Ethical and legal issues in psychedelic harm reduction and integration therapy

Developing the Open Psychedelic Evaluation Nexus consensus measures for assessment of supervised psilocybin services: An e-Delphi study

BACKGROUND

Voter initiatives in Oregon and Colorado authorize legal frameworks for supervised psilocybin services, but no measures monitor safety or outcomes.

AIMS

To develop core measures of best practices.

METHODS

A three-phase e-Delphi process recruited 36 experts with 5 or more years' experience facilitating psilocybin experiences in various contexts (e.g., ceremonial settings, indigenous practices, clinical trials), or other pertinent psilocybin expertise. Phase I, an on-line survey with qualitative, open-ended text responses, generated potential measures to assess processes, outcomes, and structure reflecting high quality psilocybin services. In Phase II, experts used seven-point Likert scales to rate the importance and feasibility of the Phase I measures. Measures were priority ranked. Qualitative interviews and analysis in Phase III refined top-rated measures.

RESULTS

Experts (n = 36; 53% female; 71% white; 56% heterosexual) reported currently providing psilocybin services (64%) for a mean of 15.2 [SD 13.1] years, experience with indigenous psychedelic practices (67%), and/or conducting clinical trials (36%). Thematic analysis of Phase I responses yielded 55 candidate process measures (e.g., preparatory hours with client, total dose of psilocybin administered, documentation of touch/sexual boundaries), outcome measures (e.g., adverse events, well-being, anxiety/depression symptoms), and structure measures (e.g., facilitator training in trauma informed care, referral capacity for medical/psychiatric issues). In Phase II and III, experts prioritized a core set of 11 process, 11 outcome, and 17 structure measures that balanced importance and feasibility.

CONCLUSION

Service providers and policy makers should consider standardizing core measures developed in this study to monitor the safety, quality, and outcomes of community-based psilocybin services.

The effects of psilocybin on cognition and emotional processing in healthy adults and adults with depression: a systematic literature review

INTRODUCTION

Psilocybin, a naturally occurring serotonergic agonist in some mushroom species, has shown promise as a novel, fast-acting pharmacotherapy seeking to overcome the limitations of conventional first-line antidepressants. Studying psilocybin effects on cognition and emotional processing may help to clarify the mechanisms underlying the therapeutic potential of psilocybin and may also support studies with people suffering from depression. Thus, this review aims to provide a comprehensive overview of the current literature regarding the effects of psilocybin on these two key areas in both healthy and depressed populations.

METHOD

A systematic search was performed on 29 January 2024, in the PubMed, EBSCOhost, Web of Science and SCOPUS databases. After duplicates removal, study selection was conducted considering pre-specified criteria. Data extraction was then performed. The quality assessment of the studies was carried out using the Cochrane Collaboration tools for randomized (RoB 2.0) and non-randomized (ROBINS-I) controlled trials.

RESULTS

Twenty articles were included, with 18 targeting healthy adults and two adults with depression. Results point to impairments within attentional and inhibitory processes, and improvements in the domains of creativity and social cognition in healthy individuals. In the population with depression, only cognitive flexibility and emotional recognition were affected, both being enhanced. The comparison of outcomes from both populations proved limited.

CONCLUSIONS

Psilocybin acutely alters several cognitive domains, with a localized rather than global focus, in a dose- and time-dependent manner. However, the significant methodological constraints call for further research, in the context of depression and with standardized protocols, with longitudinal studies also imperative.

The entactogen 3,4-methylenedioxymethamphetamine (MDMA; ecstasy) as a treatment aid in psychotherapy and its safety concerns

The phenylethylamine, 3,4-methylenedioxymethamphetamine (MDMA, 'ecstasy'), is the prototypical example of an entactogen. Its original placement in highly restrictive drug usage categories in the US and UK, led to an inevitable restriction on MDMA neuroscience research and treatment. The dominant pharmacological effects of MDMA are its properties of release and inhibition of reuptake of amine neurotransmitter transporters for dopamine, norepinephrine, and serotonin. MDMA is an agonist of a wide range of receptors; its mood-altering effects are mediated via 5-HT2A receptors; this receptor may also mediate its effects on body temperature, analgesia, and anxiolytic properties. The mechanisms underlying MDMA's entactogenic properties of sociability and interpersonal closeness are not known but release and involvement of oxytocin, a peptide thought by some to be involved in social bonding, has been suggested. Adverse effects of MDMA are mostly transient; acute multiorgan adverse effects occurring during raves or crowded dance gatherings include dehydration, hyperthermia, seizures, rhabdomyolysis, disseminated intravascular coagulation, and acute renal failure. Deaths following MDMA taken by itself are rare compared to fatalities following coadministration with other drugs. A recent FDA-approved phase 3 clinical trial of MDMA for post-traumatic stress disorder (PTSD) led to the conclusion that MDMA-assisted therapy represents a potential breakthrough treatment meriting expedited clinical evaluation. Despite the ongoing deliberations by the FDA and EMA for approval of MDMA treatment of PTSD, the Australian Therapeutic Goods Administration (TGA) recently announced that after an evaluation of the therapeutic value, benefits, and risks of MDMA, it will permit its prescribing for the treatment of PTSD. Further examples of regulatory relaxation toward MDMA-assisted psychotherapy are underway. These include the FDA's recently approved clinical trial to assess MDMA's efficacy in the treatment of "asociality" in patients with schizophrenia and an open trial of MDMA treatment for alcohol-use disorder which showed decreased alcohol consumption. There are also ongoing studies on the little understood startle response, anxiety associated with life-threatening illness, and social anxiety in autistic adults.

Measuring psychotherapeutic processes in the context of psychedelic experiences: Validation of the General Change Mechanisms Questionnaire (GCMQ)

BACKGROUND

Therapeutic and salutogenic effects of psychedelic drugs have been attributed to psychotherapeutic or psychotherapy-like processes that can unfold during the acute psychedelic experience and beyond. Currently, there are no psychometric instruments available to comprehensively assess psychotherapeutic processes (as conceptualized by empirical psychotherapy research) in the context of psychedelic experiences.

