The year is 2035. The weekend is looming. You're thinking maybe some fun down at the beach with friends is on the cards. It's not really looking like an alcohol-fueled gathering so instead of going to the liquor store you swing by a psychedelic clinic to pick up some psilocybin, or maybe MDMA. Before you buy your drugs for the weekend you flash your license, which allows you to buy small quantities of several different kinds of psychedelics.
This vision of a future where psychedelics are legalized comes from Rick Doblin, founder of MAPS (Multidisciplinary Association for Psychedelic Studies), an organization that has been working for nearly 40 years to re-legitimize psychedelics. Doblin's strategy has been to slowly and fastidiously prove certain drugs considered by government agencies to be harmful and addictive are actually safe and beneficial in medical contexts.
Doblin has primarily focused on research with MDMA, first eliminating the myth that the drug is toxic to humans and then embarking on clinical work demonstrating how it can be used to treat post-traumatic stress disorder (PTSD). While Doblin's MAPS work is ostensibly geared toward the very specific goal of getting FDA approval for MDMA-assisted psychotherapy for PTSD, in actuality this is just one part of a much larger project aimed at changing the public's perception of "illicit" drugs.
The mantra here is "medicalization leads to legalization." The idea is that once previously taboo substances such as MDMA and psilocybin become approved medicines, and the general public begins to see others successfully and safely using these drugs, there will be a natural movement towards broader community access.
"We have roughly 10 to 15 years of thousands of psychedelic clinics being set up all over," Doblin said in a recent interview. "And these clinics eventually are going to be for people that work with ketamine, with MDMA, with psilocybin. Once you see all of those, people get comfortable and they start hearing stories of people getting better, then their attitude starts changing. And then 2035, they end prohibition of psychedelics and have what we call licensed legalization."
But could it be as simple as that? Will turning MDMA and psilocybin into clinical medicines for certain conditions automatically lead to widespread legalization, or even basic decriminalization? Or could going down a pathway of medicalization actually hinder work to end drug prohibition and make broad equitable community access to these substances even more difficult?
Mainstreaming psychedelics
The so-called "psychedelic community" is a broad church. Neuroscientists, crystal-healers, psychonauts, social justice activists, psychologists, plant-heads, anthropologists, and drug reform advocates all play a part in the community. And what gels this stunningly disparate group of people together is a shared belief in the value of psychedelic drugs. A belief that more than half a century of drug war prohibition has caused immense harm, criminalizing users and perpetuating misinformation.
But within the community there are major divisions – disagreements over how we reach a world where drug use is not criminalized and everyone is free to use psychedelics for healing, spirituality or personal growth.
Over the past century the outlawing of different drugs have often followed the same playbook, be it cannabis in the early 20th century, classical psychedelics in the 1960s and 70s, or MDMA in the 1980s. A drug first became prevalent in certain subcultures and then the government moved to restrict access to those substances by portraying them as harmful and addictive.
In the United States the modern war on drugs really kicked up a notch in 1970, with the passing of the Controlled Substances Act. This is the classification structure that places drugs into one of five different "schedules."
Perhaps the most well-known is Schedule I, which means a drug is completely outlawed for any kind of use. For a drug to be placed in Schedule I it needs to fulfill three criteria: it must have a "high potential for abuse," it must have no accepted medical use, and it must be fundamentally unsafe for human use, even under medical supervision.
All classical psychedelics (LSD, psilocybin, mescaline, DMT) are listed as Schedule I drugs. And this scheduling strategy, along with the establishment of the Drug Enforcement Administration (DEA) in 1973, criminalized all uses of these drugs in the United States, while also freezing all clinical and scientific research.
So, a new generation of psychedelic advocates arose in the wake of the 1960s counterculture movement and looked strategically at how to bring psychedelics back into the mainstream. And, as MAPS' Director of Policy and Advocacy Ismail Ali explained back in 2018, one crucial tactic was to scientifically establish the medical value of psychedelics.
"Despite the fact that paltry scientific evidence was presented or sought to justify their criminalization when psychedelic substances were originally outlawed, the only way, besides Congressional intervention, to take them out of Schedule I – the most restrictive category – is to prove to the FDA that they are, in fact, safe for humans to take, have medical value, and are not as prone to abuse as originally asserted," Ali noted. "In other words, the effort to destigmatize and legalize psychedelic substances via medicalization is a deliberate and strategic response to the original, flawed justification behind criminalization."
For quite literally decades, scientists have slowly and onerously worked to bring psychedelics back into the mainstream. MAPS' work with MDMA first established the drug was safe in animals, before painstakingly moving through multiple phases of clinical work, showing it to be non-toxic in humans and then therapeutically effective in treating PTSD.
And across many steps of this process the psychedelic community mostly cheered in unison. After so many years in the wilderness, for many it was genuinely thrilling to see legitimate clinical research published in credible scientific journals espousing the benefits of psychedelic drugs.
