Doing drugs at Davos

The elite ponder the emergence of psychedelic medicines

Photo by Fredrik Solli Wandem on Unsplash

Every year in the tiny Swiss mountain town of Davos, presidents, prime ministers, billionaires and a hefty chunk of the global elite gather to hobnob and push their agendas. The main event in town is the World Economic Forum. It is coming again soon. Don’t hurry over. For lesser mortals like you and I, it is an extremely expensive event to attend, and difficult to get into. The fringe events are easier to access. Most of the town is taken over to run hospitality shops, such as Ukraine House, or SAP House. Here PR flunkies, flanked by trays of tiny burgers on sticks, will corner anyone who crosses the threshold.

One of the more curious houses last year was in a nightclub. The Psychedelic House of Davos hosted a range of discussions around psychedelics. Most were about medical use. A few were in the eye-rolling “woo woo” realm, such as “How do we catalyze consciousness in the wake of existential crisis?” The house was hosted by an incubation venture firm Tabula Rasa and sponsored by the somewhat mysterious Energia Holdings LLC. (“We invest in, acquire, and operate companies that radically redefine the future of health.”)

It was this visit that lead me to write a story on rising corporate interest in psychedelic therapies. I’m afraid no actual drugs were consumed, at least, not by myself. Despite warnings by the organisers of the Psychedelic House that drugs were not to be consumed, it looked like quite a few folks had, ahem, catalysed their consciousness—including possibly one or two of the panelists.

The general vibe was a largely celebratory discussion of the debut of psychedelic therapies into the mainstream. Yet one question that rattled around at the end was “what is going to go wrong?” And that is a question that needs to be addressed.

Beckley Park, Oxford. 2022

Psychedelic medicines have been overhyped

Five years ago the idea that psychedelic drugs might be used to treat people with mental health conditions was a cranky idea. In fact, folks like Amanda Fielding of the Beckley Foundation in Oxford, and others, had spent decades in the wilderness just trying to get anyone to listen to the proposal. Thus the early media popularisers of psychedelic medicines had to create a strong counter-narrative to the idea that they were a stupid thing to want to take. Unfortunately, this has now been done so well we are left with an unbalanced view of their promise and potential. (This has also gone hand-in-hand with investment into the industry.)

There are many problems with the overhyping of psychedelics. One is that patients who are seriously mentally ill are being left with the impression that these drugs will deliver a radical improvement in their mental health. They can. They might. But people vary in their response to medicines, so they might not. Psychedelics seem to be tools that help people to address mental health problems. But opening a door to change does not mean that patients are able to benefit from it.

That leads to another problem—that of the durability of the treatment. The experience itself may lead to welcome short-term relief but longer-term gains only seem likely with the sort of self-development work that usually comes with psychiatric support. And, perhaps, many more trips than have been explained. Work by psychiatrists in Switzerland, who have been using assisted therapy under license for decades, suggest that the treatment of PTSD required between one and nine MDMA applications, and one to 12 of LSD. This is not a message I’m hearing from people testing these therapies, nor from media coverage.

There are other concerns. If we are selling a narrative of radical change for the desperately unwell, what does that mean for those who try psychedelics and fail? One conversation I had with a clinician and academic in ketamine-assisted therapy warned if you want to avoid making patients feel more suicidal, you need to set their expectations carefully and warn them that their treatment may indeed fail. Without this, the risk is that very sick people are going to try psychedelic treatments, fail, believe that they are incurable and feel suicidal.

One might argue that within the context of properly-assisted therapy, this should not happen (about which, more, later). But these drugs are widely available illegally and the current hype cycle means that they are frequently used within settings that are either recreational or are given in bogus therapeutic settings. Any idiot can call themselves a shaman and offer “plant medicine” at a private retreat. But is this safe? If it is operating illegally then no. Absolutely not. These people are unregulated and if they are providing illegal drugs then they are acquiring them illegally. Mentally unwell people need to be warned to steer clear of illegal recreational psychedelic settings.

That is because there is a chance that the experience may worsen your mental health, indeed suicidally so. Take Kate Hyatt, a young actress of 32. She was suffering from depression. In June last year, she attended a three-night retreat in Worcestershire. It isn’t entirely clear what was taken but The Daily Mail and The Times (on January 6th) report that she took wachuma and ayahuasca. After attending the course, her mental health deteriorated, and she was referred to a mental health crisis team suffering from “severe” issues. Tragically, she went on to kill herself. According to The Times, in the month before her death, she wrote “it feels like my nervous system is on fire as well as my brain”. The coroner’s report said she had had signs of psychosis prior to the retreat and these worsened afterward.

