Legalization of Psychedelic Substances

Novel ethical and policy issues in psychiatric uses of psychedelic substances

Classic psychedelics and related substances have shown promising initial research results. However, they raise a number of relatively novel ethical and policy challenges in light of their psychoactive properties, their emergence from the unregulated "underground" settings in which they have been used, their rapid commercialization, and the means and speed with which they are moving from a Schedule 1 drug to legalized use. All of these issues are affected by the current limits to the evidence base on use of psychedelics. Here we survey these novel challenges, illustrating the issues raised regarding each, and offering suggestions for how to address them. Emerging findings on psychedelic therapies suggest promise in treating psychiatric disorders, including major depressive disorder with psilocybin (Carhart-Harris et al., 2021; Compass pathways, 2021; Davis et al., 2021) and post-traumatic stress disorder (PTSD) with 3,4-methylenedioxymethamphetamine (MDMA) (Mitchell et al., 2021). Additional research is underway on other conditions (Reiff et al., 2020). At this early stage in the research process, the published evidence supporting psychedelic use is limited by relatively small sample sizes (as compared to Phase 3 trials for conventional anti-depressants), highly selected and perhaps atypical participants, and the need for replication (Smith and Appelbaum, 2021b). Nevertheless, the promise of these findings and the emerging efforts at legalization and/or decriminalization in several parts of the country, utilizing a diversity of mechanisms, raise important ethical and policy questions that have received little systematic exploration. To help address this deficit, this commentary surveys four domains in which ethical and policy questions arise. We focus chiefly on psilocybin, the most promising of the psychedelics now being investigated, though our conclusions may generalize to other classic psychedelics or related agents, like MDMA. Of note, we focus here on questions that are relatively novel or particularly important for psychedelics. Many other ethical issues regarding psychedelics in both research and clinical contexts will be similar to those for other treatment modalities. As with other modalities, when used in clinical practice there will be ethical challenges regarding patient confidentiality, informed consent, balancing the risks and benefits of treatment, and provision of equitable access. Clinical research on psychedelic compounds is not unusual in raising concerns about the adequacy of understanding of randomization and possibility of allocation to the control arm of the trial, therapeutic misconception, and exclusion or exploitation of marginalized or otherwise disadvantaged groups (Emanuel et al., 2000). Regarding disadvantaged groups, like many other areas of medical research, early psychedelic research had a significant history of exploitation of vulnerable populations including imprisoned persons and people of color (Strauss et al., 2021). Although we acknowledge the importance of issues that are very similar to those for other treatment modalities, we do not discuss them in detail.

Disruptive innovation in psychiatry

Disruptive innovation is a cornerstone of various disciplines, particularly in the business world, where paradigm‐altering approaches are often lauded. As a construct, disruptive psychiatry can be considered to embody such an approach by the pursuit of innovations within the field which test boundaries and shake up the status quo. Given the importance of addressing the current mental health pandemic, and the deficit of highly effective pharmacological treatments for various conditions, innovative disruptive thinking is required. Significant promise exists via the provision of potentially more effective innovative therapeutic options, including digital interventions, psychedelic medicines, microbiome‐altering treatments, brain stimulation technology, and nanotechnology‐based delivery systems. These approaches may be further advanced by individualization of the treatments using computational technology (including quantum computing, machine learning, and artificial intelligence) and genomics.