But as this medicalization strategy progressed, certain regulatory issues became more pressing. For example, what exactly does a world with MDMA-assisted psychotherapy look like? How are therapists certified to deliver the treatment? Who is allowed to administer these drugs and where can they be given? The idealistic suggestion that medicalization would just automatically lead to equitable access or broader decriminalization suddenly seemed less realistic, and much more complicated.
It's gonna be just like cannabis ... maybe
Sam Douglas is an academic philosopher and president of the Australian Psychedelic Society (APS). Part of his work with the APS is to advocate for the decriminalization of psychedelics and break stigmas associated with psychedelic use.
While Douglas, and the APS, strongly support psychedelic clinical research, he is wary of the idea that medicalizing these substances will automatically lead to broader community access. In fact, Douglas suggests there are many other drugs, such as ketamine, with proven medical uses that haven't been decriminalized or legalized.
"If it were always true that medicalization led to broader legalization I could just pop down to the dispensary and buy myself some recreational morphine, right, or ketamine," Douglas said to New Atlas. "That connection between medicalization and broader legalization, clearly it's not automatic."
The big example often cited by psychedelic medicalization advocates is the story of medical cannabis in the United States. In a 2021 keynote address at Harvard Law School launching a new research initiative focusing on psychedelic law and regulation, Rick Doblin explicitly laid out the analogy between medical cannabis and medical psychedelics.
Showing 50 years of polling data tracking American opinions on legalizing cannabis, Doblin suggested public sentiment for legalization began to grow from 1997 onwards. What happened in 1997? California and Arizona passed the country's first medical cannabis laws.
"So the rise of medical marijuana tracks the rise in support for marijuana legalization," Doblin said. "I think medical use gives people access to stories of people that it's helpful for. It changes their risk-benefit analysis."
Sam Douglas is a little skeptical of the idea that medical cannabis directly paved the way for broader recreational legalization. He used to think these two pathways were interlinked but nowadays he is not so sure.
"Now, looking back, I wonder is this the wrong analysis of what actually happened?" Douglas asked. "Was it already that groundswell of support for recreational access was just so strong?"
Part of Douglas' skepticism over the cannabis analogy comes from his experiences in Australia watching a highly politicized and convoluted medical cannabis roll-out over the last decade. He believes politicians and regulatory bodies in Australia saw the possible connections between medical cannabis and recreational legalization in the United States and explicitly crafted policies to make sure the same thing didn't happen.
"My personal opinion is the politicians and regulators here watched what happened in Oregon and California, and went right, we have to allow medical access to cannabis but we're going to do our best to deliberately create a system that will never ever lead to that same outcome with recreational cannabis," said Douglas. "It's bureaucratic, it's tedious. It's so tightly controlled. It's made to be as difficult and as expensive as possible."
The both-and strategy
About four years ago Tehseen Noorani, an honorary research fellow in anthropology at Durham University, wrote an article highlighting some ways the medicalization of psychedelics could hinder efforts towards decriminalization or legalization. Noorani's article proved surprisingly prescient, highlighting a tension in the psychedelic community that has only become more prominent in the intervening years.
One of Noorani's concerns in the article surrounded the implications of turning psychedelic drugs into pharmaceutical medicines. By creating a clinical "set and setting" for psychedelic use that is considered safe and proper the process of medicalization inherently generates a binary that then implies other uses are improper, illicit, unsafe, or irresponsible.
"In providing frameworks for 'proper use,' medicalization delineates the conditions of 'abuse.' Clinical trials are generating findings with no wider ecological validity than the highly demarcated use of a highly rarified grade of a specific psychedelic substance," Noorani writes in the article.
So while the process of medicalizing psychedelics can certainly lead to broader therapeutic access for many people, it also does little to embrace the vast alternative suite of uses that many cultures and communities have developed over the years. In fact, turning psychedelics into clinical medicines could amplify vilification of other uses.
From the perspective of a general public entrenched in a Western healthcare model, "medicines" are to be only used in strictly controlled, clinical environments supervised by doctors or trained therapists. You take medicine when you are sick. Medicines are not to be used recreationally and medicines are never "fun."
Noorani's suggestion is a parallel pathway strategy where both medicalization and decriminalization are pursued alongside one another. This both-and strategy cannot counter all the concerns surrounding psychedelic medicalization, but it can be one way to ensure there is a plurality of psychedelic experiences presented to the public as these drugs move into the mainstream.
Out of the shadows and into the Colorado light
Until recently these debates within the psychedelic community have remained largely philosophical. However, as both MDMA and psilocybin clinical studies reach the final stages of human trials, and FDA authorization looms, the hard reality of psychedelic medicalization has hit home. And activists around the United States are working fast to introduce legal frameworks to try and steer things in certain directions before the medicines are approved.
But, unsurprisingly, not everyone agrees on what the "right" direction is for mainstreaming psychedelics. This acrimony within the psychedelic community perhaps reached its most public flashpoint in Colorado this year, ahead of the upcoming November midterm elections.
