Takeaway
There’s been growing interest in the therapeutic potential of psychedelics. This requires that healthcare professionals be well informed and prepared to discuss this experimental therapy.
Lifelong Learning in Clinical Excellence | April 13, 2023 | 5 min read
By Natalie Gukasyan, MD, Johns Hopkins Medicine
The last two decades have seen remarkable growth in public and scientific interest in the therapeutic potential of psychedelics. Access to these drugs has also increased in this time through the proliferation of international and underground retreats, as well as through decriminalization and legalization efforts at state and local levels.
In this rapidly changing landscape, clinicians may increasingly be approached by patients with questions about these drugs and their potential risks and benefits. Mental healthcare professionals in particular must be prepared to engage in informed and have nonjudgmental discussions with their patients on this topic. The following isn’t an exhaustive guide but contains general tips that can help frame these conversations.
1. Acknowledge your patient’s willingness to broach the subject and clarify the nature of their interest.
Classic psychedelics and related drugs like 3,4-methylenedioxymethamphetamine (MDMA) are still designated as Schedule I under the Controlled Substances Act. This places them in the same category as bath salts, heroin, and other drugs that are known to have substantial abuse liability and serious adverse effects on health. Possession or sale of these drugs outside of approved research settings is a criminal offense in most parts of the country. Understandably, patients may feel uncomfortable or fearful of asking a clinician about this topic and this may be a particularly sensitive issue for individuals belonging to marginalized groups. Your first duty is to reassure your patients that your office is an appropriate and safe venue to discuss their questions.
Next, clarify the nature of their interest. Media representation of psychedelics over the last several years has been generally quite positive, with many articles, books, and other media touting supposed benefits for health and wellness. Is your patient interested in this because they feel it will help improve their mental health, enhance their performance, facilitate self-inquiry, etc.? This may be an opportunity to discuss whether you and your patient are on the same page about treatment goals. For example, one potential advantage of psychedelic-assisted therapy is that it appears to be associated with long-lasting improvements without the need for ongoing daily medication use. Your patient may be dealing with unwanted side effects from prescribed medications and may be interested in alternative therapies. This may be an opportunity to evaluate the efficacy and tolerability of their existing treatment and determine whether other changes may be helpful.
2. Be prepared to answer questions about the current state of psychedelic-assisted therapy research.
Physicians should be able to offer accurate information about the effects of psychedelics and related drugs. Unfortunately, many clinical training programs have yet to catch up with the quick pace of development in this area. You may need to seek out additional, trusted sources of information to stay informed. This includes knowing the legal status of psychedelics in your area. Free or reasonably priced continuing medical education is available through major professional organizations like the American Psychiatric Association.
3. If your patient is interested in trying psychedelic-assisted therapy:
At the time of this writing, the only clearly legal way to access psychedelic-assisted therapy in the United States is via an approved clinical trial. You or your patient can find a current list of active clinical trials by visiting www.clinicaltrials.gov and searching for the condition or drug of interest. Study screening involves medical and psychiatric evaluation, during which possible risk factors will be assessed. To receive a drug like psilocybin, prospective participants will usually need to be free from any psychotropic medications. Whether medication tapering needs to be done before screening varies by study and is usually indicated on the clinicaltrials.gov information page. If you’re concerned that your patient may not be able to tolerate several weeks or months without being on their psychiatric medication, this is worth discussing with them. Also note that some trials have a placebo-controlled design with no crossover condition, which means that a significant portion of participants may receive a placebo rather than active study drug. Be sure that your patient understands the study design and its implications.
Local efforts to decriminalize and legalize psychedelics are rapidly progressing and are likely to expand in the coming years in a pattern like that seen with cannabis. It’s important to clarify for patients that at the time of this writing, Phase III studies are still underway, and that there isn’t yet adequate evidence to recommend the use of psychedelics for any indication. Further, efficacy and safety in existing research has been achieved with thorough screening and robust preparation/aftercare with qualified therapists. Simply taking a psychedelic on its own does not ensure a positive outcome and may carry additional risk. “Underground” treatment, like therapeutic use of a psychedelic drug with a provider outside of a legal and regulated setting, also carries risks including the potential for exploitation or abuse.
4. Discuss risks in a tailored way.
As a harm reduction measure, patients should be informed of potential risks of use. Since psychedelics are generally unregulated in the U.S., it’s possible that substances obtained outside of clinical trial settings may be misidentified or adulterated with other drugs.
Psychedelic use also comes with potential psychiatric and medical risks. There is a potential for “challenging” or psychologically difficult experiences, some of which may be associated with acute or enduring negative effects. Most modern clinical research with psychedelics has excluded patients with bipolar and schizophrenia spectrum disorders. If your patient has a personal history or a first degree relative with such disorders, they should be strongly cautioned about the risk of precipitating mania or psychosis. There’s also a general risk that a mental health condition may worsen. Other contraindications include seizure disorders, uncontrolled hypertension, or other cardiovascular conditions. Review your patient’s medications and determine whether any hard contraindications exist, e.g., lithium, which carries a high risk of precipitating seizures when combined with classic psychedelics. A recent review on drug interactions with psychedelics contains additional details. Other potentially enduring negative effects such as hallucinogen persisting perceptual disorder (HPPD) should also be noted.
In conclusion, the growing interest in the therapeutic potential of psychedelics, along with increased accessibility through legal and underground channels, necessitates that healthcare providers are well informed and prepared to address patients’ questions and concerns. By acknowledging the patient’s willingness to discuss the topic, providing accurate information on research and risks, and adopting a harm reduction approach, clinicians can help their patients make informed decisions about the use of psychedelics. As the field continues to evolve, it’s essential for healthcare professionals to stay up to date on research and legal developments and be prepared to have open and nonjudgmental conversations about the potential benefits and risks associated with these substances.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.