EP 2:31: Chemsex And the Brain with Stephen

If we could just have more information on the front end, you know, if somebody could have told me before I took the pipe in my hand, you know, this is what it does. You know, this is the long-term effects it's going to have on your life, then I probably maybe wouldn't have. The Aftermath Podcast is an outreach tool to help men who have sex with men break free from the addictive patterns associated with chemsex, otherwise known as crystal meth or Tina. I'm your host, Dr. Dallas Bragg, a former crystal meth user, now recovery coach. Here you will find a repository of tools and resources intended to eradicate the epidemic that is plaguing our MSM population. Please note that the views expressed on this podcast are not to be taken as medical advice. Also, we will be talking about drugs and sex, so if you feel triggered to use, stop listening and contact your local emergency system And/or your support network.

Let's go.

Welcome back to the Aftermath Podcast. I'm Dallas Bragg, your host, as you should know by now. I'm grateful that you are here, and you're going to enjoy this conversation today because I got a lot of questions about what has happened to my brain, what kind of damage am I doing to my brain, is it something that can be fixed, all kinds of questions like that. And I don't think that we We that have been using or are using really clearly understand exactly what we're doing to the brain when we inhale the chemicals we're inhaling. And if you look at the ingredients in crystal meth, you would never put anything like that by itself in your body. So I can't imagine that it's helping. So today we're going to talk to a researcher who is answering these, some of these questions, or at least wants to answer some of these questions. I don't want to put him on the spot that as if he knows all the answers, but he's doing some good, good work. Um, don't forget, if you're listening today, that— oh, I hear some seagulls in the background. Are you near the beach?

That's because I'm in Brighton.

Yeah. Sorry. Oh, nice. No, I love it. I love it. It really caught me off guard. Um, yeah. So if you're listening and you want to, to dive in deeper, each episode has a study guide. It's a study guide that is a supplemental to the episode where you can dive a little deeper. It includes journal prompts, reflective questions for you, and one actionable exercise and a summary of the podcast. If you like that, the link for it will be in the show notes, or you can actually get it to your inbox if you go to drdallasbragg.com, go to blog, and subscribe to my mailing list. If you subscribe, you also get a weekly newsletter that is also a working newsletter. Keeps you busy and out of trouble. All right, so much— let's get started here. I'm going to introduce my new friend, Stephen Knowles, who lives— well, he's in Brighton right now, but we're going to let you introduce yourself. Tell us all about you, please.

Yeah, great. Thank you so much for having me on the podcast. I really appreciate it. It's a great podcast that you've got running and a wonderful Instagram page. So very grateful that you've, uh, made the time to let me come on. Um, yeah, as you've already heard in the intro from the seagulls in the background, I'm based in Brighton, uh, which is a town on the south coast of England, about an hour on the train away from London. Um, and I guess the, the reason why I've come on the podcast to speak to you and why we've been chatting recently, uh, is because, uh, I'm a medical doctor by background, uh, and I specialize in psychiatry. Um, and there's a research initiative that I have recently launched called Chemsex and the Brain.

Mm-hmm.

Um, and that effectively is, uh, my attempt and my, my, my associate's attempts to better understand what the long and short-term impact of involvement in chemsex might have on both brain structure and function. Um, so I guess that's what we're going to talk about a little bit today.

Yeah, yeah. I, I'm surprised there hasn't been much research done already. I mean, I, there, I know there's a, there's a study that I quote all the time. that shows that it's like 12 to 24 months for brain scans to kind of like your brain to look like it's functioning normal after using. I know that that's kind of a standard. It's an older study, but it's something that we kind of go by. It's the only thing we really have. So why do you think there's a lack of research?

Yeah, so it's probably important to clarify. So obviously, the definition that I use of chemsex, I accept that people have different definitions.

Yes.

But the definition that I would use is the use of 4 main drugs. So crystal meth, Tina, uh, GHB or GBL, uh, mephedrone, um, or ketamine in a sexual context for the purpose of either, uh, prolonging, facilitating, or enhancing sex. So we absolutely have brain imaging studies that look at those substances individually.

Ah.

For example, we've got, we've got quite a lot of information about how meth affects the brain. Um, what we don't have though is any studies that look at chemsex itself as a phenomenon and that unique kind of polysubstance use that people have. So people combining a bit of Tina and then using some G to come back down again when they're feeling too high, both of which are quite neurotoxic drugs individually.

Mm-hmm.

