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Dr. Henry Abraham on HPPD and Gateway Drugs

Krystle Cole: How does a person get Hallucinogen Persisting Perception Disorder (HPPD)?

Dr. Henry Abraham: By definition, HPPD arises following the use of an hallucinogenic drug. By far the most heavily studied, and probably most causative drug, is LSD, but I have seen HPPD arise from others, including MDMA, Ritalin, marijuana and the amphetamines. These last three are much rarer in my experience, and may reflect a pre-existing problem in how the brain handles visual information. That is, an individual can function perfectly well with an undiscovered condition from, e.g. an old head injury or seizure disorder, and then trigger HPPD with an activating drug.

KC: What are the most common symptoms of HPPD?

HA: About 59% of patients with HPPD see geometric patterns on blank surfaces like walls. Almost as many folks see false movements of still objects, usually in the peripheral visual fields. Others reports flashes of light, trailing images behind moving objects, intensified colors, and afterimagery.

KC: How is HPPD treated?

HA: My approach to HPPD involves abstinence from all abusable substances, stress reduction, and treatment of the commonest psychiatric problems associated with HPPD, namely, depression, anxiety, alcohol abuse, and less often, psychosis. These last are critical to care, since while we don’t have a cure for HPPD, we do have effective ways of treating these co-morbid illnesses.

KC: How long does HPPD usually last?

HA: In half of the patients, HPPD can slowly reverse in any time frame from a month to five years. In the other half, recovery can still occur, but is much slower. The good news is that HPPD can be bothersome, but a person can live a good and full life with it. I have treated many people over the years who are successful parents and professionals with HPPD.

KC: Why do you think teen prescription drug use is rising in the United States?

HA: My guess is that a number of factors are at work. The first is availability. Every medicine cabinet in the country is filled with medicines of one kind or another, and kids have become sophisticated about routing out unused drugs that alter consciousness. The second is the recent trend of drug companies to market directly to the public. The psychological impact on these ad campaigns is to remove medical opinion from the loop of medical care, despite the ads that tell you to “ask your doctor.” Research shows that “asking” your doctor creates a definite pressure on the busy doctor to “do something,” even if the drug is dangerous or ineffective for the problem at hand. The third factor is how physicians and dentists prescribe narcotic pain relievers. I don’t know of such a study, but how much time a prescriber spends educating a patient about such drugs, and advising them to “throw them out” when the job is done, probably impacts greatly on their later abuse.

KC: As a country, what can we do to stop this trend?

HA: Much of this trend can be disrupted by a periodic purging of unneeded drugs from the medicine cabinet. Educating the consumer is also important.

KC: Is Ritalin a gateway drug? Why?

HA: I don’t believe it is. Cigarette smoking is a gateway. So are alcohol and heavy marijuana use, but not Ritalin. The idea that Ritalin is a gateway to cigarettes was set forth in a controversial study by Lambert and Hartsough in 1998 in an article in the Journal of Learning Disabilities. These researchers found that daily cigarette smoking by patients with hyperactivity (ADHD) at age 17 was nearly double the rate among kids without ADHD. They suspected that Ritalin treatment was behind it. But two years later Schubiner and colleagues found a large overlap between ADHD and a history of childhood conduct disorder. Conduct disorder is a well known risk factor for drug abuse. Then, in 2003, Barkley and others found no association between severity of treatment of ADHD kids over a 13 year period and the development of drug abuse once they controlled for conduct disorder. This is an important controversy, because every drug needs to help people without hurting them. Lambert may be right, but she found an excess in smokers in 36 cases. This compares to the millions of persons over the decades that have benefited from the medical treatment of ADHD. In nine years I have not seen any other study that supports her argument.

HPPD relevant publications:

1. Abraham HD, Duffy, FH. EEG coherence in post-LSD visual hallucinations. Psychiatry Research:Neuroimaging, 107:151-163, 2001.

2. Abraham HD. New hope for hallucinogen persisting perception disorder? Journal of Clinical Psychopharmacology 21:343, 2001.

3. Abraham HD, Duffy FH. Stable qEEG differences in post-LSD visual disorder by split half analyses: Evidence for disinhibition. Psychiatry Research:Neuroimaging, 67:173-187, 1996.

