On the Massachusetts Ballot: Psychedelics for All! The Harm it will cause, the Benefit it won't have
A Clinical Analysis
The group that promotes Psychedelics for All calls itself “Massachusetts for Mental Health Options.” That sounds so friendly: we’d all like to have options. But by options they mean: Get rid of the medical establishment; let people use psychedelics however they like, with a friendly civilian, who likes psychedelics too, by their side.
The psychiatric profession is a reasonable profession, too reasonable probably. We like to go along with others. So, most psychiatrists aren’t saying that psychedelics are a bad idea. They say: We’re interested too! This is a good idea but let us be part of the process. This ballot question is opposed by Massachusetts Psychiatric Society, of which I am the current president, and by the Masschusetts Medical Society, and many clinicians not because psychedelics are bad, but because their medical aspect is being sidelined.
We could discuss the pros and cons of that aspect, medical supervision. We might analogize to ketamine, which is in the same class clinically (a hallucinogen or so-called “psychedelic”). Why is there no ballot question to use ketamine whenever people like, instead of receiving it only with a prescription? Ketamine is allowed and legal, but with medical supervision. Many clinicians would support the same approach to psilocybin or ayahuasca or other such agents.
The most humble – and mildest - hallucinogen is marijuana; obviously no one is supervising anything there. Potency matters. Amphetamines have exactly the same mechanism as cocaine –direct dopamine agonism – but they’re milder. Dextroamphetamine is given with a prescription; cocaine isn’t. Potency matters.
The term “psychedelic” itself is misleading. It’s a made-up term with no scientific meaning, created by the writer Aldous Huxley in the 1950s. In fact, it’s just a class of drugs that causes delusions or hallucinations. The term “hallucinogen” is more accurate. Ketamine does the same; cannabis does the same. We refer to dissociation, which is a sensory hallucinogenic state. A “bad trip” is just a disturbing sensory hallucinogenic state.
So, let’s not pretend: These drugs are hallucinogens. The only question is how severe and harmful their hallucinogenic effects are, compared to their purported benefits.
Regarding benefits, let’s also be clear: Nothing has been proven using standard randomized placebo-controlled paradigms, with large samples and replication. Further those studies, besides being small and typically nonreplicated, are short-term, meaning weeks or months long.
My main critique of these hallucinogens is not that they are harmful, which they are; not that they are addictive, which they are; not that they are poorly proven, which is the case. My critique is that their benefit, if present, is always just symptomatic and short-term, not disease-modifying and long-term. They are not transformative at all.
Let me explain.
All drugs are of two kinds: they either improve symptoms or modify underlying disease. Some drugs do one or the other; some do both; but all can be characterized by these two major effects.
Symptomatic drugs are agents like aspirin, Tylenol, ibuprofen, steroids. Disease-modifying drugs are like statins, antihypertensive drugs, chemotherapies, immunotherapies in multiple sclerosis (literally classed as “disease-modifying therapies”).
Current randomized evidence supports possible short term symptomatic benefit with psychedelics only. There are no randomized studies that support long-term change in the course of illness. Open non-randomized follow-up doesn’t count; it proves nothing, since natural history and other factors can explain any benefit.
The classic symptomatic drugs of medicine are useful, but if that’s all we had, we wouldn’t be very effective physicians. “Take two aspirin and call me in the morning” is wise advice, because aspirin helps all kinds of symptoms within hours; by the morning if gone, there might be nothing wrong. Or maybe the symptoms come back the next day and the next day, and the doctor realizes there’s an underlying disease to identify and treat. Steroids, another classic symptomatic class, can be life-saving, but they usually need to be followed by a search for the underlying disease, like multiple sclerosis, to be improved long-term with other medications.
Most of our psychiatric drugs are of this ilk – they are symptomatic: antidepressants, anxiolytics, amphetamines and even antipsychotics. 90% or more of the studies of these agents are just symptomatic: a month or two of treatment of current symptoms. That’s by definition symptomatic only.
The clinical hallmark of disease modification is improving the course of the illness in the long run, rather than treating current symptoms in the short run. That’s what statins and antihypertensives do: they prevent future strokes and heart attacks. That’s what lithium does for both unipolar depression and bipolar illness: it prevents future depressive or manic episodes. There is decent evidence that all these agents reduce mortality.
Psychedelics don’t do any of that. They certainly haven’t been proven. They’re not even being tested.
Why is everyone so excited?