And then combining that with the additional strong behavioral component of sexual activity. Nobody's ever delineated how those things together affect the brain in the long term. And I suspect it will have quite profound effects. But of course, nobody's done that research yet. And that's the gap that we're trying to fill.

Gotcha, gotcha. Yeah, okay. Yeah, that makes sense. Because that study that I read that I always quote, it does only talk about Tina, crystal meth, right? And I have seen, I have seen some studies on GHB, but not really how it affects the brain. Not that I'm deep in the research either. But I see what you're saying. So the actual chemsex, and so you define chemsex, because that's been a big question on here too, is what is chemsex? Yeah, but, but you're defining it as these 4 drugs. And I'm assuming in the population of men who have sex with men.

Yeah, I think that the way— so I think it has to be LGBT community. And I guess I don't think you can define chemsex without first defining sexualized drug use. So for me, sexualized drug use is kind of the broad term at the top, which is, yeah, anybody who is having sex whilst under the influence of drugs. And I would go as far as to say that that includes being drunk on alcohol, or, yeah, you know, if you want to be really extreme about caffeine, for example. I mean, that's a bit extreme, but to kind of define it, that's what sexualized drug use would be for me. And really, the definition of chemsex goes back to an article written by David Stewart, who was based in London in Soho and unfortunately has passed away now, um, where he defines it as being inextricably linked to historic aspects of minority stress that queer people have experienced. And by that, we mean, uh, the, the legacy of the HIV and AIDS crisis, um, uh, aspects of minority stress from growing up maybe in small-c conservative, uh, religious or otherwise backgrounds that kind of shun homosexuality, and also the advent of, uh, hookup apps where there's almost this like queer-specific rejection based on like, uh, body type and perceived attraction, all of which come together to create either like a sense of danger or shame for some people associated with queer sex that these drugs enable some people to overcome. So that's why I think it has to be specifically queer people. And David Stewart actually went as far as to say that he thinks, or thought it was an act of harm to say that heterosexual people could take part in chemsex because they haven't been subject to the same kind of historic issues and trauma that queer people have. And, you know, having kind of engaged with people who, who work in this sphere for a while, I think that I have come around to agreeing with that definition. But ultimately, you can get to a point where you kind of try to overly— you go, you become too anthropological about it, and you go into the phenomenology too much. And ultimately, if people are using these drugs in this context, and they're encountering harm, then we should, then we should care about helping them. But that's the definition that I would adopt based on all of the literature that's out there.

It's interesting. It's interesting, because I get comments a lot on social media from, and that, you know, from straight people who say, you know, well, we, we have sexualized drug use too, you're not special. you know, we have— we fuck on Tina too, right? That kind of thing. But I, I do think what you're kind of— what you're saying, I think what you're saying is that it's the reasons why too, right? Like, you— like, heterosexual people may be having sexualized drug use, but they're not doing it to escape danger and shame and possible harm.

Is that right? Absolutely. I think, I think so. And I also think it's important to say that The, the chemsex literature compared to other literature within like the addiction sphere isn't as far along as, so for example, think about tobacco addiction or alcohol addiction.

Mm-hmm.

You know, that, that has existed for decades and there's a huge body of research. I don't think that we have yet strictly and clearly defined all of the different populations that are involved in chemsex. So absolutely, I think that there'll be some people who will be involved in it because of a classic minority stress model. I think that there will be some people who are neurodivergent. Um, so for people who aren't familiar with what that is, kind of a, a pattern of kind of brain development that is different to neurotypical brains, so the standard brain development. That includes things like ADHD, autism. Lots of people might be using, um, stimulants that might go into a sexualized setting. So for example, Tina, to help with some of the differences that they encounter because of that. Um, and then you might have kind of a more hedonistic reason. You know, there's nothing wrong with going to a club or going to a sauna and wanting to have fun. You know, we shouldn't stigmatize that, in my view. So I think, I think there probably is a spectrum of people that are involved in it, even within the queer community. And those different populations will probably have different reasons for being involved and different things that we can do to help them. Um, but at the moment, we seem to be treating it as one homogeneous group, which actually might not be that useful. Does that make sense?

Yeah, it does. Yeah, it does. That— I mean, that makes researching a little, I guess, a little more difficult too because there's so many nuances, right?

