Electronic Summer 2023 | Issue 55

Psychedelic Legalization: A Step in the Right Direction or a Hasty Decision?

By: Luke Lammers
CCOM OMS-III

During their most recent midterm elections, the citizens of Colorado voted to decriminalize and allow regulated use of plant-based psychedelic compounds such as psilocybin. What does this mean for psychiatry and the rest of the mental health space? In this article, we will review the history of psychedelics - (focusing mainly on psilocybin and LSD), the current state of their research, discuss a movement to legalize psychedelics in Illinois, and finally consider potential issues with the research and legalization.

Let’s first dive into the history of psychedelics. Given that many of these substances are naturally derived from fungi, cacti, and other plants, it is impossible to say when humans began to utilize their psychoactive effects for recreation, medicinal or spiritual use. Some people, such as the supporters of the “Stoned Ape Theory,” popularized by Terrence McKenna, believe that psychedelics helped humans to evolve a higher level of consciousness.1 More conservative theories suggest that these compounds were used in spiritual rituals among our ancestors. The truth, as always, probably lies somewhere in the middle. Either way, the use of psychedelics dates back thousands of years into our ancestry. The use of psychedelics in western culture was diminished to almost zero during the early 20th century, until 1957 when Gordon Wasson, a New York Banker, traveled to Mexico to trial “divine mushrooms,”2 and wrote about his experiences in Life Magazine. He ate the mushrooms with a spiritual guide and wrote of his experience, stating “for the first time the word ecstasy took on real meaning.” It should be noted that this article prompted a massive unwanted wave of white tourists desiring to experience the same divine effects, which ultimately led to the spiritual guide being shunned and having her hut burned to the ground by her peers for bringing this terror upon them.14 years earlier, LSD was discovered by accident by Dr. Albert Hofman while working for Sandoz Pharmaceuticals.3 These two substances, though mostly LSD, were integrated into the culture (or more appropriately - the counterculture) of the 60’s and 70’s. This largely included recreational use, but there was also a focus on these substances in psychiatric research. However, these studies were not always conducted in ethical and rigorous ways. Consequently, the haphazard use of psychedelics led to their outlaw in 1973.4

Federally, this psychedelic prohibition is still in place today, though illegal, recreational use still flourishes around the country. However, reminiscent of cannabis legalization, certain states have begun to introduce and even pass bills legalizing the medical use of psychedelics, as well as their decriminalization. Where did this resurgence come from? Though there was a base level of research going on throughout the prohibition, research into psychedelics began to explode in the 2010s.5

One of the main studies that caught my attention personally was published in 2016. It focused on the possible use of psilocybin at end of life, for anxiety associated with terminal cancer. In this double-blinded study, researchers found that a single session of high-dose psilocybin greatly reduced end-of-life anxiety. More interestingly, these effects held over time. Even after 6 months, “more than 80% of patients showed either moderately or greater improved well-being and life satisfaction”.6 Studies have investigated psilocybin’s therapeutic potential for a multitude of diagnoses including treatment-resistant depression7,8, OCD9,10, and addiction11. There are ongoing studies through Johns Hopkins investigating its use in Alzheimer’s disease, post-treatment Lyme disease, and co-occurring alcohol use and depression.

In addition to the academic psychedelic renaissance, there has been a cultural shift in attitude towards the molecules as well. This is best evidenced by the popularity of Michael Pollan’s book “How to Change Your Mind.” Published in 2018, Pollan’s book is a #1 New York Times’ Best Seller, and in 2022 was also made into a popular Netflix documentary with the same title, in which Pollan describes the history of psychedelics as well as first-hand accounts of his psychedelic experiences. This cultural and academic resurgence has brought political change with it as well.

As mentioned, states such as Colorado and Washington have legalized them for medical use and decriminalized their possession. A similar movement is being propelled in Illinois as well. EnthoIL is a non-profit working right now to legalize the medicinal use of psilocybin in Illinois through the ILCURE act. Under this act, certain psychedelics would be decriminalized, while specified “licensed facilitators” would be able to provide psychedelic treatment to patients. This means that the use would be overseen in specialized facilities and patients would not be able to bring the substances home with them. That being said, it begs the question as to who these “licensed facilitators” would be. Will it be confined to psychiatrists? Will psychologists be included? What about therapists?

