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Psychedelics can have enormous benefits, but the risks shouldn’t be ignored

As access grows, we need better research and education on bad trips.

A head with two faces looking in different directions, one looking upward in a pleasing psychedelic array of colors, another looking down, in a darker, gloomier direction. wildpixel/Getty Images
Oshan Jarow is a Future Perfect fellow, where he focuses on economics, consciousness studies, and varieties of progress. Before joining Vox, he co-founded the Library of Economic Possibility, where he led policy research and digital media strategy.

The term “psychedelic” was coined by psychiatrist Humphry Osmond: “To fathom Hell or go angelic / Just take a pinch of psychedelic.” But today’s public messaging around psychedelics has a dangerous tendency to gloss over the “fathoming hell” part, which has been euphemized into the language of a “bad” or “challenging” trip.

Challenging trips are generally ones that involve encounters with intense anxiety, unwelcome loss of control, surfaced trauma, or physical discomfort. They’re difficult experiences in the moment, but ultimately, once things settle down, they can be cast in a therapeutic light, and people look back on them as worthwhile.

Then there are just plain bad trips that do not resolve into a harmonious insight, no matter how much therapy, intention, and journaling you throw at them. “Choking, breathless, I was having a grief-tinged cosmic panic attack,” the Harvard theologian Rachael Petersen wrote of her experience in a psilocybin clinical trial. “A small kernel of doubt: a splinter wedged between me and the world ... What if terror is just that — terrible, terrifying, absolute?”

The positive sides of psychedelics — therapeutic promise, spiritual renewal, and radical forms of creativity — attract more interest, and more funding, than research into what might go wrong for a minority of users. And to be clear, even outside of the well-controlled settings of clinical trials, the majority of psychedelic trips do seem to lean positive. One recent study that surveyed 613 lifetime psychedelic users drawn from a nationally representative sample found that 82.4 percent reported “never” or “rarely” experiencing bad trips. More than 90 percent reported either no subsequent impairment in their ability to function, or difficulties lasting no more than 24 hours.

But the attention capture of good trips has fed a poor understanding of the vast array of experiences that fall into the “bad trips” category, leaving those who suffer from them without much institutional support or information, even as states have begun providing regulated access to psychedelics and decriminalizing them for personal use.

“We need to learn more about the risks and harms of psychedelics … We’re still at the beginning of that process, in my view,” said Jules Evans, director of the Challenging Psychedelic Experiences Project. “It’s not just about researchers trying to be more rigorous in reporting adverse experiences in trials. It’s also about actively researching harms and how to treat them.”

In the late 1960s, poor public understanding of the actual risks of psychedelics allowed misinformation and sensationalized stories — of LSD users leaping from tall buildings to their death under the impression that they could fly, or irreparably damaged chromosomes — to spread, stoking a moral panic that led to the prohibition that is only just being relaxed, more than 50 years later.

This time around, we run a similar risk. Except now, many of those who are working to spread awareness of the potential harms don’t want another prohibition, and opposing one shouldn’t mean sweeping the risks under the rug so as to rush through legislation. Instead, an honest and transparent account of both the benefits and risks of psychedelics can help build a better, more resilient post-prohibition world.

If good trips can change long-term behaviors, so can bad ones

Last month, an off-duty pilot aboard a flight to San Francisco tried pulling the plane’s emergency shut-off handles because he thought he was in a dream and crashing would wake him up. He had struggled with depression for six years and also reported struggling with the recent death of a friend. Forty-eight hours before the flight, he tried psilocybin mushrooms for the first time, had a terrible experience, and hadn’t slept since.

In the subsequent media coverage, experts debated what role the drugs — whose subjective effects generally fade after six hours — might have played in the episode two days later. While it might seem strange that psychedelics could play a role in behavior changes that take place well after the molecules have left the body (psilocybin is generally metabolized within 24 hours), most of the hype around their therapeutic effects depends on it.

Current research on psilocybin suggests that a single dose, coupled with psychological support, can reduce symptoms of treatment-resistant depression for at least three weeks or help people quit smoking for good. If that’s the case, why wouldn’t it be possible to see negative effects persist along the same timelines? Why couldn’t the psilocybin have something to do with an episode occurring 48 hours later?

“There is hardly any empirical research on how best to treat extended difficulties. That’s one example of a massive research gap that still exists,” Evans said. At least until last month, when a new study he co-authored was published, surveying 608 psychedelic users who all reported extended difficulties lasting more than 24 hours after the trip itself subsided. Thirty-two percent reported difficulties persisting longer than a year.

Participants reported using a number of drugs — mostly LSD and psilocybin — in a broad range of settings, including solo trips, underground ceremonies, clinical trials, therapy sessions, and raves. The most common type of difficulty reported was emotional, including things like anxiety, depression, paranoia, and low mood. Another 42 percent reported “existential difficulties,” consisting of subtypes like “existential struggle,” derealization (when the world comes to feel “less real,” or as if it’s a dream, akin to what the pilot reported), and difficulties integrating experiences into everyday life. In total, the report divided the blunt category of “extended bad trips” into nine themes and 62 subthemes, creating a more granular account of what exactly people experience.

Despite the entire sample reporting extended difficulties, about 90 percent agreed that “the insights and healings gained from psychedelics” are worth the risks, “when taken in a supportive setting,” which is left open to interpretation.

What should bad trips mean for regulation and access?

“None of us want to see psychedelics become less accessible,” Erica Siegal, a social worker who supports victims of sexual assault who were harmed while on psychedelics, told the Berkeley Center for the Science of Psychedelics’ newsletter, the Microdose.

That’s a big shift from the late 1960s, when stories of distressed airline pilots or psychedelic sexual abuse might have fed directly into prohibition efforts. But if heavy restrictions are not what’s wanted, then what to do?

According to Katrina Michelle, the former director of harm reduction for the Multidisciplinary Association for Psychedelic Studies (MAPS), “The power lies in educating people and empowering them with information to make intelligent choices.” She explains that public access to information about risk management can help mold the public’s idea of what responsible use looks like. Society uses a similar approach to cars and alcohol, where after meeting basic accessibility criteria or obtaining a license, we rely on a mix of public education and individual responsibility.

Evans offers another metaphor, likening psychedelics to “dangerous sports, like diving or mountain climbing. It took humans decades to develop safety protocols for these sports, and even now there are accidents.”

He outlines four pillars for improving psychedelic safety: researching harms, communicating them, supporting those who experience them, and regulating the emerging psychedelic markets to minimize those harms.

That last point will be thorny, especially since we don’t know what types of markets will be legalized (state-level reforms have focused on decriminalization, research, and restricted access rather than full commercialization). Transform, a UK-based drug policy foundation, will publish a report next week that provides guidance on four different approaches: decriminalized private use and non-commercial sharing, nonprofit membership associations (a model pioneered by cannabis social clubs in Spain), licensed production and retail, and commercial guided experiences.

“Despite there being plentiful, eloquent critiques of the failure of prohibition, these have not necessarily produced credible visions for an alternative approach which public, professional and policy-maker audiences can buy into,” the report states.

As these regulatory visions take shape, addressing the imbalance in research on benefits and risks could be an important part of building good institutions for the next era of legal psychedelic use. It won’t be easy, but Evans sees a few hopeful signs. “Thankfully, I see some of the big psychedelic philanthropists now looking to fund more research in this area,” he said. “I also see younger psychedelic researchers keen to learn more to make the field safer.”