Absolutely. I think that's completely right. I mean, trying to— I, I won't bore your listeners or you with talking about kind of statistical power and things like that, but yeah, every time you add in another variable— for example, if you want to explore the role of ADHD, for example, in people involved in ChemSec— yeah, well, that means that you need to put loads more people into your study to be able to adequately detect a difference. So yeah, constructing a study where you look at all of those little tendrils is, is quite challenging, especially when it's a really stigmatized group. And I guess the other thing that I should say is that for me, chemsex seems to be stigmatized for various reasons. I mean, it's got the drug use which drives it to the fringes, it's got that it's often non-monogamous which drives it to the fringes, and also that it's queer people who face stigma across kind of all walks of life. And all of those things make it a very fringe issue, which makes it very easy to ignore. And I suspect, going back to your original question, that's probably why it's taken so long to get kind of neurobiology-driven imaging studies specifically looking at the phenomenon of chemsex.

Hmm. So driving it to the fringe makes it easy to ignore. I like that.

Yeah, I think so. I think so. I think if the kinds of headlines that we'd seen about gay men dying of GHB overdoses, which we saw a lot of in London in the last few years, were about straight middle-class white men, and on the level that we've seen in queer people, I think that people would be paying a lot more attention. Um, and it reminds me of a lot of the advocacy that queer people have historically had to do, where it's been very much our community advocating for ourselves, banging on the door to get the mainstream to listen. I suspect there's part of that going on there.

Yeah, yeah. Interesting. Very interesting. Thank you for that. So what got you interested in this? Is it because you saw a gap in the research, or—

Um, so I think, I mean, the first time that I ever came across chemsex as a phenomenon was when I was still a medical student in London. And I remember I was in the emergency department on a placement. And I just decided that I was interested in psychiatry as my specialty. And so the A&E doctors sent me to what we call in England take a history from the patient, but it's basically where you clerk the patient. You kind of see why they've come in. And the patient that I saw was somebody who was presenting in the context of a GHB overdose. And I found that the A&E doctors were quite dismissive of that person. They were like, oh, he's a frequent flyer, he comes here all the time. quite a lot of shame associated with him and his presentation. But because I was interested in psychiatry, I took a bit of a longer history from him. And actually, I found out from him that him and his partner had been involved in chemsex together, and his partner had actually died relatively recently of a GHB overdose. They'd woken up in bed together and his partner had died.

Hmm.

Um, and obviously that's an incredibly traumatic story to hear from somebody, and to me it felt like that was still driving some of his behavior and that he hadn't been offered adequate support. Um, and I thought if it was any other addiction presenting to an emergency department in the same way, there was an established pathway for it where we could help people. And I felt like that didn't really exist for chemsex. And then the more that I delved into that as I graduated and became a psychiatrist and became more involved in research, the more I saw there was this kind of rich psychosocial, psychosexual understanding of what chemsex is. But yeah, that there was this gap for kind of chemsex and the brain, the underlying neurobiology. And actually, I think if we want to take this seriously and get people to listen, we need to think about all of the ways that it affects people. And sexual health doctors are doing a fantastic job with chemsex and have done a fantastic job with chemsex. But I feel as a matter of health equity that psychiatrists now have to, have to get on board. And we have to try to find out more about the neurobiology that might be driving this too. Um, so that's, that's where I, that's where I come at it from.

I love that. Yeah, you dug a little deeper to somewhere people weren't— other people were— other professionals weren't digging. Yeah, because I hear, you know, it's, it's often that I hear from men who say, you know, I, I see a therapist or a psychiatrist, but they, they don't understand. They're, they're not understanding what I'm trying to tell them about my chemsex use. They're grouping it into any other addiction, you know. And there's this, there's this misnomer. And then, you know, they start telling stories about things they did in chemsex, and it becomes a shock to the therapist or the psychiatrist, and then that brings on more shame. Um, so I think informing the psychiatrists and the professionals, even the, even addiction counselors, even treatment centers, informing them more on chemsex is going to be so helpful.

Yeah, I mean, it's really, it's really interesting, Dallas. And I'd be interested to know what the setup is in, in America, because I don't know the way that the services for this are provided in America, for example. But in, in the UK, the way that somebody would present, I guess, for, for support in relation to chemsex isn't they'd necessarily like walk into a specific center for it. They might, they might pop up at a sexual health clinic because they have symptoms of an STI. They might pop up in an accident and emergency department with a drug-induced psychosis or with an GHB overdose perhaps. Um, or they might come to a psychiatrist with kind of emerging symptoms of psychosis. So there's various places that they can first access services, but actually there's very few places in the UK where there's one cohesive joined-up service to provide people. And I think obviously if you're a sexual health doctor and you've got 10 minutes with people, you're going to focus on the sexual health components. If you're an A&E doctor, you're going to deal with the Immediate overdose, get them fixed, and then get them out, aren't you? Because you're really busy. Um, so, you know, it's inevitable that doctors are going to do that. They're going to think about their specialty. But I do think there is a gap there for kind of more joined-up thinking. And there are some places in the UK, for example in Soho in the middle of London, where they do that. But I think in other places we could try to do it a bit more too. And certainly, just to answer your point about psychiatrists, sorry, I'm kind of rambling on a bit now, but—

Do it.