There are currently psychedelic training programs where after about a year therapists can become a “psychedelic assisted therapy provider”. These programs accept therapists, physicians, counselors, chaplains, and social workers. While this class trains them to oversee ketamine therapy, they are also being advertised as making practitioners “ready for the anticipated approvals of [...] psilocybin.”14 The most likely answer is that a prescription written by a provider would be required, and then “licensed facilitators” would be people of many different backgrounds providing and overseeing the psychedelic experience, however these regulations would be discussed after a bill has passed.

While preliminary data is promising, there is a lack of large population, double-blinded, controlled studies in the psychedelic space. A recent meta-analysis of all psychedelic studies conducted from 1960-2020 found that 93% of studies used a control, and among those that did, 61.2% used an inert control, 20% used active comparators, 15% used both and 3.8% used different psychedelic doses. Furthermore, and more problematically, only 17.3% of the studies used a blind assessment,12 meaning that they did not assess the patients and doctors to see if they knew who was getting which treatment. Why would they leave out this critical piece of information? In my opinion, it is because it is almost impossible to control for a drug like psilocybin. Depending on what people have heard about the psychedelic experience, it may be easy to tell when someone, be it yourself or a patient, is “tripping.”

A recent study looked at what is encompassed by the “psychedelic experience,” and some words used to describe it were: “emotional breakthrough,” “oceanic boundlessness,” “universal interconnectedness,” “mystical experiences,” and “transcendence of time and space.”13 Personally, I am not sure how to blind someone from experiencing a transcendence of time and space, or oceanic boundlessness. How would someone not realize that they must be a part of the control arm of the study if they are not experiencing these effects? The same goes for the practitioner administering the drugs. Herein lies a major problem with the study of psychedelics. Not only is it very difficult to control for, but the placebo effect, in a way, compounds the effects of the psychedelic itself. It is commonly advised that people must pay attention to the “set and the setting” in which they undergo a psychedelic journey. The set means the person’s mindset, and the setting being their environment: the music, the people surrounding them, their visual environment, and more. Science aims to control and regulate all of these to study the chemical itself, but for psychedelics, these factors can be a very important aspect to the healing experience itself.

So, how to go about fixing these issues? To me, it seems that we must use controls in the same way that we go about studying anything that cannot be properly controlled: by comparing the experimental compound to the current best treatment. This was done in 2021 for depression in particular and found that two doses of psilocybin 3 weeks apart were comparable in efficacy to treatment with escitalopram15. Again, however, this study only enrolled 59 patients. That being said, this preliminary study shows promise for a controlled psychedelic experience being, if not better, at least as good as current therapy. And what if we were able to further hone in the dosing, set, setting, and other factors regarding a psychedelic journey? Would this further improve the statistics regarding psychedelic therapy efficacy?

The conclusion of this article is that we simply need to do more research into the efficacy of psychedelic drugs and to answer many more questions before releasing them to the public. We need to study questions like: who is psychedelic therapy best used on? Does it matter if someone has used psychedelics recreationally in the past? How does dosing affect the outcome? Do people need to re-dose after a certain amount of time, or are the effects lifelong? If so, after how long should people be re-dosing? There are also more practical questions that need to be answered: Who will be providing the medication prescriptions? Who will be with the patient during their psychedelic experience? Should there even be anyone with them during the experience? What type of therapy is best suited, before, during, and after the psychedelic experience? What set and setting is the best for psychedelic use? Are the different psychedelic drugs equal in their efficacy? Who will benefit from LSD vs. psilocybin vs. Ketamine vs. Ayahuasca etc.? These are just a few of the multitude of questions that must be answered regarding the nuance of psychedelic treatment - in addition to simply establishing their efficacy and safety.

The main requirement necessary, however, is studies with greater power. We need studies with higher numbers of participants to tease out the more subtle findings, as well as evaluate any possible harmful effects of the drug. The reason that it is so difficult to do this now, is because most psychedelics are schedule I substances, which means their research is heavily regulated and expensive. Descheduling the drugs would allow much more research to be conducted, while not declaring open season and allowing psychedelic treatment to begin with limited oversight. In my opinion, this field is out-driving its headlights, and is moving a little bit too quickly to properly study its effects. But, I do also believe in the capacity of psychedelics to not only provide relief to those struggling, but also help people to get to the root of their problems and begin to work on a solution. To give psychedelics the respect that they deserve, they should be properly studied before their clinical use to avoid a repeat of the 60’s and 70’s. That being said, I support the continued research of psychedelics within psychiatry and think that they could be a great medication to add to psychiatry’s limited toolbox.

