Chapter 51. How the hazards of LSD were augmented, 1962-1969

As LSD use became more widespread the drug also became far more hazardous. Many reports appeared of large numbers of LSD users hospitalized–– some of them for considerable periods–– following LSD trips. Reports of LSD accidents also increased–– falls or jumps from windows, death when someone on LSD threw himself in front of a passing car, and so on.

There is adequate reason to believe that such hospitalizations and accidents did in fact occur with markedly increased frequency from 1962 until about 1969. The increase in adverse effects, moreover, did not result simply from an increase in the number of users; the  proportion of adverse effects per 1,000 users also increased. At least twelve reasons for this increase warrant discussion.

1. Increased expectations of adverse effects. The American Indians who used LSD-like drugs learned long ago that the  expectations present in the mind of a user before he takes the drug are among the major factors determining the nature of his reaction to the drug; they took the drug within a framework that dictated favorable expectations. Scientists subsequently confirmed this phenomenon for LSD itself. Dr. Sidney Cohen, for example, had noted in 1960 that "those with excessive initial apprehension" are particularly likely to experience bad trips.

One effect of the nationwide warnings against LSD from 1962 on was to arouse "excessive initial apprehension" in the minds of countless LSD users. The result was what might have been anticipated. Bizarre behavior increased markedly from 1962 to 1969. Some users, warned that LSD might cause them to jump out of the window, did in fact jump out of the window. Many who were warned that LSD would drive them crazy did in fact suffer severe panic reactions, fearing that LSD had driven them crazy. Thus the warnings proved self-fulfilling prophecies, and enhanced the hazards of the drug.

2. Unknown dosages. Patients and others who took LSD before 1962 received precisely measured doses. When the curtailment of the Sandoz supply triggered the clandestine manufacture of black-market LSD, no such precision was possible. An LSD sugar cube or capsule might contain too little LSD to engender a trip–– or many times the recommended amount. The classic example was the Haight-Ashbury's "Pink Wedge incident" on November 11, 1967, when a batch of LSD shaped like pink wedges, and adulterated with another LSD-like drug, STP, hit the San Francisco market. "We treated 18 cases of acute toxic psychosis generated by the 'Pink Wedge' in a five-hour period," Dr. David E. Smith of the Haight-Ashbury Medical Clinic later recalled. "Most of the people seen were having acute panic reactions due to the strength of the dose, which was more than most of the young persons had been used to."

3. Contamination. Some of the black-market LSD available after 1962, as noted earlier, was of excellent quality. But other batches, synthesized by amateurs, were contaminated. As we have shown, true LSD-25 d-lysergic acid diethylamide–– was one of twenty-five closely related ergot derivatives synthesized by Sandoz before 1938, and many more were to follow. The effects of many of these LSD congeners are poorly understood. Even a slight error in the process of synthesizing LSD-25 may result in an end product containing not only the desired chemical but also admixtures of these potentially hazardous congeners. Many analyses of black-market LSD have shown the presence of substances that are not in fact LSD but apparently some unknown congener. It is impossible to determine how much of the difference between pre-1962 and post-1962 LSD effects resulted from this kind of contamination.

4. Adulteration. In addition to contaminants accidentally introduced into black-market LSD through errors of synthesis, some black-market suppliers deliberately adulterated their LSD with a variety of substances, including amphetamines * and even strychnine. It was necessary, of course, to mix LSD with a bulking agent of some kind; the amount of LSD needed for one trip is so small as to be barely visible and it cannot be safely or conveniently handled. One reason for using potent substances as bulking agents may have been to provide an  immediate effect; half an hour or more is likely to elapse before the first effects of true LSD-25 are felt. Or potent drugs may have been used as adulterants merely because the distributors of clandestine LSD happened to have them conveniently available.

* Dr. David E. Smith said (1967): "Methamphetamine crystals or 'speed' have appeared in great abundance in the Haight-Ashbury. Because of its small cost and ease of synthesis, it is often mixed with small quantities of LSD, and sold as 'pure acid.' This mixture increases the likelihood of a 'bad trip', primarily due to the intense sympathomimetic effects of the amphetamines. The tachycardia, muscle tremor, and anxiety produced by 'speed' is often magnified by the LSD-sensitized mind into a panic reaction."

Some of the adulterants also complicated the  therapy for adverse reactions. "The admixture of chemicals with atropine-like properties to LSD changes the response to the usual antidotes to LSD which may, under these circumstances, instead of lessening the effects of a 'bad trip,' actually increase the toxic reaction ."

5. Mistaken attribution. A substantial proportion of LSD users experiencing adverse reactions also used other drugs–– either at the same time or at other times. There was a widespread tendency to attribute adverse effects to the LSD rather than to the other drugs–– especially in statements designed to warn against LSD.

