavioral days). Participants were subsequently contacted again four factors required for healthy functioning, including: attention weeks following the retreats, and monthly thereafter for five and inhibitory control, the salience of and response to reward months, for further data collection using the same six stimuli, and the ability to maintain perspective in response to measures. Additionally, at the urging of several study strong emotional states [30]. Mindfulness training, with its participants, the research team added a short semi-structured focus on assisting substance users to be fully aware of the interview, subsequent to amended ethics approval, as part of present moment and to cultivate acceptance of their the final follow-up session to collect qualitative data about emotions, can address the affective deficiencies sometimes participant experiences and impressions during and after the associated with problematic substance use. A review of 51 retreats (Table 1). published studies showed that mindfulness practice can 4 Current Drug Abuse Reviews, 2013, Vol. 6, No. 1 Thomas et al.

Table 1. Schedule of Application of Survey Instruments

Orientation Meeting Immediately Following Last Week 4/ Months 2-6 Week 2 Month 6 (Pre Treatment) Session of the Retreat (Total of 6 Assessments)

DERS X X X PHLMS X X X MQL X X X ES X X X HS X X X 4WSUS X X X SOCQ X Qualitative interview X influence the brain, the autonomic nervous system, stress Following this logic, elements directed at enhancing hormones, the immune system, and health behaviors empowerment have been incorporated into substance use including problematic substance use [31]. A more recent prevention and addiction treatment programs for review of five controlled studies found that mindfulness marginalized youth (including American Indian youths), training improved outcomes for substance dependent clients women who have experienced trauma, and marginalized over control conditions by allowing them to: 1) accept ethnic minorities [41-44]. We included empowerment as an unusual physical sensations that might be confused with independent factor in this observational study of participants withdrawal symptoms, 2) decentre from a strong urge and drawn from a First Nation band, due specifically to the not act impulsively, 3) reduce the susceptibility to act in documented inter-generational trauma that this population response to a drug cue, 4) maintain perspective in response has experienced over the last several generations and the to strong emotional states and decrease dysfunctional documented relationship between trauma, powerlessness and avoidance, and 5) increase the saliency of natural reinforcers problematic substance use [45]. [32]. Several empirically validated forms of treatment for Hope Scale (HS) is a 12-item psychometric questionnaire substance dependence and mood disorders are based on or providing a behaviorally relevant measure of hopefulness by incorporate mindfulness training, including: mindfulness- assessing the presence of successful agency (goal-directed based relapse prevention [33], mindfulness-based stress determination) and pathways (planning of ways to meet reduction [34], Acceptance and Commitment Therapy (ACT) goals) in study participants. [35], Dialectical Behaviour Therapy (DBT) [36], and Cognitive Behavioral Therapy (CBT) [37]. Further, since Rationale: Although there is some debate as to whether aspects of the group counselling provided by the retreat team depression and substance dependence are directly causal to during the workshops are specifically directed at enhancing one another or whether they simply share common present-moment awareness and acceptance of participants, etiological roots, their co-occurrence is widely this measure was included to assess the mindfulness of acknowledged. Specifically, epidemiological research participants before and after the intervention to assess consistently verifies that depression is relatively common improvement and see if it was correlated with reductions in among substance dependent individuals, and problematic substance use. substance use is relatively common among those with a primary diagnosis of depression [46]. The association Empowerment Scale (ES) is a 28-item questionnaire between hopelessness and substance dependence is so assessing psychological and social empowerment over five fundamental, in fact, that in their work to identify basic dimensions: self-efficacy/self-esteem, power/powerlessness, personality traits associated with increased risk of substance affecting change, optimism/control over future, righteous use problems, researchers from Canada and elsewhere anger, and group/community action. The scale was identify “hopelessness” as one of four main at-risk constructed through a process involving consumers of personality traits [the others are anxiety sensitivity, sensation mental health services and demonstrates acceptable internal seeking and impulsivity) [47]. At the same time, consistency [38]. Several of the scale’s sub-factors (i.e., self- hopefulness—here defined in terms of agency (goal-directed efficacy/self-esteem, power/powerlessness, community determination) and pathways (planning of ways to meet activism, and optimism-control over the future) have been goals)—has been shown to be a protective factor against shown to be associated with patterns of problematic psychological problems such as depression and behavioral substance use. problems such as substance dependence, and so was Rationale: Psychological and social empowerment have included in the study to assess changes in these measures been identified as effective components of prevention and stemming from participation in the “Working with Addiction health promotion interventions due to their ability to: 1) and Stress” retreats. increase a sense of personal control, and 2) enhance beliefs McGill Quality of Life (MQL) survey is a 17-item in the ability of people to act to change their own lives [39]. questionnaire that has been validated for use with clinical The issue of empowerment appears to be particularly palliative care patients assessing quality of life along four important