Psychiatrists, I think we have to acknowledge that we've got an incredibly problematic history with the queer community, um, you know, lobotomizing people for being gay going back decades. And in some sense, the reason why people, queer people, feel comfortable going to sexual health services is because they developed a cultural competence. It feels safe to go there and, you know, talk about fisting, talk about the kinds of things that you've been up to at a party, and you won't be judged for that.

Yeah.

So there is work to be done in psychiatry and in other medical specialties to develop that cultural competence. And then I think when that happens, people will feel more comfortable disclosing these kinds of behaviors to us. But I also think there's a lot of work to be done there, and I think psychiatry has got to be honest in acknowledging that.

Mm-hmm. Yeah, yeah. No, I mean, I think you may have fragmented services there, but it's even more so here. I mean, we have some treatment centers that are specializing in chemsex now that you could go to, but in terms of, you know, coordinating services, no. You know, I had Ben Kay on here. Do you know Ben Kay? he's in the— he's in London.

Okay.

He's been doing— he's been educating like police officers, first responders, you know, just kind of trying to coordinate services so that people on the front lines, when they, they, you know, they come in contact with somebody who's been involved with chemsex, they'll know what to ask. And they'll know kind of more of how to treat that person. Because that, you know, drug-induced psychosis from that could be different than somebody who's in, in a psychotic break of some other kind. Um, but, you know, education, education is the key, right? Which is what you're trying to do here.

Yeah, well, um, once we— I guess once we get the answers to some of these questions, then educating people. Uh, but it's quite, it's quite exciting not knowing what we'll, what we'll find. We're about— we've scanned about, we scanned about 20 people today, and we're— we still got a few more people to scan, but we've got some kind of emerging, emerging results which are interesting, um, from one modality, but we've got various other modalities to, to analyze. So yeah, first of all, get the answers and then give it to people in an accessible, accessible way that people can understand.

Um, yeah. Yeah. Well, let's talk about your, your study. So your website is chemsexbrain.com.

Yep.

Uh, I have it pulled up here. Um, this is more, more or less explaining why you're here and then how to sign up for the study.

Yeah. Uh, and I should say the, the brain imaging study is the, the first study and the main study, but we have other studies planned further down the line specifically focusing on this question of chemsex and the brain. And one neuroimaging study isn't going to answer all of those questions. So yeah, there's lots of things in the pipeworks. The best way to find out more about the work we're doing is to sign up to the mailing list that's linked on the website. And then when new studies are launched and when we get results from the studies, that's where we'll be sharing them. And on our Instagram as well, which is @chemsexbrain.

@chemsexbrain. And we'll put all of this in the show notes, obviously. So you, you're getting volunteers and I'm just, I guess they have to be local. You know, I don't think anybody's going to fly. You have to be there personally, right?

Yeah. Yeah. I mean, there's no, there's no specific reason why I wouldn't scan somebody from elsewhere. It's just we can't— we, we're a limited study. We can't afford to pay for people to fly transatlantically, unfortunately.

Do you have any kind of idea of what you might find? Do you have a hypothesis, if that's the right word, in terms of, you know, what are you looking for?

Yeah, so I guess the, uh, the main, the main modality to speak about at the moment, which I think is interesting and relatively accessible for people to understand, um, is a type of imaging called neuromelanin MRI. And again, we can put this in the show notes if people want to look it up.

Sure.

Because it, it's complicated science, obviously, because it's imaging. But basically, dopamine, which is your main, uh, reward neurotransmitter in the brain, activates something called your mesolimbic pathway, which is again your main reward pathway. It connects 2 areas of the brain, the ventral tegmental area and the nucleus accumbens. So When you do something rewarding, whether that be do a hit of Tina, whether it be go for a run, whether it be eat some nice sugary chocolate, dopamine gets released on that pathway, and that's what makes you feel good. And that's why that pathway is implicated in the development of addiction to substances or in behavioral addictions. And I guess chemsex is interesting, right, in that it traverses this middle ground between being drugs but also a behavior.