The organisation running the retreat, and named in the coroner’s report, has disputed the account of its actions. What is undisputed, though, is that during this break, someone gave Ms Wyatt illegal drugs will the intention of making an improve her mental health. They either didn’t know or didn’t try to find out, that she had had symptoms of psychosis prior to the trip. If Ms Wyatt had been attempting to access a psychedelic medicine within a regulated context (such as an approved medication or in a jurisdiction where such drugs are permitted and regulated), she would have been screened out by medical staff. That is because they would have known that any sort of psychosis, whether a family history or symptoms during depression, is a contraindication for psychedelics which increase the risk of future psychotic episodes. The same is true of anyone with a significant history of trauma who has not learned coping skills. Borderline personality disorder is also known to be a reason for excluding patients.

Psychedelics allow you to relive traumatic experiences, including repressed memories. There is a much risk when people who are mentally unwell take these drugs outside of proper medical settings. Yet two days after Ms Wyatt’s story appeared in The Times, a lawyer, Pandora Morris, talks in very positive terms about how a mushroom trip “helped her crushing OCD”. She travelled abroad for a trip with a “psychiatrist/shaman” in a remote farmhouse. She reports that “every single nerve ending in my body was on fire”. Luckily, Ms Morris says she feels better.

These sorts of solo media accounts are increasingly unhelpful for people with mental health disorders. The family and friends of people with mental health conditions are likely to ask: “have you thought about trying psychedelic drugs? They helped this woman in the newspaper.” We need proper trials. And we need the delivery of these drugs to patients to be legal and regulated. Trials will tell us who benefits, and what the risks are. Regulated delivery will screen out patients who shouldn’t be taking them, and offer the proper support to people who do.

None of this is going to come from a West-country shaman with a nose ring and a cool tattoo. Is your shaman able to deal with adverse events? What happens when someone uncovers, and relives, a terrifying, painful, or buried, episode of childhood sexual abuse? That might call for psychological help and even medication—as was the case for one woman in a Swiss study. In another example in a medical setting, a woman using LSD for cluster headaches had an acute attack that had to be treated with ketamine and lorazepam. She didn’t try to repeat the experience.

In the course of talking to many people in the psychedelic movement, I’ve heard people voice quiet concerns about bad players harming people, and of the problems of self-medication by the mentally unwell. One thing that can happen is that someone will have a bad experience or trip with self-medication, and then decide they need to do another experience to deal with the fallout from the first. Here there is a risk of getting stuck in a cycle of psychological addiction. (And ketamine users risk more traditional addiction.)

Advocates will wave their hands and talk in a wafty way about healing plant medicine. But you can’t rationally argue that they are powerful but also insist that they are harmless. All drugs can cause unwanted side effects. Trials show us the risks, how to minimise them and allow regulators to set them against the benefits they bring.

One of the most interesting talks at the Psychedelic House was by Joshua White, at the Fireside Project, which offers a US support line for those having trouble with psychedelic trips. Mr White estimates that millions of people in America are using psychedelics in a non-clinical context. “There is a lot of press coverage some of which focuses only on the benefits and not enough on the risks. But what we know is that psychedelics can cause anxiety, fear, paranoia, overwhelm, confusion, and a feeling of dying”.

The Global Drug Survey shows that the rates at which people end up in the emergency room after taking various different drugs, including alcohol, do not highlight any particular risks of psychedelics, (see page 20). However Mr White says the rate of admission to the emergency room went up four-fold when people take psychedelics when they have underlying psychiatric conditions including depression and anxiety.

Fireside has also been able to gather some useful (anonymous) data from its callers. Many callers have therapists but are unable to get an appointment when they need to talk. In a period of approximately one year running from 2021 to 2022, there were 3,100 conversations. Most people reached out in a state of psychological distress, mostly processing past psychedelic experiences; 750 called during a trip. What are people taking? Most (51%) are taking psilocybin, but that could reflect the prevalence of use rather than of problems. Nonetheless, Mr White says their experience has been that 5-MeO-DMT is one of the hardest psychedelic substances to “integrate”. Integration is the process of engaging in the experience, gaining insights, and translating it into everyday life. “People regularly tell us that they are not prepared for reactivations, which is like a flashback which is extremely destabilising”.

