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      Ethical and legal issues in psychedelic harm reduction and integration therapy

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          Abstract

          Psychedelic-assisted therapy may represent an upcoming paradigm shift in the treatment of mental health problems as recent clinical trials have demonstrated strong evidence of their therapeutic benefits. While psychedelics are currently prohibited substances in most countries, the growing popularity of their therapeutic potential is leading many people to use psychedelics on their own rather than waiting for legal medical access. Therapists therefore have an ethical duty to meet this need by providing support for clients using psychedelics. However, incorporating psychedelics into traditional psychotherapy poses some risk given their prohibited status and many therapists are unsure of how they might practice in this area. This paper explicates such risks and describes ways in which therapists can mitigate them and strive to practice within legal and ethical boundaries. A harm reduction approach will be emphasized as a useful framework for conducting therapy around clients' use of psychedelics. It is argued that therapists can meet with clients before and after their own personal psychedelic experiences in order to help clients minimize risk and maximize benefit. Common clinical scenarios in this growing clinical area will also be discussed.

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          Most cited references70

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          Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial

          Cancer patients often develop chronic, clinically significant symptoms of depression and anxiety. Previous studies suggest that psilocybin may decrease depression and anxiety in cancer patients. The effects of psilocybin were studied in 51 cancer patients with life-threatening diagnoses and symptoms of depression and/or anxiety. This randomized, double-blind, cross-over trial investigated the effects of a very low (placebo-like) dose (1 or 3 mg/70 kg) vs. a high dose (22 or 30 mg/70 kg) of psilocybin administered in counterbalanced sequence with 5 weeks between sessions and a 6-month follow-up. Instructions to participants and staff minimized expectancy effects. Participants, staff, and community observers rated participant moods, attitudes, and behaviors throughout the study. High-dose psilocybin produced large decreases in clinician- and self-rated measures of depressed mood and anxiety, along with increases in quality of life, life meaning, and optimism, and decreases in death anxiety. At 6-month follow-up, these changes were sustained, with about 80% of participants continuing to show clinically significant decreases in depressed mood and anxiety. Participants attributed improvements in attitudes about life/self, mood, relationships, and spirituality to the high-dose experience, with >80% endorsing moderately or greater increased well-being/life satisfaction. Community observer ratings showed corresponding changes. Mystical-type psilocybin experience on session day mediated the effect of psilocybin dose on therapeutic outcomes. Trial Registration ClinicalTrials.gov identifier: NCT00465595
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            Psychedelics.

            Psychedelics (serotonergic hallucinogens) are powerful psychoactive substances that alter perception and mood and affect numerous cognitive processes. They are generally considered physiologically safe and do not lead to dependence or addiction. Their origin predates written history, and they were employed by early cultures in many sociocultural and ritual contexts. After the virtually contemporaneous discovery of (5R,8R)-(+)-lysergic acid-N,N-diethylamide (LSD)-25 and the identification of serotonin in the brain, early research focused intensively on the possibility that LSD and other psychedelics had a serotonergic basis for their action. Today there is a consensus that psychedelics are agonists or partial agonists at brain serotonin 5-hydroxytryptamine 2A receptors, with particular importance on those expressed on apical dendrites of neocortical pyramidal cells in layer V. Several useful rodent models have been developed over the years to help unravel the neurochemical correlates of serotonin 5-hydroxytryptamine 2A receptor activation in the brain, and a variety of imaging techniques have been employed to identify key brain areas that are directly affected by psychedelics. Recent and exciting developments in the field have occurred in clinical research, where several double-blind placebo-controlled phase 2 studies of psilocybin-assisted psychotherapy in patients with cancer-related psychosocial distress have demonstrated unprecedented positive relief of anxiety and depression. Two small pilot studies of psilocybin-assisted psychotherapy also have shown positive benefit in treating both alcohol and nicotine addiction. Recently, blood oxygen level-dependent functional magnetic resonance imaging and magnetoencephalography have been employed for in vivo brain imaging in humans after administration of a psychedelic, and results indicate that intravenously administered psilocybin and LSD produce decreases in oscillatory power in areas of the brain's default mode network.
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              Human hallucinogen research: guidelines for safety.

              There has recently been a renewal of human research with classical hallucinogens (psychedelics). This paper first briefly discusses the unique history of human hallucinogen research, and then reviews the risks of hallucinogen administration and safeguards for minimizing these risks. Although hallucinogens are relatively safe physiologically and are not considered drugs of dependence, their administration involves unique psychological risks. The most likely risk is overwhelming distress during drug action ('bad trip'), which could lead to potentially dangerous behaviour such as leaving the study site. Less common are prolonged psychoses triggered by hallucinogens. Safeguards against these risks include the exclusion of volunteers with personal or family history of psychotic disorders or other severe psychiatric disorders, establishing trust and rapport between session monitors and volunteer before the session, careful volunteer preparation, a safe physical session environment and interpersonal support from at least two study monitors during the session. Investigators should probe for the relatively rare hallucinogen persisting perception disorder in follow-up contact. Persisting adverse reactions are rare when research is conducted along these guidelines. Incautious research may jeopardize participant safety and future research. However, carefully conducted research may inform the treatment of psychiatric disorders, and may lead to advances in basic science.
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                Author and article information

                Contributors
                bpilecki@portlandpsychotherapy.com
                Journal
                Harm Reduct J
                Harm Reduct J
                Harm Reduction Journal
                BioMed Central (London )
                1477-7517
                7 April 2021
                7 April 2021
                2021
                : 18
                : 40
                Affiliations
                [1 ]Portland Psychotherapy Clinic, Research, & Training Center, 3700 N Williams Ave, Portland, OR 97227 USA
                [2 ]GRID grid.417699.4, ISNI 0000 0004 0531 8683, Department of Counseling and Integrated Programs, , Adler University, ; 17 N Dearborn, Chicago, IL 60602 USA
                [3 ]Attorney, Palm Springs, CA USA
                [4 ]Students for Sensible Drug Policy, 2370 Champlain St NW Ste #12, Washington DC, 20009 USA
                Author information
                http://orcid.org/0000-0002-6211-4586
                Article
                489
                10.1186/s12954-021-00489-1
                8028769
                33827588
                112c18df-441f-4776-9efc-39a93ca26d25
                © The Author(s) 2021

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 2 December 2020
                : 29 March 2021
                Funding
                Funded by: None
                Categories
                Opinion
                Custom metadata
                © The Author(s) 2021

                Health & Social care
                psychedelics,psychedelic-assisted therapy,psychedelic integration,harm reduction

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