for those who have experienced trauma [40]. Ayahuasca-Assisted Therapy for Addiction Current Drug Abuse Reviews, 2013, Vol. 6, No. 1 5 subscales: physical symptoms, psychological symptoms, includes existential elements (McGill Quality of Life), and outlook on life, and meaningful existence. the main outcome measure that assesses problematic substance use (4WSUS). Rationale: There is theory and some evidence that quality of life and wellness can influence substance dependence After hearing from a number of participants that the patterns, with higher life quality posited to be a protective questionnaires and surveys were not capturing the totality of and rehabilitative factor and lower quality of life posited to their , the study team sought and was granted be a risk factor, especially for relapse [48, 49]. In this study, ethics approval to add a short semi-structured interview as quality of life is interpreted as both an independent factor part of the seventh follow-up session to collect qualitative potentially influencing patterns of substance use, and a data about their experience of the retreat in their own words. dependent variable that we predict would increase when the The interviews focused on three questions: wholly independent factors (emotional regulation, 1. Did the stress and addiction retreat have any impact mindfulness, hopefulness and empowerment) increased. It on your life (Y or N)? was chosen for this study because it includes existential elements related to mattering (i.e., the meaning of life) as 2. On a scale of one to ten, with one being extremely well as measures of physical and psychological well-being negative and ten being extremely positive, how would [50]. The existential aspect is important for this study given you rank the effects of the stress and addiction retreat the reported effects of ayahuasca on subjective perceptions on your life? of the meaning and nature of existence [51]. 3. Please describe how this experience a) impacted your 4 Week Substance Use Scale (4WSUS) is an 11-item connection to yourself, others, and nature or spirit; b) questionnaire based on the World Health Organization’s affected your substance use; c) differed from past Alcohol, Smoking and Substance Involvement Screening drug treatments or therapies. Test (ASSIST) questionnaire that screens for the hazardous The questions about connection were asked to capture the use of various legal and illegal psychoactive substances, participant’s experiences that were not addressed in the including prescription drugs. survey instruments we had pre-selected, but arose in Rationale: The ASSIST questionnaire is a valid and discussions during the retreats and follow-ups. reliable screen for problematic substance use [52], which has been employed in prevalence studies in several countries, Statistical Analysis Procedures including Canada [53, 54]. The 4WSUS is the main behavioral outcome variable for this study. We modified the Scale scores were calculated for the following measures: 4WSUS slightly to assess use over the past two weeks rather mindfulness, empowerment, emotional regulation, than the past four weeks for the first follow-up so that hopefulness and quality of life (which included five sub- shorter-term changes in substance use patterns could be scales: overall quality of life [one question], physical identified. Like the ASSIST, the 4WSUS measures symptoms, psychological symptoms, outlook, and meaning). problematic substance use by assessing the levels and Missing values were imputed by using the mean of the valid patterns of use of various substances (i.e., alcohol, tobacco, responses when fewer than 20% of the questions were cannabis, , , , , and missing for each scale of a participant. Imputations were prescription drugs) and several related elements, including necessary for less than 5% of questions overall, so should the frequency and intensity of cravings for use and also not substantially affect the statistical validity of the analysis. harms resulting from the subject’s substance use. In our The Four Week Substance Use Survey (4WSUS) was findings, we report on substance use two ways: 1) did the used to assess problematic substance use. Scores were based participant report using the substance at baseline and at six on three questions assessing frequency and patterns of months (yes/no)?; and 2) did the 4WSUS scores for each substance use, desire to use (cravings), and harm from use. participant change significantly from baseline to month six? Due to variation in the timing of the follow ups, the time In addition to collecting data using the instruments frame assessed by the substance use survey also varied: at described above, immediately following completion of the baseline participants were asked about their substance use in retreats, the States of Consciousness Questionnaire (SOCQ), the past four weeks, in the first follow up they were asked which assesses the nature and intensity of experiences during about substance use in the past two weeks, and for the rest of the two ayahuasca ceremonies, was administered to all the six post-treatment follow ups the retrospective time participants in a group setting. Data from the SOCQ is not frame was again extended to four weeks. The 4WSUS included in this analysis, but will be reported on in future scoring ranges from 0-39 (with the exception of tobacco, papers. which ranges from 0-31), with higher values indicating more problematic use. As the 4WSUS questions did not all use the In summary, we selected the various psychological and same scale for each item, no imputations were done. behavioral instruments listed above based on a holistic interpretation of the bio-psycho-social-spiritual model of Since the same participants were measured in each phase human behavior, trauma and substance dependence. Our of the study, a one-group repeated-measures ANOVA was model identifies four inter-related factors that have been conducted on each of the scale measures—emotional shown to affect patterns of substance use (i.e., emotional regulation, mindfulness, empowerment, hope and all quality regulation, mindfulness, empowerment and hopefulness), of