AIMS

We report the initial validation of the General Change Mechanisms Questionnaire (GCMQ), a self-report instrument designed to measure five empirically established general change mechanisms (GCMs) of psychotherapy-(1) resource activation, (2) therapeutic relationship, (3) problem actuation, (4) clarification, and (5) mastery-in the context of psychedelic experiences.

METHODS

An online survey in a sample of 1153 English-speaking and 714 German-speaking psychedelic users was conducted to evaluate simultaneously developed English- and German-language versions of the GCMQ.

RESULTS

The theory-based factor structure was confirmed. The five GCMQ scales showed good internal consistency. Evidence for convergent validity with external measures was obtained. Significant associations with different settings and with therapeutic, hedonic, and escapist use motives confirmed the hypothesized context dependence of GCM-related psychedelic experiences. Indicating potential therapeutic effects, the association between cumulative stressful life events and well-being was significantly moderated by resource activation, clarification, and mastery. Factor mixture modeling revealed five distinct profiles of GCM-related psychedelic experiences.

CONCLUSION

Initial testing indicates that the GCMQ is a valid and reliable instrument that can be used in future clinical and nonclinical psychedelic research. The five identified profiles of GCM-related experiences may be relevant to clinical uses of psychedelics and psychedelic harm reduction.

Review of Psilocybin Use for Depression among Cancer Patients after Approval in Oregon

Despite the legalization of psilocybin therapy for depression in terminal illnesses such as advanced cancer through Oregon's Measure 109 in 2020, significant challenges have impeded its implementation. This review synthesizes the empirical data supporting the utilization of psilocybin therapy for addressing cancer-related depression, including an evaluation of its purported benefits and potential adverse effects. It provides a comprehensive examination of therapeutic strategies, dosing regimens, and barriers to ensuring responsible and equitable access. Salient issues explored include the development of ethical protocols, integration within healthcare systems, ensuring statewide availability, resolving legal ambiguities, and defining clinical standards. Oregon's pioneering role serves as a case study, highlighting the necessity of addressing regulatory, logistical, and ethical obstacles to ensure the establishment of rigorous and equitable psilocybin care models.

Multimodal Neuroimaging of the Effect of Serotonergic Psychedelics on the Brain

The neurobiological mechanisms underpinning psychiatric disorders such as treatment-resistant major depression, post-traumatic stress disorder, and substance use disorders, remain unknown. Psychedelic compounds, such as psilocybin, lysergic acid diethylamide, and N,N-dimethyltryptamine, have emerged as potential therapies for these disorders because of their hypothesized ability to induce neuroplastic effects and alter functional networks in the brain. Yet, the mechanisms underpinning the neurobiological treatment response remain obscure. Quantitative neuroimaging is uniquely positioned to provide insight into the neurobiological mechanisms of these emerging therapies and quantify the patient treatment response. This review aims to synthesize our current state-of-the-art understanding of the functional changes occurring in the brain following psilocybin, lysergic acid diethylamide, or N,N-dimethyltryptamine administration in human participants with fMRI and PET. We further aim to disseminate our understanding of psychedelic compounds as they relate to neuroimaging with the goal of improved diagnostics and treatment of neuropsychiatric illness.

When the Trial Ends: The Case for Post-Trial Provisions in Clinical Psychedelic Research

The ethical value-and to some scholars, necessity-of providing trial patients with post-trial access (PTA) to an investigational drug has been subject to significant attention in the field of research ethics. Although no consensus has emerged, it seems clear that, in some trial contexts, various factors make PTA particularly appropriate. We outline the atypical aspects of psychedelic clinical trials that support the case for introducing the provision of PTA within research in this field, including the broader legal status of psychedelics, the nature of the researcher-therapist/participant relationship, and the extended time-frame of the full therapeutic process. As is increasingly understood, the efficacy of psychedelic-assisted psychotherapy is driven as much by extrapharmacological elements and the cultural therapeutic container as by the drug itself. As such, we also advocate for a refocusing of attention from post-trial access to a broader concept encompassing other elements of post-trial care. We provide an overview of some of the potential post-trial care provisions that may be appropriate in psychedelic clinical trials. Although the World Medical Association's Declaration of Helsinki calls on researchers, sponsors, and governments to make provisions for post-trial access, such provision may feel impracticable or out-of-reach within psychedelic trials that are already constrained by a high resource demand and significant bureaucratic burden. We show how conceiving of post-trial provision as an integral site of the research process, and an appropriate destination for research funding, will serve to develop the infrastructure necessary for the post-legalisation psychedelic medicine ecosystem.

Three Decades of Research on the Development of Ibogaine Treatment of Substance Use Disorders: A Scientometric Analysis

Ibogaine is a natural psychoactive drug that has been investigated for its potential role in the treatment of substance use disorders since the mid-1960s. To evaluate the interest in ibogaine's use as a therapeutic agent, we performed a scientometric analysis covering the last three decades (1993-2002, 2003-2012, and 2013-2022). A complementary analysis was performed to select and describe published clinical trials and meta-analyses. A total of 1523 references were found. Linear growth of publications in the first and third decades were identified, and the average number of publications from 1993 to 2002 was lower than that in the other two decades. Researchers from five continents were identified. Globally, academic research centers in the United States and Canada were the most productive. Cocaine, tobacco, morphine, and alcohol prevailed as major keywords in the first two decades and opioids and psychedelics were included in the third decade. A few key authors were the most co-referenced. One preclinical meta-analysis and no meta-analysis in humans were found. Research trends for ibogaine are widespread, growing, and consonant with current attentiveness in drug abuse. Our findings support the pressing need for rigorous clinical research on ibogaine to evaluate its efficacy and safety.

