Alternately venerated as sacred medicines and vilified as narcotics with little medicinal value, psychedelics have had a chequered past.

In the West, during the 1960s and the 1970s, research on the therapeutic and clinical use of psychedelic drugs gained prominence, but soon their illicit use in counterculture sullied their reputation. Research on psychedelics was prematurely abandoned in the 1960s, primarily because of US President Richard Nixon’s “war on drugs”. They became the black sheep of the drug family, becoming taboo after being censured in the media and society.

But a resurgence in psychedelic research, since the past few years, is turning the tide.

In pop culture, this comeback is due to endorsement from celebrities. Will Smith, Miley Cyrus and Lindsay Lohan are some of the stars who have recently opened up about how their lives have been transformed by ‘natural’ psychedelics such as ayahuasca, a South American psychoactive brew. Mainstream media and podcasts are billing DMT (occurring in many plants and animals) as a transcendental psychedelic and documenting its powerful, almost rapture-like effects on the brain.

Can the renewed interest in the use of psychedelic drugs for mental health treatments in the West find potential in the paucity of psychiatric care that Pakistan offers?

This renewed interest has led to clinical, philanthropic, financial and private industry interest in psychedelics research, which was once considered fringe but has now become mainstream. Business Insider called it a “psychedelics renaissance”, ushered in by investors pouring millions into start-ups that are researching psychedelics’ potential as medications for conditions such as depression and post-traumatic stress disorder (PTSD).

A London-based psychedelics giant, Compass Pathways, raised $146.6 million in its US initial public offering and is valued at more than $1 billion. Psychedelics companies Field Trip Health and Havn Life Sciences recently started trading in Canada. Meanwhile, the psychedelics industry is drawing attention from biotech investors keen to cash in on the burgeoning demand on mental healthcare.

So what exactly are psychedelics?

HOW PSYCHEDELICS WORK

Psychedelics (also known as hallucinogens) are a class of psychoactive substances that produce changes in perception, mood and cognitive processes. These drugs are able to induce states of altered perception and thought, frequently with heightened awareness of sensory input, but with diminished control over what is being experienced.

MDMA (3,4-Methyl​enedioxy ​metha­mphetamine), LSD (Lysergic acid diethylamide), DMT (N,N-Dimethyltryptamine), Ketamine, Mescaline and Psilocybin are some of the popular psychedelics.

A critical way in which psychedelics can help alleviate treatment-resistant psychiatric disorders is in their ability to enhance neural plasticity — the process that allows the brain to adapt to new experiences — which, when combined with brain modulation therapies, may lead to rapid recovery.

Other possible explanations for their effectiveness are that most psychedelics act on the brain’s serotonin receptors, which are implicated in major mental health disorders. In addition, increased suggestibility after using psychedelics can make people more responsive to positive suggestions from a therapist, or even to the benefits of their own hallucinations.

The idea is that the altered perception induced by the substance allows practitioners to work through a patient’s trauma by contextually manipulating their environment. This flexible state might endow them with the kind of insight and the kind of positive transformative experience that leads to therapeutic change.

While psychedelics have shown effectiveness in treating a few conditions, there are still many unknowns about why they may be beneficial or how they work.

Psychedelic therapy usually does not work in isolation but is accompanied by other trauma-focused therapeutic interventions. Psilocybin and transcranial magnetic stimulation work together, for example, to provide lasting relief for stress-related depression and anxiety, especially for people who have not had success with more traditional treatments. Especially in cases of chronic PTSD, psychedelics can play a key role in changing the relationship and association with trauma by activating new neural pathways.

There are two broad approaches to psychedelic therapy: Psychedelic Harm Reduction and Integration (PHRI) incorporates various approaches and does not provide the actual psychedelic experience as part of the treatment. On the other hand, Psychedelic-Assisted Psychotherapy (PAP) consists of administering a psychedelic, in the presence of a therapist providing psychological support.

THE CASE OF PAKISTAN

In March, the UK opened its first high-street clinic offering psychedelics-assisted therapy. In the US, the Johns Hopkins University launched a dedicated centre for psychedelics studies. In July, Harvard Law School’s Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics launched a first-of-its-kind research initiative, focused on psychedelics, law and its research and treatment.

Does this treatment have crossover potential in Pakistan?

According to Dr Hadi Usmani, a clinical researcher with a focus on psychiatric novel therapies, psychedelics modalities are very effective from the get-go, so even with one session, patients can report a significant change in their behaviour, mood and lifestyle. Hence, we can see some rapid progress that might not be possible with psychiatric medications.

