The Ethic of Access: An AIDS Activist Won Public Access to Experimental Therapies, and This Must Now Extend to Psychedelics for Mental Illness

Expanded access to investigational drugs in psychiatry: A systematic review

Some psychiatric patients have exhausted all approved treatment options. Numerous investigational drugs are currently being developed and tested in clinical trials. However, not all patients can participate in clinical trials. Expanded access programs may provide an opportunity for patients who cannot participate in clinical trials to use investigational drugs as a therapeutic option outside of clinical trials. It is unknown to what extent expanded access occurs in psychiatry. We conducted a systematic literature search on PubMed, Embase, and PscyInfo, with additional information from ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform and FDA/EMA approvals, in order to find all expanded access programs ever conducted, globally, in the field of psychiatry. This resulted in a total of fourteen expanded access programs ever conducted in psychiatry. Given the prevalence of psychiatric disorders, the activity in clinical research in psychiatry, the regulatory framework enabling expanded access, and the impact of psychiatric disorders on patients, their families, and society, we had expected a higher utilization of expanded access. We propose that the psychiatric community, with pharmaceutical industry, should consider establishing and optimizing expanded access programs.

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.