Stigmatized Drugs for Stigmatized People

advocacy mental health policy Apr 09, 2019

As a psychiatric pharmacist with a background in public health, I have a passion for psychoactive drugs that can affect psychological states to mediate mental healing processes and duty to serve and advocate for those struggling with mental illness. Psychedelic drugs such as psilocybin, methylenedioxymethamphetamine (MDMA), lysergic acid diethylamide (LSD), and dimethyltryptamine (DMT) among others have recently garnered renewed interest in the treatment of psychiatric illness [1-3].

The term psychedelic means ‘mind-manifesting’ and psychedelic drugs have been used by indigenous peoples around the globe as spiritual sacraments for connecting with the divine for millennia [3]. They are powerful mind-altering substances that have been termed psychotomimetic due to their ability to induce a state that mimicked psychosis to the observer or hallucinogens due to their propensity to induce profound perceptual distortions at high doses [4]. Recently, they have been classified as entheogens meaning ‘to cultivate the divine from within’ or psychotoplastogens based on their ability to promote neuronal growth [5,6].

Psychedelics were outlawed by the Controlled Substances Act (CSA) of 1970 and have remained largely illegal since then. They popularized in the West during the 1950’s and 1960’s and were used liberally by ‘hippies’. They became associated with counter-culture and anti-establishment modes of thinking, sparked by Vietnam War era protests, fanatic promotion for widespread use, and music festivals such as Woodstock. On rare occasions, LSD has been documented to cause long lasting disturbances to visual perception [7]. Additional case studies of LSD in the hands of people with psychopathy such as Charles Manson have demonstrated a capacity for gross manipulation of other humans that resulted in homicide. The War on Drugs and false narratives around psychedelics (LSD stays in your spine forever and can recreate the experience at any moment) led to a large decline in use and negative public attitudes toward use. These events have created a stigma around psychedelic drug use and the altered states of consciousness they’re capable of producing. Not the type of reputation and track record that is ideal for potential treatments of vulnerable populations such as those afflicted with mental illness. 

In short, psychedelics are heavily stigmatized

When a drug is made illicit it is placed in the CI category which means a drug has ‘high potential for abuse and no accepted medical use’ – a label which has proven difficult to undo. Placement of a drug in this category largely creates a prohibitive climate for research and effectively froze what was a thriving psychedelic research agenda for the best part of half a century [8,9]. The catch 22 of the situation is that there was no evidence to support psychedelics lacked medical utility, in fact evidence existed to the contrary, and placing the drugs in the CI category effectively deters medical research [10]. While strategies for protecting the public from harms associated with psychedelic misuse deserve serious conversation, the potential for abuse alone should not dictate placement in the CI category of drugs.

To society, this should represent an unacceptable paradigm of drug regulation as legitimate scientific questions and medical research that could benefit those suffering is being oppressed.

While any illness presents obstacles for persons and their caregivers to work through, they are exceptional in persons with psychiatric illness. Stigma is a well-documented phenomenon associated with mental illness and occurs at both the societal and individual level [11]. Research funding for new psychotropic medications is prioritized lower than other disease states such as cancer or diabetes [12]. Community resources are often inadequate, there is a critical shortage of psychiatrists, inpatient psychiatric care has been significantly downsized, and mental illness has been equated with criminality in many cases [13-16].

Current offerings in therapy are helpful, although leave a lot to be desired.

Pharmacotherapies such as first line antidepressants for depressive and anxiety disorders provide only symptomatic relief and while they are helpful for many people, for others they have underwhelming efficacy or intolerable adverse effects [17,18]. Psychotherapies can delve into issues that may help unearth the etiologic root of illness, although understanding the root conceptually and affecting it on an emotional level with enduring permanence are two different endeavors, the second of which is much more difficult to do with the rational mind. Benefits of psychotherapy may be limited in duration upon discontinuation and is resource intensive to be done on a continuous basis.

It is apparent that new approaches are needed.

