Open letter to Dr. Anahita Dua: Why Question 4 is safe and promotes health
Dear Dr. Anahita Dua, Chair of the Coalition for Safe Communities,
Thank you for your many years of service treating patients and advancing the field of medicine through your research. And thank you as well for speaking up in defense of public health from your perspective. As a psychiatric patient and caregiver, I have great appreciation for the responsibility you carry as a practicing physician, and I would never want you to stay silent about a dangerous policy.
That said, Question 4 is not a dangerous policy, so I am hoping this message may convince you to reconsider your stance. As someone who has twice cared for loved ones with severe depression leading to hospitalization, including my best friend who died by suicide, I recognize the high emotional stakes, and I am sympathetic to cautious approaches. But I am also assured by the evidence, including research from the Dana-Farber Cancer Institute, Johns Hopkins, and other leading medical institutions, that the natural psychedelics ballot measure is responsible legislation, benefiting veterans with service-related distress, end-of-life patients, and others with serious mental health struggles.[1]
Nowhere in the world has legal access to the substances in the measure been observed to harm public health.[2] There are quite a few countries where one or more of these substances are legally accessible, including the Bahamas, Costa Rica, Jamaica, Mexico, the Netherlands, New Zealand, Peru, South Africa, and (very recently) Australia.[3]
In the United States, Oregon and Colorado recently passed measures similar to that proposed by Question 4.[4] In Colorado, where the measure was practically identical to that of Question 4, impaired-driving related fatalities and the percentage of drug and alcohol-related arrests related to psychedelics went down after the measure passed in 2022.[5] Similarly, the percentage of hospitalizations related to psychedelics stayed practically the same and remained lower than in 2020.[6]
Furthermore, in Massachusetts, the deprioritization of arrests related to psychedelics by eight localities, encompassing over 390,000 residents, has not appeared detrimental.[7]
Significantly, all the substances in the measure are nonaddictive, a fact reflected in the tiny percentage of adults who use them annually, both in the US and abroad.[8] Even in the Netherlands, where psilocybin-containing products have been legally sold over-the-counter for decades, a 2020 study estimated that less than 1% of Dutch adults consume psilocybin each year.[9]
Especially in light of the observational research suggesting naturalistic psychedelics use is more beneficial than harmful, the removal of criminal penalties for limited personal use, in line with the American Medical Association’s official recommendation in favor of the “elimination of criminal penalties for drug possession for personal use,” does not seem a danger to public health.[10]
Criminalization does not prevent people from accessing psychedelics, but it does force them to navigate a risky underground environment or travel out-of-state to do so. In addition, it perpetuates a stigma that discourages honest communication with healthcare providers about positive as well as adverse experiences.
It is important to note that Question 4 does not allow retail sales or storefronts.[11] Rather, it establishes a regulatory framework for psychedelic therapy centers, which would administer psychedelics exclusively under the supervision of licensed facilitators, with an approximately two-year implementation period.[12] In Oregon, where a similar program is in place, licensed facilitators, as a baseline, are required to have 160 hours of specialized training, more than that of the therapists in an ongoing Phase Ⅲ clinical trial of psilocybin.[13]
I recognize the importance of a Phase Ⅲ trial and the fact that treatments that appear promising can disappoint in Phase Ⅲ. But comparing the substances in the measure to newly invented drugs going through the FDA approval process is an apples to oranges comparison. Illustrating the point: tens of millions of people have already used psilocybin, compared to the less than 10,000 who used Prozac before it was approved as an antidepressant.[14]
Psilocybin and ibogaine are already prescription medications abroad for treating treatment-resistant depression and (essentially off-label) opioid addiction.[15] Mescaline and DMT-containing ayahuasca have extensive histories of therapeutic spiritual use.[16] And the clinical and observational research on these substances so far is supportive of their therapeutic value, as reflected in the testimony of Dr. John Fromson as president of the Massachusetts Psychiatric Society this year: “For many individuals, psychedelics can and do work.”[17] In Oregon alone, over 4,000 people have consumed psilocybin at psychedelic therapy centers, far more than the hundreds who have participated in clinical trials of psilocybin.[18] As a testament to the program’s safety, emergency services have been called to respond on only 4 occasions, even though 12,699 doses of psilocybin have been legally administered in Oregon as of September 3, 2024.[19] Since psilocybin and the other substances in the measure are already recognized and used relatively safely as therapeutics, it seems prudent to provide regulated access for harm reduction purposes at the very least.