life subscales—to statistically assess any changes over one factor that is both a potential influencer of patterns of time. In order to retain the highest number of completed substance use and an outcome measure that explicitly cases in the analyses, the means of the second and third, the 6 Current Drug Abuse Reviews, 2013, Vol. 6, No. 1 Thomas et al. fourth and fifth, and the sixth and seventh survey scale Day 1 of the Retreat scores were aggregated to deal with missing follow-up Participants arrived in the mid-afternoon and laid down surveys; this provided five temporal data points in total for mattresses and bedding in a circle. After dinner, the retreat each subject and each scale. The baseline and first follow-up team arrived and was greeted by a local First Nations spirit- were not aggregated, as the majority of participants completed these. When using a repeated-measures design, an keeper with songs of welcome, strength and courage for the participants, healers and the research team. A round of important assumption is that of sphericity (the variances introductions then took place, after which the retreat team between all possible pairs are equal). Sphericity was tested explained the process that was about to take place over the using Mauchly’s W; if Mauchly’s W < 0.05, then we next few days. concluded that significant differences exist between the variance of differences, and sphericity was not met. If sphericity was not met, corrections were applied to the Day 2, Morning/Afternoon degrees of freedom using one or a set of correction methods The retreat team arrived at about 10 a.m. After a silent [55]. Further, if a measure showed significant differences meditation, the retreat team led a discussion to elicit between time points, a trend analysis was conducted. Finally, reflection by participants about their addictions or as four participants received the intervention twice (n=4), a compulsive behaviours—loosely resembling Prochaska et second repeated-measures ANOVA was conducted, which al.’s stages of changes and decisional balance for problem included an interaction term between having done the study behaviors [58]—which provided an opportunity for twice and the scale scores over time. individuals to re-conceptualize their own addictions beyond Additionally, the semi-structured interviews were personal weaknesses or shortcomings. recorded and transcribed for subsequent analysis. Answers to Beyond the self-introspection that was encouraged the the first two questions were quantified, and content analysis first morning, the group setting created a sense of shared was conducted on answers to the third question to identify empathy and understanding, and a safe space for information useful for interpreting the quantitative findings. forthcoming exploration into the multi-generational trauma endured by retreat participants. The afternoon continued with THE INTERVENTION: “WORKING WITH ADDICT- further psychosomatic (e.g. breathing, meditation) exercises ION AND STRESS” RETREATS and group sharing/counseling. The retreats involved participants assembling for four consecutive days and three nights in the band’s longhouse Day 2, Evening (traditional community ceremonial space), which had been After dinner and a sweat lodge ceremony, all participants blessed by band elders in preparation for these special gathered back in the longhouse to share their intentions for events. The longhouse was prepared by spreading cedar the ayahuasca ceremony. At approximately 9: 00 p.m. boughs over the large dirt floor, similar to preparations for participants sat or lay on their beds in the large darkened the band’s traditional Coast Salish dance rituals [56], which room, and were individually invited to sit in front of the take place over the winter months. master ayahuasquero to drink a small glass (50-100 Participants resided at the longhouse for the full length of millilitres) of ayahuasca, after which all light sources were the retreat, with meals prepared on-site by a local caterer and shut off. After about an hour of silence, the ayahuasqueros in accordance with the traditional strict dietary requirements began to chant icaros (traditional chants believed to assist in of Shipibo (Peruvian Amazonian indigenous) ayahuasca healing), which continued for the duration of the experience ceremonies. This included restrictions on meat, sugar, (4-5 hours). During the ceremony, some participants purged alcohol, salt and other strong seasonings. Members of the (i.e., vomited, a common and not necessarily adverse effect research team were invited to be present as observers of ayahuasca) and each participant was invited to sit in front throughout the retreat, including the ayahuasca ceremonies. of the ayahuasquero to receive a soplada, a chant (sung in Shipibo, Quechua or Spanish) selected for that individual The retreats incorporated two ayahuasca ceremonies, one and accompanied by blowing of perfume or mapacho on the second and one on the third evening, led by a Shipibo (Amazonian tobacco) smoke on them. At approximately master ayahuasquero and three (non-aboriginal) Canadian 3:00 a.m., the ceremony ended, the retreat team left for the apprentice ayahuasqueros. While not overtly religious night, while participants slept in the longhouse under the events, ayahuasca ceremonies in the Peruvian indigenous supervision of the observers from the band’s health office. tradition typically have the solemnity of a serious spiritual practice [57]. The retreat team provided the ayahuasca brew, which had been ritually prepared according to Shipibo Day 3 customs. At various intervals during the four days, the retreat The next morning began with unstructured dialogue team led group talk therapy sessions to elicit personal about the previous evening’s experience among participants reflection and insights about traumatic life experiences and during breakfast, followed by a more formal debrief with the consequent emotional and psychological responses, retreat team. The second ayahuasca ceremony took place on including compulsions such as dependent substance use. the third night with all participants present, although

