Opinion: Oregon’s sketchy framework for psilocybin program portends a new implementation disaster
Published: Aug. 13, 2023, 6:15 a.m. Original article in Oregon Online
By Brian Holoyda
Holoyda is a forensic psychiatrist who evaluates prisoners in the Oregon Department of Corrections and lives in Denver. He recently published a commentary piece on Oregon’s psilocybin program in the Journal of the American Academy of Psychiatry and the Law.
In November 2020, Oregon voters passed Ballot Measure 109, which legalized the administration of psilocybin – a chemical found in “magic mushrooms” – at supervised, licensed facilities in the state. The associated statute, ORS 475A, explained the rationale for the measure as an effort to combat the state’s mental health and addiction crises, noting Oregon’s high prevalence of mental illness with “one in every five adults in Oregon … coping with a mental health condition.” The implication, offered without evidence, was that psilocybin might help this state of affairs.
Unfortunately, that unsupported assertion is only the tip of the iceberg when it comes to the state’s ill-informed approach to implementing Measure 109. The program set up by the state allows facilitators with no mental health or medical training to conduct psilocybin sessions, ignores best practices in this emerging therapy and fails to adequately consider the serious risk that clients may face. With psilocybin services now starting to be offered, Oregonians may soon bear the price of the state’s poor implementation of this experimental ballot measure.
Psilocybin is a psychedelic compound capable of fundamentally altering an individual’s conscious experience, affecting one’s emotional, cognitive and perceptual processes in ways that can be splendid, revealing or even transcendent – as well as frightening, nerve-racking or terrifying. As part of the so-called “psychedelic renaissance” of the last few decades, there has been a renewed interest in the potential benefits of psilocybin to treat mental health disorders, following a moratorium on research after psychedelics were classified on Schedule I per the Controlled Substances Act of 1970.
For example, one recent clinical trial found that two doses of psilocybin were as effective for moderate-to-severe depression as treatment with the standard anti-depressant escitalopram. There remains insufficient evidence regarding the safety of psilocybin, however. In addition, clinical trials have been extremely exclusionary in selecting participants, so there is little data on the effect of psilocybin in real-world populations of patients with psychiatric disorders.
Though it may seem unwise for a state to legalize the administration of an insufficiently researched, unpredictable drug without any established protocols for recommending or administering treatment, Oregon’s framework is particularly alarming. Most research on psilocybin has involved “psilocybin-assisted psychotherapy” in which one or two trained professional psychotherapists support a patient during the psilocybin experience, which can be challenging and destabilizing.
Oregon, however, has established a licensure pathway for “psilocybin facilitators” without requiring any medical or mental health training. In fact, the only education required is a high school diploma; a 120-hour course that includes instruction on irrelevant topics including history and cultural equity; and 40 hours of in-person training. Potential psilocybin users must review a mandatory “informed consent” document with these woefully ill-prepared facilitators and write their initials next to 30 bullet points, one of which reads, “I understand that psilocybin services do not require medical diagnosis or referral and that psilocybin services are not a medical or clinical treatment.” So much for the Oregon Legislature’s lip service to its mental health crisis.
At the point of administration, a psilocybin user self-doses the drug and then sits with the facilitator, who is expected to “utilize their training to distinguish between typical side effects of consuming psilocybin and medical emergencies.” How a person with no health care background should be able to distinguish between medical emergencies and the effects of a mind-altering drug is unclear.
Oregon’s psilocybin policy poses serious risk in other ways, as well. Individuals who may be predisposed to a negative psilocybin experience (or a “bad trip”), such as those with psychotic disorders, severe mood disorders, or personality disorders, will have ready access to the drug and some may have long-lasting negative effects from receiving it. In a recent study of individuals with self-reported bipolar disorder, 32% described unwanted outcomes, including increasing manic symptoms, during or within 14 days of a “full psychedelic journey” from psilocybin.
Notably, Oregon does not restrict individuals with bipolar disorder from receiving psilocybin – nor would facilitators necessarily know, since it is up to clients to share their medical information. For those who do have a bad trip and develop agitation or aggression, the facilitator is legally allowed to provide only supportive touch, or touch “limited to hugs or placing hands on the client’s hands, feet or shoulders.” Any further efforts to restrain an agitated person intoxicated with psilocybin could foreseeably lead to allegations of battery. Someone having a bad trip who attempts to stand or leave the facility will likely be able to do so, potentially placing other clients, staff and the general public at risk.
I suspect that Oregon is not ready for the onslaught of lawsuits likely to stem from the harm inflicted on vulnerable people because of its misguided policy. Instead of targeting Oregon’s mental health crisis by providing mental health services, the state legalized the recreational use of an unapproved, unpredictable and consciousness-altering drug overseen by high school graduates with no legitimate professional training. The threadbare framework developed by the Oregon Psilocybin Advisory Board makes it clear that the psychiatric justification for the measure was just that: a cynical rationalization.
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This response appeared today in Oregon Live. Apparently submitted by an anonymous reader. I (Sonoramo) am not the writer of this published opinion, though I agree with it entirely. The last paragraph is behind a paywall; it is recovered by examining the article server's unparsed response text. Reply link
Updated: Aug. 27, 2023, 6:03 a.m.
I have a few points to make regarding the recent op-ed on Oregon’s system for psilocybin treatment, (“Opinion: Oregon’s sketchy framework for psilocybin program portends a new implementation disaster,” Aug. 13).
First, we have no idea how this is all going to play out, so sounding the alarm is premature.
Second, the treatment centers can provide screenings and post-journey referrals to mental health specialists to help clients process what they experienced.
Third, as a licensed counselor myself, I’m thrilled that the psychiatric profession is not in control of this whole thing. Psychiatry has its place, but that place doesn’t include “We get to control everything humans do to alter their mental state.” If it did, all bars would have mandatory psych screenings at the door.
And fourth: Reality. Lots of people are doing mushrooms and other psychedelics anyway. At least the Oregon centers will provide safe places for the experience with supportive people to assist. The people who wrote the Oregon law did it thoughtfully and over a long time, and it’s going to be a model for other states. I congratulate the pioneers who are starting these centers.
Edited by sonoramo (08/27/23 08:44 PM)
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