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When Will the Psychiatric Establishment Reject the Drug War and Embrace Psychedelic Research?

For 50 years the discussion of drugs has been polarized between drugs that are therapeutic and drugs that can be abused.
 
 
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It is clear that the cultural zeitgeist has turned towards the therapeutic use of psychedelics. Recent articles in The New York Times and CNN are slowly informing the public of the exciting research that MAPS supporters have known about for some time—that some psychedelics, even with their historic baggage, their potential for misuse, and vilified reputation, have some of  the most promising therapeutic potential that we have seen in psychopharmacology in a generation.

However, what are the attitudes of those clinicians who would be empowered to prescribe these substances, should the  FDA approve them as safe and effective therapeutic agents and the DEA reschedule them to make them able to be prescribed legally?
 
Unfortunately, the discussion around drugs in the United States, for at least the last 50 years, has largely been polarized between drugs that are therapeutic and drugs that can be abused. Even though some of our most effective psychotherapeutic  agents (e.g. stimulants and benzodiazepines) are also some of the most likely to be abused, there is a distinct discomfort that arises among clinicians when a substance, which historically has been abused, is suggested to be therapeutic.
 
Perhaps it is because, as clinicians, when it comes to substance abuse, we often only see the casualties, and this perspective has created a bias that a substance that can be abused can never have therapeutic utility (witness MDMA for the treatment of PTSD or the dramatic response to ketamine from sufferers of severe major depression). Rarely do we hear about how a drug changed someone’s life for the better. In some ways, the more esoteric the substance, the less reflexive resistance it elicits.
 
It was interesting to see attendees at last November’s U.S. Psychiatric and Mental Health Congress in San Diego stop by the understated MAPS booth in the convention hall, where it shared space with much glitzier displays for conventional psychiatric medications. Many people would ask, “What’s MDMA?” having not associated it with the cultural baggage associated with “Ecstasy.” Scientists who want to study compounds such as ibogaine or psilocybin will likely have an easier time getting past the negative biases that have accreted against more commonly used (and abused) substances such as cannabis and LSD. 
 
I would propose that the attitudes that most people have regarding psychedelics fall into one of four broad categories:
 
(1) I have tried them and they have changed my life for the better.
(2) I have tried them and was unchanged or had a negative experience.
(3) I have never tried them but have an open mind about them.
(4) I have not tried them and can only imagine they are more dangerous than helpful. 
 
I suspect that there are more than a few clinicians who fall into category 1, but feel uncomfortable sharing their experiences for fear of compromising their professional reputations. However, I suspect most mainstream psychiatric providers, having seen the negative outcomes of patient substance abuse  and influenced by 45 years of anti-drug propaganda, would ally themselves squarely with those in category 4. I suspect most people reading this Bulletin are in category 1. They are the converted. Through whatever experiences they have had, they believe in the power of these substances to serve as tools to help people towards greater health and emotional wholeness. However, most psychiatric providers have not had these same experiences, and are prone to view the elusiveness with which those in category 1 may share their experiences with a certain degree of suspicion.
 
This is why we must have data to support the assertions that these substances are therapeutic. We need to have the science that supports the theories of why these compounds can have the profound effects that they do. Data is the currency of practice change, and without it, all the tales of the converted are relegated to low grade, “anecdotal data”—interesting, but nothing that most people in a professional role would be willing to risk the sanctions of loss of license, professional status, or clinical/academic position to pursue. That’s why what MAPS is doing is so critical for changing the attitudes around these substances and the role that they can play in mainstream psychiatry. By focusing on conditions such as PTSD that suffer from a dearth of effective treatments and by generating robust research findings, their studies provide both hope for difficult-to-treat conditions and compelling data for effective treatments. 
 
Hopefully, it will be only a few short years before the data that MAPS-sponsored studies have generated can be leveraged to make these substances legal as prescribed medicine. When that day comes, MAPS would be wise to take a lesson from the more mainstream pharmaceutical industry and use marketing as a means to change attitudes and encourage appropriate use of these agents.
 
The pharmaceutical industry spent $27.7 billion dollars in 20041 to market medications because that investment was returned many times over in increased sales. MAPS has a mission that is even more important than increasing returns to stockholders: making effective medications available to patients who need them and to advance a more enlightened attitude towards psychedelics. Armed with the data from these studies, the medium of advertising can shift the attitudes of clinicians who will prescribe these medications.
 
The aesthetics of these marketing messages should reflect the controlled and sober use of these compounds for therapeutic purposes. Psychedelic imagery, for example, may appeal to those who have had positive experiences with these compounds, but may also serve to alienate a more conservative medical establishment. As important as marketing is the impact that respected fellow clinicians have on the practice patterns of other clinicians. The mainstream pharmaceutical industry has long known this, and has used “key opinion leaders” or “thought leaders” to deliver marketing talks about new drugs.2
 
Clinicians trust their peers more than a sales representative. Those who are well versed in the research findings and convinced about the benefit of these compounds can engage peers in compelling conversations about the value of these drugs. At the end of the day, stories engage, but data convinces.
 
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References: 
 
1. Gagnon M-A, Lexchin J (2008) The Cost of Pushing Pills: A New Estimate of Pharmaceutical Promotion Expenditures in the United States. PLoS Med 5(1): e1. doi:10.1371/journal.pmed.0050001
 
2. Carlat (2010) Unhinged: The Trouble with Psychiatry, Free Press, NY