Ayahuasca-Assisted Therapy for Addiction Current Drug Abuse Reviews, 2013, Vol. 6, No. 1 7

(over the course of the two different retreats) one of the retreats and over the 6 month follow-up period could be twelve participants chose not to drink ayahuasca on the interpreted as contributing to alleviation of problematic second night. substance use following ayahuasca-assisted therapy for problematic substance use. Day 4 Figs. (1-3) show the changes in average scale scores for There was a final debrief on the morning of the last day quality of life-meaning, mindfulness, and hopefulness over of the retreat, and the first retreat ended with the participants the study period. The reliability of the psychosocial scales at presenting the retreat team leaders with gifts. All participants baseline ranged from Cronbach’s alpha = 0.408 to 0.929, left the site of the retreat before noon, with the band’s health with both hope and mindfulness having alphas lower than office agreeing to monitor them for any potential adverse 0.700, which is typically used as the cut-off to determine after-effects. good internal validity for a psychometric measure.

RESULTS – PSYCHOSOCIAL AND SUBSTANCE USE MEASURES

The results we report are from the twelve participants who attended at least one retreat and had no missing data when all imputations were done and when we combined the second and third, fourth and fifth, and sixth and seventh. Of the 18 participants originally recruited, two ultimately chose not to participate in the retreats, one left following the first night due to a pre-existing health condition, and three others completed the retreats and some of the follow-ups but had missing data. Additionally, while some participants Fig. (1). Average quality of life-meaning score. suggested they had some initial difficulty in incorporating the retreat experience into their day-to-day lives, there were no serious adverse health or psychological consequences reported to either the research team or the band’s health office after the retreats. For the twelve who were retained in the study, mindfulness, empowerment, hopefulness, quality of life-meaning, and quality of life-outlook showed statistically significant improvements over time (p<.05). While emotional regulation, quality of life-overall and quality of life-psychological all showed improvements, these changes were not statistically significant (Table 2).