The most common experiences of the callers were anxiety and a feeling of being overwhelmed, feelings of fear, and loneliness—half of callers are alone when taking these drugs. How did they arrive at this point? Mr White says his callers are consuming popular media articles talking about how amazing psychedelics are with no discussions of the risks and then end up having serious problems and not knowing how to handle them. “We don’t keep data on how many people mentioned Michael Pollan’s book but it’s pretty darn high”. One take-home message he wants to get across is this: “we need to stop saying that psychedelics are 10 years of therapy… it sets people up for disappointment. We have people who are in a profound state of disappointment because of this borderline fetishizing of the healing potential of psychedelics”.

Another take-home message was: “beware of unscrupulous facilitators. We are seeing more and more of these…. everything from facilitators who make physical contact without consent, to ketamine telehealth platforms who leave patients on their own for integration support leaving them enraged and betrayed.” It is little pondered, but likely to be the case, that in the hours and days after a psychedelic experience, there is a window of neuroplasticity that means that people are more vulnerable and open to both positive, and negative, experiences. That may be good for learning to examine one’s own feelings, but it can equally mean that negative experiences in the period after psychedelics, perhaps the loss of a loved one, could have a greater psychological impact than they would otherwise.

Delivery of these medicines will be expensive and it doesn’t scale well

The answer to many of these problems is that in the right setting, with the right supervision, and the correct screening of patients, psychedelic medicines are likely to be a relatively safe therapy that offers treatment options for people who have failed on so many other lines of therapy. Late last year I attended a psychedelic trip legally delivered in Amsterdam by a legitimate provider. Allowing a journalist to come in indicated to me that the business had quite a high degree of confidence in what was being delivered.

Yet high-end services such as the one I saw are expensive to deliver, with a lot of one-on-one attention from qualified healthcare professionals and this might include psychiatrists. None of this scales well. That then means that legal access to these therapies will be restricted, reducing the scope of this therapy to help patients.

That, in turn, will lead to attempts to innovate around the business model to improve access. This will cause further problems. Beyond Mr White’s observations, there are already media reports about concerns over online firms in America delivering ketamine therapy via telemedicine. And even within a clinical trial setting of MDMA for PTSD we have seen a sexual misconduct scandal. Misconduct and human error occur, at low rates, in all therapeutic settings involving humans—whether or not they involve psychedelics. Yet as large cohorts of therapists are trained to deliver psychedelic therapies—which by their nature can be chaotic experiences at times—there is a risk that patients will be mistreated. And as these drugs are used more widely, we will start to realise that they are not as harmless as we have been told. There are worries, for example, about how repeated microdosing may cause heart disease (and may not actually bring the medical benefits that some users tout).

There is no Psychedelic House at Davos this year but there will be plenty of folks mulling the future transformation of health systems. This article is intended as a warning shot about some of the problems ahead. It isn’t comprehensive. Riding the wave of the promise in psychedelics, riding any new wave of excitement, are the blaggers, charlatans, and downright frauds. Mix in mental health conditions with mind-bending drugs and there is a recipe for both triumph and disaster. To triumph we need to get real about the risks. Even those trying to deliver legitimate medicines will be damaged if the widening recreational use of psychedelics bleeds into self-medication.

Update, February 11th.

After this post an old school friend got in touch to challenge the use of the words “mentally unwell” in this article. She said it is a catch-all phrase that describes little about the human condition, suffering and that my commentary separates people into “them” and “us”. And in my take that those who take these medications are “them”. And that I’m labelling people.

First of all I am very aware that all mental health concerns lay on a spectrum and most of us lay on it in one way or another. But the point about regulated medicines is that they have to be given for an indication, for something. So if you are talking about the medical use of psychedelics, which this post is, it is difficult to not talk about the patient group that might need them. And as psychedelics are being explored for a range of conditions, a general term like “mentally unwell” is meant only as a way of including everything from depression to PTSD an addiction. It isn’t ideal, granted, but it was the best I could come up with at the time. It isn’t meant to label or pigeonhole anyone. The friend suggested that “diagnosable illness” might have been better. That isn’t specific, although you could say “diagnosable mental illness”. I’m not sure I love it, but I’ll certainly try to give the phrase a workout and see how it feels next time.

Another criticism (there were a few!) was that this commentary leaves out people who no longer believe in the current model for medicine. Yes, it does. This post is a pushback to the hype over the medicalisation of psychedelics. It is a necessary antidote as the death described in this article shows. I hope the post makes those with a diagnosable mental illness think twice before they experiment on their own, and seek a jurisdiction in the world where they can have a property supported journey. Experimenting on your own with your mental health is not the same as having a colonic and getting acupuncture. We are only just at the start of a long journey to understand the brain. As the comments below highlight, we don’t even fully understand the adverse events that are possible with psychedelics. NL, February 11th.