Yep.

Which is interesting. Neuromelanin MRI is a type of MRI scan that can show basically a proxy level of dopamine structures in that part of the brain, the ventral tegmental area, because basically dopamine gets metabolized into, into neuromelanin. It gets broken down into neuromelanin, and, and that will show up on an MRI as basically a brightness, a whiteness on a T1 MRI. Again, we can put more detail in the show notes. Now, in people with addiction to stimulants, so things like crystal meth, or in people that have been using cocaine, studies have shown that there are alterations in the signal intensity in that part of the brain, meaning that that main dopamine reward pathway where it originates is either becoming more or less active in response to repeated use over time.

Okay.

There's also some emerging evidence from groups both in Canada and also in uh, in, in London, uh, that, uh, higher levels of activity there can be associated with psychosis.

Okay.

So what we hypothesize is that there will be changes in that pathway in response to chronic use of chemsex. Now, it may be the case that in the short term, when people are first starting to do chems, that that's higher activity because you're kind of activating and activating and activating that pathway. And it then may be the case that over time, in response to repeated kind of stress on that pathway, that becomes less active. And that's why it's really important that we recruit as many people as possible and get a really thorough history of their chems use, because it might be that there's more than one group there driving a heterogeneity, almost like a wide spread in the signal that we see in that area of the brain. So I'm not sure if that made any sense at all, but that's, that's one modality that we're using amongst 4 other modalities.

Okay. Well, so I like to be talked to like a 2-year-old. And so that wasn't, but, but what I got from that, you tell me if I'm right, is so the, that dopamine pathway that gets lit up, right? When with crystal meth or stimulants, it can, it's going to be the more repeated use of the stimulant, the more active it is, the more brighter it is, right? And you're saying that the more active it is, the more likely— likelihood of psychosis?

We haven't put those things together yet. But what we have seen is that in that area, there are— there's evidence of increased level of activity in people with psychosis. But also, we know separately that stimulants activate similar parts of the brain. So putting those 2 things together hasn't been done. Just because they both do it, it doesn't mean that they're connected, but it's possible. And of course, we know anyway that crystal meth is independently associated with psychosis. So sure, that could be one of the mechanisms, but that's not been robustly answered.

Yeah. So does the pathway stay Does the pathway stay there once you stop using the stimulant? I mean, is it that dopamine pathway always going to be there?

So that's— so that pathway is your body's main reward pathway. So it probably developed in evolutionary terms so that, you know, 1,000 years ago when we were— 1,000 years ago? How long ago were we hunter-gatherers? Anyway, whenever we were hunter-gatherers, when you found your prey and you ate, food, for example, would activate that pathway, and then you would associate, you would associate that activity with feeling good, and therefore you would try to do it again.

Okay.

So I guess the, the corollary of that for addiction is you're taking a drug which is activating it, which then makes you want to do it again. And so you strengthen that connection over time, which is why it can be so difficult for people to then stop using drugs, because you get the craving in response to wanting to chase that high again, that that rewarding feeling.

Yes.

So you've kind of almost hijacked your body's evolutionary reward pathway, but that's an anatomical link that exists in everyone.

Yes.

Okay. Yeah. And in people who are experiencing addiction, yes, that pathway absolutely is, is altered in many people. Um, and so it's reasonable to expect that in people who have an addiction to chemsex that we'll see those same kinds of changes. But again, it speaks to the kind of stigma that these people are experiencing, that that's not been done yet. And that's what we're hoping to try to answer. And then I guess I hope what will be achieved from that, if that is proven, is like almost people take, take it a bit more seriously. Like this is something that is having a profound biological impact on people's brains. It's not just kind of a hedonistic activity that people are doing on the fringes that we can kind of ignore.

Right, right. Yeah, because, you know, you hear the— you do hear some guys saying, just let us have fun. Or I get comments from gay guys say, why don't you just let these queers have fun?

You know? I think, I think not all chemsex and not all drug use is innately harmful. That's, that's my view. Um, it's my per— that's my personal view. Um, but And so, because of that, I'm a huge advocate for harm reduction. So, um, accepting that in an, in an imperfect world, people are going to want to use drugs, and therefore accepting that pragmatically, how can we help them to do it safer? I don't think that you can give solid harm reduction advice about chemsex until you know all of the harms. And without this kind of research, we don't know the harms.

Mm-hmm.