Psychologists' and psychotherapists' knowledge, attitudes, and clinical practices regarding the therapeutic use of psychedelics

INTRODUCTION

This study explored the current knowledge, attitudes, and clinical practices regarding psychedelics among mental health professionals in California, where state legislation to decriminalize psychedelics has been proposed.

METHOD

Two hundred thirty-seven mental health providers (74% female; mean age 54; 83% White; 46% psychologists) completed a 37-item online survey between November 2021 and February 2022, disseminated through local and state-wide professional organizations in California.

RESULTS

Providers endorsed limited knowledge about the risks and benefits of psychedelic use (M = 4.7 and 5.4, respectively, with 10 = high knowledge) and inadequate knowledge to counsel patients on use (45%). Gaps in knowledge related to psychedelic drug scheduling and current use in clinical research were identified. Providers expressed support for additional psychedelic research (97%), approval of recreational (66%) and medical (91%) psychedelic use, belief in the potential therapeutic benefits of psychedelics (89%), and concerns about safety (33%) and potential psychiatric risks (27%). Results indicated that most providers discuss psychedelic use with patients (73%), yet many do not feel comfortable addressing the effects of use (49%). There were significant correlations between knowledge and attitudes towards psychedelics (r = 0.2, p = .006; r = 0.31, p < .001) and attitudes and clinical practices (r = 0.34, p < .001).

CONCLUSIONS

Findings suggest that providers are interested in psychedelic-assisted treatments and hold favourable attitudes towards the therapeutic use of psychedelics yet lack the knowledge to appropriately counsel patients, highlighting the need for additional provider education about psychedelics.

Back from the rabbit hole. Theoretical considerations and practical guidelines on psychedelic integration for mental health specialists

The growing interest in and prevalence of the use of psychedelics, as well as the potential benefits and negative consequences associated with psychedelic experiences, create a need for mental health specialists to be able to provide adequate and effective intervention regarding the content and consequences of these experiences, that is, psychedelic integration. At the same time, current graduate training in psychiatry, psychology, psychotherapy, counseling, etc., fails to adequately prepare professionals for such interventions. In order to fill this gap, an international, bottom-up project was established to attempt developing guidelines. This project was conducted by means of literature reviews as well as roundtable discussions among project participants, leading to a consensus on the guidelines' final scope and content. Drawing from the outcomes of this project, this article presents proposed comprehensive guidelines covering both theoretical and practical aspects of psychedelic integration, that are intended to serve as a resource for various mental health specialists who may encounter individuals in need of support considering their psychedelic experiences. These guidelines encompass clinician-friendly information on the effects of psychedelics, a definition of psychedelic integration, the general theoretical considerations linked to utilization of psychedelic experiences in clinical practice, a simple model organizing the course of psychedelic integration practice, as well as an overview of the current models of psychedelic integration, along with a selective presentation of basic and specific interventions derived from various psychotherapeutic approaches that can be employed in the practice of psychedelic integration.

Case analysis of long-term negative psychological responses to psychedelics

Recent controversies have arisen regarding claims of uncritical positive regard and hype surrounding psychedelic drugs and their therapeutic potential. Criticisms have included that study designs and reporting styles bias positive over negative outcomes. The present study was motivated by a desire to address this alleged bias by intentionally focusing exclusively on negative outcomes, defined as self-perceived 'negative' psychological responses lasting for at least 72 h after psychedelic use. A strong justification for this selective focus was that it might improve our ability to capture otherwise missed cases of negative response, enabling us to validate their existence and better examine their nature, as well as possible causes, which could inspire risk-mitigation strategies. Via advertisements posted on social media, individuals were recruited who reported experiencing negative psychological responses to psychedelics (defined as classic psychedelics plus MDMA) lasting for greater than 72 h since using. Volunteers were directed to an online questionnaire requiring quantitative and qualitative input. A key second phase of this study involved reviewing all of the submitted cases, identifying the most severe-e.g., where new psychiatric diagnoses were made or pre-existing symptoms made worse post psychedelic-use-and inviting these individuals to participate in a semi-structured interview with two members of our research team, during which participant experiences and backgrounds were examined in greater depth. Based on the content of these interviews, a brief summary of each case was compiled, and an explorative thematic analysis was used to identify salient and consistent themes and infer common causes. 32 individuals fully completed an onboarding questionnaire (56% male, 53% < age 25); 37.5% of completers had a psychiatric diagnosis that emerged after their psychedelic experience, and anxiety symptoms arose or worsened in 87%. Twenty of the seemingly severer cases were invited to be interviewed; of these, 15 accepted an in-depth interview that lasted on average 60 min. This sample was 40% male, mean age = 31 ± 7. Five of the 15 (i.e., 33%) reported receiving new psychiatric diagnoses after psychedelic-use and all fifteen reported the occurrence or worsening of psychiatric symptoms post use, with a predominance of anxiety symptoms (93%). Distilling the content of the interviews suggested the following potential causal factors: unsafe or complex environments during or surrounding the experience, unpleasant acute experiences (classic psychedelics), prior psychological vulnerabilities, high- or unknown drug quantities and young age. The current exploratory findings corroborate the reality of mental health iatrogenesis via psychedelic-use but due to design limitations and sample size, cannot be used to infer on its prevalence. Based on interview reports, we can infer a common, albeit multifaceted, causal mechanism, namely the combining of a pro-plasticity drug-that was often 'over-dosed'-with adverse contextual conditions and/or special psychological vulnerability-either by young age or significant psychiatric history. Results should be interpreted with caution due to the small sample size and selective sample and study focus.