6. Side effects of law enforcement. The imprisonment of young people while they were on "trips" unquestionably contributed to adverse effects. One well-known example occurred on June 21, 1967, when 5,000 tablets of the LSD-like drug STP were distributed without charge at a celebration in San Francisco's Golden Gate Park. Scores of young people suffered bad trips; 60 of the 5,000 users came to professional attention. Of the 60, 32 were treated at the Haight-Ashbury Medical Clinic. "All but one of these 32 patients were returned to their homes or to the care of their friends within a few hours, following explanation and very mild sedation," Dr. David E. Smith subsequently reported. Seven other users, however, were arrested and imprisoned–– and then, as their symptoms grew worse, were taken to the San Francisco General Hospital. They suffered much more severe and prolonged illnesses. "Our hypothesis is," Dr. Smith explained, "that these patients differed from those seen at the Clinic, not so much in the intensity of their reaction as in its management. In the supportive atmosphere of the room of a friend or the Clinic, the patient recognized the drug-induced nature of his experience. If he was incarcerated, his paranoid, hallucinatory behavior was intensified and prolonged."

7. Lack of supervision. "That the person under the influence of LSD should not be left alone is universally agreed," Dr. Sidney Cohen had noted in 1960. As LSD became freely available on the black market, this safeguard was occasionally ignored. More commonly, the others present were also "tripping" on LSD, and were concerned primarily with their own trips. Or unskilled young people panicked when one of their number panicked, and thus compounded his reactions. No one took the simple measures which can favorably alter the course of an LSD trip–– assuring the user, for example, that this is just a drug experience and that it will in due course fade away, or distracting his attention from whatever unpleasant is preoccupying him to something else: a rose, a tune, a photograph. In the absence of such simple supervisory techniques, the proportion and severity of bad trips increased.

8. Mishandling of panic reactions. When an LSD user and the people around him panicked, the user was sometimes rushed to the emergency room of a nearby hospital; indeed, most of the accounts of adverse LSD effects during the 1960s came from these emergency rooms, where personnel in those days were usually quite inexperienced. They sometimes did not diagnose an LSD trip correctly. Whether or not they diagnosed it correctly, they sometimes used wholly inappropriate treatment such as washing out the patient's stomach (a traumatic experience in any event, and far more so in the middle of an LSD trip); or they initiated other procedures that frightened the patient and complicated his bad trip. Even in the absence of such procedures, the impersonal hostility to drug users in some emergency rooms was a complicating factor. As better ways of treating bad trips were introduced (see Part IX), their severity declined.

9. Misinterpretation of reactions. Before 1962, when LSD bad trips occurred, they were accepted as an inherent part of the total LSD experience; sometimes they were even perceived as therapeutic in themselves, and therefore welcomed. After 1962, however, these bad trips were labeled  psychotic. From a review of the medical literature of the 1960s it is evident that some of the "psychotic reactions" of that decade were actually bad trips similar to what therapists and patients alike bad taken in their stride during the 1950s. Indeed, the label "psychotic" itself affected the reactions of both physicians and patients and thus contributed its share to making bad trips worse.

10. Flashbacks. One widely publicized adverse effect of the LSD trip is the "flashbacks sudden and unexpected reexperiencing of some portion of an earlier trip, weeks or even months afterward.

Dr. Sidney Cohen, interestingly enough, did not receive a single report of flashbacks during his 1960 study of adverse LSD reactions. No doubt some earlier users experienced flashbacks–– but they were not perceived in those days as adverse reactions. As late as 1967, only 11 cases of flashbacks were reported in the medical literature, though no doubt more were occurring. Then the flashback hazard was widely publicized–– and a flood of reports promptly followed. By 1969, according to Dr. M. J. Horowitz, about one out of every 20 "hippies" who used LSD suffered flashbacks of some kind. Characteristically, Dr. Horowitz reported, such flashbacks occur without apparent stimulus, and are not subject to the volitional control of the individual. Those who used LSD repeatedly seemed to encounter the most severe forms of flashback. Dr. Horowitz noted that out of 22 cases of "massive drug use, defined as a history of more than 15 LSD 'trips' and considerable use of other agents," 7 cases reported flashbacks.

A simple explanation of LSD flashbacks, and of their changed character after 1967, is available. According to this theory, almost everybody suffers flashbacks with or without LSD. Any intense emotional experience–– the death of a loved one, the moment of discovery that one is in love, the moment of an automobile smashup or of a narrow escape from smashup may subsequently and unexpectedly return vividly to consciousness weeks or months later. Since the LSD trip is often an intense emotional experience, it is hardly surprising that it may similarly "flash back." Once flashbacks were labeled as "psychotic episodes" and warned against, they could no longer be taken in stride. They produced anxiety, even panic, in some LSD users.

It should be added, however, that some LSD users who have experienced flashbacks report the LSD flashback to be altogether different from the recurrence of emotionally laden nondrug experiences. We shall return to this issue.

