Capstone Project

Brief Review of Literature

A more recent approach to recovery involves the careful use of psychedelic therapy to treat substance use disorders. This approach carries with it additional stigma, on top of the stigma those suffering from substance disorder already bear, which may serve as a barrier to seeking alternative addiction treatment or support. The proposed project aims to create a survey to describe the perceptions of and responses to the various stigmas associated with addiction recovery and psychedelic use.  The hope is to develop appropriate public health education strategies for reducing stigma and supporting psychedelic users in their treatment protocol.   

Understanding how individuals perceive and respond to stigma is fundamental in the development of strategies aimed at reducing stigma associated with the use of psychedelics as treatment and thereby address barriers faced by those using this medicine. In order to understand how to reduce stigma, it is important to understand how psychedelics first became stigmatized. Stigma is defined as “the phenomenon whereby an individual with an attribute, which is deeply discredited by his/her society is rejected as a result of an attribute” (Goffman 1963). As such, people who are perceived by others to deviate physically and behaviorally from societal norms and values often experience discrimination and loss of status (Bottorff 2013). By the end of the 1970s, many psychedelics were heavily restricted or outright banned both in the United States and abroad. Researchers were forced to cease experiments, and thus, many questions regarding the therapeutic application of these drugs remain unanswered. Tobacco smoke and alcohol are among the most dangerous substances that can legally be consumed. Cigarettes and alcohol have no legitimate medical uses and impose significant costs on society far greater than those attributed to psychedelics. Yet they can be purchased by anyone of legal age at nearly any store. The fact that most psychedelics are Schedule I controlled substances contributes to the stigma. It inhibits physicians from learning about or discussing psychedelics as a treatment option and it could prevent patients from enrolling in legitimate research programs (Marks 2018).

One ongoing clinical trial at NYU is studying psilocybin to treat alcohol dependence. In a pilot study, they found that psilocybin increased abstinence in participants with alcohol dependence (Journal of Psychopharmacology, Vol. 29, No. 3, 2015). An open-label pilot study at Johns Hopkins found that nine of the 15 smokers in the study who received psilocybin were still abstaining from cigarettes at least 16 months later (American Journal of Drug and Alcohol Abuse, Vol. 43, No. 1, 2017).

With few traditional drugs that are safe and available, and current available treatment options that are costly and ineffective, psychedelics could be one of the best options for improving mental health and addiction treatment.  To realize and harness the potential of psychedelic medicine, the stigma associated with their use must be reduced. Dissemination of the potential health impacts of psychedelic use is hindered by limited evidence as psychedelics remain Schedule I substances, and a tainted history of emphasizing negative stereotypes for non health related reasons. In order to reduce stigma around psychedelic use as a therapeutic treatment, public health professionals face a critical challenge of not stigmatizing use (which deters people from potential beneficial treatment). 

Theory

The Theory of Reasoned Action (TRA) was used to guide the development of the survey and subsequent health education recommendations. The aim of this thesis is to better understand the stigma experienced by those using psychedelic medicine as an aid to addiction recovery and why individuals might seek (or not seek) addiction treatment using psychedelic medication. This is suggestive of a behavioral intention -- the intention to seek treatment for substance use disorder aided by psychedelic medicine. Secondarily, the proximal constructs of attitude and subjective norm align with the two concepts that are of interest in addiction recovery:  perceived stigma and social support.

Methods

Survey Development and design: This anonymous (i.e. no name or IP address recorded) survey will be conducted online via Redcap. Questions will be created or borrowed from existing literature. The survey will be piloted for readability and time. The survey categories of questions are following the TRA: Addiction Stigma, Psychedelic Stigma, Mediated Stigma of combined addiction and psychedelics. The survey will be submitted for IRB approval.

Recruitment and Sample: This will be an opportunity sample, and participants will not receive compensation. Recruitment will be from psychedelic societies and recovery groups across the country. Inclusion criteria are that participants are at least 18 years of age, and were able to speak, read, and write English fluently.