Quality of life-meaning showed a significant linear component and also a quadratic component: it increased Fig. (2). Average mindfulness score. from baseline at the first follow up and then decreased before Table 3 shows the proportion of participants (among increasing again consistently after the third data point (Fig. those who completed the seventh follow-up) who reported 1), whereas mindfulness and hope had a significant linear using each type of substance in the four weeks prior to component indicating continued increase over time (Figs. 2, baseline and the four weeks prior to the seventh (six-month) 3). As such, we suggest that improvement in these psycho- follow-up. As with the psychosocial scales, the follow-ups social and behavioral measures immediately following the were aggregated so that the means of follow-up two and

Table 2. Results of Repeated-Measures ANOVA – Psychosocial Scales

Scale F Score P Value n Cronbach’s Alpha

hope 3.14 .023 12 0.456 empowerment 5.07 .002 10 0.702 mindfulness 2.76 .041 11 0.408 emotional regulation 1.96 .124 9 0.929 quality of life- overall 2.05 .105 11 n/a quality of life- psy 2.52 .055 12 0.736 quality of life- meaning 4.36 .005 12 0.879 quality of life- outlook 4.43 .004 12 0.925 *Sphericity is assumed as Mauchly’s W is > .05 for all measures. aLower scores equal greater emotional regulation. 8 Current Drug Abuse Reviews, 2013, Vol. 6, No. 1 Thomas et al. three, four and five as well as six and seven were used. impact on their lives, and when asked to rank the experience These data indicate that alcohol, tobacco and cocaine were of the retreats on a scale from 1 (extremely negative) to 10 used by fewer participants in the four weeks preceding the (extremely positive), the mean was 7.95 (n = 11), with eight seventh and final follow up than in the four weeks before participants ranking it as 8 or higher, and no one ranking it attending the retreat (baseline). The past-month use of below 5. cannabis and opiates showed no change in use during the study. One participant reported using hallucinogens during the last 4 weeks of the study, resulting in an increase in the proportion of users from baseline of 9.1%.

Fig. (4). Changes in 4WSUS scores for tobacco, alcohol, cannabis and cocaine. The following quotations are excerpts from interviews with participants responding to questions about a) the impact of the retreats on their relationship with themselves, others, Fig. (3). Average hope score. and with nature or spirit; b) how the retreats affected their use of substances; and c) how the retreat experience differed Table 3. Proportion of those who Responded that they had Used a Substance at Baseline and the Last Follow- from other types of treatments or therapies they had Up, of those who Completed the 7th Follow-Up encountered.

Connection with Self Proportion that had Proportion that had Substance Used at Baseline (%) Used at Last Follow-Up (%) S1 (male, age 30): “With my last experience with the n = 11 n = 11 ayahuasca, I really faced myself. Like, my fear, my anger. Which really, I think is a big part of my addictions. Like, Tobacco 81.8 63.6 running away from myself pretty much. And I think I Alcohol* 50 20 overcame that in the ceremonies. That was a pretty big deal for me . . . I wish I was introduced to it [ayahuasca] like Cannabis 45.5 45.5 twenty years ago. It could have saved me a lot of time and Cocaine* 60 0 trouble.” 0 0 S2 (female, age 41): “[The retreat] affected my life in giving me another chance at life rather than being stuck in Inhalants 0 0 my addiction and just living for my addiction. . . . I realize Sedatives 18.2 18.2 that I deserve a better life and I love myself. And I have Hallucinogens 0 9.1 more respect for myself. And the honesty that, just being honest with myself and others, had a major impact . . . 9.1 9.1 [Ayahuasca] really opened my eyes. It was like I was shut * n= 10; 1 participant did not answer the question at one phase. down [before drinking ayahuasca]. My mind and my eyes were shut down to everything. After the retreat I felt like a Fig. (4) shows changes in the 4WSUS scores measuring brick was lifted off of my shoulders and I was just feeling changes in participants’ levels and patterns of use, cravings free.” and substance-related harm for the substances used by at least 40% of the participants at baseline—tobacco, alcohol, Connection with Others cannabis and cocaine. 4WSUS scores decreased for all S3 (male, age 56): “It’s opened up where I felt I had a substances except cannabis, with statistically significant door closed to allow and to be, to allow my close family reductions documented for problematic cocaine use over the members inside me. It’s a . . . I can’t describe it right now study period. but, I see the changes in my grandkids’ response towards me, and they are always like, want to be around, around me and RESULTS – SEMI-STRUCTURED INTERVIEWS my wife so, it’s lots to tell you there. Safety I guess, from Interviews were conducted with eleven study participants our change.” at the seventh data collection session to collect additional S5 (male, age 51): “With my relationships, I think it’s qualitative information about the effects they felt the retreats coming a lot better with my family now. Because I wasn’t had on their lives. All eleven participants who completed the really seeing my family. I just wanted to stick by myself, but semi-structured interviews said that the retreats had some nowadays I’m spending more time with my family now.”

