Psychedelic drugs, with the exception of ketamine, remain illegal on the federal level, and none have been officially approved for the treatment of addiction. At the same time, psychedelic drugs have been heralded as a potentially revolutionizing treatment for addiction. In the last few years, research studies on substances, in particular psilocybin, have affirmed their effectiveness for substance use disorder.
Researchers and psychotherapists anticipate FDA approval of MDMA and psilocybin, expanding access to people who could benefit from them. When finally legal, though, these drugs may not be the best option for every person suffering from substance use disorder, and may be most effective when utilized in tandem with other methods of support and care, including psychotherapy and 12-step programs.
What do psychedelics offer people suffering from substance use disorder, and how can mental health professionals prepare for their coming legalization? And what do existing treatments, including 12-step programs, have to offer psychedelic-assisted therapy? As ideas about what addiction is and how to treat it continue to evolve, psychedelics are becoming increasingly central to research and conversation.
Over the centuries, addiction’s purported causes have included moral failing, weak will, disease, and sociocultural crisis. The disease model, which groups like Alcoholic Anonymous were pivotal in bringing into mainstream awareness in the early twentieth century, helped combat social stigma and paved the way for insurance companies to cover treatment.
However, it also ignores systemic issues that may have far more impact on people suffering from substance use disorder. The opioid crisis “highlighted the gaps in the disease model,” says Kevin Franciotti, a Denver based writer and licensed addiction counselor trained in psychedelic-assisted therapy, and an advocate for psychedelics and recovery.
“Research on chronic pain patients has shown that, under proper medical supervision, most people don’t become addicted,” says Franciotti. He highlights investigation into the opioid crisis by researchers like Dr. Dan Ciccarone, who traces the epidemic’s sociocultural evolution, including overprescription, market saturation, the illicit supply chain, and policies that have swung sharply in one direction or the other.
Treatment for addiction has been as varied as its definitions, but psychedelic-assisted therapy, when it becomes widely available, could create a sea change, presenting new challenges – and opportunities – for an entrenched medical business model that has historically privileged profit and incentives.
“What is inspiring in research and training programs is that all of these schools training psychedelic-assisted therapists discuss these systemic issues, including racial and ethnic disparities and gender disparities,” says Franciotti.
Psilocybin’s Promise for Substance Use Disorder
The field of research on psychedelics’ effect on substance use disorder is growing. A study published in October of 2022 on treating alcohol use disorder with psilocybin suggests that psilocybin could facilitate lasting behavior changes for individuals suffering from substance use disorder. Dr. Jeffrey Guss, a Lead Trainer at Fluence and a therapist supporting lead investigators for that study, witnessed study participants feeling the negative consequences of their drinking “at a very deep level.”
“Often people with alcohol problems know that negative consequences exist, but they don’t have an emotional resonance with them,” adds Guss. “With the psilocybin experience, this was felt much more deeply, and therefore had a much more powerful impact. Deeply feeling the consequences of your drinking can lead you to be more motivated to change.”
Guss also notes that participants who received doses of psilocybin felt more self-efficacy. “People realize that they have a problem, but they just can’t do anything about it,” he continues. “The effect of the psychedelic journey was a shift in the sense that not only knowing they really needed to do something, but that they could do it too – a sense of confidence that they can act in accordance with their own values. That’s something people described psilocybin helping them with. The only time people stop drinking is when they can imagine a life that’s better, and then feeling like they can achieve that life.”
An increased sense of connection was one other experience shared by study participants who received psilocybin. “Many people with alcohol use disorder feel alone and isolated,” says Guss. “After their journey they felt they became more connected to the people, places, and things that are most important.”
Franciotti clarifies that psychedelics are not one-size-fits-all for sufferers. The habit-forming potential of psychedelics “has been dangerously minimized by some of the leading advocates.” Part of that reason for this, he explains, is because not drawing attention to potential abuse has helped attract broader political acceptance and support from the public. “But there is a need for communication and public education to bring more nuance into this conversation,” he notes.