Citizens in the state of Colorado will soon vote on a ballot measure called the Natural Medicine Health Act (NMHA). The ballot measure requires the state to develop regulatory structures that will allow people over the age of 21 to have access to clinical psilocybin therapy by late 2024 or early 2025.
Beyond simply suggesting a roll-out of regulated psychedelic clinics in Colorado, the NMHA presents a robust assortment of addendums to try and maintain equitable access to these treatments. For example, as a way of keeping big business from monopolizing the space no single corporate entity will be allowed to run more than five clinics. Plus, subsidized access to these treatments is hoped to reduce the costs for low-income communities.
Alongside the introduction of regulated psychedelic clinics, the NMHA embraces the spirit of a both-and strategy by decriminalizing personal possession, growing, sharing, and use – but not sale – of naturally occurring psychedelics, including mushrooms containing psilocybin.
The NMHA is inarguably the single-most progressive drug reform bill ever put to a public vote. But it also has revealed deep divisions in the psychedelic community, with several prominent activists loudly campaigning for people to vote against it.
Those against the NMHA argue the focus of the act is to place control of psychedelic medicine into the hands of corporate interests. Matthew Duffy, co-founder of the Society for Psychedelic Outreach Reform and Education (SPORE), has urged Coloradans to vote against the measure claiming the act, "puts profit over people and commercialization over the community."
"The NMHA is a corporate power grab, setting a corrupt foundation for the future of medicine stewardship in Colorado," Duffy wrote in a recent Denver Post editorial. "The people who stand to benefit the most from the NMHA will be those who have the power and capital to set up shop in Colorado, selling “healing” and “transformational experiences” to anyone around the world willing to travel to Colorado for licensed psychedelic services."
Those against the NMHA also criticize the act's vague language around decriminalization. While personal use provisions are addressed in the act, there are no strict amounts specified, leading to potential problems for community groups that may want to nurture broader sharing models involving larger volumes of psychedelics.
A more straightforward decriminalization proposal was originally presented by some in the psychedelic community. The proposal, dubbed Initiative 61, was one page and straight to the point. It proposed decriminalized possession, use, cultivation, production, and sharing of all natural psychedelics. Period.
It didn't gather enough signatures to ultimately reach the ballot at this upcoming November election.
This is the "boring and hard" part
Addiction counselor, psychotherapist, and drug reform advocate Kevin Franciotti is sympathetic to the concerns of those against the NMHA. But he says the irony behind decriminalizing everything without any plans for regulatory pathways means it is just as possible for corporate interests to flourish in that kind of unregulated landscape.
"[Complete decriminalization] doesn't set up any kind of system for any oversight of anything," Franciotti told New Atlas. "So who's to say that all of the concerns about things like big business, and cultural appropriation, and extractivism, would not loom large and run amok in that kind of regulatory landscape?"
David Bronner is a philanthropist who has invested millions of dollars in organizations supporting drug policy reform and development of psychedelic clinical medicines. One of Bronner's organizations is a lobby group called New Approach, which played a significant role in the crafting of Colorado's NMHA.
Bronner argues the problem with a decriminalization-only approach to drug reform is that if you want to deliver these psychedelic therapies in modern medical contexts then you need to establish regulatory pathways to integrate them into pre-existing medical systems. He suggests most Americans will only feel comfortable accessing psychedelic medicines if they are offered within regulated and familiar frameworks.
"Most psychedelically-naïve people want professionally trained, licensed, and accountable facilitators working in clinics and settings that look and feel like what’s being done at John Hopkins and NYU," Bronner explained. "Through data gathering in a professionalized delivery of care model, we can show psilocybin therapy is a cost-effective intervention in depression, alcoholism, cluster headaches, end-of-life anxiety and numerous other conditions, and eventually get Medicaid and Medicare to cover, along with private insurers."
Franciotti sees the real hard work actually beginning with the passing of a bill like the NMHA. Public health educators and harm reduction providers will face a huge burden making sure the general community is given the right information as these drugs become increasingly accessible. Especially with a both-and approach meaning someone looking to experiment with psychedelics would plausibly have a choice between going to an accredited psilocybin psychotherapist or finding some magic mushroom through a local community group and trying it alone. Pushing back against commercial interests and educating people how to safely engage with psychedelic experiences is going to be a huge challenge but Franciotti is still excited.
For years those in the psychedelic community fantasized about a world where these substances were not criminalized and more accessible. And according to Franciotti, now that we are closer to that goal the tough, boring regulatory work is beginning. It's not fun, he notes, but it is the only way forward.
"We've had these fever dream conversations, and moments of profound joy anytime a clinical trial gets rolled out and makes huge positive headlines all throughout the world, only to arrive at the point where we're having these boring, hard conversations, it sucks. But it's super important. We need to do it."
"And ultimately, this is what we've been working at. Yeah, it would be lovely to not have to deal with any of it. And those of us who are hip to how to have a good time and how to stay safe, sure, to see that all potentially be threatened is unfortunate. But in the grand scheme of things it's the necessary next step."