Ayahuasca-Assisted Therapy for Addiction Current Drug Abuse Reviews, 2013, Vol. 6, No. 1 9

Connection with Spirit and Nature and the States of Consciousness Questionnaire will be the subject of a future publication. S6 (female, age 19): “A week or two after [the retreat] I was just waking up every morning at like five, six in the morning and going outside and . . . I just sat and stared at the DISCUSSION trees and the wind for like two hours, I would sit outside and We found that participating in the “Working with it was just beautiful. I’ve never noticed it that much ever in Addiction and Stress” retreats correlated with improvements my life. And after I had the ayahuasca it was just amazing, in several cognitive and behavioral states—including the connection with nature.” enhanced mindfulness, personal empowerment and S7 (female, age 49): “I got my spirit back, for one. hopefulness—which we hypothesized may be associated Nature, like it’s saying “wake up and smell the coffee.” Like with recovery from problematic substance use. Participating it’s so beautiful outside, and where was all that all this time? in the retreats also correlated with improvements in quality You know, I was just living [with] a black cloud over me. of life (meaning and outlook), and subjective feelings of And the black cloud’s been removed basically. Because life connection with self, others, spirit and nature. The results is a lot nicer than it ever was. You know? I go spirit bathing also suggest that this form of ayahuasca-assisted group every morning.” therapy may be associated with reductions in substance use, particularly reductions in problematic cocaine use. The changes in substance use reported by participants by the end Substance Use of the study period—that is, that cocaine, alcohol and S2 (female, age 41): “Before the ceremony I was tobacco use declined, whereas cannabis, sedative and opiate struggling with my addiction, crack cocaine, for many years. use did not—may reflect the fact that in some cases the latter And when I went to this retreat, it more or less helped me substances were medically prescribed. Some participants release the hurt and pain that I was carrying around and reported being in a methadone maintenance program (which trying to bury that hurt and pain with drugs and alcohol. Ever was not a criterion for exclusion from the study) and others since this retreat I’ve been clean and sober. So it had a major reported using under the recommendation impact on my life in a positive way . . . My family is back in of a physician. Of note is the fact that cocaine and alcohol my life. My daughter is back at home. And, we are getting were identified as the substances of primary concern by the closer and closer every day as time goes on.” majority of participants. S3 (male, age 56): “No cravings whatsoever for the crack These findings suggest that this novel form of treatment cocaine or drinking, whatsoever. It’s pretty strong that may facilitate positive health changes, including reduced Ayahuasca as far as removing that craving, that desire, that problematic cocaine use, in a rural aboriginal population. habit, or however you want to describe it, for me it’s not The entheogenic use of ayahuasca may have functional even there.” effects similar to those of , which is used ceremonially by aboriginal members of the Differed from Past Treatment or Therapies without any evident psychological or cognitive deficits [59], and has historically been incorporated into addiction S1 (male, age 30): “I had no sense of before treatment interventions for aboriginal populations [60]. Our really, coming clean and sober even while I was going findings are also consistent with scientific evidence on the through, like AA and NA. They tell you to reach your higher utility of psychedelic substances—such as LSD, power or whatever. I thought that was a bunch of bull. But and —as therapeutic agents for treating addiction after the retreats I’ve really opened up to spirituality big and catalysts for personal transformation [61-64]. It may be time. I smudge every night before bed. I pray. I, you know, I that ayahuasca can function to increase the personality trait say thanks to whatever is out there, you know?” of openness, demonstrated experimentally to be a correlation S8 (male, age 55): “Other treatments [for my addiction] of mystical or spiritual experiences induced by psilocybin (a sort of like scraped the surface as they say. This one got close analog of one of ayahuasca’s psychoactive chemical deep, deep into myself, which I’ve never admitted to or constituents, DMT) [65]. In