“Anything that changes an individual’s mood or has mind-altering effects can be habit forming,” says Franciotti. “Is it as likely as the far better known, physiologically addictive drugs like nicotine, alcohol, stimulants, or opiates? Of course not.” He points to the rapid building of tolerance and the challenging or uncomfortable aspects of the experience as reasons that people are less likely to take psychedelics in quick succession. But, he notes, a psychedelic experience could still end in relapse. “It’s a risk when people who have long bought into the idea of abstinence become bought into psychedelics without a container of personal and social accountability, and without resources to prevent their whole orientation unraveling because of misguided information. Mental health professionals need to be aware that the individuals they are treating may be developing a habit-forming relationship with psychedelics that could be misdiagnosed or undiagnosed,” including using psychedelics to self-medicate a mental health syndrome.
12 Steps to Healing?
Currently, research on psychedelic treatment for addiction looks at “short-term acute interventions in the hopes of achieving long term efficacy,” says Franciotti. That contrasts with 12-step programs, the “best known and most widely available” options for treatment of substance abuse disorder, according to the AMA Journal of Ethics.
“The 12-step program is designed to be an available service through the entirety of the experience in recovery,” says Franctiotti. “Issues you might have 20 or 40 years into an abstinence-based approach are very different from issues you have 30, 60, or 90 days away from illicit substance use.”
But 12-step programs have “struggled with innovative psychological interventions for mental health and substance use disorders,” explains Franciotti.
An extensive 2020 review published in the Cochrane Database of Systematic Review found that the 12-step program, Alcoholics Anonymous, was “nearly always more effective than psychotherapy in achieving abstinence,” mostly due to the social interaction and emotional support members experience in groups.
However, 12-step programs and psychedelics have not historically been bedfellows. Programs more often take a strict stance on total abstinence. Individual groups affiliated with programs like AA and Narcotics Anonymous “have taken the position that people receiving medication-assisted therapy,” like methadone or medically-assisted therapy “are not fully leaning on their higher power” and are not allowed to hold service positions, be speaker leads, or chair meetings, says Franciotti. “It perpetuates the idea that someone who has achieved stabilization from medication-assisted therapy is still kind of in disease.”
Franciotti is among a group of people trying to shift the thinking on how psychedelics can be part of a recovery path that also includes 12-step programs. Psychedelics in Recovery embraces a 12-step ideology, but is fully separate from AA and NA. “No one needs to force AA or NA to change,” he says, “and we also don’t want to put the onus on the individual. We want to avoid controversy by inviting folks under one umbrella that allows them to receive the support they need and avoid controversy.”
Psychedelic-assisted therapy, Franciotti adds, “hasn’t done a great job in recognizing that addiction is considered a chronic and relapsing disorder. The model of an acute intervention needs at some point to go through its own form of innovation to handle folks who are experiencing relapse and may need an immersive reconnection that might be lost as they struggled to maintain a lifestyle of abstinence.”
Franciotti envisions a future where there is “synergy between acute intervention and long-term tiered support.” One piece of that: harm reduction, an important component of trainings like those offered by Fluence. “True harm reduction meets people where they’re at,” he says. “It celebrates gradual, incremental, person-centered positive change that is not coercive, but is steeped in unconditional compassionate love, and exists not to serve an outcome but perpetual need for humans to be deserving of love and compassion, regardless of whether they achieve true change from their behaviors.”
Treating addiction will ultimately require individualized solutions. “Addiction is such a complicated syndrome on a personal, familial, and societal level that there will not be a single strategy that will be effective,” says Franciotti. “We need a range of options, because one intervention will work for some and another for others. I want to invite the idea that this is not an either/or conversation. We need all of the options on the table.”
Franciotti will be in conversation with Fluence co-founder Elizabeth Nielson this April for a special webinar on the 12-step oriented mutual aid group Psychedelics in Recovery, of which he is a founding member.