Should Physicians Decide Who Gets to Use Psychedelics?

If MDMA and psilocybin move from schedule I to prescription status in the next decade–and there’s good reason to think they will–obtaining the drugs will require going to a doctor and using them in a controlled setting.

In the new issue of Drug Science, Policy and Law, the University of Amsterdam’s James W.B. Elsey argues that while the medicalization of psychedelic drugs makes sense from a health care perspective, “the nebulous boundary between treatment and enhancement, and indeed between religious and personal discovery or spiritual uses, raises problems for the clarity of law”:

For example, is a person who has used a psychedelic to try and gain insight into their non-clinical levels of anxiety considered to be self-medicating, or enhancing their self? Is this use to be considered wrong purely by virtue of being outside of a healthcare setting and therefore illegal? Moreover, the distinction between treatment and enhancement does not track any meaningful change in the cost to society that the law is aimed at protecting, nor benefits that might be gleaned by the individuals that make up society.

Creating medical and religious exemptions for psychedelic use leaves a large swath of potential beneficiaries overly reliant on the black market. In lieu of stopping there, Elsey suggests the creation of a regulatory framework in which “[p]roduction, purity, and sale of the drugs could be monitored and controlled, and tax revenue could be increased.” He also suggests that the same certification process required to administer psychedelics in a clinical setting could be adapted to recreational settings.

While libertarians will find Elsey’s argument old hat, I think he’s underestimating the potential for medicalization to eventually make psychedelics broadly available.

Consider amphetamines and testosterone: Both are controlled substances that are available via prescription, which means regulatory bodies consider them more dangerous than antibiotics, but less dangerous than, well, psychedelics.

Despite being controlled substances, they are both relatively easy to acquire for those willing to kowtow to a physician and shell out the cash commanded by pharmaceutical companies.

I spoke to several doctors while writing my testosterone piece and several more after it came out. None of them said they were prescribing the drug for performance enhancement reasons. But the criteria for prescribing testosterone is so broad and vague–Are you tired? Less strong? Is your sex life not what it once was?–that it’s incredibly easy to get a prescription. (Not to mention, many medical professionals who oppose expanding access to TRT believe many doctors are essentially enhancing perfectly healthy patients.)

The huge increase in adults using ADHD drugs, meanwhile, suggests doctors are essentially writing prescriptions for performance enhancement in the workplace. They won’t ever cop to that, because you can’t bill an insurance company for enhancing a person’s ability to do the white collar equivalent of shit work. But in quite a few medical practices, getting a prescription for Adderall or Vyvanse is as easy as parroting the text at the end of the ad you saw for it on TV.

The indications for these drugs haven’t expanded that much since they came to market; one ADHD drug is now indicated for binge-eating disorder, and many physicians want testosterone indicated for aging, rather than just testosterone boosting. But they have proven safe enough over time in ever-expanding patient populations that more doctors are willing to prescribe them to people who barely fit the indications. As a result, Americans now legally buy billions of dollars worth of amphetamines and testosterone replacement therapy each year.

While this gatekeeping is essentially a form of welfare for physicians and pharmaceutical companies, the flip side of that tradeoff is safe access and safe drugs. You don’t have to worry about getting caught in a sting when you pick up your Adderall prescription at Rite Aid, or injecting a mystery concoction when you take your TRT.

It may take a decade or two, but I suspect we’ll get there with prescription psychedelics.