Predictors of Psychedelic Experience: A Thematic Analysis

Research on the therapeutic potential of psychedelic substances is expanding. A limitation within this field is the unpredictability of individual responses to psychedelics. Better understanding of factors predicting psychedelic experience is essential to clinical progress and wider harm reduction frameworks. Ketamine, MDMA, LSD and psilocybin were selected for comparison due to their promising therapeutic effects and different mechanisms of action. This study aimed to (a) identify factors that produce positive and adverse psychedelic experience, and (b) compare these potential predictors across four psychedelic substances. A thematic analysis was conducted on twenty-two first-person reports of psychedelic use (six per substance), sourced from the Erowid database. This revealed three external predictors (nature, music, and preparation) and three internal predictors (understanding, mind-set, and motivation). Each factor identified contained two sub-themes that further elucidated meaning and impact. Nature and music emerged as potential tools for de-escalating adverse reactions to psychedelics. Substance-specific perceptual and sensorial effects were also examined. Finally, the importance of, and interrelationship between, preparation, mind-set, understanding, and motivation was examined as common themes that emerged. The broader clinical and sociological implications are discussed, with reference to developing harm reduction frameworks. These findings constitute an early step in developing a more nuanced understanding of factors shaping psychedelic experience.

Naturalistic Psychedelic Use: A World Apart from Clinical Care

Interest in and availability of psychedelics for therapeutic purposes has increased in recent decades. In a large, anonymous, online survey, we investigated patterns of communication with healthcare providers and awareness and utilization of substance testing kits or services among people using psychedelics naturalistically. The sample population included attendees of a psychedelic activism event and users of psychedelic social media forums. Among 1,435 participants, 72.5% never discussed psychedelic use with their primary care provider (PCP). Only 4.4% reported using psychedelics with a therapist and 3% in clinical settings, although 77.8% were very or extremely likely to take psychedelics with a therapist if one were legally available. While 62.6% of participants were aware of substance testing services, 42.6% of these indicated never using them. Regression analyses identified several variables associated with disclosure to PCP and utilization of substance testing services including age, gender, frequency and number of psychedelics used, and likelihood of consuming psychedelics under the guidance of a therapist if one were legally available. Further research is necessary to investigate these findings among other groups. Our findings suggest that relevant training and education for healthcare providers is needed, along with more visible options for substance identity testing.

Predictors of Pharmacy Students' Attitudes About the Therapeutic Use of Psilocybin

Background Psilocybin has been studied for its potential therapeutic benefits, particularly for the treatment of psychiatric disorders such as anxiety, depression, and obsessive-compulsive disorder. While more research is needed as psilocybin-assisted therapy becomes more prevalent, future pharmacists will probably be involved at some level. At present, pharmacists receive minimal training on psilocybin, and little is known about their attitudes toward its use for medical purposes. Findings from recent clinical studies have attempted to establish the safety and medical efficacy of psilocybin, leading to an increased interest in therapeutic psilocybin use in the United States. This study aimed to assess if self-assessed knowledge of psilocybin, concerns about adverse effects, and opinions about legalization will make statistically significant contributions to pharmacy students' attitudes about psilocybin use in practice. Methods Pharmacy students' self-assessed knowledge, concern for potential adverse effects, and perceptions of psilocybin were investigated using a cross-sectional survey study design. Data were collected from March 13 to April 7, 2023, from a convenience sample of 161 pharmacy students enrolled in an accredited pharmacy school in the southern region of the United States using a 41-item anonymous quantitative survey developed by the researchers that contained validated scales. The survey was delivered electronically. Multiple regression modeling was conducted to determine if self-assessed knowledge, concerns for adverse effects, and opinions about legalization would predict pharmacy students' attitudes about therapy-assisted psilocybin use. This study was approved by the Institutional Review Board of the authors' university. Results The mean age of the 161 participants was 24 years (SD = 2.981; range 20-40 years). Twenty (12.4%) participants reported previous use of psilocybin for recreational purposes and two (1.2%) reported having used it therapeutically. Many (n =121; 75.2%) of the participants believed that psilocybin should be decriminalized for therapeutic use, but only 54 (33.5%) thought it should be decriminalized for recreational use. A multiple linear regression model predicting "attitudes about psilocybin" (dependent variable) produced significant results: (F(4, 122) = 40.575, p < 0.001), with an R2 = 0.571 (adjusted R2 = 0.557). Greater "self-assessed knowledge about psilocybin," less "concern about possible negative effects," greater "belief in the decriminalization of psilocybin for recreational use," and greater "belief in the decriminalization of psilocybin for therapeutic use" (all independent variables) were associated with more positive perceptions about medical psilocybin. The percentage of variance in the scores accounted for by the model was 57%. Conclusions Pharmacy students may lack information and training regarding psilocybin and report a desire to learn more about it. Their attitudes about medical psilocybin may be driven by this desire to learn in addition to concerns about adverse effects and legalization issues. Due to the dearth of published information regarding the knowledge and acceptance of psilocybin as a viable treatment option for patients, further research in psychedelic-assisted treatments may be warranted.

Ethical and Practical Considerations for the Use of Psychedelics in Psychiatry

In recent years, psychedelic-assisted psychotherapies have reentered the realm of rigorous scientific inquiry, garnering much attention from both the psychiatric community and the broader public. Headlines on major media platforms frequently tout the psychedelic future of psychiatry, and patients increasingly ask about the prospect of using psychedelics during their sessions. Despite this enthusiasm, psychedelics remain in an investigational stage, and more research and regulatory work are required before psychedelics can be deemed appropriate for general clinical use. In this climate, psychiatrists are increasingly curious about the prospects of psychedelic treatments. This review's goal was to help psychiatrists better understand the complexities of the burgeoning field of psychedelic-assisted psychotherapy. The discussion encompasses issues surrounding psychedelics in their current investigational stage and issues for psychiatrists to consider should psychedelics become available for broad clinical use. This review discusses research equipoise in the context of the current enthusiasm for psychedelics, informed consent, patient vulnerability, equity and access, differences between clinical and nonclinical psychedelic uses, and psychedelic self-enhancement. As psychedelics move closer toward regulatory approval beyond research settings, it is vital that these promising treatments be used ethically. The unique features of psychedelic therapies, including the altered states of consciousness they produce and the vulnerability that such states entail for patients, require careful consideration to minimize potential ethical pitfalls. This review seeks to ensure that psychiatrists are equipped to use psychedelic psychotherapy both ethically and effectively.

