Why decriminalization policies require public education on risks

You shouldn't make psychedelics commercially available without providing information about their adverse effects, argues Joseph Holcomb Adams

WARNING: This article contains mention of self harm and suicide, which may be upsetting or traumatic for some readers. If you or someone you know is struggling with thoughts of self harm or suicidal ideation please call 988 in the US or the Samaritans in the UK. We’re making this article free - subscribe to support our work.

In the first installment of this two-part series, I discussed the differences between different types of “psychedelic decriminalization” policies, and argued that psychedelic policy advocates are morally obligated to communicate more transparently, thoroughly, and accurately with the public about the specifics of particular proposals.

Here, I’m going to argue for the following thesis: It would be irresponsible to open an unregulated psychedelic economy without (ideally first) implementing an essential safeguard: a robust public education campaign.

In this article, I do not take a stand on questions related to potential role of regulation in psychedelic policy. Regulation is a tricky and controversial topic in the psychedelic space, for many reasons. In the future, I will write another piece exclusively on the topic of regulation in psychedelic policy, but for now, however, I will steer clear of the regulation debates and instead focus on arguing for the urgent need for public education.

Let’s start things off with the most pressing concern: when unregulated psychedelic economies are opened without implementing public education efforts, people predictably get hurt, sometimes in incredibly serious ways, because they have not been properly informed about the risks involved in using psychedelics or about the ways these risks can be avoided or mitigated.

Just this week, someone told me an incredibly tragic story that demonstrates just how high the stakes are here, and shows us what can happen when people have easy, legal or effectively legal access to psychedelics without being provided with any education about how to use the substances safely.

This story came from a mother whose 21-year-old child died in late 2022 as a result of the adverse behavioral and psychological effects of a psilocybin mushroom experience. I will refer to the deceased young adult by the pseudonym “Cassidy," because the family’s wounds are still very fresh and I was asked to omit identifying details at this time.

A couple of months before taking that mushroom trip, Cassidy told their parents that they were interested in trying psilocybin for the first time. Cassidy had heard that Oakland had decriminalized the distribution of psilocybin mushrooms to adults 21 years of age or older, and waited until just after their 21st birthday to go into the city and purchase the substances from a local dispensary.

According to Cassidy’s mother, this dispensary did not provide Cassidy with information about any of the risks that come with using psilocybin, and did not provide them with any information about how to mitigate these risks and use the drug in a safe manner. Crucially, the dispensary did not inform Cassidy about the dangers associated with using psilocybin alone, without the supervision and support of another person.

Cassidy’s mother believes that Cassidy had done some of their own research on the internet prior to taking the mushrooms, but it was clear later on that this internet research did not provide Cassidy with the information that they needed to make safe choices about using the substance.

Cassidy was alone in their apartment when they ingested about 4 grams of the psilocybin mushrooms that they purchased at the dispensary in Oakland. Cassidy became overwhelmed by the effects of the drug, experiencing frightening hallucinations and spinning out into a psychotic state. No one was there to support Cassidy, calm them down, reassure them, or prevent them from engaging in dangerous behavior.

During that spun-out psychedelic experience, Cassidy eventually began to engage in self-harm. While these actions could have easily resulted in Cassidy’s death during the psilocybin experience, Cassidy luckily did not sustain any life-threatening injuries from the self-harm behavior. Unfortunately, this already extremely upsetting story does not end with this close call.

In the day following the psilocybin trip, Cassidy remained in a destabilized, traumatized state of mind, and according to their mother, seemed to be deeply, deeply depressed. Cassidy felt that they had never “come down” from the insanity of the psychedelic experience, and expressed fear that the “drugs would never leave their system.” Cassidy was horrified and ashamed by the visible injuries that they had inflicted with the self-harm behavior, and felt extreme hopelessness about the prospect of living in the world after what had happened the day before. That same day, Cassidy took their own life.

This tragedy never should have happened. What went wrong, what would have made things go differently? We don’t entirely know, because there are so many unknowns regarding how different people may react to the substances when using them in different circumstances, but we can reasonably say that:

1. If Cassidy had been more aware of the effects and risks of using psilocybin, they might have approached the activity much more carefully.

2. If Cassidy had taken a smaller, more manageable dose, they may have not had such an overwhelming, terrifying, damaging, and dangerous experience.

3. If Cassidy had been with another person, especially a sober person, things most likely would not have turned so bad during the experience (especially in terms of the self-harm).

4. If Cassidy had taken the trip within a different “set and setting” (including preparation), they might not have had that horrible, dangerous experience.

5. If Cassidy had integration and post-experience care, they would have had support during their mental health crisis, and would most likely have been prevented from ending their own life.

Regulation is one way to address the above problems (e.g. only allowing access under the supervision and support of trained facilitators, within the constraints of particular safety guidelines, etc.), but we’re not talking about regulation in this article. However, it is important to note that while policies that open unregulated economies are more likely to lead to increased easy access (including through entanglement with and expansion of illicit markets), it is the case that even when there is regulated access, there will likely still be plenty of illicit use outside of the regulatory constraints (for example, check out what’s happening in Oregon).

So, how could public education have prevented this event, or at least made it much less likely to occur? I argue that if Cassidy had known about those five above points, most primarily the need for having someone else around and a safe container while taking the mushrooms (especially when taking such a substantial dose for the first time), things would have most likely turned out differently, and Cassidy would still be with us today.

