Should Physicians Decide Who Gets to Use Psychedelics?

Medicalization means kowtowing to gatekeepers in exchange for safe drugs.


Good luck controlling access to stuff that grows in cow dung. PHOTO CREDIT: Scienceman71/WikimediaCommons

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 creating 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.

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  1. 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?

    *** takes deep breath ***

    Which interpretation yields more revenue?

    1. To the prison guards union? Throwing you in jail, of course!

      1. “Got your ‘self-enhancement’ right here!”

    2. It won’t be lsd. A typical 45 minute session leaves the patient on his own too soon afterwards, with much to explore and such a short time frame would be unethical in my estimation. A psychiatrist needs to set aside maybe the full afternoon, with some entertainment on the front end that guides towards some introspection. Lsd is sometimes an amplifier – if a patient is fixated on negative thoughts when it kicks in [or worse has psychotic issues], that gets bigger and there is alot of work in steering them away from the negative and they cannot be abandoned in that condition.

      1. I can tell you I needed supervision just forever!
        Or not.

    3. Forgot “…or engaging in quasi-mystical quackery.”

  2. I sure hope you are reading the tea leaves correctly on MDMA and psilocybin. It would be a trip itself watching all the sploding heads.

  3. The potential consumer of the psychedelic should be the one to decide.

    But, if we’re going to be paternalistic, the doctor deciding is a lot better than the government deciding.

    1. There is suspicion in Austin that cattle feed is poisoned by Feds to kill mushrooms. They were everywhere in the 1970s, and have since grown rare as hen’s teeth.

      1. Hank, how many tin-foil hats do you own?

  4. and many physicians want testosterone indicated for aging

    Hey! I’m aging! Is anyone else here aging?

    1. Not me!

      I’m against aging.

  5. The part I hate is how gray-red and pear-shaped their condescension is.

  6. In the video, bearded guy at 0:51 has been standing there, unblinking, unmoving, for seven hours.

  7. Made into prescription drugs? Sounds good-enough to me.

    I’d prefer just decriminalizing drugs broadly, and let insurers decide under what conditions they’ll reimburse, but that’s probably not going to happen. So making it harder to be thrown in jail over “drugs”? Still an incremental state towards a better world.

    1. Grace Slick says to avoid pharma drugs on the assertion that street drugs are safer. She should know.

  8. While libertarians will find Elsey’s argument old hat

    Why do you say that? He’s making a utilitarian, not a libertarian argument. The libertarian argument is that the entire prescription control mechanism should be flushed (although I suggest there’s still room for debate in libertarian circles regarding uncontrolled anti-biotic usage and the public health risk of such).

    1. Yes, there’s an environmental pollution issue with antibiotics.

  9. We have the same problem with “medical marijuana”. Letting doctors profit from being the gatekeepers could eventually make full legalization more difficult.

    1. But it doesn’t seem to have worked that way. Med mj seems to have paved the way for rec mj.

      1. Results are mixed on that. California went from medical to legalization, but in other states, like Arizona and Maryland, the medical program seems to have become an obstacle to full legalization. We certainly can’t say that progression from medical to full legalization is the norm yet.

        1. I concur, it’s a mixed bag at best.

    2. Most doctors are just parrots for the CDC, and tend to get booted off staff if they do something innovative for fear of government retribution. They aren’t gatekeepers of much anymore, but rather a front end for federal databases and not by choice on balance. Case in point: HIPAA. We the patient actually receive zero protections under it. Nothing – those “rights” are a big fat zero. What does happen however, is that the government can land on the doctors head if he cannot provide proof of notification to the patient of our so called “rights”. As part of this coercion, parts of patient files data get shared with the government. Do you recall the move under Bill Clinton to get your doctor to ask via pre-screening “do you own a gun?” That was a political question most doctors could give a flip about, and those doctors willing to ask it were forwarding your answer.
      If we could get the government out of medicine, then your concerns about the doctor would be negligible. As a side note, most health insurance companies have become polluted by homogenizing their systems to cope with medicare standards of care – which are always behind the curve to boot.

