The era of psychedelic medicine may have arrived.
On February 3, Australia's Therapeutic Goods Administration announced that, beginning July 1, 2023, authorized psychiatrists would be able to prescribe medicines containing psilocybin and the synthetic drug MDMA (known as ecstasy) to treat certain mental health conditions, including depression and post-traumatic stress disorder. Australia thus became the first country to officially recognize psychedelic substances as medicines.
For many patients with specific treatment-resistant mental illnesses, the decision is a welcome response to the current lack of treatment options. Advocates are hopeful that this is the first step of many to expand the use of psychedelics to other countries and to treat a range of conditions, from alcoholism to obsessive-compulsive disorder.
For life and health insurers, the implications could be profound. As the need for mental health services and associated insurance coverage increases, the quest for solutions becomes more urgent. Psychedelics may be part of the solution. (Note: This article focuses on non-synthetic, natural substances vs. synthetics like MDMA.)
Psychedelic substances, commonly called hallucinogens, are psychoactive compounds that occur naturally in plants or are made synthetically in a laboratory. At specified dosages, they can cause a person to hallucinate and can affect a person鈥檚 thinking, mood, sense of place and time, and bodily control. Psychedelic plants have been used for centuries and were traditionally consumed during sacred ceremonies. Today, many botanicals that contain hallucinogenic substances, such as ayahuasca (dimethyltryptamine/DMT), 鈥渕agic mushrooms鈥 (psilocybin), peyote (mescaline), and salvia divinorum (salvinorin-A), are used as alternative treatments for conditions such as anxiety, stress, depression, substance addiction, and pain.
Lysergic acid diethylamide (LSD) is probably the best-known synthetic psychotropic substance (drugs that affect the mind). LSD became popular in the 1960s but was subsequently designated a Schedule I drug by the U.S. Drug Enforcement Agency (DEA) in 1968. Schedule I drugs are defined as those with 鈥渘o currently accepted medical use and a high potential for abuse.鈥1 They include synthetic 2C-B (2,5-dimethoxy-4-bromophenethylamine), DMT, mescaline, and psilocybin.2
The European Monitoring Centre for Drugs and Drug Addiction, which follows the U.N.鈥檚 system, lists psychotropic substances, such as 2C-B, DMT, LSD, mescaline, and psilocybin, as Schedule I substances, noting that such drugs present 鈥渁 high risk of abuse, posing a particularly serious threat to public health which are of very little or no therapeutic value.鈥3
The Global Drug Survey 2021, based on data from over 32,000 people in 22 countries, showed that lifetime use and last year use of psilocybin (鈥渕agic mushrooms鈥) was 33.4% and 15.7% respectively. For DMT, a substance found in ayahuasca, respondents reported lifetime use at 8.9% and last year use at 4.3%. By comparison, cannabis tetrahydrocannabinol (marijuana), which is not a psychedelic, was by far the most popular drug with lifetime use and last year use of cannabis tetrahydrocannabinol reported at 74.5% and 57.4%, respectively.4
Figure: Rates of global drug use (%) 2021 by category4
The 2019 U.S. National Survey on Drug Use and Health estimated 1.9 million Americans aged 12 and older had used hallucinogenic substances within the past month, akin to the level of misuse of pain relievers, cocaine, and tranquilizers/sedatives (2 million each). Past-year users of hallucinogens totaled 6 million, higher than tranquilizer or sedative misuse (5.9 million), or cocaine use (5.5 million). Hallucinogen use among people aged 12 and older increased from 1.8% in 2015 to 2.2% in 2019, and among adults aged 26 and older, it increased from 0.8% in 2015 to 1.5% in 2019.5
Ayahuasca is a psychedelic tea made from the leaves and stalks of two plants native to the Amazon region. The leaves of the Psychotria viridis shrub contain N-N-dimethyltryptamine (DMT), a potent psychedelic substance, while the stalks of the Banisteriopsis caapi vine contain monoamine oxidase inhibitors (MAOIs) called beta-carbolines, which stop the breakdown of DMT.
Effects are normally felt within the first hour of consumption and can last up to six hours. Although not known to be addictive, high doses of DMT can cause seizures, respiratory arrest, and coma, as well as adverse reactions for users with pre-existing psychological conditions. Although DMT is a controlled substance in the U.S., the U.S. Religious Freedom Restoration Act permits its use at modern-day ayahuasca churches. The DEA and the U.S. Food and Drug Administration (FDA) also permit clinical research of the substance.