light of the limited success of confronted I guess you could say in the other treatments. currently available medical treatments for treating substance And this was just a mind-bending experience, boy! [laughs]. dependence in aboriginal populations, further research I can’t believe what I saw and who I talked to, like my mom efforts, including randomized controlled trials, are necessary and my dad and my granddaughter who are in the next world to determine whether and how ayahuasca might be added to there [i.e., have passed away]. And it really, really touched available approaches for treating drug or other addictions. me deeply and I think about that every day.” This study of ayahuasca-assisted group therapy has a As these comments from participants illustrate, the semi- number of limitations. The small-scale observational study structured interviews proved useful in increasing our design was limited to eighteen convenience sample understanding of how the “Working with Addiction and participants who self-identified as having an interest in Stress” retreats and the incorporation of ayahuasca participating in the retreats, with 2 who ultimately chose not ceremonies affected the lives of participants in the short and to attend the retreats, one drop-out on the second day of the medium term, while also highlighting the limitations of first retreat, and three whom the researchers lost contact with purely quantitative methods in studying the subjective during the six-month follow-up period. This limited number, impacts of this kind of therapy. A more comprehensive along with the absence of any matched controls, makes it analysis and discussion of the qualitative results of this study impossible to assign direct causality to the treatment or to determine whether the findings may be generalizable to other 10 Current Drug Abuse Reviews, 2013, Vol. 6, No. 1 Thomas et al. populations. Also, the study was not designed to assess the empowerment, hopefulness and quality of life-outlook and relative effects of the group therapy work, other ancillary quality of life-meaning. It may also have contributed to potentially therapeutic elements (spirit baths, sweat lodges), statistically significant reductions in cocaine use. The the pharmacological action of the ayahuasca, or the findings of this research on ayahuasca-assisted treatment for psychodynamic context of the retreats combining these addictions, although preliminary, corroborate those of various elements, and did not track whether participants were previous studies showing salutogenic effects of ceremonial involved in other forms of treatment during the follow-up ayahuasca drinking. period. Further, all substance use measures were based on Given the potential to decrease the personal suffering and self-report, and could not be verified by independent means, social costs associated with addiction, further research on such as urine or blood toxicology screens. ayahuasca-assisted addictions treatment is warranted. Additionally, it is possible that the intercultural bridging Clinical trials with people who have had poor outcomes with occasioned by the ceremonies may have introduced a conventional psychological or pharmacological addiction confounding, although not necessarily undesirable, treatments would help determine which adjunct therapeutic salutogenic effect to the retreats. The connection between the approaches might produce the best outcomes for particular Shipibo Amazonian and North American indigenous populations, and further our understanding of ayahuasca- peoples, in the context of the former sharing an important assisted treatments for problematic substance use. ceremonial healing practice, may have had positive therapeutic effects on its own, independent of the ayahuasca ADDENDUM – LEGAL STATUS OF AYAHUASCA IN drinking. Either way, it is not possible from this study to CANADA make any claims whether the observed positive effects of ayahuasca-assisted therapy may be generalizable to other At the time that the retreats described in this study were First Nations peoples in Canada, or to other aboriginal conducted, Health Canada had provided a recommendation for peoples elsewhere in the world. approval “in principle” to exempt certain forms of ceremonial ayahuasca use from the Canadian Controlled Drugs and Another limitation arises from the pharmacology of Substances Act [68]. The investigation into ayahuasca by Health ayahuasca, a brew made from two plants that contain a Canada’s Office of Controlled Substances between 2001 and number of alkaloids whose relative concentrations vary 2008 found