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Health Education Competencies

Area 1: Assess Needs, Resources, and Capacity for Health Education/Promotion

This survey gave me experience with primary data as I developed an individual survey (1.3.1), selected an online instrument (Red Cap) for my data collection method (1.3.2), and developed a data collection procedure as outlined in 1.3.3. Throughout this process I also met sub-competency 1.2.3 (review related literature) when I identified and reported upon gaps in the secondary data (1.2.4) related to this project and developed my survey based on what I found. 

Area 2: Plan Health Education/Promotion

In development of this project, I identified and engaged stakeholders and priority populations. As psychedlic medicine gains national attention, there are many organizations and groups that exist to support those who are using psychedelic medicine to aid in their addiction recovery. I engaged these organizations (multiple psychedlic societies, addiction recovery/psychedelic support groups) to evaluate interest of the priority population (2.1.1). In being a part of these organizations, I was able to make participation in the survey seamless for the participants by keeping them updated on the status of the completion of the survey, and directly share it with members of the organizations with the ability to disseminate it to the priority population (2.1.2). As part of the survey development, I got the input from individuals who represent the priority population, leaders of the organization the priority population is a part of, as well as experienced survey developers (2.1.4). This helped the survey gain support and I received commitment to share the survey by organizations and individuals representing the priority population (2.1.5). I developed this survey out of desire to create public health recommendations to serve this at-risk population. Addiction recovery falls primarily in tertiary prevention, and I hope that my survey will highlight barriers to psychedlic treatment that can be reduced through intentional health education and promotion efforts (2.2.1). Throughout this process it was imperative to apply cultural competence in designing the survey. Addiction does not discriminate. The priority population includes a broad range of individuals, and it was crucial to make the survey accessible to them all, and capture their unique experience (2.3.4). I pilot tested the survey with both individuals from the priority population and refined questions and survey development based on feedback (2.3.9, 2.3.10). As always, it was paramount to apply ethical principles to this project, and the IRB process ensured participation safety and protection (2.3.11). Survey design included thoughtful consideration of the sequence of questions, time restrictions, and the culture of the priority population (2.4.3). The channels for delivering the survey were both group, community, and interactive media facilitated by both myself as primary investigator as well as organizations that chose to share the survey with their members (2.4.6). 

Area 4: Conduct Evaluation and Research Related to Health Education/Promotion

I developed an analysis plan (4.1.9) which helped organize (and eventually summarize) the data collected in order to understand it in order to develop recommendations. The analysis plan identifies items to be used in answering the research question, and guides the data collection including qualitative and quantitative data. I also met competencies in 4.2 Develop a research plan, when I created a statement of purpose (4.2.1) “ is to understand the use of psychedelics by people in addiction recovery by surveying members of psychedelic societies and addiction recovery groups to ascertain barriers to psychedelic aided recovery.” Assessed feasibility of conducting research (4.2.2) by considering factors like time constraints (final semester), recruitment potential (opportunity sample), and the need for qualitative and quantitative data. In designing the survey, I conducted a systematic review of literature and searched for related literature (4.2.3) by identifying key terms, relevant and recent sources, characteristics to the population (recovery literature, stigma literature, psychedelic treatment literature). I then analyzed the data found in the literature (4.2.4) and highlighted gaps, identified current trends, and used the literature as a base to create research questions. From there, I was able to develop a research question (4.2.5) “is the use of psychedelics as a treatment for addiction stigmatized/are there barriers to psychedelic aided recovery treatment” and hypothesis “expect to find people who use psychedelics to support their recovery effort will experience barriers including stigmatizing behavior.” In assessing the merits and limitations of qualitative and quantitative data (4.2.6) I decided a mix of the two would best answer my research question and provide data to make public health recommendations. Although the survey was self conducted electronically, it was still people centered and dynamic, thus this non experimental design was chosen for this research (4.2.7). I had to determine the suitability of the data collection instrument (4.2.8), and decided to use Redcap, which is a HIPPA compliant, secure, online platform. In identifying research participants (4.2.9), I had to consider the population and sample size, as well as inclusion criteria “In order to participate, you must be at least 18 years of age, able to write, speak, and understand English fluently. You must also have experience and/or are currently using psychedelics to aid in addiction recovery,” as well as develop a sampling plan (4.2.10) that selects participants that represent the population of interest “Michigan Psychedelic Society, Decriminalize Nature Michigan, San Francisco Psychedelic Society, Portland Psychedelic Society, Project New Day, LYT Mind, Psychedelics in Recovery, Psychonaut Recovery,  and Tam Integration”. When I considered data collection procedures (4.2.11), my goal was to ensure no bias was introduced to the survey. I created questions and answers that covered a broad range of experiences and left an option for participants to not answer as well as fill in their own answer if none fit the description of their experience. Redcap works with data analysis software SPSS, so the data analysis plan (4.2.12) included how the data would be transferred from the instrument to the software (internal). I would then use statistical methods for data analysis (frequency distributions, measures of central tendency, measures of variation, etc.). As this is a completely anonymous and confidential survey, I was not able to develop a plan for non-respondent follow up (4.2.13), however, I was hoping for at least 25 complete responses to the survey, and at the time of this writing, have 20 complete out of 45 total responses. The survey will continue to be available for completion for several more weeks.