11. Preexisting pathology. A major cause of the increase in adverse LSD effects after 1962 was almost certainly the drug's availability to everyone, including schizophrenics and schizoid personalities, who are most likely to experience adverse effects. Indeed, there is some reason to believe that the youth drug scene in general, and LSD in particular, had a special attraction to these troubled people. Among 47 users of LSD and LSD-like drugs admitted to Bellevue Hospital, New York, during the first half of 1967, "almost 50 percent ... showed signs of schizophrenia or were treated for that condition before ever taking LSD." An additional 20 percent showed schizoid features prior to the hallucinogen intake."

This does not mean, of course, that  only schizophrenics or schizoid personalities suffer severe or prolonged effects following LSD. In a 1970  Archives of General Psychiatry paper entitled "Chronic Psychosis Associated with Long-Term Psychotomimetic Drug Abuse," Drs. George S. Glass and Malcolm B. Bowers of the Connecticut Mental Health Center in New Haven reported 4 cases of psychosis requiring prolonged hospitalization in young male LS15 users. "Their personalities had allegedly been very different prior to their beginning of heavy drug ingestion," Drs. Glass and Bowers noted. After repeated LSD trips, "these individuals were withdrawn and isolated on the ward. Their affect was shallow, and thought processes, while not loose, were bizarre and centered on eastern religious mysticism. Primarily these patients utilized mechanisms of denial and projection, even to the extent of paranoid delusion formation.... The overwhelming passivity, evasive style of interaction, and peculiar manner of thinking seemed not to be a part of an acute process, but rather an integral part of each patient's personality." No doubt other cases might be cited of apparently psychotic reactions following LSD in persons who revealed no visible foreshadowings of psychosis before LSD. The incidence of such cases, however, remains in doubt. One might also question whether lengthy hospitalization is the treatment of choice in such cases, or whether it might prolong and exacerbate the symptoms.

12. Unwitting use. A number of adverse reactions during the 1960s resulted from the administering of LSD covertly to people who did not know they were receiving it. Sometimes the LSD was given as a prank; sometimes it was a well-meant but misguided effort to provide the benefits of the LSD experience to a reluctant nonuser. In either case, a person experiencing a "trip" without knowing he has taken a drug naturally concludes that he has suddenly "gone crazy"–– a highly traumatic experience.

Some observers have suggested that adolescents may be more vulnerable than adults to the adverse effects of LSD, and that the increase in adverse effects after 1962 may be due in part to increased LSD use by adolescents. Other observers, however, believe that adolescents are better able than adults to take LSD effects in their stride. No comparative studies exist on this issue.

The twelve factors cited above–– increased expectation of adverse effects engendered by anti-LSD warnings, unknown and in some cases excessive dosages of black-market LSD, contaminated black-market LSD, adulterated black-market LSD, the popular attribution to LSD of the adverse effects of other drugs, the arrest and incarceration of LSD users while they were on "bad trips," trips taken without skilled supervision, the mishandling of panic reactions, the labeling of "bad trips" and of "flashbacks" as "psychotic," the failure to screen out schizophrenics and schizoid personalities, and the unwitting consumption of LSD–– serve to explain at least in considerable part why a drug that produced relatively few adverse effects during the 1950s became the "horror drug" of the 1960s. By altering those factors, a notable reduction in the damage done by LSD could no doubt be achieved, even though its use were to continue. There would no doubt remain some adverse effects, which might prove serious in isolated cases–– but the scale of the damage might be markedly reduced.

Since the adverse effects of LSD from 1962 to 1969 were in considerable part traceable to the anti-LSD publicity and to other nonpharmacological factors, there was reason to hope that once the excitement died down, the acute adverse effects would become fewer and less severe–– and this is what has now happened. The re-emergence of LSD as a less hazardous drug is discussed more fully in Parts IX and X.

Footnotes
Chapter 51

1. Sidney Cohen, "Lysergic Acid Diethylamide: Side Effects and Complications,"  Journal of Nervous and Mental Disease, 130 (January, 1960): 39.

2. David E. Smith and Alan J. Rose, "LSD: Its Use, Abuse and Suggested Treatment,"  Journal of Psychedelic Drugs, vol. I, no. 2 (1967-1968): 122).

3. Ibid., p. 120.

4. Le Dain Commission Interim Report, p, 209.

5. Frederick H. Meyers, Alan J. Rose, David E. Smith, et al., "Incidents Involving the Haight-Ashbury Population and Some Uncommonly Used Drugs,"  Journal of Psychedelic Drugs, vol. I, no. 2 (1967--1968): 143.

6. Ibid.

7. Sidney Cohen, "Lysergic Acid Diethylamide," p. 31.

8. Mardi J. Horowitz, "Flashbacks: Recurrent intrusive Images After the Use of LSD,"  American Journal of Psychiatry, 126 (October, 1969): 565-569.

9. Leon J. Hekimian and Samuel Gershon, "Characteristics of Drug Abusers Admitted to a Psychiatric Hospital,"  JAMA, 205 (July 15, 1968): 125--130.

10. George S. Glass and Malcolm B. Bowers, Jr., "Chronic Psychosis Associated with Long-Term Psychotomimetic Drug Abuse,"  Archives of General Psychiatry, 23 (August, 1970): 97-103.