Pattern breaking: a complex systems approach to psychedelic medicine

Recent research has demonstrated the potential of psychedelic therapy for mental health care. However, the psychological experience underlying its therapeutic effects remains poorly understood. This paper proposes a framework that suggests psychedelics act as destabilizers, both psychologically and neurophysiologically. Drawing on the 'entropic brain' hypothesis and the 'RElaxed Beliefs Under pSychedelics' model, this paper focuses on the richness of psychological experience. Through a complex systems theory perspective, we suggest that psychedelics destabilize fixed points or attractors, breaking reinforced patterns of thinking and behaving. Our approach explains how psychedelic-induced increases in brain entropy destabilize neurophysiological set points and lead to new conceptualizations of psychedelic psychotherapy. These insights have important implications for risk mitigation and treatment optimization in psychedelic medicine, both during the peak psychedelic experience and during the subacute period of potential recovery.

ARC: a framework for access, reciprocity and conduct in psychedelic therapies

The field of psychedelic assisted therapy (PAT) is growing at an unprecedented pace. The immense pressures this places on those working in this burgeoning field have already begun to raise important questions about risk and responsibility. It is imperative that the development of an ethical and equitable infrastructure for psychedelic care is prioritized to support this rapid expansion of PAT in research and clinical settings. Here we present Access, Reciprocity and Conduct (ARC); a framework for a culturally informed ethical infrastructure for ARC in psychedelic therapies. These three parallel yet interdependent pillars of ARC provide the bedrock for a sustainable psychedelic infrastructure which prioritized equal access to PAT for those in need of mental health treatment (Access), promotes the safety of those delivering and receiving PAT in clinical contexts (Conduct), and respects the traditional and spiritual uses of psychedelic medicines which often precede their clinical use (Reciprocity). In the development of ARC, we are taking a novel dual-phase co-design approach. The first phase involves co-development of an ethics statement for each arm with stakeholders from research, industry, therapy, community, and indigenous settings. A second phase will further disseminate the statements for collaborative review to a wider audience from these different stakeholder communities within the psychedelic therapy field to invite feedback and further refinement. By presenting ARC at this early stage, we hope to draw upon the collective wisdom of the wider psychedelic community and inspire the open dialogue and collaboration upon which the process of co-design depends. We aim to offer a framework through which psychedelic researchers, therapists and other stakeholders, may begin tackling the complex ethical questions arising within their own organizations and individual practice of PAT.

Psilocybin in Palliative Care: An Update

Purpose of Review

This review article summarizes clinically and socially relevant developments over the past five years in the therapeutic use of the classical tryptamine psychedelic substance psilocybin, with respect to the common challenges faced by palliative care patients and their care teams. Psilocybin is available in whole fungal and isolated forms but is not yet approved for therapeutic use in the United States. Using targeted database and gray literature searches, and author recall, key sources were identified, reviewed, and synthesized as to the safety and efficacy of psilocybin in palliative care.

Recent Findings

Life-threatening or life-limiting illnesses and faced by palliative care patients are comorbid with emotional and spiritual distress. Research and field reports reviewed suggest that psilocybin has significant and in some cases, sustained anxiolytic, antidepressant, anti-inflammatory and entheogenic effects with a favorable safety profile. Limitations of the research include the risk for selection bias toward healthy, white, financially privileged individuals, and in general, follow-up timelines too short to appropriately evaluate durability of outcomes in psychospiritual benefits and quality of life.

Summary

While more research is needed for palliative care populations specifically, reasonable inferences can be made regarding the potential for benefit to palliative care patients from psilocybin's demonstrated anxiolytic, antidepressant, anti-inflammatory and entheogenic effects. However, major legal, ethical and financial barriers to access exist for the general population; obstacles which are likely worsened for geriatric and palliative care patients. Empiric treatment and large-scale controlled trials of psilocybin should be conducted to further investigate the findings of the smaller studies reviewed here across a variety of populations, for a greater understanding of therapeutic benefit and clinically relevant safety criteria, and to support thoughtful legalization and medical access.

The need for establishing best practices and gold standards in psychedelic medicine

Psychedelic substances are under investigation in several drug development programs. Controlled clinical trials are providing evidence for safe and effective use of psychedelic therapies for treating mental health conditions. With the anticipated FDA approval of MDMA-assisted therapy for posttraumatic stress disorder in 2023 and psilocybin therapy for depression disorders soon after, now is the time for the medical community to become informed on best practices and to actively participate in developing standards of care for these new treatments. Given the emergence of numerous drug sponsors and other companies developing therapeutic modalities for combination with psychedelic medications, it is essential that the medical professional field is at the forefront of communicating unbiased information related to safety and effectiveness. Gold standards have long been a part of medicine and serve to distinguish treatments and assessments as the highest quality by which all others can be compared to. For a treatment to be established as a gold standard, several factors are considered including the quantity and quality of the supporting data, the rigor of trials, and the safety and efficacy compared to other treatments. In this article, we review the origins of psychedelic-assisted therapy (PAT), minimum requirements for safe use of psychedelics, criteria for gold standards in mental health, and the nuances regarding how to establish gold standards in psychedelic medicine and guide clinical decision making.

Investigation of self-treatment with lysergic acid diethylamide and psilocybin mushrooms: Findings from the Global Drug Survey 2020

BACKGROUND

Growing numbers of people are using psychedelics for personal psychotherapy outside clinical settings, but research on such use is scarce.