  10. Crusty Juggler sent me a photo similar to the top one, but he only had one mushroom in his hand.

    1. Yeah, I saw that. Weird how it’s 3 times wider than long.

  11. Should Physicians Decide Who Gets to Use Psychedelics?

    They can do whatever the fuck strikes their fancy, and we have the right to tell them to go have sex with themselves or to practice their Aedipus Rex with their mothers.

  12. Didn’t read the article, answer is “No.”

    1. I read it now. I’m bothered by this arguments. I agree with them, and I understand why the arguments are phrased this wat.

      My true libertarian self still just wants to argue from a purist angle. Who are we to get in the way of what people do to themselves. If people do LSD because they like the taste, how can I tell him no?

      It’s been bothering me about the recent drug legalization talked. Everything is phrased in terms of health. And I just feel that’s not a libertarian argument. That’s still a regulatory committee decided what is good for you.

      1. Apparently there is a church in AZ where you can legally do peyote.

        Where it is, I’ll leave as an exercise for the reader.

        1. Certain tribes get permission. That would be my guess. If it is tribal, my guess is you can’t get in.

          1. It’s tribal, yes. For a long time, Peyote was banned even for religious purposes, but IIRC that was overturned within the last 20 years.

        2. Yeah, its called the Native American church.

          Its on your nearest reservation.

          And that won’t do you any good as only registered tribal members get the religious exemption and only at recognized tribal religious ceremonies.

          Palefaces need not apply.

          Unless you’re Mashantucket Pequot.

      2. I also dislike these kinds of utilitarian arguments. It’s a basic liberty issue dammit.

        I don’t have the power to tell my neighbor what to smoke or ingest, so I sure as hell can’t delegate that power to the state.

        But I’ll take what incremental progress I can get. Progressives make ‘progress’ because they always accept incrementalism.

        1. Yes. It’s definitely a good thing overall.

          I just wish there was more discussion here that included this framing of the argument as well.

      3. Yeah – the ban on psychedelics was never for health reasons, anyway. The have essentially no demonstrable physiological effect. They were outlawed because LSD freaked out the squares. Aldous Huxley predicted that that would be the outcome of Leary and Ginsburg’s campaign to publicize LSD, get it into the kids, and thereby save the world – polite society would completely freak and outlaw it.

        Now that it’s outlawed it gets shoehorned into the conversation about what should be prescription-only and what shouldn’t and for what reasons, when it just doesn’t belong in that discussion at all.

        1. The worst thing that can happen is for something to be labeled a pharmaceutical. It’s a somewhat arbitrary category anyway, as we can see by alcohols continuing special privileges.

  13. Latest Rule 34 evidence:

    “Manhunt underway for man caught ‘pleasuring himself’ during ‘The Emoji Movie'”…

    1. I can kind of understand. Emojis are big circles just like vaginas. So there’s something there.

  14. Maybe not get picked up in a sting on the way to pick up your Adderall prescription from the pharmacy. But God forbid your medicine gets stolen for it’s black market value, I have the experience to tell you definitively not to bother reporting it to the police. Take your chances screwing something up at work or falling asleep behind the wheel over getting arrested. Need that prescription pain killer swiped from your purse? Better to suffer debilitating pain at home than a jail cell.

  15. I prefer black markets, thank you.

    1. You misspelled “men”.

  16. I hope more stuff gets legalized while I’m still young and willing to do drugs

  17. Has anyone done an article on how on how christianofascist prohibitionism banned peyote and mescalin in 1929? The crumpled remains of the 13th (conscription), 4th, 5th, 6th and 10th Amendments were smoldering to ashes at the time, but the story of how it was done could sure use some daylight. Remember sovereign tribal autonomy?

    1. Remember that we won? (said the old fat white guy)

  18. “…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.”…”

    The first two have been handled pretty well without the government fro quite a while.
    The last is the reason I voted *against* weed legalization.