The measure in Question 4 provides additional alternatives to, but not mandatory substitutes for, conventional treatments. Research on the substances can and will continue, and clinicians can and should be honest with patients about the limits of our understanding when it comes to psychedelics. But this does not preclude individuals from making informed decisions about whether to access psychedelic treatments.
Notably, 72.3% of American psychiatrists in a recent poll agreed that psilocybin/psilocin, mescaline, DMT, and DMT-containing ayahuasca should be legalized for “medical use.”[20] Furthermore, in the same poll, 57.3% of the psychiatrists disagreed with the criminalization of personal use of psilocybin/psilocin, mescaline, DMT, and DMT-containing ayahuasca (they were not asked about non-classic psychedelics such as ibogaine and MDMA).[21]
If you remain convinced of your position, I encourage you to share any research that I and other proponents of Question 4, including practicing psychiatrists in Massachusetts, may have overlooked. To my knowledge, it is difficult to craft a compelling, evidence-based argument that the measure is likely to do more harm than good.
Please refrain from personally attacking supporters of Question 4 for good faith policy disagreements. In response to our recent supporter press conference, featuring veteran and patient voices, your opposition committee issued the following statement: “It is shameful to deliberately mislead and provide false hope to our brave service members who are battling mental health issues with this dangerous ballot question.”[22] This implicit characterization of Question 4 supporters, including veterans and their spouses, as deliberately harming service members is unfounded and unconducive to the evidence-based dialogue Massachusetts deserves on this issue.
Our campaign does not think anyone with a life-threatening or debilitating condition, including PTSD, opioid addiction, and end-of-life anxiety and depression, should be legally prohibited from accessing potentially life-saving treatments. Our coalition, whose goals are aligned with your long-standing advocacy on behalf of patients, would be happy to advance the health of Massachusetts alongside you.
Thank you again for your many years of service to patients and the field of medicine, and thank you for your time and consideration.
With appreciation and gratitude,
Graham Moore
Educational Outreach Director
Yes on 4 / Massachusetts for Mental Health Options
References
[1] Note: below are just a few examples of the research referred to.
Bogenschutz, M. P., Ross, S., Bhatt, S., Baron, T., Forcehimes, A. A., Laska, E., Mennenga, S. E., O’Donnell, K., Owens, L. T., Podrebarac, S., Rotrosen, J., Tonigan, J. S., & Worth, L. (2022). Percentage of Heavy Drinking Days Following Psilocybin-Assisted Psychotherapy vs Placebo in the Treatment of Adult Patients With Alcohol Use Disorder: A Randomized Clinical Trial. JAMA psychiatry, 79(10), 953–962. https://doi.org/10.1001/jamapsychiatry.2022.2096
Cherian, K. N., Keynan, J. N., Anker, L., Faerman, A., Brown, R. E., Shamma, A., Keynan, O., Coetzee, J. P., Batail, J., Philips, A., Bassano, N. J. Sahlem, G. L., Inzuna, J. Millar, T., Dickinson, J., Rolle, C. E., Keller, J. Adamson, M., Kratter, I. H., & Williams, N. R. (2024). Magnesium–ibogaine therapy in veterans with traumatic brain injuries. Nature Medicine, 30, 373–381. https://doi.org/10.1038/s41591-023-02705-w
Griffiths, R. R., Johnson, M. W., Carducci, M. A., Umbricht, A., Richards, W. A., Richards, B. D., Cosimano, M. P., & Klinedinst, M. A. (2016). Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial. Journal of psychopharmacology (Oxford, England), 30(12), 1181–1197. https://doi.org/10.1177/0269881116675513
Gukasyan, N., Davis, A. K., Barrett, F. S., Cosimano, M. P., Sepeda, N. D., Johnson, M. W., & Griffiths, R. R. (2022). Efficacy and safety of psilocybin-assisted treatment for major depressive disorder: Prospective 12-month follow-up. Journal of psychopharmacology (Oxford, England), 36(2), 151–158. https://doi.org/10.1177/02698811211073759
Weiss, B., Dinh-Williams, L.-A. L., Beller, N., Raugh, I. M., Strauss, G. P., & Campbell, W. K. (2023). Ayahuasca in the treatment of posttraumatic stress disorder: Mixed-methods case series evaluation in military combat veterans. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. https://doi.org/10.1037/tra0001625
[2] Note: No study has associated legal access to any of the substances in the measure with harm to public health while controlling for other relevant variables. A Dutch investigation (reference below) into the harm potential of magic mushroom use, once legal in the Netherlands, concluded the “public health and criminal aspects [are] negligible.” Psilocybin-containing products (truffles rather than mushrooms) are still legally sold for retail in the Netherlands.