AIMS

This study investigated the patterns of use, self-reported outcomes and outcome predictors of psychedelic 'self-treatment' of mental health conditions or specific worries/concerns in life.

METHODS

We use data from the Global Drug Survey 2020, a large online survey on drug use collected between November 2019 and February 2020. In all, 3364 respondents reported their self-treatment experiences with lysergic acid diethylamide (N = 1996) or psilocybin mushrooms (N = 1368). The primary outcome of interest was the 17-item self-treatment outcome scale, items reflecting aspects of well-being, psychiatric symptoms, social-emotional skills, and health behaviours.

RESULTS

Positive changes were observed across all 17 outcome items, with the strongest benefits on items related to insight and mood. Negative effects were reported by 22.5% of respondents. High intensity of psychedelic experience, seeking advice before treatment, treating with psilocybin mushrooms and treating post-traumatic stress disorder were associated with higher scores on the self-treatment outcome scale after averaging values across all 17 items. Younger age, high intensity of experience and treating with LSD were associated with increased number of negative outcomes.

CONCLUSIONS

This study brings important insights into self-treatment practices with psychedelics in a large international sample. Outcomes were generally favourable, but negative effects appeared more frequent than in clinical settings. Our findings can help inform safe practices of psychedelic use in the community, and inspire clinical research. Future research can be improved with utilisation of prospective designs and additional predictive variables.

The Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force Report: Serotonergic Psychedelic Treatments for Major Depressive Disorder

OBJECTIVE

Serotonergic psychedelics are re-emerging as potential novel treatments for several psychiatric disorders including major depressive disorder. The Canadian Network for Mood and Anxiety Treatments (CANMAT) convened a task force to review the evidence and provide a consensus recommendation for the clinical use of psychedelic treatments for major depressive disorder.

METHODS

A systematic review was conducted to identify contemporary clinical trials of serotonergic psychedelics for the treatment of major depressive disorder and cancer-related depression. Studies published between January 1990 and July 2021 were identified using combinations of search terms, inspection of bibliographies and review of other psychedelic reviews and consensus statements. The levels of evidence for efficacy were graded according to the Canadian Network for Mood and Anxiety Treatments criteria.

RESULTS

Only psilocybin and ayahuasca have contemporary clinical trials evaluating antidepressant effects. Two pilot studies showed preliminary positive effects of single-dose ayahuasca for treatment-resistant depression (Level 3 evidence). Small randomized controlled trials of psilocybin combined with psychotherapy showed superiority to waitlist controls and comparable efficacy and safety to an active comparator (escitalopram with supportive psychotherapy) in major depressive disorder, with additional randomized controlled trials showing efficacy specifically in cancer-related depression (Level 3 evidence). There was only one open-label trial of psilocybin in treatment-resistant unipolar depression (Level 4 evidence). Small sample sizes and functional unblinding were major limitations in all studies. Adverse events associated with psychedelics, including psychological (e.g., psychotomimetic effects) and physical (e.g., nausea, emesis and headaches) effects, were generally transient.

CONCLUSIONS

There is currently only low-level evidence to support the efficacy and safety of psychedelics for major depressive disorder. In Canada, as of 2022, psilocybin remains an experimental option that is only available through clinical trials or the special access program. As such, Canadian Network for Mood and Anxiety Treatments considers psilocybin an experimental treatment and recommends its use primarily within clinical trials, or, less commonly, through the special access program in rare, special circumstances.

Are you tripping comfortably? Investigating the relationship between harm reduction and the psychedelic experience

Background

Alongside a recent revival in the use of psychedelics in clinical settings, there have been increases in the prevalence of recreational use, with many using psychedelics to deal with difficult emotions or to improve well-being. While clinical research is conducted in carefully controlled settings, this is not necessarily the case for recreational use. In this mixed methods online survey study, we aimed to develop an understanding of frequently used psychedelic harm reduction practices in recreational settings and how their use relates to the psychedelic experience. We also aimed to characterise users’ first and most recent psychedelic trips to understand how harm reduction changes with experience.

Methods

Participants (n = 163) recounted their first and most recent psychedelic experience by providing details about the harm reduction practices they employed and completing the Challenging Experience Questionnaire (CEQ) and Emotional Breakthrough Inventory (EBI). We also asked open-ended questions for a more in-depth qualitative understanding of their views on psychedelic harm reduction.

Results

Using ANOVA, we observe greater use of harm reduction practices for participants’ most recent versus first psychedelic experience and that use of these practices is positively associated with EBI scores and negatively associated with CEQ scores (particularly for the first experience). Participants engaged in a wide range of harm reduction practices and we provide details of those which are most commonly used and those which are deemed most important by experienced users. Our qualitative analysis indicated that participants were largely positive about psychedelics and many recounted profound positive experiences. While specifics of the drug they were taking was important for aspects of harm reduction, participants largely focused on the importance of ensuring a good “set and setting” for enhancing positive effects.

Conclusions

Our research helps us understand how engagement in harm reduction may increase with experience. Our mixed methods data shed light on the perceived importance of different harm reduction practices and examine their association with the psychedelic experience itself. Together, our research has important implications for the development of psychedelic harm reduction advice and provides opportunities for future research to explore the importance of these different practices in more detail.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-022-00662-0.

Policy considerations that support equitable access to responsible, accountable, safe, and ethical uses of psychedelic medicines

There is mounting evidence suggesting psychedelic and entactogen medicines (namely psilocybin and 3,4-methylenedioxymethamphetamine [MDMA]), in conjunction with proper psychosocial support, hold the potential to provide safe, rapid acting, and robust clinical improvements with durable effects. In the US, both psilocybin and MDMA have been granted Breakthrough Therapy designations by the US Food and Drug Administration and may potentially receive full FDA approval with similar regulatory considerations occurring in multiple countries. At the same time, regulatory changes are poised to increase access to legal or decriminalized psychedelic use in various non-medical settings. This review provides a brief discussion on the historical use of psychedelic medicines, the status of the empirical evidence, and numerous significant policy considerations that must be thoughtfully addressed regarding standards-of-practice, consumer protection, engagement of communities, safeguarding access for all, and developing data standards, which supports the responsible, accountable, safe, and ethical uses of these medicines in clinical, faith-based, and other contexts. We provide suggestions for how public health and harm reduction can be supported through a public-private partnership that engages a community of stakeholders from various disciplines in the co-creation and dissemination of best practices and public policies.