4. Abraham HD, Mamen A. LSD-like panic from risperidone in post-LSD visual disorder. J Clin Psychopharmacol, 16:238-241, 1996.

5. Abraham HD, Aldridge A, Gogia P. Psychopharmacology of the hallucinogens. Neuropsychopharmacology, 14:285-298, 1996.

6. Abraham HD, Aldridge A. LSD: A point well taken. Addiction, 89, 763, 1994.

7. Abraham HD, Aldridge A. Adverse consequences of lysergic acid diethylamide. Addiction, 88:1327-1334, 1993.

8. Abraham HD, Duffy FH. Computed EEG abnormalities in panic disorder with and without premorbid drug abuse. Biological Psychiatry 29:687-690, 1991.

9. Abraham HD. Stimulants, panic and BEAM EEG abnormalities. Am J Psychiatry (letter) 147:847‑848, 1989

10. Abraham HD, Wolf E. Visual function in past users of LSD: psychophysical findings. J Abnormal Psychology 97(4):443‑447, 1988

11. Abraham HD. Do psychostimulants kindle panic disorder? American J Psychiatry (letter) 143:1627, 1986.

12. Abraham HD. Visual phenomenology of the LSD flashback. Arch Gen Psychiatry; 40: 884‑889, 1983.

13. Abraham HD. L‑5‑hydroxytryptophan for LSD‑induced psychosis. Am J Psychiatry. 140:456‑458, 1983.

14. Abraham HD. A chronic impairment of colour vision in users of LSD. Brit J Psychiatry. 140: 518‑520, 1981

15. Abraham HD. Psychiatric illness in drug abusers. N England Journal of Medicine 302: 868‑869, 1980

16. Abraham HD. What’s A Parent to Do? New Horizon Press, East Rutherford NJ, 2004.

17. Abraham HD. Drug Education for Teens, Film series, Schlessinger Media, Wynnewood PA, 2004

18. El-Mallakh R, Halpern J, and Abraham HD. Hallucinogen and MDMA Related Disorders. In Tasman A, Kay J, and Lieberman JA (eds.), Psychiatry, 2nd Edition, 2003.

19. Abraham HD, Ricaurte G, and McCann U. Chapter 108, Psychedelic drugs. In Davis KL, Charney D, Coyle JT, Nemeroff C (eds). Neuropsychopharmacology, The Fifth Generation of Progress. Lippincott Williams and Wilkins, Philadelphia, 2002.

20. Abraham HD. Disorders relating to the use of phencyclidine and hallucinogens. In Gelder MG, Lopez-Ibor JJ, and Andreasen N. Oxford Textbook of Psychiatry, Chapter 4.2.3.4, Oxford University Press, Oxford, 2000.

21. Abraham HD. Hallucinogen-Related disorders. In Kaplan HI and Sadock BJ (eds.) Comprehensive Textbook of Psychiatry, Seventh Edition, Chapter 11.7, pp. 1015-1024. Lippincott, Williams and Wilkins, Philadelphia, 2000.

22. Abraham HD. Hallucinogens, Inhalants, and Designer Drugs, Chp. 114, p. 1-8. In Michels R et al. (eds.) Textbook of Psychiatry, Lippincott, Philadelphia, 1995.

23. Abraham HD, Aldridge A. Lysergic Acid Diethylamide: clinical, therapeutic and scientific considerations. Presented to NIDA Technical Review Meeting on Hallucinogens, July 14, 1992.

24. Abraham HD. A man who saw the air. In Spitzer RL, Gibbon M, Skodol AE et al. DSM‑III‑R Case Book, pp. 167‑168, Washington DC, American Psychiatric Press, 1989.

25. Abraham HD. LSD flashbacks. Arch Gen Psychiatry (letter), 1984;41:632‑633.

26. Abraham HD. Psychiatric aspects of marijuana use. In: Manschreck T, Murry G, eds. Psychiatric Medicine Update: Massachusetts General Hospital Reviews for Physicians, Vol. 3, New York, Elsevier North Holland, NY 1984.

27. Committee of the Institute of Medicine: Marijuana and Health, National Academy Press, Washington, DC 1982.

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