Van Amsterdam, J., Opperhuizen, A., & van den Brink, W. (2011). Harm potential of magic mushroom use: a review. Regulatory toxicology and pharmacology : RTP, 59(3), 423–429. https://doi.org/10.1016/j.yrtph.2011.01.006
[3] https://www.bbc.com/future/article/20240320-legal-status-of-psychedelics-around-the-world
https://www.theguardian.com/society/2023/jan/23/ibogaine-iboga-drug-addiction-psychedelic-gabon
[4] https://www.nytimes.com/2023/01/03/health/psychedelic-drugs-mushrooms-oregon.html
[5] https://reason.org/commentary/a-glimpse-into-colorados-emerging-legal-psychedelics-scene/
https://www.codot.gov/safety/impaired-driving
[6] https://reason.org/commentary/a-glimpse-into-colorados-emerging-legal-psychedelics-scene/
[7] Note: to my knowledge, there have not been any reports of harm resulting from the Massachusetts deprioritization measures, and a researcher investigating the public health impacts informed our campaign that the available data strongly suggests public health was not adversely impacted by the measures.
[8] https://www.medicalnewstoday.com/articles/are-psychedelics-addictive-side-effects-and-risks
https://www.euda.europa.eu/publications/european-drug-report/2023/other-drugs_en
https://www.wbur.org/hereandnow/2024/03/27/ibogaine-drug-addiction-cure
Kilmer, B., Priest, M. Ramchand, R., Rogers, R. C., Senator, B., & Palmer, K. (2024). Considering Alternatives to Psychedelic Drug Prohibition. RAND. https://www.rand.org/content/dam/rand/pubs/research_reports/RRA2800/RRA2825-1/RAND_RRA2825-1.pdf
Koenig, X., & Hilber, K. (2015). The anti-addiction drug ibogaine and the heart: a delicate relation. Molecules (Basel, Switzerland), 20(2), 2208–2228. https://doi.org/10.3390/molecules20022208
[9] https://www.themanual.com/travel/psychedelic-guide-to-amsterdam-travel/
https://blossomanalysis.com/countries/netherlands/
Van Laar, M. W., & van Miltenburg, C. J. A. (2020). Epidemiologie van het gebruik van psychedelica in Nederland [Epidemiology of hallucinogenic drug use in the Netherlands]. Tijdschrift voor psychiatrie, 62(8), 684–692.
[10] Note: Below is a non-exhaustive, but representative, collection of supporting citations.
https://www.medpagetoday.com/meetingcoverage/ama/110619
https://www.marijuanamoment.net/american-medical-association-endorses-drug-decriminalization/
Agin-Liebes, G., Haas, T. F., Lancelotta, R., Uthaug, M. V., Ramaekers, J. G., & Davis, A. K. (2021). Naturalistic Use of Mescaline Is Associated with Self-Reported Psychiatric Improvements and Enduring Positive Life Changes. ACS pharmacology & translational science, 4(2), 543–552. https://doi.org/10.1021/acsptsci.1c00018
Carbonaro, T. M., & Gatch, M. B. (2016). Neuropharmacology of N,N-dimethyltryptamine. Brain research bulletin, 126(Pt 1), 74–88. https://doi.org/10.1016/j.brainresbull.2016.04.016
Fearn, K., & Bhattacharyya, K. K. (2024) Is Use of Psychedelic Drugs a Risk or Protective Factor for Late-Life Cognitive Decline? Gerontology and Geriatric Medicine. https://doi.org/10.1177/23337214241250108