Psychedelic therapy for body dysmorphic disorder

In this opinion piece we propose the investigation of psychedelic-assisted psychotherapy for the treatment of body dysmorphic disorder (BDD). BDD is a psychiatric disorder characterised by appearance-based preoccupations and accompanying compulsions. While safe and effective treatments for BDD exist, non-response and relapse rates remain high. Therefore, there is a need to investigate promising new treatment options for this highly debilitating condition. Preliminary evidence suggests safety, feasibility, and potential efficacy of psychedelic treatments in disorders that share similar psychopathological mechanisms with BDD. Drawing on this evidence, as well as on relevant qualitative reports and theoretical proposals, we argue that it would be worthwhile to conduct a phase 2a study aimed at assessing the safety and feasibility of psychedelic-assisted psychotherapy in BDD. We also offer some suggestions for how future research ought to proceed.

The Psychedelic Integration Scales: Tools for Measuring Psychedelic Integration Behaviors and Experiences

In this study, we describe the development and initial validation of two psychometric scales for measuring psychedelic integration. Psychedelic integration refers to the post-acute period of time following psychedelic drug administration. We created the Integration Engagement Scale (IES) to capture positive behavioral engagement with integration and the Experienced Integration Scale (EIS) to capture internal aspects of feeling integrated. These scales were developed to measure post-acute psychedelic administration dynamics in order to inform the creation of enhanced integration support and to help refine a general conceptual understanding of the construct of psychedelic integration. The scales are brief and face valid instruments designed for practical use in applied and research settings. Scale items were generated and refined using the Iterative Process Model of scale development, with input from psychedelics experts and clinicians. Content validity, internal structure, and reliability were assessed via expert surveys, content validity analysis, cognitive interviewing, convergent validity analysis, exploratory factor analysis, and confirmatory factor analysis. The data indicates the scales are valid and reliable measurements of the behavioral and experiential forms of Psychedelic Integration.

Psychedelic assisted therapy for major depressive disorder: Recent work and clinical directions

Psychedelic substances such as psilocybin and ketamine may represent the future of antidepressant treatment, due to their rapid and prolonged effects on mood and cognition. The current body of psychedelic research has focused on administration and treatment within a psychiatric context. Here, instead, we put to the test the contention that it is necessary to evaluate the current state of this literature from a broader biopsychosocial perspective. Examining these arguably neglected social and psychological aspects of psychedelic treatment can provide a more holistic understanding of the interplay between the interconnected domains. This review of six major clinical trials applies a biopsychosocial model to evaluate the antidepressant effects of psilocybin and ketamine assisted therapy. We conclude that combination psychedelic treatment and psychotherapy facilitate more enduring and profound antidepressant effects than produced by ketamine or psilocybin alone. Emphasising the advantages of therapeutic intervention will encourage those who may attempt to self-medicate with psychedelics to instead seek a framework of psychological support, minimising associated risks of unregulated use.

Mystical experiences without mysticism: An argument for mystical fictionalism in psychedelics

Mystical experiences frequently precede decreases in human suffering or increased functioning. Therapies that include the ingestion of psychoactive substances in supportive environments often lead to improvements that correlate with the magnitude of the mystical experiences generated. A close look at these phenomena from a philosophy of science perspective might put empiricists in a quandary. Arguments with critics of the import of these mystical experiences, prohibitionists, or others who are apprehensive about psychedelic-assisted treatments, might prove awkward or difficult given the tacit assertion that the mystical genuinely exists. The assumption might even dampen theorizing in ways that remain outside of theorists' awareness. The predicament might lack the epistemic humility ideal for good science as well. Nevertheless, abandoning the construct of mystical experiences would require ignoring compelling, replicated empirical work. We argue that a version of philosophical fictionalism that draws on research in logic and linguistics can help investigators engage in this discourse without implying a belief in the mystical. Comparable approaches have proven helpful in mathematics and empiricism more broadly. Mystical fictionalism could help theorists view reports of mystical experiences as true even if the mystical fails to be veridical. The approach creates an expressive advantage that could assist researchers and theorists eager to refine our understanding of mystical experiences and improve psychedelic-assisted treatments. Mystical fictionalism might also inspire novel looks at correlates of mystical experiences that might serve as mediators of their effects, potentially generating models with comparable explanatory power that sidestep the need for a fictionalist approach.

New Paradigms of Old Psychedelics in Schizophrenia

Psychedelics such as lysergic acid diethylamide (LSD), psilocybin (magic mushrooms), and mescaline exhibit intense effects on the human brain and behaviour. In recent years, there has been a surge in studies investigating these drugs because clinical studies have shown that these once banned drugs are well tolerated and efficacious in medically supervised low doses called microdosing. Psychedelics have demonstrated efficacy in treating neuropsychiatric maladies such as difficult to treat anxiety, depression, mood disorders, obsessive compulsive disorders, suicidal ideation, posttraumatic stress disorder, and also in treating substance use disorders. The primary mode of action of psychedelics is activation of serotonin 5-HT_2A receptors affecting cognition and brain connectivity through the modulation of several downstream signalling pathways via complex molecular mechanisms. Some atypical antipsychotic drugs (APDs) primarily exhibit pharmacological actions through 5-HT_2A receptors, which are also the target of psychedelic drugs. Psychedelic drugs including the newer second generation along with the glutamatergic APDs are thought to mediate pharmacological actions through a common pathway, i.e., a complex serotonin-glutamate receptor interaction in cortical neurons of pyramidal origin. Furthermore, psychedelic drugs have been reported to act via a complex interplay between 5HT_2A, mGlu2/3, and NMDA receptors to mediate neurobehavioral and pharmacological actions. Findings from recent studies have suggested that serotoninergic and glutamatergic neurotransmissions are very closely connected in producing pharmacological responses to psychedelics and antipsychotic medication. Emerging hypotheses suggest that psychedelics work through brain resetting mechanisms. Hence, there is a need to dig deeply into psychedelic neurobiology to uncover how psychedelics could best be used as scientific tools to benefit psychiatric disorders including schizophrenia.