Usmani serves as the Clinical Research Coordinator at the Canadian College of Healthcare and Pharmaceutics, with community insight into psychedelics spanning over a decade. According to him, psychedelic therapies are extremely applicable, since they come under the realm of alternative therapies. Hence, they can help overcome the barriers that our population faces to get proper psychotherapy and psychiatric care.

There aren’t enough current solutions available to make an impact on the provision of mental health in Pakistan. “We need any new modalities and new novel technologies to bolster the situation and create an impact that maybe traditional methods haven’t been able to do,” he says.

But Aisha Sanober Chachar, a consultant psychiatrist and co-founder of Synapse Pakistan Neuroscience Institute, has a cautionary outlook. The rush to approve psychedelic therapy can compromise safety and efficacy, she says.

“We need to define ethical standards, train professionals and examine long-term safety and monitoring,” Chachar tells Eos. Another problem, according to her, is the availability of enough psychedelics-trained therapists and ensuring standard evidence-based ethical practice.

Pakistan is among the nations that recently adopted an autonomous Drug Regulatory Authority, with a comprehensive national pharmacovigilance system. Although Pakistan has undergone many reforms and policy changes to ensure safe and productive medicines, resource limitation has remained a concern.

Additionally, there are poor regulatory controls and the continuous delivery of quality medicines is unreliable. Local regulators and researchers are barely aware of the affordable technologies and strategies related to implementing cost-effective policies.

Dr Nazila Bano Khalid, a certified psychiatric rehabilitation practitioner, warns that a lack of regulation means that if psychedelic therapy is practised in Pakistan, quacks will have access to these drugs and then they will potentially abuse it.

“People themselves can abuse them even if they find out through word of mouth. They can get them over the counter, since they will be easily accessible,” she says. “From time to time, we get patients who have tried these drugs by themselves and reported significant improvement, especially in depression and anxiety.”

Usmani sees the lack of regulation as an opportunity. In Pakistan, there is little regulation in terms of the psychiatric care that can be given, so novel research can be done on psychedelics. In contrast, in the West, there are a lot of barriers in place because of state-sponsored and governmental laws that have limited the scope of psychedelic therapies.

“So Pakistan, in that way, is primed for a psychedelics revolution where these new medicines can be used to hit the ground running,” Usmani says. “You don’t even necessarily need a psychiatrist to oversee the procedure. You can have a psychedelics-trained professional that can fill in the gap.”

To prevent quacks from abusing this, he advises a one-year course from an internationally accredited organisation could be made mandatory to become a certified psychedelics-based intervention therapist.

According to him, the potential danger is that these psychedelics are used in a more informal, abusive or a party-oriented environment. Regulations will have to be put in place to prevent that. Proper drug education about the use of these substances and safety around them is also imperative.

The biggest barrier is overcoming religious and cultural biases against ‘drugs’ because psychedelics may be pushed into that category. “Because it is something that has not really infiltrated the cultural consciousness as it has in the West, it is not seen as a negative thing yet,” says Usmani. “So we are in a better position to create a new narrative around these substances and, if we can show people that within certain dosages we can work in a clinical way with these substances, there is a lot of potential.”

Khalid points out that the Drug Regulatory Authority of Pakistan (DRAP) has not addressed this issue yet. From a religious perspective, these drugs are considered “nasha” [intoxicants] so people are not ready to advocate for it. It should be noted that, last year, Pakistan approved the license for industrial, medicinal use of hemp, which is a cannabis plant.

The total market for psychedelics-related medicines could eventually reach $100 billion, as per a Business Insider report. A key factor into this newfound interest in the field is that mental health has now become a rapidly growing, lucrative field. The pandemic has caused an exponential surge in the prevalence rate of psychological issues, so the global mental health market is estimated to reach $537.97 million by 2030.

In Pakistan, there are less than 600 adult psychiatrists and less than 10 child psychiatrists. Given this background, if and when the glorified idea of psychedelics-assisted therapy becomes legal, it will presumably be too costly and unaffordable for the general population, unlike the claim.

In the US, for instance, the estimate of a course of MDMA treatment is around $15,000. “Even if this makes it to Pakistan, the high cost will make it inaccessible to many, placing barriers to access in non-affording populations,” says Chachar. “Unfortunately, the popularity will promote active secretive use of psychedelic medicines for individuals who may not be able to afford the legal versions. There are doubtless considerable profits for suppliers and traffickers of illicit drugs.”

The writer is a clinical associate psychologist and freelance journalist. She can be reached at rabeea.saleem21@gmail.com

Published in Dawn, EOS, January 2nd, 2022