Frecska, E., Bokor, P., & Winkelman, M. (2016). The Therapeutic Potentials of Ayahuasca: Possible Effects against Various Diseases of Civilization. Frontiers in pharmacology, 7, 35. https://doi.org/10.3389/fphar.2016.00035
Garcia-Romeu, A., Davis, A. K., Erowid, E., Erowid, F., Griffiths, R. R., & Johnson, M. W. (2020). Persisting Reductions in Cannabis, Opioid, and Stimulant Misuse After Naturalistic Psychedelic Use: An Online Survey. Frontiers in psychiatry, 10, 955. https://doi.org/10.3389/fpsyt.2019.00955
Hendricks, P. S., Thorne, C. B., Clark, C. B., Coombs, D. W., & Johnson, M. W. (2015). Classic psychedelic use is associated with reduced psychological distress and suicidality in the United States adult population. Journal of psychopharmacology (Oxford, England), 29(3), 280–288. https://doi.org/10.1177/0269881114565653
Johansen, P. Ø., & Krebs, T. S. (2015). Psychedelics not linked to mental health problems or suicidal behavior: a population study. Journal of psychopharmacology (Oxford, England), 29(3), 270–279. https://doi.org/10.1177/0269881114568039
Johnson, M. W., Griffiths, R. R., Hendricks, P. S., & Henningfield, J. E. (2018). The abuse potential of medical psilocybin according to the 8 factors of the Controlled Substances Act. Neuropharmacology, 142, 143–166. https://doi.org/10.1016/j.neuropharm.2018.05.012
Juul, T. S., Jensen, M. E., & Fink-Jensen, A. (2023). The use of classic psychedelics among adults: a Danish online survey study.” Nordic Journal of Psychiatry. https://doi.org/10.1080/08039488.2022.2125069
Nayak, S. M., Jackson, H., Sepeda, N. D., Mathai, D. S., So, S., Yaffe, A., Zaki, H., Brasher, T. J., Lowe, M. X., Jolly, D. R. P., Barrett, F. S., Griffiths, R. R., Strickland, J. C., Johnson, M. W., Jackson, H., & Garcia-Romeu, A. (2023). Naturalistic psilocybin use is associated with persisting improvements in mental health and wellbeing: results from a prospective, longitudinal survey. Frontiers in psychiatry, 14, 1199642. https://doi.org/10.3389/fpsyt.2023.1199642
Raison, C. L., Jain, R., Penn, A. D., Cole, S. P., & Jain, S. (2022). Effects of Naturalistic Psychedelic Use on Depression, Anxiety, and Well-Being: Associations With Patterns of Use, Reported Harms, and Transformative Mental States. Frontiers in psychiatry, 13, 831092. https://doi.org/10.3389/fpsyt.2022.831092
Ruffell, S. G. D., Crosland-Wood, M., Palmer, R., Netzband, N., Tsang, W., Weiss, B., Gandy, S., Cowley-Court, T., Halman, A., McHerron, D., Jong, A., Kennedy, T., White, E., Perkins, D., Terhune, D. B., & Sarris, J. (2023). Ayahuasca: A review of historical, pharmacological, and therapeutic aspects. PCN reports : psychiatry and clinical neurosciences, 2(4), e146. https://doi.org/10.1002/pcn5.146
[11] https://www.mass.gov/doc/23-13-initiative-petition-for-a-law-relative-to-the-regulation-and-taxation-of-natural-psychedelic-substances-version-a/download
[12] https://www.mass.gov/doc/23-13-initiative-petition-for-a-law-relative-to-the-regulation-and-taxation-of-natural-psychedelic-substances-version-a/download
[13] Note: Oregon’s program, as baseline requirements, mandates 120 hours of core training plus 40 hours of practicum training for licensed psilocybin facilitators.