The Pharmacology and Clinical Applications of Psychedelic Medicines Within Midwifery Practice

The research and use of psychedelic medicines to treat common mental health disorders has increased substantially in the past 2 decades. At the same time, knowledge is relatively uncommon among midwives regarding (1) the relative benefits of psychedelic-assisted therapy, (2) best practices associated with the delivery of psychedelic-assisted therapy, and (3) responsible integration of this potentially useful intervention into mental health treatment plans. The purpose of this review is to describe current applications of psychedelic medicines to treat common mental health disorders, to describe the current legal status of these medicines used in this context, and to explore the potential for midwifery practice in this area with further training. This article also addresses the disparities regarding LGBTQIA+ and BIPOC populations in relation to this topic and their historical exclusion from research and treatment access in this field.

Integration in Psychedelic-Assisted Treatments: Recurring Themes in Current Providers’ Definitions, Challenges, and Concerns

Integration therapy, an integral part of psychedelic-assisted treatment, usually includes sessions devoted to making meaning of relevant psychedelic experiences after subjective effects have subsided. As the psychedelic renaissance continues, offers for this integration therapy have proliferated. In the present project, semi-structured interviews with 30 integration therapists focused on definitions of integration as well as challenges and concerns that they associated with the practice. A mixed-methods approach revealed 19 themes that coders identified reliably. Prevalent themes included expressing concern about nonresponsive clients, defining integration as a bridge between the psychedelic experience and daily life, and apprehensions about the commercialization of psychedelic psychotherapy. Interviewees viewed integration as a process that begins prior to the administration of substances, never ends, makes sense of the psychoactive experience, creates behavioral change, is personalized, and makes the individual whole. Most participants also discussed issues related to client resistance, unrealistic expectations of psychedelic psychotherapy, problems associated with power differentials, the importance of an integration therapist’s connection to other service providers, and the need for self-care. These data might help the standardization of integration therapy, inform lay impressions of the process, and help generate hypotheses for continued research on this aspect of psychedelic-assisted treatment. These data also suggest that psychedelic integration practitioners would appreciate regular support from a community of like-minded colleagues.

Enhancing equity-oriented care in psychedelic medicine: Utilizing the EQUIP framework

Psychedelic-assisted therapies are experiencing a re-emergence in mainstream medicine and mental health contexts. A wide variety of psychedelic-assisted therapy modalities are being utilized to address mental health issues such as substance use disorders, end of life anxiety, treatment-resistant depression, suicidality, PTSD and other conditions. The novel and inchoate acceptance of psychedelic-assisted therapies into mainstream medical and therapeutic realms raises questions of equity. Concerns have been raised that individuals and communities facing structural inequities are perhaps least able to access these treatments including Black, Indigenous and people of colour (BIPOC) as well as people who use drugs. Psychedelic-assisted therapies may exemplify the inverse law of care whereby services are most inaccessible to communities with the most need, especially if these therapies are regulated into the private sector. As legalization and wider implementation of these therapies appears to be imminent, now is a critical time to consider how health equity may be promoted within psychedelic medicine. This paper examines how the EQUIP Health Care approach (https://equiphealthcare.ca) may inform the development and provision of equity-oriented psychedelic-assisted therapies. The EQUIP approach seeks to reduce the effects of structural inequities on people's health, the impacts of discrimination and stigma, and the mismatches between usual approaches to care and the needs of people most affected by health and social inequities. Key dimensions of the EQUIP intervention include cultural safety, harm reduction, trauma and violence-informed care, and contextual tailoring.

Translating Psychedelic Therapies From Clinical Trials to Community Clinics: Building Bridges and Addressing Potential Challenges Ahead

Research exploring the potential of psychedelic-assisted therapies to treat a range of mental illnesses is flourishing, after the problematic sociopolitical history of psychedelics led to the shutdown of clinical research for almost 40 years. Encouraged by positive results, clinicians and patients are now hopeful that further interruptions to research will be avoided, so that the early promise of these therapies might be fulfilled. At this early stage of renewed interest, researchers are understandably focusing more on clinical trials to investigate safety and efficacy, than on longer-term goals such as progression to community practice. Looking to identify and avoid potential pitfalls on the path to community clinics, the authors, a group of Australian clinicians and researchers, met to discuss possible obstacles. Five broad categories of challenge were identified: 1) inherent risks; 2) poor clinical practice; 3) inadequate infrastructure; 4) problematic perceptions; and 5) divisive relationships and fractionation of the field. Our analysis led us to propose some strategies, including public sector support of research and training to establish best practice and optimize translation, and funding to address issues of equitable access to treatment. Above all, we believe that strategic planning and professional cohesion will be crucial for success. Accordingly, our key recommendation is the establishment of a multidisciplinary advisory body, broadly endorsed and representing all major stakeholders, to guide policy and implementation of psychedelic-assisted therapies in Australia. Although these challenges and strategies are framed within the Australian context, we sense that they may generalize to other parts of the world. Wherever they apply, we believe that anticipation of potential difficulties, and creative responses to address them, will be important to avoid roadblocks in the future and keep the "psychedelic renaissance" on track.