Josh Short MD
Sometimes tripping means falling down
Updated: Apr 30
When a friend and I discovered that our high school had no debate team, we realized that a golden opportunity existed. By creating a debate team, we would both have a reason to explain frequent absences from home for “practice” and we would have an opportunity to endlessly quibble with people about ambiguous topics, which was a mutual teenage passion of ours. Most of the other high school teams had coaches, understood the rules of Lincoln-Douglas style debate, and actually gave a shit if they won or not. We just really enjoyed arguing and finding bizarre research to support our ludicrous assertions. After we found research funded by Exxon “proving” that oil spills were good for native bird populations, it became an experiment in seeing whether we could keep a straight face while passionately citing research that flew in the face of commons sense, logic, or even human decency. It was a good time until we cited a study suggesting that celibacy lead to anxiety disorders and inquired about a high-strung opponent’s sex life as part of a match, for which we were immediately disqualified.
Amusing and slightly disgusting in retrospect, like many teenage preoccupations, it was also an early experiment in informational literacy, or the ability to rank information based on its likelihood of helping you make a good decision. Studies by an oil company showing that oil spills are good for wildlife should not be used to guide environmental policy. It is smugly obvious that this is a bad idea. Yet, we are prescribing Paxlovid (new COVID antiviral) by the bucketful based on a single excerpt from an unpublished study by its manufacturer. As a country, we have access to exponentially more information daily, but we have very few skills in determining which information is useful or how useful it is.
Medical school is a strange place full of strange people; professional hoop jumpers, workaholics, messiahs, saints, and former raft guides in over their heads. I remain astonished that we had exactly 3 hours of lecture on nutrition and not a single minute on physical therapy. The combination of those two things could prevent most of the problems that fill doctor’s offices.
Nonetheless, we did spend hundreds of hours learning how to interpret research. What were the cohorts and confidence intervals? Were the statistical methods used valid? Was the data retrospective or prospective? Reading the conclusion of a study is very easy. It is also completely meaningless unless you understand how the authors arrived at that conclusion. This was largely the basis of the disconnect between scientists and the general public during the worst of COVID. When people want what they read on facebook to be taken seriously as scientific inquiry, I see it as similar to the times that I have wondered why my children’s refrigerator doodles aren’t in a modern art gallery, since they look so similar. But having been a scientist my entire life, I have learned to quickly see the difference between research and propaganda the same way an art gallery owner knows the difference between modern art and children’s scribbling.
What makes someone an expert is their ability to realize what they DO NOT know. Western medicine is full of pharmaceutical propaganda, arrogant charlatans, and just outright nonsense. But at the heart of its reliance on evidence is a very important idea: “First, do no harm." This is often the primary use of scientific evidence in medicine. It’s why we don’t give children aspirin for viral infections, and why we stopped using extra oxygen for heart attacks. First, don’t make things worse. An expert is someone who knows the limits of their knowledge and exercises appropriate caution when they are asked to make decisions with limited information. A good western medicine doctor uses the skills they have learned in informational literacy to prevent harm and to acknowledge when they are ignorant or when there is no evidence to guide a decision.
What does this have to do with psychedelic medicine? Unfortunately, in our country, the answer is “everything”. By medicalizing psychedelic therapies, we have placed physicians in the role of gatekeeper. We certainly did not spend any time in medical school talking about how to use psychedelic therapies well. We also have almost no experience with medicines whose effect depend on where they are taken and how people feel before they are taken. But here we are, using expanded access through the FDA to offer MDMA and conducting phase 2 studies on psilocybin so that doctors can “prescribe” these agents. It’s frightening and we do not know where the harms are yet.
For so long, we have known that psychedelic therapies have promise and at last we are seeing the loosening of governmental regulations that may allow people access to these valuable therapies. But in our culture that combines healthcare with capitalism, we have gone from complete restriction to unchecked momentum in a very short amount of time. Articles about the promise of psychedelics are everywhere and people feel increasingly comfortable sharing their own experiences around hallucinogens. It has become easy to think that these therapies have no harm or that we even know how to use them well. Information does not equal expertise. Already large companies backed by venture capital are creating arbitrary standards of care and pricing schemes based on profit margins rather than patient outcomes.
Perhaps the most dangerous phrase in America right now is “I’ve done my own research”. We are all drowning in information and our access to information is throttled by algorithms that show us what we want to see while demonizing what we do not. There is very little high quality evidence surrounding long term outcomes with psychedelic medicines. There are bound to be harms we have not discovered yet and we need to move very slowly while we are in the “too good to be true” phase of things. I feel reassured by clients who are uncertain about whether psychedelic therapies are a good idea for them and I worry about clients who have become convinced that a single big trip will change their life. As physicians who have been involuntarily made the gatekeepers of these powerful and untested tools, we are ethically obligated to move more slowly than capitalism would like us to.
As a physician at an integrative psychiatric practice that focuses on psychedelic therapy and nature connection, many people assume that I have a greater enthusiasm for psychedelics than I do. (I am speaking with regards to the treatment of mental health. For backpacking and festivals, I have a great passion for recreational hallucinogens). Our mission statement is printed at the end of this piece, but a goal of our practice and the providers that we collaborate with is to create a standard of care around the use of psychedelics. This standard begins with avoiding harm, which means moving slowly and acknowledging our ignorance when we reach the limits of what is known about these compounds and how to use them safely. For many people, recreational psychedelics and underground shamanic work can be very valuable. It can also be profoundly destabilizing even if legal concerns are avoided. If some shrooms at a festival changed your life that’s really great and we love talking about that kind of thing, but if you want to find out how to use these medicines safely and effectively, it can be very helpful to seek out expertise and providers who have tempered their enthusiasm with caution.
Please be very careful with psychedelic medicines.
Please encourage others to do the same.
“Our mission is to nourish each individual’s innate ability to heal themselves. We believe that the foundations of self healing are a strong connection to the natural world and an integrative approach to healthcare that embraces both ancient and emerging perspectives. We also believe that joy is good for our health and that creating joy is meaningful work.”