This paper (2018) reviews the history of psychedelics as a therapeutic agent and suggests that it is time to revisit this class of drugs as a possible option to alleviate suffering.
Abstract
“Background: Psychiatric research in the 1950s and 1960s showed potential for psychedelic medications to markedly alleviate depression and suffering associated with terminal illness. More recent published studies have demonstrated the safety and efficacy of psilocybin, MDMA, and ketamine when administered in a medically supervised and monitored approach. A single or brief series of sessions often results in substantial and sustained improvement among people with treatment-resistant depression and anxiety, including those with serious medical conditions.
Need and Clinical Considerations: Palliative care clinicians occasionally encounter patients with emotional, existential, or spiritual suffering, which persists despite optimal existing treatments. Such suffering may rob people of a sense that life is worth living. Data from Oregon show that most terminally people who obtain prescriptions to intentionally end their lives are motivated by non-physical suffering. This paper overviews the history of this class of drugs and their therapeutic potential. Clinical cautions, adverse reactions, and important steps related to safe administration of psychedelics are presented, emphasizing careful patient screening, preparation, setting and supervision.
Conclusion: Even with an expanding evidence base confirming safety and benefits, political, regulatory, and industry issues impose challenges to the legitimate use of psychedelics. The federal expanded access program and right-to-try laws in multiple states provide precendents for giving terminally ill patients access to medications that have not yet earned FDA approval. Given the prevalence of persistent suffering and growing acceptance of physician-hastened death as a medical response, it is time to revisit the legitimate therapeutic use of psychedelics.”
Author: Ira Byock
Summary
Psilocybin, MDMA, and ketamine have been shown to alleviate depression and suffering associated with terminal illness.
Recently published studies and high-profile articles have rekindled professional and public interest in the therapeutic use of psychedelic drugs. However, clinicians who care for profoundly depressed, anxious, and seriously ill patients have every reason to be skeptical.
Psychedelics carry real risks and are formally designated Schedule I drugs. However, given the extent of persistent emotional and existential suffering that palliative care clinicians encounter, these medications deserve serious consideration by our field.
Background
Psychedelic properties of specific plants have been used by indigenous cultures to induce expanded states of consciousness and spiritual experiences. Several clinical studies have been conducted with psilocybin and MDMA, more commonly known by their street names, Ecstasy and Molly, in the past decade.
Recently published research strengthens findings of earlier studies that psilocybin, ketamine, and MDMA can be used as adjuncts to psychotherapy for patients with treatment-resistant depression, anxiety, and depression associated with terminal illness.
Skepticism is warranted, but cynical nonscientific bias can result in therapeutic nihilism. Medical advances like small pox vaccination, penicillin, and computed tomography scans remind us to suspend cynicism.
The Need Is Great
Palliative care teams treat the sickest patients in our health systems and communities. When pain, dyspnea, seizures, or agitated delirium persist and cause intolerable suffering, comfort can reliably be achieved with proportionate sedation.
Palliative care clinicians and teams encounter patients whose misery is rooted in emotional, social, existential, or spiritual distress. These patients often say they have lost any reason to go on living.
People who are incurably ill and living with progressive disease-related disabilities can experience anxiety, depression, and demoralization. Psychotherapy and drug treatments for such syndromes are often insufficient, and medications may cause mental slowing and confusion.
Severe psychological and existential suffering can rob people of the feeling that life is worth living. Suicide rates have risen 24% over the past two decades and are highest among middle-aged and elderly adults, particularly men.
Exercising Abundance of Caution: Screening, Supervision, Set and Setting
Psilocybin and MDMA are safe when prescribed to carefully screened patients, in recommended doses, under professional counseling and supervision. They do not dull the senses or induce sleepiness.
Psychedelics can cause nausea, vomiting, anxiety, and sympathetic nervous system arousal. They dissolve barriers between physical senses, resulting in synesthesia, and can evoke visual images and sounds.
Screening
People with cognitive and emotional conditions associated with disorganized or diminished ego strength are not good candidates for therapy involving psychedelic drugs. MDMA may represent a partial exception.
Supervision
Supervision is necessary for ensuring safety of psychedelic experiences. These drugs can cause death if used unsupervised, and professionals who are skilled in managing adverse effects must be present.
Set and setting
Anthropologists have recognized the influence of expectations and motivation on subjective experience. When taken in a controlled setting with elements of soft light, art, and appropriate music, or nature, and gentle, compassionate people, psychedelic experiences prove beneficial in a high proportion of cases.
Therapeutic Effects
Clinical case studies and research trials report that people with severe anxiety and depression report heightened cognitive clarity and expanded emotional receptivity after psychedelic experience.
People who take psychedelics for spiritual introspection often report that the drugs opened windows into deeper realms of existential experience. They often experience a sense of exhilaration, insight, strengthened connection to others, and a renewed or enhanced recognition of intrinsic meaning and value of life.
Not all psychedelic drugs are alike and subcategories have been described. MDMA is characterized as an empathogen, and a single six to eight-hour session or short series of sessions suffices for therapeutic benefit.
Political and Regulatory Considerations
Psychedelic drugs were closely associated with the cultural wars of the 1960s and 1970s, and MDMA became well known as Ecstasy or Molly. In the mid-1980s the FDA declared MDMA a Schedule I agent.
Psychedelics have been renewed for clinical research, but political resistance is expected. There are compelling reasons to proceed with reclassification.
Treatment-resistant depression and anxiety associated with PTSD causes suffering and contributes to thousands of deaths each year. Suicide is becoming less shameful and more socially acceptable, lowering barriers for people who feel hopeless.
Political conservatives and progressives, as well as those on opposing sides of the issue of legalizing physician-hastened death, may be able to build consensus by recognizing that psychedelics may have greater life-saving effects than other drugs that have earned right-to-try and expanded access status.
Business Considerations
Business models for medical uses of these drugs are not clearly defined, and industry lobbying may complicate regulatory processes. However, folding the cost of these medications into professional fees for pharmaco-assisted therapy may be the way forward.
Final Thoughts
Skepticism is warranted when faced with novel therapies that seem too good to be true, but cynicism may prove more dangerous. Palliative specialists must explore the use of psychedelics in pharmaco-assisted therapy to protect vulnerable patients from harm.