Psychedelics: safely navigating a new frontier

Authors

Dr. Rachel Grimminck (biography and disclosures), Dr. Jo Hoffman (biography, no disclosures), and Dr. Laura McLean (biography, no disclosures)

Dr. Rachel Grimminck’s disclosures: Honoria for speaking engagements related to physician wellness. Funding for stigma reduction workshop development from the University of Calgary EMBER project funded by Calgary Health Foundation. This funding has not influenced the article’s content. Mitigating potential bias: Recommendations are consistent with published literature including CANMAT guidelines. Treatments or recommendations in this article are unrelated to services/treatments involved in disclosure statements.

What we did before

Case vignette: A 24-year-old patient who is well known to you, sheepishly admits they are not taking the antidepressant you prescribed. They heard that SRIs were “not that effective” and might affect their “sex drive”. With optimism, they say a friend told them psilocybin is “easy to get’’ and helpful for mood. Your patient decided they’d “better come and talk it over” with you, because it’s “not legal yet, so maybe it’s dangerous?” Then they wonder about other psychedelic options and the effectiveness of microdosing vs macrodosing.

We were aware psychedelics had ‘resurfaced’ in recent years as having promise for mental health problems, but our knowledge was limited to knowing that most of these drugs had been classed as prohibited under the Controlled Drugs and Substances Act (CDSA).¹

We shied away from discussing psychedelics due to a lack of knowledge, but this left patients alone to navigate the tsunami of information flooding the internet. We feared patients sensed our discomfort and would be hesitant to bring it up, especially if they encountered any problems.

What changed our practice

There is increasing tolerance among the public for the use of psychedelics, whether legally accessed or obtained illicitly.^2,3 This shift in public perception has been fueled by the portrayal of psychedelics in popular media, recent clinical studies, and the ease of access online or through dispensaries.^4-7 Health Canada recently announced $3 million in funding for psilocybin-assisted therapy.⁸

The legal landscape for these substances has rapidly evolved over the past several years. British Columbia decriminalized possession of small amounts of MDMA but not psilocybin in 2023.^1,9,10 Ketamine is now offered in most health authorities for treatment-resistant depression, and ketamine-assisted psychotherapy is being offered privately in individual and group settings for a variety of indications throughout BC. Currently, the only legal routes for the therapeutic use of psilocybin and MDMA are through Health Canada’s Special Access Program or section 56 exemptions^11,12 though few have been granted.^13,14 Australia has legalized MDMA for the treatment of PTSD and psilocybin for treatment-resistant depression,¹⁵ and both are expected to be legalized in the US and Canada in the next few years.¹⁶

Evidence:

Over the past decade, the published research on psychedelics has exploded. In response to these studies, MDMA, psilocybin, and ketamine have been designated ‘breakthrough’ therapies by the US Food and Drug Administration (FDA).^17-19 This designation reflects that these substances hold promise for treating illnesses inadequately addressed by current treatment options and may offer distinct and significant advantages over standard therapies.²⁰

Intravenous ketamine has Level 1 evidence for treatment-resistant Major Depressive Disorder (MDD).²² Systematic reviews and meta-analyses demonstrate benefits from ketamine for treatment of MDD and suicidal ideation.²³ There is lower-quality evidence for bipolar depression, post-traumatic stress disorder, obsessive-compulsive disorder, anxiety disorders, and substance use disorders.²³

Psilocybin-assisted psychotherapy produces significant and sustained antidepressant effects in patients with MDD^24-30 and is effective for end-of-life distress.^31-34

MDMA in conjunction with psychotherapy produces substantial and durable reductions of symptoms and functional impairment in PTSD.^35,36

Microdosing refers to the practice of regularly taking small amounts (typically about one-tenth of a recreational dose) of a psychedelic drug, such as psilocybin or LSD.³⁷ Observational and retrospective research on microdosing has shown self-reported improvements in symptoms of depression, anxiety, and stress however there are no RCTs supporting these findings.^37-41

What we do now

Given the rapidly shifting social, political, and legal contexts surrounding the use of psychedelics, we realized the need to offer an informed opinion on the use of psychedelics in the same way we offer information and harm reduction strategies for substances such as opiates, cannabis, and alcohol.

A study by Nutt et al. from the UK, which ranked 20 drugs on 16 measures of harm to users and harm to wider society, showed psychedelics to be dramatically less harmful than all other substances, including alcohol which was the most harmful.⁴² Figure 2 lists drugs ordered by their overall harm scores, showing separate contributions to the overall scores of harm to users and harm to others.

A harm reduction approach aims to reduce the negative consequences of using substances, without necessarily reducing substance use itself.⁴³ Priorities for harm reduction with psychedelics include drug testing for purity and contamination and overdose prevention (see patient resources below), accessibility of support including attention to set or “mindset” and setting, as well as preparation and integration with safe and trustworthy individuals.⁴⁴

Although classical serotonergic hallucinogens like psilocybin and LSD are generally considered safe compared to other substances, there are contraindications and risks to be aware of including:

1. Personal or family history of bipolar disorder or primary psychotic disorders
2. Concurrent use of MAOIs is an absolute contraindication due to the high risk of serotonin syndrome; while use with SRI has a lower risk⁴⁵
3. A rare risk of persistent changes in perception^46,47

Ethical and legal issues for providers:

The regulatory framework is evolving across Canada. Alberta is currently the only province to have psychedelic-assisted therapy regulations.⁴⁸ Presently in BC, there are no practice standards for prescribing and administration of psychedelics for the treatment of mental health conditions. The CPSBC does provide interim guidance to physicians providing ketamine-assisted therapy.⁴⁹

Physicians can mitigate their own legal risk in this evolving space in the following ways:

1. Staying informed about the legal context and evidence base including information on potential side effects and contraindications
2. Practicing within scope of practice and competency
3. Providing information about legal routes for accessing psychedelics
4. Refraining from communication suggesting the use of psychedelics that have not yet received regulatory approval
5. Refraining from coordinating with underground therapists
6. Having clear written materials describing psychedelic harm reduction and integration therapy⁵⁰

In conclusion, psychedelics have been used ceremonially across cultures and around the world for millennia. Developing an appreciation of historical and current contextual factors is essential for physicians if Western biomedical medicine is to play a generative role as psychedelics re-emerge as a treatment for mental illness and to enhance well-being.

As physicians grounded in ethical practice, we face the challenge of prioritizing autonomy and respecting patient values and preferences while remaining committed to legal and safe practice.⁵¹

Resources

1. Fentanyl test strips can be obtained for free in all supervised consumption and overdose prevention sites in BC. Get Your Drugs Tested is a free community service offered by The Medicinal Cannabis Dispensary in Vancouver. They will analyze samples of street drugs received in person and through the mail using FTIR spectrometer, as well as immunoassay test strips that check for substances like fentanyl, benzodiazepines, and LSD.⁵²
2. Health authority websites in British Columbia provide excellent patient information on overdose prevention.⁵³
3. Naloxone kits are available from public health clinics and many pharmacies.

References

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3. Canadian Psychedelic Association. New poll shows a strong base of Canadians overwhelmingly support controlled legal access to psilocybin-assisted therapy; Canadian Psychedelic Association responds with memorandum of regulatory approval (MORA). GlobeNewswire News Room. August 4, 2021. Accessed October 24, 2023. (View)
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