January 22, 2024

After more than two decades as a practicing psychiatrist, I’ll be the first to admit that we need new and innovative treatments to treat depression, anxiety, and other psychiatric disorders. Psychedelics like LSD, psilocybin, and MDMA (Ecstasy) are being researched and promoted as ground-breaking advances for combatting mental illness. Multiple jurisdictions have already relaxed laws or policies related to these substances, often with an eye toward therapeutic use.

But the evidence to support the therapeutic use of psychedelics is not yet robust enough to justify liberalized access, especially for unsupervised use. Even more concerning, I see eerie similarities between the promotion of medicinal psychedelics today and medicinal opioids beginning in the 1990s, based on unsubstantiated claims of high benefit and low risk. Full disclosure, I have been retained as a medical expert witness in opioid litigation against Purdue Pharma and others.

The unsubstantiated claims about opioids are the following: (1) Opioids are the safest and best treatment for chronic pain; (2) opioids are the answer to our epidemic of pain; (3) opioids are ‘rarely’ addictive when prescribed by a doctor for a patient with pain.

In fact, the evidence shows that opioids are no better than Tylenol in the treatment of chronic pain and incur more medication-related adverse events. The increase in opioid prescribing did not decrease the population pain burden and was instead a major contributor to today’s opioid epidemic of addiction and overdose death. Far from being ‘rare,’ getting addicted to opioids through a doctor’s prescription is tragically common.

Almost identical false claims used to promote opioids are now being used to promote psychedelics.

The first unsubstantiated claim about psychedelics is that they are safe and effective treatment for a variety of mental health disorders. Bottom line, we do not yet have sufficient evidence that psychedelics are safe and effective treatment for any mental health condition. Limitations in the studies of medicinal psychedelics to date -- many studies are funded by the psychedelic industry and/or authored by individuals with close ties to the industry, studies are too short to assess efficacy for chronic mental health conditions, studies lack robust control groups, and studies are plagued by systematic underreporting of adverse events -- mean they’re not yet ready for prime time. The absence of reliable data on psychedelics highlights the need to loosen restrictions on Schedule I drugs so that it is easier to conduct this much needed, unbiased research.

Just to highlight the egregious lack of data on harms, and the way that spurious datapoints are used to promote a false sense of safety, note that this oft-cited paper which gives the “lowest overall harm scores” to “mushrooms” as compared with 19 other drugs, is based not on data but on ‘expert consensus,’ with some of those experts having a vested interest in the psychedelic industry. This so-called study further fails to take into account the prevalence of drug use in the population. When access to psychedelics was low, evidence of harm was correspondingly less. We just published data showing that with increased access to psychedelics in the state of California between 2016 and 2022, observed hallucinogen-associated ED visits increased by 54% between 2016 and 2022, (from 2,260 visits to 3,476 visits), compared to a 20% decrease in alcohol-associated ED visits and a 15% increase in cannabis-associated ED visits. The observed hallucinogen-associated hospitalizations increased by 55% over the same period, (from 2,556 to 3,965 hospitalizations), compared to a 1% increase in alcohol-associated hospitalizations and a 1% increase in cannabis-associated hospitalizations. This rise in hallucinogenic ED visits was significantly different from the trend in cannabis-associated (p < 0.001) and alcohol-associated (p = 0.005) ED visits. The hallucinogen associated hospitalizations trend also significantly differed when compared to cannabis (p < 0.001) and alcohol (p < 0.001) associated hospitalizations.

The second unsubstantiated claim about psychedelics is that they are the answer to our current mental health crisis. As for whether psychedelics can ameliorate our current mental health crisis, to date the evidence does not show a decrease in mental health burden as psychedelics becomes more prevalent in the community. Of course, it may be too soon to tell, but as above, data are already showing increased harms.

The third unsubstantiated claim about psychedelics is that they are rarely addictive when administered by a doctor for a patient with a mental illness. As with any mind-altering drug, psychedelics have the potential to be addictive. They are often falsely touted as non-addictive because of their rapid tolerance and limited physical withdrawal. But it is not tolerance or withdrawal that defines addiction. The hallmark of addiction is mental preoccupation with the drug and repeated use despite harms. Further, some psychedelics, like MDMA, have a clear withdrawal or comedown  (see ‘blue Mondays’).

To prevent history repeating itself, let’s press the pause button on loosening access to unproven drugs until we have more information about the risks, benefits, and alternatives, not just at the individual level, but also at the level of public health.