Let’s simplify all this: You feel terrible; you’re highly depressed, or very anxious, or have flashbacks and nightmares. You take drug X among psychedelics (it could be ketamine, LSD, whatever). You feel great! For an hour or two, or a day or two, or even a week or two, or maybe a month or two.
But is that it? Are you therefore fine forever?
We know that’s not the case. Next week or next month or next year, you’re going to feel terrible again: you’ll be highly depressed, or very anxious, or have flashbacks and nightmares. That dose of psilocybin or MDMA or ketamine didn’t cure you. It’s not disease-modifying.
But what if you took your ketamine or ayahuasca once a week or once a month for a year. Would you prevent the depressive episodes, like lithium does?
Here’s a secret: Nobody – nobody – in academic or anywhere in the $10 billion psychedelic biotech industry - is asking the asking that question. And no one is studying it. Therefore, you don’t have an answer now, and you won’t have one next year, or in five years, or likely longer.
No one cares if psychedelics are disease-modifying; they’re going to fool you by showing immediate symptomatic benefits, assuming – not proving – that it’ll last forever.
They’re going to sell you Super-Tylenol or Super-aspirin and make their billions by pretending that it’s a statin or lithium.
It’s not.
Don’t be fooled, my fellow clinicians.
Our patients already are fooled. They don’t know all this; they don’t care. They just want to feel better. And when they feel better for an hour or a day or a week or a month – they think it’ll last forever.
They mistrust psychiatrists asking questions. They want a ballot question to legalize psychedelics for all, with funding from Peter Thiel, the billionaire tech mentor of certain proto-authoritarian politicians, and his friends.
And they get pseudoscientific support from our academic “subject matter experts,” funded by the same biotech coffers, as we saw at a Massachusetts State House hearing this past spring, where Massachusetts General Hospital (MGH) psychedelic research group leaders didn’t describe the harms and limitations of psychedelics at all. Instead, they emphasized absence of tolerance or withdrawal, implying or stating that psychedelics aren’t addictive. Of course, it’s a basic medical fact that psychological addiction can happen without physiological withdrawal. See: Cocaine.
The problem here, and I am sympathetic to it as an “expert” and researcher, is that you wouldn’t spend your career studying something you felt was useless. If you study a treatment, you tend to believe it's helpful, or could be. I would never become a psychedelic expert, for all the reasons I give in this article. I would like to spend my research time on something that could be helpful, not on a dead end. So we have the paradox that “subject matter experts” often aren’t objective; they tend to support whatever is their subject matter.
It isn’t always this way. A Johns Hopkins expert who spoke at the State House was more conservative and pointed out psychedelic risks. I have studied antidepressants in bipolar depression with the perspective that they do not work. But these are exceptions. Most experts follow the funding, which, especially if private, tends to be given by those who believe in something to those who believe in something.
Our culture is going in the direction of psychoactive drugs for all; decriminalization is fine, but let’s not confuse it with legalization, in the sense that these drugs should just be available to everyone without any further thought, like alcohol or coffee. And let’s not claim that they are psychiatrically revolutionary, transforming the field.
They’re not.
They’re aspirin and Tylenol. Super-aspirin or super-Tylenol, but still aspirin or Tylenol.
That’s not transformative; they’re more of the same.
Now maybe I’m wrong, at least in part. Maybe it will be proven in PTSD – for instance - that one or a few doses of a hallucinogen, followed by months of psychotherapy, produces major long-lasting improvement in the course of illness. That would be great. We can hope for it. But we can’t assume it. It needs to be proven, just like anything else, if we want to know what we’re doing as opposed to just guessing.
Proof means randomizing to treatment versus placebo, and no other treatments, for one year or longer. The plural of anecdote is not evidence, as E. Fuller Torrey used to say.
None of the current or planned PTSD trials have this design; they’re all about short-term benefit: symptomatic effects; aspirin, Tylenol.
These reflections are about science. The November ballot is about opinion. Psychedelic advocates with psychiatric conditions will be sorely disappointed, whether they win or lose. If they lose, they’ll be mad. If they win, they’ll be disappointed, in the long run. In the meantime, their funders will make their billions.
And we’ll still be stuck where we are, with a few thousand yearly extra emergency room crises, added to the current emergency room overcrowding tragedy, as a consequence.
With their $5-10 million of funding and a cultural wave, the psychedelic advocates may win at the ballot box. Their academic enablers may reap funding benefits. Their right-wing donors may grow richer. But the world will be worse off.
Truth, after all, as Thoreau reminds us, is not a matter of majority vote.