June 20, 2023

Clinicians Emphasize Harm Reduction When Counseling Patients About the Use of Psychedelics

Growing public interest in hallucinogens highlights their therapeutic promise and potential perils

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Interest in the therapeutic potential of psychedelics has swelled in recent years, thanks in part to a growing body of research that supports the use of these once-polarizing substances for the treatment of mental illness. A corresponding surge of media attention has further stoked public curiosity about these mind-altering drugs, compelling clinicians to help their patients better understand the risks of psychedelic “trips” – and navigate the hype.

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Early research into the healing powers of psychedelics showed promise, but studies in the U.S. came to an abrupt halt in the early 1970s with the passage of the federal Controlled Substances Act, which provided a legal framework for regulating drugs believed to pose a risk of misuse.

Fifty years later, however, psychedelics have reemerged as fertile scientific ground. New clinical research has pointed to the possible benefits of these substances for the management of certain behavioral health problems, including addiction, treatment-resistant depression, anxiety and post-traumatic stress disorder.

“Despite the stigma that plagued psychedelics for decades, current research is redefining the role they may soon play in Western medicine,” says Brian Barnett, MD, a psychiatrist in the Center for Adult Behavioral Health at Cleveland Clinic Lutheran Hospital and co-director of the hospital’s Treatment-Resistant Depression Clinic. Cleveland Clinic is one of several participating sites in a national study to determine whether a single dose of lysergic acid diethylamide (LSD), when administered in a controlled, supportive setting, can help alleviate severe anxiety.

New state of mind

Loosely translated from Greek to mean “mind manifesting,” the word psychedelics describes a class of drugs that can produce profound states of altered perception, thoughts, feelings and consciousness. Consuming these structurally diverse compounds, including psilocybin (the active chemical in “magic mushrooms”) and LSD, has been shown to induce intense — even mystical — subjective experiences that can lead to profound, long-lasting changes in an individual’s mindset and sense of purpose.

Although these changes may set the stage for more adaptive ways of thinking, Dr. Barnett reminds patients that clinical research is only beginning to reveal the complex neural mechanisms at the root of mind-altering experiences and how they might be used to heal psychiatric disorders.

“We’re seeing an increasing number of patients who are self-treating with psychedelics, some of whom report traveling to countries where the drugs can be legally obtained – often through participation in ‘plant medicine’ retreats centered on substances like ayahuasca and psilocybin,” he says. “Unfortunately, it’s risky at this point to experiment with these substances or replicate therapeutic protocols without expert oversight.”

Optimizing set and setting

When administered safely, psychedelics may help patients experience self-compassion or develop new insights about their own mental health, but Dr. Barnett stresses that a healthy mindset and controlled therapeutic environment are paramount for producing a positive experience.

In clinical trials, subjects are typically required to participate in a series of preparatory sessions prior to taking any psychedelic substance. Before, during and after the treatment is administered, patients remain in the company of trained providers: therapists, psychedelic facilitators, physicians and clinical research coordinators.

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In addition, research subjects take part in integration sessions following their psychedelic experience, in which a trained psychotherapist can help the patient process any insights or challenges they may have encountered and translate their observations into meaningful long-term change.

“To realize the full benefit of these substances, it’s vital to take advantage of the increased cognitive flexibility they provide,” explains Dr. Barnett. “It appears that psychedelics can, for some people, be a catalyst for healing – but I think the real work begins after the psychedelic experience ends, while the therapeutic window is still open. During this period of malleability, patients often succeed in shifting away from the maladaptive behavioral and thought patterns that have caused them difficulties in the past.”

Providing options, guidance

Although he remains optimistic about the therapeutic possibilities of psychedelics, Dr. Barnett stresses the invaluable role that harm reduction should play when counseling patients about the risks of using these substances.

“These conversations are also ideal opportunities to explore alternative treatments that may better address the patient’s desired goals,” he says. “It’s essential for clinicians to help their patients develop realistic expectations about the therapeutic benefits of any treatment they choose, and a frank discussion about the therapies they’ve already tried can be a good place to start. It’s common for those suffering from depression, for example, to trial a couple of popular antidepressants – and if they don’t appear to work, they’ll often stop there. They may believe that there’s nothing else available, but there are a number of highly effective – and legal – treatments for depression, many of which they may not have considered.”

Dr. Barnett encourages clinicians to educate their patients about approved alternatives for the treatment of mental health concerns, including monoamine oxidase inhibitors, transcranial magnetic stimulation, electroconvulsive therapy and ketamine, just to name a few. In addition to traditional therapeutic approaches, there are various holistic options that many patients find beneficial, including meditation, breathwork and mindfulness, he notes.

“It’s important we approach our patients as the competent adults they are by providing them with the facts they need to make informed decisions about their own healthcare,” he says. “Because psychedelics are illegal and not FDA-approved, it would be inappropriate for any clinician to recommend them at this point. However, we still have an ethical responsibility to communicate candidly with patients who are interested in exploring these drugs or are currently using them. The goal is to help people make smart choices that take the emotional and physical risks of all available treatments into account.”

Cautionary tales

First and foremost, Dr. Barnett discourages patients from using any mind-altering substance alone. “It bears repeating that psychedelics can produce dramatic effects that can sometimes be frightening and even dangerous without the right safeguards in place – and that includes having trained professionals nearby to provide support and guidance,” he says.

Patients under the influence of mind-altering substances can also be at particular risk of sexual abuse and assault, especially when the drug is being taken in an illicit or “underground” environment without formal supervision, says Dr. Barnett.

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In addition, hallucinogens can precipitate modest but predictable increases in blood pressure and heart rate. Although these effects are benign in most people, they can be potentially life-threatening for those in poor cardiac health (e.g., a history of stroke, cardiac surgery or myocardial infarction).

Ibogaine, a psychoactive substance under examination for its ability to treat drug addiction, appears to pose a particularly high risk of cardiac problems because of its propensity to prolong the heart’s QT interval. Ayahuasca, a potent hallucinogenic brew, can lead to serotonin syndrome in patients taking certain serotonergic medications, including SSRI and SNRI antidepressants. Additionally, psychedelics can trigger mania or psychosis in people at risk for serious mental illness, such as bipolar disorder and schizophrenia.

“There are multiple case reports of patients dying after taking psychedelic substances they’ve purchased online or in countries where they are less regulated,” says Dr. Barnett. “Fatal outcomes are uncommon, but they do happen. It’s crucial to stress that proper medical screening prior to taking a psychedelic can reduce the chances of a negative outcome.”

Bright but uncertain future

Although burgeoning research has found promise in psychedelics for the management of certain psychiatric conditions, the future legal landscape for these compounds remains unclear, he explains.

“There is good evidence to suggest that psychedelics will eventually be helpful for patients with certain hard-to-treat mental health disorders, but we still have much to learn,” Dr. Barnett adds. “I don’t anticipate public interest in these drugs slowing anytime soon, so clinicians have a growing responsibility to understand their implications and risks. But perhaps more importantly, we must be prepared to discuss these complicated issues with our patients – without judgment but with a sober warning about the unanswered questions that remain.”

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