States of consciousness other than the logical and rational modes we’re accustomed to in our productive lives have been systematically de-valued by our society and reduced to ‘getting high’. Yet, we tolerate sedatives that lead to belligerence or even death such as alcohol, which causes incredible amounts of harm and destruction to society [19]. Therefore, it’s clear that the amount of harm a drug imposes or addictive potential is not the primary motivating factor for federal regulation of drugs under the CSA [20].

Corporate sponsors have been traditionally uninterested in pursuing psychedelics as therapies for many possible reasons including the aforementioned prohibitive research climate and cultural stigma. Tension between societal expectations of altruism and corporate livelihood have been a struggle of increasing public concern for the pharmaceutical industry [21]. There is also an incentive to bring drugs that relieve symptoms to market rather than drugs that treat etiology. This is because drugs that focus on symptom relief need to be taken daily on an indefinite basis versus a drug treating etiology that is taken a few times and then stopped.

All of this is slowly changing though.

In the last 15 years there has been renewed interest in the use of many psychedelics including psilocybin, LSD, MDMA , and DMT/harmala alkaloids (ayahuasca) for a variety of psychiatric indications including depression, Post-Traumatic Stress Disorder (PTSD), substance use disorders, and anxiety associated with a life threatening illness [10,22-34].

Most current research is focused on psychedelic-assisted psychotherapy, which combines elements of psychotherapy with non-linear modes of thinking induced by psychedelic drugs. It appears that insight and emotional repair is possible in the altered state of consciousness induced by psychedelics that is not possible in rational thinking states. The ability of psychedelics to promote neurogenesis and synaptic plasticity in mood regulating neurocircuits may help explain why psychedelics appear to render people vulnerable and malleable, for better or worse [6,35]. This approach uses moderate doses of pure substances in controlled environments with direct medical supervision and is given only to patients that have been screened carefully. By using psychedelics in this manner the risks associated with recreational or illicit use are mitigated and so far the results have been unprecedented.

MDMA, known on the street as ecstasy, is now in the final and most rigorous stage of clinical trials for treatment-refractory PTSD. In one of the previous phase II trials over 80% of participants (10 out of 12) achieved remission criteria that was persistent at 2 months follow up from a single drug session [32]. At least 3 other phase II trials treating over 100 persons total have produced similar outcomes. Results have been shown to endure with robust longevity in the large majority of those treated and may be associated with personality changes such as increased openness or decreased neuroticism [33,36]. In response to these results the Food and Drug Administration (FDA) has designated the therapy as a ‘breakthrough.’ The research is being sponsored by a crowd-funded 501(c)3 non-profit clinical research organization: the Multidisciplinary Association of Psychedelic Studies. If the drug is successful in gaining FDA approval it would be historic: The first psychedelic drug approval. The first drug to be crowd-funded. The first drug to be rescheduled from the CI category. Last and most importantly, the first drug to give sustained and incredibly clinically meaningful results from a small number of administrations to those that have suffered trauma.

Psilocybin, the active ingredient in ‘magic mushrooms’ or psiolocybe spp., is preparing to enter phase III trials. It has been explored for several purposes including anxiety and depression associated with a life threatening illness, tobacco and alcohol use disorder, treatment refractory depression, and obsessive compulsive disorder [23-26,37-39].  To date, anxiety and depression associated with a life threatening illness has the most amount of data, although all studies have shown positive outcomes. Similar to MDMA, is has been granted a breakthrough designation by the FDA. Ayahuasca was recently shown to be effective for depression in a couple small randomized trials and has widespread reports of benefit on a number of psychometric measures [40-43].

The use of psychedelic drugs for psychiatric illness may challenge many of societies’ beliefs about drugs and persons with mental illness. I invite you to compassionately reflect on the ideas you hold and ask if they are based in science or in the stigmatic dogma that has prevailed in the last 50 years. People with mental illness have enough obstacles to deal with, let’s help overcome some of the ones standing between them and more effective treatments. It's time to advocate for rescheduling psychedelic substances to facilitate medical progress.


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