References

1 Sloat, S. (2017, July 14). In “stoned ape” theory, Consciousness has roots in psilocybin. Inverse. https://www.inverse.com/article/34186-stoned-ape-hypothesis

2 Wasson, G. (1957, May 13). Seeking the magic mushroom. Life Magazine, 42(19), 100–108.

3 The accidental discovery of LSD (video). American Chemical Society. (2017, April 11). https://www.acs.org/pressroom/newsreleases/2017/april/the-accidental-discovery-of-lsd-video.html

4 Smith, W. R., & Appelbaum, P. S. (2021). Two models of legalization of psychedelic substances. JAMA, 326(8), 697. https://doi.org/10.1001/jama.2021.12481

5 The Beckley Foundation. (2017, February 23). Psychedelic research timeline. Psychedelic Research Timeline. https://www.beckleyfoundation.org/psychedelic-research-timeline-2/

6 Griffiths, R. R., Johnson, M. W., Carducci, M. A., Umbricht, A., Richards, W. A., Richards, B. D., Cosimano, M. P., & Klinedinst, M. A. (2016). Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial. Journal of Psychopharmacology, 30(12), 1181–1197. https://doi.org/10.1177/0269881116675513

7 Carhart-Harris, R. L., Bolstridge, M., Rucker, J., Day, C. M., Erritzoe, D., Kaelen, M., Bloomfield, M., Rickard, J. A., Forbes, B., Feilding, A., Taylor, D., Pilling, S., Curran, V. H., & Nutt, D. J. (2016). Psilocybin with psychological support for treatment-resistant depression: An open-label Feasibility Study. The Lancet Psychiatry, 3(7), 619–627. https://doi.org/10.1016/s2215-0366(16)30065-7

8Watts, R., Day, C., Krzanowski, J., Nutt, D., & Carhart-Harris, R. (2017). Patients’ accounts of increased “connectedness” and “acceptance” after psilocybin for treatment-resistant depression. Journal of Humanistic Psychology, 57(5), 520–564. https://doi.org/10.1177/0022167817709585

9 James Allen Wilcox (2014) Psilocybin and Obsessive Compulsive Disorder, Journal of Psychoactive Drugs, 46:5, 393-395, DOI: 10.1080/02791072.2014.963754

10 Ballenger, J. C. (2008). Safety, tolerability, and efficacy of psilocybin in 9 patients with obsessive-compulsive disorder. Yearbook of Psychiatry and Applied Mental Health, 2008, 242–243. https://doi.org/10.1016/s0084-3970(08)70820-x

11 van der Meer, P. B., Fuentes, J. J., Kaptein, A. A., Schoones, J. W., de Waal, M. M., Goudriaan, A. E., Kramers, K., Schellekens, A., Somers, M., Bossong, M. G., & Batalla, A. (2023). Therapeutic effect of psilocybin in addiction: A systematic review. Frontiers in Psychiatry, 14. https://doi.org/10.3389/fpsyt.2023.1134454

12Nayak, S. M., Bradley, M. K., Kleykamp, B. A., Strain, E. C., Dworkin, R. H., & Johnson, M. W. (2023). Control conditions in randomized trials of psychedelics. The Journal of Clinical Psychiatry, 84(3). https://doi.org/10.4088/jcp.22r14518

13 Ko, K., Knight, G., Rucker, J. J., & Cleare, A. J. (2022). Psychedelics, mystical experience, and therapeutic efficacy: A systematic review. Frontiers in Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.917199

14 Ipi year-long psychedelic-assisted therapy training - psychedelic support. Integrative Psychiatry Institute. (2023, June 1). https://psychiatryinstitute.com/psychedelicsupport-2/

15 Carhart-Harris, R., Giribaldi, B., Watts, R., Baker-Jones, M., Murphy-Beiner, A., Murphy, R., Martell, J., Blemings, A., Erritzoe, D., & Nutt, D. J. (2021). Trial of psilocybin versus escitalopram for depression. New England Journal of Medicine, 384(15), 1402–1411. https://doi.org/10.1056/nejmoa2032994