Selling psychedelics - to government, policy makers and a sceptical public

One of the big things on many people's horizon as 'the next big thing' in mental health is the use of psychedelics. Although the label 'psychedelic' has largely replaced the old word  'hallucinogen' (for reasons of technical inaccuracy), its literal meaning - as 'mind revealing' - is also true for Ketamine and MDMA, which are also known as a 'dissociative anaesthetic' and an 'empathogen', respectively - but they are not hallucinogens. Therefore I use 'psychedelic' to cover them all. 

To reduce it to the usual diagnostic straitjackets I will simplify the reasons for which they are thought to be therapeutic. The list that follows is in order of current and likely future legalisation. 

 

K-hole

Ketamine for 'TRD' (Treatment Resistant Depression') - a controlled drug already prescribable off-label by anesthetists and maybe others, and prescribable on-label as the absurdly expensive separated S-enantiomer called 'esketamine' and marketed as a nasal spray (Spravato). Only a handful of UK clinics exist, charging about £5000 or more per treatment, including preparation and integration psychotherapy sessions before and after the medicine dosing. There is a much wider range of formats in USA and overseas - from wholly biomedical IV infusions, through IM, sublingual lozenges and oral sustained release resin-pearls (which have imperceptible psychological effects).

Smiley

MDMA for PTSD - with excellent studies and high quality evidence, particularly from the US East Coast. There are initiatives to develop new formats of therapy in at least Europe and USA (eg couples, families and groups) but it is only legal to do so as part of fully registered clinical trials. MDMA's professional therapeutic use is nearly always as a facilitator of psychotherapy. The onerous requirements for research trials entail a great deal of burdensome bureaucracy. It is therefore likely that much informal / underground / illegal therapeutic work is already taking place. Smart money is on UK approval for medical use within about 2 years - although details of how this will work are unknown.

Magic

Psilocybin for Depression, 'End of Life Anxiety' and addictions. Psilocybin is the most 'natural' of these three, being likely to have been used for several thousand years in religious and ceremonial settings. However, the formulation used for clinical trials must be synthesised de nove in the laboratory and adds vast costs to the administrative, clinical and practical hurdles of running rigorous research trials. Despite these difficulties, some very good randomised trials have been run - with impressive outcome results. However, they have had their credibility questioned by pedantic academic requirements concerning the choice of 'primary outcome measure'. Nonetheless, psilocybin holds out much promise for being an effective medicine of the future (and long-distant past, probably). Licensing for medical use is probably at least 3 years away in the UK.

Others currently in the frame include DMT or 5-MeO-DMT for very short and intense psychedelic experiences (much more convenient for administering in clinical settings) - for similar indications to psilocybin. Ibogaine is a more hazardous substance, with another long history of ceremonial use, with early research indications of likely effectiveness for addictions. Ayahuasca is a herbal concoction with probably as long a history of cultural use as any of the other natural psychedelics, particularly in South America: it is unlikely to gain clinical recognition in the west as it requires variably potent natural ingredients and shamanic expertise in brewing it. LSD is - at least in modern western circles - the granddaddy of them all, and is a powerful and very safe psychedelic. It was intensively and extensively researched in the 1950s and before 'the War on Drugs', but probably now carries too strong a taint or stigma from its widespread countercultural use in the 1960s. Of course, there are many others both natural (such as mescaline) and synthetic (a vast range of 'designer drugs' - particularly tryptamines and phenethylamines) - but they are much lower down the list of medicines likely to gain approval for clinical use.

 

BUT (1)...

Perhaps the true place of psychedelics is not in the treatment of what we call 'mental illness', but more in a well-being and preventative role perhaps in the context of a safe and benevolent community of users of mixed age and experience - to include the wisdom of elders and those with special experience. The danger of the field being taken over by medicalisation (including psychotherapy) is that far too much dominance will be given to the vary narrow view of effectiveness as researched by modern 'evidence-based medicine'; the numinous, ineffable, spiritual and mystical aspects (which are so often cited as transformative factors) could be lost in the world of highly-qualified and highly intelligent boffins.

 

BUT (2)...

Even more persuasive than the power of massed biomedical academics is that of venture capital. The language is of 'startups' and 'incubators', as well as 'return on investment' and 'leverage'. A long way indeed from human needs, relationships, emotions and distress - also from 5HT receptors and synapses, neuroplasticity, the default mode network and glutamate systems. The only driver behind this very powerful force of change is money, and a very great deal of it. I find that rather worrying

 

BUT (3)...

Many many people, myself included, are disillusioned and almost despairing about the state of the world, and how humankind appear to be destroying it. Hence the vigor of activist movements such as Occupy, Me Too, Black Lives Matter and Extinction Rebellion. Last week, I went to a 'Seeds' talk in Swindon with the title 'Science of Psychedelics', given by a speaker who clearly knew his stuff, and could communicate it vividly and passionately. But more influential than the facts he presented was his manner and milieu. The 200+ audience could have come straight from Swindon shopping centre once they had bought their Eventbrite tickets. When I arrived the setting looked much more like a rock concert than the sort of professional lecture I am used to - and had a long queue to the bar and a faint aroma of patchouli oil. The speaker - with very respectable academic credentials - looked for all the world like a bass guitarist without his bass guitar - strutting up and down the stage with the sort of cool and sex appeal that no clinicians that I know could do or would dare to attempt! 

Where's your bass guitar?

Just a few quick reactions: 

• it is great that science and new information are being publicly disseminated so effectively
• this is picking up on a much wider disagio diffuso - like the better known activist movements that want to change the world
• it takes too long to change public opinions and demands by professional medical research
• it feels sad that it is all becoming so commercialised and managed by PR experts.
• there isn't a single mastermind behind all these mechanisms for publicising psychedelics, and selling the potential importance of them, but many very committed, determined and intelligent individuals who are often working together.
• Are they missing something? (I have a feeling they are, but I don't know what it is!)