    1. Good thinking. Who forces the bigger markup on product: mexican drug cartels, or the federal government? A toothpick for example is worth barely a penny – unless it becomes a ‘medical device’ for some reason. Then the cost of full regs set in, and it becomes a $2 item. Apply this level of inflation, and not only does weed get more expensive, but the profit margins get slashed – the lions share goes to government by a kaleidoscope of cost punitive devices [only some of which are taxes]. It’s why… if the ACA continues to it’s logical conclusion, we might consider getting legally declared dogs in order to cut our medical costs by 80% as a means to avoid being bankrupted by corrupt pinheads and their mastermind fixations bordering on OCD.

      1. No, bad thinking. You always have the option of acting illegally, if the legal way’s too expensive.

        1. Robert|8.3.17 @ 10:39PM|#
          “No, bad thinking. You always have the option of acting illegally, if the legal way’s too expensive.”

          So the state controlling most of the production into taxed avenues won’t reduce supply and drive up black market costs?
          Bad (or no) thinking on your part.

          1. What part of having the option to act illegally don’t you understand? How does the state control more prod’n & reduce supplies when the only prod’n they control is that which is legal?

            The only way your idea would make sense is if people are irrational, taking more costly options.

  19. Good luck controlling access to stuff that grows in cow dung

    Goddamn hippie trespassers !

  20. Putting aside the laugh-ability of governments naming banned substances as “controlled” [whilst they abdicate distribution to unqualified and sometimes ruthless black marketeers], something very real is touched on during the interview: linear thinking. It’s been many years since I read the material, but electrically speaking, linear activity in the brain is highly abnormal. In fact, it’s the stuff epilepsy is made of, and is seen during seizures. Because of the apparent electrical randomness of a healthy brain, one other thing should be pondered: can thought even be measured by electrical activity? I suspect the answer is no, but since there is so much unknown about the brain, stuffing politically unpleasant parts of science into a closet and barring the door is likely more reprehensible than a wilful rectal cranial inversion. Of further interest is the apparent “breakdowns” of structure he describes with lsd present: is this perhaps the event people describe as “religious”, and what parallels do we find with “normal” people with full sobriety? And speaking of structure, let’s be careful – we just might need it in our daily lives, but perhaps a brief vacation is cathartic and frees us from defective self erected structure every once in a while. Your brain is not a sport, so don’t go the Timothy Leary route and treat psychedelics with the glibness of your tv remote.

  21. Should Physicians Decide Who Gets to Use Psychedelics?


    1. Think I found the “single issue.”

  22. Not only that, but what about birth control, hair growth, and penis erection pills? Nobody even pretends prescribing pills for birth control is anything other than interfering with normal fx, although the same meds can also be used to treat illnesses. For that matter, what about cosmetic surgery?

    1. Plastic surgery is a strange area I think people don’t want to conflate with medicine. I like it though, because it points at the fact that we have a completely insurance free medical procedure. It is significantly less regulated than other medical areas. And it is affordable enough that people pay out of pocket.

      1. It’s almost like it operates in a free market!

      2. It’s another non-health-related thing that people go to a licensed doctor for.

  23. Interesting guy.

    It should be said that people do have very bad experiences on LSD. I dipped my toe into the psychedelic experimentation of the early 70s and among some very pleasant experiences had one nasty trip. It’s possible that in a clinical setting, with an experienced supervisor, the experience could be guided, or, in bad cases when things go wrong, be quickly terminated by another medication. But I’d worry about poor quality health providers in bad settings. This drug is very powerful.

    There is no doubt that LSD opens the doors of perception, my creativity was absolutely jump started by psychedelics, as well as my fundamental sense of reality, (or non reality) and in a good way. But I also thought I was losing my mind for about 8 hours, a trauma that can’t be unremembered.

  24. Reason’s version of Libertopia is where the peasants get to beg a rent-seeking mafia for access to Medicine


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