So I, I would quite happily have a conversation with a patient who wanted to carry on using G and T at sex parties. But I'd want to be able to tell them, this is what we think the long-term effects on your brain might be, so that they understand that. And if they want to carry on, fine, carry on.

I don't care.

I won't judge you. Um, but I don't think that— I don't think we can have that conversation with them until they know.

That's right. Yeah, that's right. That's right. I mean, I just— if we could just have more information on the front end, you know, if somebody could have told me before I took the pipe in my hand, you know, this is what it does, you know, this is the long-term effects it's going to have on your life, then I probably maybe wouldn't have. Yeah, I mean, most likely I wouldn't have. Um, but yeah, education is, is key here. So I know when I— when you were talking about pathways, I was thinking that they were separate pathways, but you're talking about one, one pathway. Okay, that makes, that makes sense. Uh, that makes sense to me. When you said that it's going to help with stigma, can you talk a little bit about that?

Yeah, well, I think so. I can't say it will help with stigma. My— I guess my, my hope is it, it could help with stigma.

Sure.

Um, And the reason for that is, again, as we've alluded to, I do think that there is kind of this dismissal of it. And I think, uh, particularly in psychiatric circles, it's not that well known about, as we've discussed. And I think part of that might be because we've got the psychosocial component, we've got the sexual component, they've been really well researched, but we've got an absence of neurobiological data about this phenomenon. And I think, unfortunately, there is a tendency amongst some people to say that kind of people who are experiencing addiction just need to pull themselves together. Like, if you don't, if you don't want to use the, if you don't want to use these drugs, just don't use them. Yeah, that's not how addiction works. And so if we can prove that this pathway is changed in people experiencing chemsex addiction, then I hope that can be pointed to say, no, there is an actual biological impact here that isn't as simple as this kind of clicking your fingers and saying, ah, I'm gonna stop.

Mm-hmm. Yeah. Do you think this could lead to some drugs that could help with, you know, uh, with chemsex cravings?

I think it's, it's interesting. It's definitely way too early for that because we don't know exactly. We definitely— we've got an idea of the systems that might be implicated, but we haven't definitively proved it. I mean, certainly you could argue that some of the drugs that are useful for any of the individual substances might be useful, but it would depend on the specific pattern of substance use that people, um, that people have. Um, certainly there's a role for psychotherapy there, and further down the line, if we can identify a, a target or a mechanism, there's no reason why you couldn't think about, um, a particular, particular medication for sure.

Yeah, yeah, yeah. Okay, so are you still— how long will you be accepting volunteers to be So yes, signups are still open.

And I think based on the trajectory so far, we'll certainly still be accepting people until the end of this calendar year. Okay, with the view to completing our analysis early next year.

Okay. So if you're listening to this, and we do have, we have quite a listener base in the UK, who is— you're looking for gay and bisexual men engaged in chemsex?

Yeah.

Um, is there a length of time there, or?

So you need to have— so it's, it's people who are currently involved in chemsex, not people who are now, um, abstinent from chemsex. So these would be active users of chemsex.

Okay.

And at least, at least once in the last 3 months and several times in the last 6 months. Um, if, if that applies to people, um, then they can email me and there's an information sheet with more information about the specific inclusion and exclusion criteria. You can also get to that on our website as well by signing up for the study, and there's a link to that in the sign-up sheet. And also, we're recruiting as a control group gay men who have no history of chemsex. So if you're listening to this and you're a supporter of people who are involved in chemsex and you want to advance science in this area, then you can help by coming along and being a control too.

Hmm. Yeah, yeah, yeah. Great. Good. Yeah, I will put all this on the, on the, in the show notes. So you mentioned more studies coming soon. Do you have an idea of where you want to go next? I mean, I know it's kind of maybe too soon, but you must have an idea.

Yeah. So certainly way further down, way further down the line, there's, there's the scope to do more imaging work. So for example, the study that we're doing at the moment is active chemsex use versus no chemsex use. It would be interesting to see, um, people with a history of chemsex who now no longer do it, um, to determine if there's any kind of reversibility there. Um, there's also an argument that you could do a 3-arm study of active chemsex use, no drug use, and drug use in a non-chemsex setting to see if there's any additional effects of chemsex compared to just standard drug use.

Mm-hmm.