https://secure.sos.state.or.us/oard/displayDivisionRules.action?selectedDivision=7102
[14] Krebs, T. S., & Johansen, P. Ø. (2013). Over 30 million psychedelic users in the United States. F1000Research, 2, 98. https://doi.org/10.12688/f1000research.2-98.v1
Rossi, A., Barraco, A., & Donda, P. (2004). Fluoxetine: a review on evidence based medicine. Annals of general hospital psychiatry, 3(1), 2. https://doi.org/10.1186/1475-2832-3-2
[15] https://www.theregreview.org/2024/04/23/perkins-a-new-era-of-psychedelic-medicine-in-australia/
Noller, G. E., Frampton, C. M., & Yazar-Klosinski, B. (2018). Ibogaine treatment outcomes for opioid dependence from a twelve-month follow-up observational study. The American journal of drug and alcohol abuse, 44(1), 37–46. https://doi.org/10.1080/00952990.2017.1310218
[16] Malcolm, B. J., & Lee, K. C. (2018). Ayahuasca: An ancient sacrament for treatment of contemporary psychiatric illness?. The mental health clinician, 7(1), 39–45. https://doi.org/10.9740/mhc.2017.01.039
Vamvakopoulou, I. A., Narine, K. A. D., Campbell, I., Dyck, J. R. B., & Nutt, D. J. (2023). Mescaline: The forgotten psychedelic. Neuropharmacology, 222, 109294. https://doi.org/10.1016/j.neuropharm.2022.109294
[17] Note: In the recording linked to below, Dr. Fromson (around 1:44:17 in the recording) says: “I also want to say that, in my role as president of the Massachusetts Psychiatric Society, I’m very grateful for the testimony that you heard from the advocates for this ballot initiative, sharing their experience, their strength, and their hope. It does indeed underscore that, for many individuals, psychedelics can and do work.”
https://malegislature.gov/Events/Hearings/Detail/4908/Video1
Colosimo, F.A., Borsellino, P., Krider, R.I., Marquez, R.E., & Vida, T.A. (2024). The Clinical Potential of Dimethyltryptamine: Breakthroughs into the Other Side of Mental Illness, Neurodegeneration, and Consciousness. Psychoactives. https://doi.org/10.3390/psychoactives3010007
Köck, P., Froelich, K., Walter, M., Lang, U., & Dürsteler, K. M. (2022). A systematic literature review of clinical trials and therapeutic applications of ibogaine. Journal of substance abuse treatment, 138, 108717. https://doi.org/10.1016/j.jsat.2021.108717
Reckweg, J. T., van Leeuwen, C. J., Henquet, C., van Amelsvoort, T., Theunissen, E. L., Mason, N. L., Paci, R., Terwey, T. H., & Ramaekers, J. G. (2023). A phase 1/2 trial to assess safety and efficacy of a vaporized 5-methoxy-N,N-dimethyltryptamine formulation (GH001) in patients with treatment-resistant depression. Frontiers in psychiatry, 14, 1133414. https://doi.org/10.3389/fpsyt.2023.1133414
Vamvakopoulou, I. A., Narine, K. A. D., Campbell, I., Dyck, J. R. B., & Nutt, D. J. (2023). Mescaline: The forgotten psychedelic. Neuropharmacology, 222, 109294. https://doi.org/10.1016/j.neuropharm.2022.109294
Weiss, B., Dinh-Williams, L.-A. L., Beller, N., Raugh, I. M., Strauss, G. P., & Campbell, W. K. (2023). Ayahuasca in the treatment of posttraumatic stress disorder: Mixed-methods case series evaluation in military combat veterans. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. https://doi.org/10.1037/tra0001625
Ziff, S., Stern, B., Lewis, G., Majeed, M., & Gorantla, V. R. (2022). Analysis of Psilocybin-Assisted Therapy in Medicine: A Narrative Review. Cureus, 14(2), e21944. https://doi.org/10.7759/cureus.21944
[18] https://stateofreform.com/oregon/2024/07/oregon-veterans-gain-needed-support-from-heroic-hearts-psilocybin-retreats/
[19] Oregon Health Authority (OHA) data obtained by the campaign and available upon request
[20] Barnett, B. S., Arakelian, M., Beebe, D., Ontko, J., Riegal, C., Siu, W. O., & Weleff, J. (2024). American Psychiatrists’ Opinions About Classic Hallucinogens and Their Potential Therapeutic Applications: A 7-Year Follow-Up Survey. Psychedelic Medicine. https://doi.org/10.1089/psymed.2023.0036
[21] Barnett, B. S., Arakelian, M., Beebe, D., Ontko, J., Riegal, C., Siu, W. O., & Weleff, J. (2024). American Psychiatrists’ Opinions About Classic Hallucinogens and Their Potential Therapeutic Applications: A 7-Year Follow-Up Survey. Psychedelic Medicine. https://doi.org/10.1089/psymed.2023.0036
[22] https://www.westernmassnews.com/2024/09/10/community-gathers-support-ballot-question-allow-natural-psychedelic-medicines/