the potential risks to be minimal when the brew is according to circadian timing of harvest and preparation [66, used in traditional ceremonial contexts and participants 67]. As there was no scientific chemical analysis of the brew carefully screened [69]. Despite this preliminary positive signal drunk during the ceremonies at the retreats, and as regarding the low risk potential and thus tolerability of participants received varying amounts (determined by the ceremonial ayahuasca use, in November 2011 Health Canada ayahuasqueros using traditional healing knowledge and reprimanded Dr. Maté and threatened him with legal action if he criteria), it is not possible to know the amounts or relative continued his work with ayahuasca as an addictions treatment concentrations of the psychoactive components ingested or [70]. In October 2012, against the 2008 recommendation of whether any outcomes were dose dependent. Nevertheless, department staff, the federal Health Minister Leona Aglukkaq as the participants’ qualitative interview reports suggest, the denied a request for legal exemption for ceremonial ayahuasca effects of the brew were characteristic of ayahuasca use. The Minister decreed that the Amazonian brew was an phenomenology and therefore do not suggest any concerns illicit preparation of controlled substances, and that tolerance for about its composition or potency. It must also be noted that its ceremonial use would not be in the public interest [71]. one participant opted to drink ayahuasca only once during the retreat, however our analysis was unable to account for any differences between outcomes for this participant versus CONFLICT OF INTEREST the rest who drank both nights. The authors confirm that this article content has no Finally, one unforeseen limitation was that four conflict of interest. individuals who participated in the first retreat also participated in the second; thus, one-third of 12 participants ACKNOWLEDGEMENTS participated in two retreats, and two-thirds only one retreat. The authors would like to thank the retreat participants Given the small number of participants, and that the minor who shared their experience with us, the First Nations band differences in outcomes of the repeat participants and of that made the study possible, Dr. Gabor Maté and his retreat those who participated in only one retreat were not team for allowing us to observe their work, the significant, no conclusion can be drawn from our data on the potential harms/benefits of additional treatments. Future Multidisciplinary Association for Psychedelic Studies, Dr. Bronner’s Soaps, the Riverstyx Foundation and TIDES research should include more participants, potentially with Canada for providing generous financial support for the some doing one treatment and others doing two or more in research, and Scott MacDonald, Ilsa Jerome, Brian Rush and order to determine whether there are harms/benefits to repeat the journal’s anonymous reviewers for helpful feedback on treatments. earlier drafts of this paper. CONCLUSION APPENDIX Our results suggest that this form of ayahuasca-assisted Table 4 shows that cocaine ASSIST scores, which therapy for stress and addiction was correlated with statistically significant improvements in mindfulness, combine assessments of frequency of use, desire to use and harm from use into a scale designed to assess severity of Ayahuasca-Assisted Therapy for Addiction Current Drug Abuse Reviews, 2013, Vol. 6, No. 1 11 problematic use, showed significant improvements between REFERENCES study follow-ups, while tobacco ASSIST scores improved [1] Shanon B. The antipodes of the mind: Charting the phenomenology marginally. Examining the tests of with-in subject contrasts of the ayahuasca experience. Oxford: Oxford University Press; for the cocaine ASSIST scores we find a significant (p = 2002. 0.003) linear component of cocaine over time. [2] Riba J, Rodriguez-Fornells A, Urbano G, et al. 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content/uploads/2008/08/Santo_Daime_Exemption_Health_Canada news/bc-doctor-agrees-to-stop-using-amazonian-plant-to-treat- _IAS_2008.pdf addictions/article2231413/. [70] Posner M. B.C. doctor agrees to stop using Amazonian plant to [71] Aglukkaq L. Letter to Dr. J. Rochester. Ottawa; October 23, 2012; treat addictions. November 9, 2011; Available from: Available from: http://www.bialabate.net/wp- http://www.theglobeandmail.com/life/health/new-health/health- content/uploads/2008/08/CeudoMontreal_HC-Response-Letter-23- Oct-2012-2.pdf 

Received: June 23, 2012 Revised: August 1, 2012 Accepted: August 8, 2012