Um, so those are things that could be done further down the line, but because it's bigger groups, it requires more participants, and more participants requires more money. Um, and what I do feel really strongly about is that although it would be easy to kind of jump in and do more and more research quickly, we need to do it robustly and in a way that makes a case for people to want to fund us. And then when they fund us, we do high-quality science that's well thought out and well planned. So we won't rush into anything until we've got the results from this imaging study, but certainly that's one thing we're looking at. In the near future, we'll probably be, um, hopefully before the end of this year, be launching a, um, a survey-based study looking at aspects of, um, risk perception and insight in people involved in chemsex, um, which is driven by a more kind of neurobiological approach to it rather than kind of a social approach. Um, hmm, and then we're also interested in doing some work looking at specific awareness about chemsex in mental health practitioners in the UK, which based on our conversation today, I think would be quite interesting.

Yeah, yeah, for sure. What about, what about people who aren't, who have been meth-free for a certain amount of time, looking at the effects on their brains or the repair of their brains? Is that something that—

Yeah, I think so. I suspect that there will be some literature out there about the reversibility for sure. Um, so yeah, I mean, you, you alluded to that already. Um, the challenge with— the challenge with reversibility is, let's say you scan somebody's brain and they stopped using meth 5 years ago, and you see a specific snapshot of the brain at this time point. You can't ever say that that's not how it was before they started using meth.

Mm-hmm.

Because you don't have that imaging. Um, and so, I mean, that's the other caveat that I should say about all of this research, obviously, is It's chicken and egg. If there are changes in that dopamine pathway, is it that having a less active dopamine system originally makes you more likely to pursue drugs that activate your dopamine system to make up for that loss? Or is it that it's lower because you've been using drugs and therefore it's become attenuated over time?

Mm-hmm.

So the only way to really answer that is to get people before they start using drugs, which obviously has ethical issues because then you're kind of suggesting they should go and start using illicit drugs. Um, so yeah, that— it's slightly more— it's slightly more challenging to design studies like, like that, which is why there's fewer of them. But they definitely will exist for meth, I'd imagine.

This is certainly—

if you're, you're alluding to them, I can't recall results from one off the top of my head right now.

Yeah, this is always a big question that I'd love to answer for people, you know, how long is it going to take me to get my cognitive abilities back. You know, I don't think there is a timeline, right? Plus, we don't know what kind of long-term effects there are on the brain, for even for me. So it's 7 years later. Does— has it affected me? I don't know. You know, um, I, I can tell some differences. There's a lot of times where I have time— I have trouble coming up with my words, like I have a quote-unquote brain fart.

Mm-hmm.

But I don't know if that's just me or, yeah, or an effect.

But you, yeah, you, you're, you're right in that, um, meth affects cognition specifically as a, as a, as a kind of a neurobiological domain. Um, and, uh, yeah, there's, there's some work potentially that further down the line that, that might be coming about that, but I can't speak about that too much just now because it's not fully formed. But yeah, um, absolutely, we know that meth itself can affect cognition specifically, which can lead to like memory issues, word-finding difficulties, etc. And again, is that reversible? Possibly to an extent.

Yeah, yeah. I mean, the brain's plastic, right? I mean, you hear that, we hear that a lot. Um, you know, for me, I did a lot of brain games on my phone, uh, Sudoku. I did, you know, I, I worked at it to try to get my my brain working a little faster.

Yeah, I mean, there's— the only challenging thing with things like that is there's so many, there's so many variables that affect it. So you're right, the brain's incredibly plastic. It's more plastic when you're younger than when you're older generally, but there's various things that you can do in your life that will affect the plasticity. And kind of, so yeah, it's— again, this is, this is the, the trickiness of designing science that tries to answer these questions, but also And that's why it's important that we try to do it because these are really difficult and profound questions about people. What will the long-term effects be on my brain? Well, we want to know, but it's really hard to design the study to answer it.

Right. Yeah, right. And maybe you can answer this, maybe not, but is psychosis reversible? There's permanent psychosis that's out there that's caused by meth use. Is that reversible?

Yes. Okay, great. Yeah, yes, yes, categorically. With, with, with, with treatment, yes. Wow.

So if you listen to this, really hear what he just said, you know, because I have, I have guys who have been, who have stopped for a while, but they're still in this paranoid state, you know, where they feel like somebody's watching them or following them. They have to check their door, the checked their locks many times, you know, and they're in this, they, they, they're working themselves up to, is this me for the rest of my life? You know, how did I get here? But you're saying with treatment, with some work, that is totally reversible.

Anybody experiencing symptoms like that should absolutely reach out to a psychiatrist because there are medications that we can use to help, but also there are talking therapies. So absolutely, if you have symptoms like that, speak to a doctor.