The process of going through the IRB made sure that I applied ethical principles to the research process (4.2.14), even though at this point, I do not have plans to publish the findings in a thesis, I do plan to write public health recommendations based on findings. I based the questions in the survey off existing survey literature (4.3.1, 4.3.2, 4.3.3, 4.3.4) and adapted the questions (and used previously tested, reliable items from existing instruments) as well as developed new questions to answer my research question. The instrument was pilot tested (4.3.7, 4.3.8, 4.3.9, 4.3.10) for readability and reliability, and I developed the questionnaire by writing easy to understand questions, asked the most important questions first, organized the questions in logical order, used plain, easy to understand language, used an even number of responses and similar response structure throughout the survey, was sensitive to the difficult nature of the questions, kept it short, and thanked all participants for their time. Over the course of development of this survey and after pilot testing, I made modifications when necessary to better suit the priority population (4.3.5). In creating new items to be used in data collection (4.3.6) I made sure to mediate scales so as to leave room for both ends of extremes, adapted the language so it was familiar to the participants, and included Likert-scale, multiple choice, and open ended questions. As I am still collecting data, I have not mastered competency 4.4 Collect and manage data, though I do have experience in collecting data based on my research plan (4.4.2), monitoring and managing data collection (4.4.3) by logging into the secure Redcap system to determine how much data has been collected thus far and organize it according to completeness and quality control, in using the online survey tool (Redcap) to collect, monitor, and manage data (4.4.4), complying with laws and regulations when collecting, storing, and protecting data (4.4.5) per the IRB ethics committee and developing and distributing informed consent. Once all data is collected, I look forward to gaining competency in 4.5 Analyze data, 4.6 Interpret results, and 4.7 Apply findings by creating public health recommendations based on findings.

Area 7: Communicate, Promote, and Advocate for Health, Health Education/Promotion and the Profession

 For the Seminar in Health Education (HLED 695), we were tasked with creating a poster presentation of our capstone project (image above). This experience gave me competency in engaging in service to advance the profession (7.4.11) by mentoring students that are just starting their graduate school careers in sharing my research experience including the struggles, successes, and insights after completing the program. 

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Summary

This project is an accomplishment I am most proud of. I worked diligently to serve this population and contribute to an emerging public health issue. Outside the scope of the health education competencies, I realized my potential to create positive change by sharing my passion and depth of knowledge. I got to work with so many individuals that helped support my journey simply because they too cared about the subject and population. As I continue to work on this project, and ultimately develop public health recommendations to serve this community, I will do so with the integrity and dedication that has brought the project this far. 

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