We currently find ourselves in an environment, an historical moment, in which accurate, unbiased, evidence-based psychedelic public education is particularly crucial. The problem is not just that more and more people are accessing or seeking access to psychedelics without sufficient information about the risks and suggested safety practices; part of the problem is that the public has been exposed to a great deal of biased, positively-skewed, misleading, and even false statements and ideas about psychedelic use that paint an overly rosy picture and hide/minimize the dangers. This has created a cultural climate in which many people have overly-enthusiastic, sometimes mistaken beliefs about psychedelic use, including decreased perceptions of the very real risks.

Psychedelics have been hyped up as revolutionary magic bullet medicines, solutions to spiritual yearning, “natural medicines” that “grow in the ground” and are therefore completely safe and beneficial, etc. Advocacy campaigns for policy proposals, and policy changes themselves, often feed this cultural climate.

It is also crucial to acknowledge the economic climate: there is now a great deal of demand and potential/expected demand for psychedelics, as well a tremendous amount of eagerness to provide the supply to meet this demand. There is a very clear gold rush mentality going on right now, especially among investors and entrepreneurs. There are also obvious financial incentives for individuals and small-scale operations to get involved in supplying psychedelics and psychedelic services to meet the demand (whether illicitly, in a gray area, or legally).

So, given these conditions, what are some other negative outcomes and problematic / dangerous situations that could occur without public education?

Firstly, acute adverse effects, such as panic, fear, intense experiential suffering; psychotic reactions, traumatic experiences, surfacing of unprocessed trauma; dangerous, or harmful behavior; making consequential choices that one normally would not, against one’s own interest, which are regretted afterwards.

Secondly, long term adverse effects: death or injury from acute behavioral toxicity or post-experience behavioral toxicity; persisting psychosis; trauma, and other long-term mental health issues from acute adverse effects; adverse effects such as HPPD, unwanted changes in thinking, etc. that do not appear obviously connected to adverse acute effects; worsening of mental illnesses (including when people seek out psychedelic services from incompetent facilitators); effects of dashed hopes or disappointed expectations (when the magic bullet solution doesn’t live up to the hype)

Thirdly, loss of opportunity for benefits: people do not take psychedelics within containers that would be most beneficial; information disparities and lack of knowledge about the role of cultural differences leads to some groups receiving more benefits than others.

Fourth, the risk of abuse, exploitation, victimization (which may be conscious or unconscious). This could involve: manipulation and abuse of power on the part of facilitators; violation of right to freedom of thought, conscience, and religion; exploitation of vulnerable populations (e.g. suffering people desperate for a cure); exploitation of uniformed or misinformed public (false or misleading claims about goods and/or services).

All of these problems can be mitigated with public education. Done well, it mitigates risks of bad outcomes, promotes good outcomes, and it is needed to promote and preserve individual/collective well-being, as well as for preventing a cultural backlash/pendulum swing/moral panic.

Specific things that must be included in public education efforts:

1. Information about known contraindications (such as personal or family history of psychosis)

2. What is known about all other potential risks and benefits

3. Guidelines for safe use (e.g. not using alone, using in safe container, etc.)

5. Education about the vulnerability involved in receiving psychedelic services (suggestibility, incapacitation, intense spiritual experiences, power dynamics with facilitator, etc.)

Public education is important not just for users and prospective users, but also for distributors and practitioners (and people considering becoming distributors or practitioners) as well, so that they understand what they are doing, what is at stake, and what their responsibilities are. It is especially important for psychedelic practitioners to become aware of how unconscious motives, beliefs, etc. can enter into the practice and exert undue influence on clients.

How might public education be effectively implemented as part of a psychedelic policy? There are many possibilities, and I encourage everyone in the psychedelic space and beyond to work together to develop ideas for how this could be best accomplished. In the meantime, I’ll offer some suggestions: The government of the jurisdiction in question could partner with external organizations such as harm-reduction non-profits, academic institutions, etc. to put together a collection of educational resources and provide these resources via social media, government websites, public service announcements and similar public communication (like billboards), and through community workshops and events (in libraries, community centers, etc.).

Education for young people is especially crucial, so it would be very important to bring unbiased, accurate, evidence-based psychedelic public education into schools, particularly high schools. If the psychedelic policy is state-level legislation, the policy could involve allocating funding to local jurisdictions so that communities could focus their educational efforts on local needs. The government, in collaboration with external organizations, could also provide materials such as templates for educational pamphlets, fact sheets, informed consent documents, etc. that psychedelic distributors and practitioners could download and provide to customers/clients.

There may also be general public support for regulatory measures like obligatory public health warnings on psychedelic products, or public health pamphlets or posters in dispensaries (including, say, local support lines). We conducted a brief straw poll on Twitter yesterday, and there seemed to be support for this sort of measure (see below).

Conclusion:

Joseph Campbell wrote that “the water in which the mystic swims is the same water a madman drowns in.” There is also a very similar quote from Terence McKenna: “A shaman is someone who swims in the same ocean as the schizophrenic, but the shaman has thousands and thousands of years of sanctioned technique and tradition to draw upon.” I argue that opening an unregulated psychedelic economy in contemporary American society without also implementing a public education campaign is akin to throwing people into these waters without providing them with any sort of swimming lessons, and without even telling them that swimming lessons are a good idea.