Yes, thank you for that. No one's ever been able to definitively say to me, so thank you for that. Um, one more thing—

well, it doesn't have to be one more thing, but you're talking about—

you've mentioned the difference between a drug dependency and a behavioral addiction. Can you talk to us how, how that works with chemsex? Can you tell us about that a little bit?

Yeah, well, it's interesting, isn't it? I, I'm I'm not, I'm not sure entirely how to answer it. I guess it's, um, yeah, I'm not, I'm not entirely sure what you're, what you're asking. Um, yeah, sorry, can you just—

Yeah, so I mean, I think that many of us will just say addiction or an addict means I'm chemically dependent on the substance. Yeah, these substances, right? But, but there's also a behavioral aspect of it. Yeah, that, that is— makes chemsex a little different.

Yeah. So the way that I think about— well, I say I think about— the way that psychiatrists in particular will think about addiction is broadly substance use or substance misuse, but I don't really like that term, but substance use addiction and then behavioral addictions. So substance use addiction, I don't really need to go into detail about it, but like cocaine, alcohol, etc. behavioral addictions, um, sex addiction, gambling addiction, gaming addiction.

Okay.

And what I mean by chemsex occupying that middle ground between the two is it's people using drugs, and people might be dependent on certain drugs that they're using, but they also might have a compulsive sexual element, which falls more in a behavioral component. It might be both, it might be neither, as we've said before, um, but Both of those things converge on that main dopamine pathway that I spoke about before. Both of those things activate that pathway. And so, uh, so for example, if you're gaming or you're gambling, kind of the buzz of gambling, for example, that activates that pathway, the thrill of winning. Um, whereas, you know, a stimulant like cocaine, for example, activates it because of the, the buzz that you get. Chemsex is probably activating both at the same time. So does that have any synergistic effect overall on this system? That's why I think it's interesting. Um, and I mean, there are, there are other examples of people using stimulants so they can stay up to game longer.

Sure.

Um, uh, people, uh, certainly in the UK drinking or using cocaine while they're gambling, um, where a behavioral addiction goes hand in hand with substance use and to me, it's interesting to what extent they facilitate each other. Does that answer the question?

Yeah, yeah, it does. It does. I kind of knew, but I just, I just wanted to make sure. We have all levels of people listening.

Yeah.

You know, and I just want to make sure we, we break down as many of those terms as we can. Now, some of the words that came out of your mouth, I'm not going to ask you about, but we, we, we get it, I think.

Yeah. Yeah. Um, but, but that's why it's important. It's important for like me to not sit in an ivory tower with the knowledge that I'm acquiring about this and then not disseminate it to, like, ordinary people who haven't had the privilege of a medical education. So, right. Yeah, I'm still learning how to do that. So if I go into jargon, you know, absolutely tell me and I'll try to explain.

Yeah, no, no, I love it because the information that you're going to provide will help me to disseminate when people ask me questions. I'll say, well, read this study, look over here. So, um, Yeah, and helped me as well in my coaching business. Um, so what did I miss, Stephen? What did I not ask about that I should have, or do you think that we may have missed here?

Um, when are you going to invite me over to California so I can enjoy the weather there?

Well, I'm in the other— I'm on the other side. I'm on, uh, I'm in North Carolina. I'm on the East.

Oh, fine.

Okay.

I thought you were in California for some reason.

Everybody does. Yes, you're invited anytime.

Fine. And you can come to Brighton and you can see the seagulls in person.

I would love to. I would love to. Actually, I am planning a trip to the UK next year, probably the spring, because I have so many people there to see. And I volunteer for controlling chemsex.

Very nice. Ignacio, big shout out to Ignacio and the team. Ignacio, yes.

Big shout out. Big shout out. I want to see them in person. They have, they have work gatherings that I never get to go to.

So yeah, lovely. Well, maybe I'll see you at one of them and we'll get some chips or something.

Yeah, I love it, love it.

I would love to.

Thank you for your time today. I really appreciate it. Thank you for your work. This is really cutting-edge stuff and important, very important, and I appreciate you.

Yeah, and likewise, thank you for the platform that you've developed and the work that you're doing to support people. We're people lifting each other up.

That's right. We need more of that. We need more of that. All right, guys, I hope you enjoyed this conversation. And if you are local in the UK, or hey, if you want to fly over and participate in the study, the bill's on you, but fly over there and get your brain scanned and help in the— help in this battle, in this, um, this urge to— this— what am I trying to say? Help in this effort to get information out. All right. Everyone, we will see you next week.