Purportedly, DMT has several health benefits, such as increasing blood flow to the brain and improving memory and emotional wellbeing. A 2017 study in mice found that beta-carbolines may have neuroprotective and cognitive-enhancing effects by reducing inflammation and anti-oxidative stress. A small study in humans showed that taking ayahuasca once a week for four weeks was as effective as an eight-week mindfulness course.6
Peyote is a small, button-shaped cactus native to parts of southern U.S. from which the psychedelic substance known as mescaline is extracted. Upon consumption, mescaline targets the serotonin receptors in the brain responsible for the psychedelic effects. Like ayahuasca, mescaline is a controlled substance allowed for use in sacred ceremonies.
Traditionally, mescaline has been used to treat pain, skin conditions, and wounds such as snake bites. Peyote can be dried and eaten, boiled to make tea, or taken in capsule form. The effects of mescaline can occur within one hour and last for up to 12 hours 鈥 twice the length of DMT.6
Psilocybin is a naturally occurring substance found in more than 180 types of mushroom species. After consumption, psilocybin converts to psilocin, the chemical that causes hallucinations. Mind-altering effects are usually felt within 30 minutes when eaten. When consumed as a liquid, the effects begin within five to 10 minutes and last from four to six hours. While recent studies have reported a range of positive cognitive effects (see Psychedelic Therapy section below), adverse effects, particularly at high doses, include panic attacks, severe flashbacks, and persistent psychosis.7
Salvinorin-A, derived from the herbal mint plant Salvia divinorum, which is native to Mexico, is a potent, naturally occurring hallucinogen that activates specific opioid receptors in the brain. It is sometimes referred to as Diviner鈥檚 Sage, Ska Maria Pastora, or Seer鈥檚 Sage. Users can purchase the drug in various forms, such as leaves, tinctures (liquids), and quids (compressed salvia), and it can be smoked, vaporized and inhaled, chewed, or brewed as tea.8 Effects, which include anxiety, amnesia, hallucinations, uncontrolled body movements, time distortion, and higher body temperature, arise within two minutes after smoking and can last 20 minutes. At present, Salvinorin-A is not identified as a controlled substance by the U.S. or the U.N., but the DEA labelled it a 鈥渄rug of concern鈥 in 2004 and it is presently illegal in some U.S. states.1
Psychedelic therapy is the use of hallucinogenic substances to improve focus, concentration, and energy or to treat health conditions such as anxiety, stress, depression, pain, and substance addiction. This type of therapy, which has yet to be sanctioned by most governing bodies, can be offered as a one-off treatment or through microdosing, where regular intake of lower doses is designed to avoid significant alteration of consciousness. Most individuals microdose with LSD or psilocybin, but 7.4% use DMT, 5% use 2C-B, and 3.4% use mescaline.4 While scientific interpretation of microdosing varies, the European Medicines Agency (EMA) and the FDA define a microdose as 1% of the pharmacologically active dose, up to a maximum of 10 micrograms (碌g). Therefore, a psychedelic microdose would be 5-10% of a usual psychoactive dose.9
Most psychedelic therapy research has focused on psilocybin. As of February 9, 2023, there were 115 interventional clinical trials studying psilocybin as a treatment for conditions such as post-traumatic stress disorder (PTSD), depression, personality disorders, and substance addiction.10 Psilocybin appears to allow nerve cells to form new connections in the brain by increasing the size and number of dendritic spines, structures that extend from nerve cells and receive information from other cells, potentially providing cognitive benefits.11
In November 2022, a large phase IIb clinical trial of 233 adults with treatment-resistant depression showed that participants taking a single 25 mg dose of psilocybin reduced depression scores significantly more than the control group taking a 1 mg dose over a period of three weeks. Participants were given one dose (10 mg or 25 mg) of synthetic psilocybin in a controlled environment, resulting in hallucinogenic effects lasting six to eight hours. The response rate was 37% in the 25 mg group, 19% in the 10 mg group and 18% in the control group. However, adverse events such as headache, nausea, and dizziness occurred in 179 participants and were higher in the 25 mg group. Larger and longer clinical trials are thus required to evaluate the efficacy and safety of psilocybin in the treatment of depression.12
The use of psychedelic substances is growing in popularity, with hallucinogenic drugs being used to improve concentration, mental health, decrease pain, and reduce substance use. Although it is still considered an experimental treatment in most instances and requires more research, psychedelic therapy is showing promising results. Australia may be the first of many countries to recognize psychedelic substances as medicine. Insurance professionals involved in medical assessment should therefore familiarize themselves with the negative as well as positive consequences increased use of psychedelics may have on human health.
