After the War on Drugs, the Post Prohibition Trust Disorder begins

A pilot, mushrooms, and a call for more honest conversations about drug use

“Do you want to be uncomfortable on your terms or on someone else’s?”

This was a question my old therapist used to ask me when I was avoiding having a difficult, uncomfortable conversation with someone important in my life. In the week following the reports of Joseph Emerson, a pilot with Alaska Airlines who reportedly was struggling with depression and recently experienced the death of a close friend, was riding along in the cockpit jump seat as a passenger when he attempted to cut the fuel to the engines, this is a question that psychedelic enthusiasts need to be asking themselves.

Agitated and confused, Emerson was wrestled out of the cockpit and the plane was diverted to Portland, where he was arrested. He reported he had taken psilocybin mushrooms for the first time, 48 hours before the incident. It was speculated that he was attempting to treat his depression with the mushrooms.

The media, of course, jumped all over this story, insinuating that he was somehow still intoxicated with the psilocybin at the time of the incident - likely an inflammatory, attention-grabbing headline. If the timing reported is accurate, this is impossible, as psilocybin’s acute effects typically only last for 6-8 hours. However, the media also reported that he told investigators he was dehydrated and had not slept for 40 hours between the incident and the psilocybin use. Insomnia following psilocybin use, leading to a transient state of psychosis or emergent mixed mania, has been reported in the literature. We reported on such a case in 2021 (Hendin & Penn, 2021), as have others (Halim et al., 2023; Gard et al., 2021).

The clinical facts of the matter remain under investigation and have not been released, so we are left to speculate on what happened. One can imagine the fear experienced by those 83 people on board when they learned how close they came to crashing. One can simultaneously feel sympathy for a man who, while attempting to find relief from depression, likely ruined his career and incurred 83 counts of attempted murder and reckless endangerment

(One thing that I think we can easily agree upon is that we need to make it easier for pilots and other people in sensitive professions (read: nurses and doctors) to seek mental health care without fear that it will end their careers or cost them their professional licenses. Full stop.)

Psychedelics are having a moment in which slow and steady research has begun to reveal potential benefits for certain psychiatric conditions. Simultaneously, the media and popular culture have highlighted potential benefits of psychedelic use outside of clinical settings. These streams have begun to erode decades of prohibitionist messages from government agencies that focus only on the harms of drug use. As a psychedelic researcher, I witnessed psychedelic enthusiasts this week attempt to divert attention from, and to explain away, the actions of this pilot. Recent discussions with friends in the psychedelic community have been disappointing, with attempts to question the link between the psilocybin use and Emerson’s actions 48 hours later. Many have deflected attention to other issues, e.g., “What about those who are harmed by prescription drugs?” (a whataboutism tactic).  

What I’m seeing are the late effects of what I call “post-prohibition trust disorder,” which manifests after we are repeated lied to by those who are supposed to be telling the truth. It is tempting to vociferously defend whatever is the opposite of that lie that we were told. As the old aphorism goes, “the enemy of my enemy is my friend.”

The prohibitionist war on drugs, begun in the 1930’s with Henry Anslinger’s racist campaign against cannabis users, was famously escalated by Richard Nixon with the signing of the Controlled Substance Act which, in 1970, declared a worldwide offensive on “America’s public enemy number one… drug abuse.”

As the Greek tragedian Aeschylus famously observed “in war, truth is the first casualty.” Reporting around the war on drugs is no different. Science was co-opted into this effort to demonize and prohibit drug use, from spurious claims that LSD damaged chromosomes to reports that MDMA caused massive dopaminergic neurotoxicity and could lead to premature Parkinson’s disease (a paper that was later retracted from the august journal Science after it was revealed that the lab had unknowingly switched vials of MDMA with methamphetamine that were injected into monkeys).

The propagandists were similarly cavalier with the truth, from the frying egg on our TV sets telling us “This is your brain on drugs” to the scare tactics of DARE, accuracy was less important than impact when teaching children about the risks of drug use. We were lied to by people who were entrusted to tell the truth. Those lies have consequences. If truth was the first casualty of the war on drugs, trust was the next to die.

In addition to a loss of credibility from “the authorities,” this leads to a more insidious trap.  Partisans in the fight begin to assume the opposite of the lies must be true. If NIDA used distortions of truth to say that psychedelics are always risky, then the reverse must be true – that psychedelics cannot cause harm, or that if harm was associated with psychedelic use, it is attributable to some factor outside the psychedelic in question.

In the psilocybin research studies that I work on, we know that all drugs carry risks and it is our job to understand the risks as well as the benefits of a treatment. This is why we monitor for what are known as “Adverse Events” (AEs) – unwanted experiences that are possibly associated with the drug we are studying. Most of these AEs are mild and expected e.g., brief nausea or yawning after psilocybin ingestion, or headaches at the end of the session. We report these to the FDA as part of our research process so that if the drug is someday approved, clinicians and patients using the drug can make reasonable predictions as to what side effects can be expected. If a “Serious Adverse Event” (SAE) occurs — one that is life threatening, results in hospitalization, injury or death — these findings are promptly reported and the FDA has the authority to halt a clinical trial.

All drugs have side effects and AEs. This is to be expected. Drugs with the potential to powerfully treat obstinate psychological problems, have the potential to cause serious psychological adverse events. AEs like transient anxiety occur between 17 and 100% of the time in psilocybin studies (Thomas et al., 2017). Fortunately, in the carefully controlled settings of psychedelic research studies, these AEs are usually manageable within the psychological containers created by therapists in the days leading up to a drug dosing session. It is rare that serious AEs occur within these settings — probably because the subjects are carefully selected and therapy so regimented. Had Mr. Emerson been a subject in a clinical trial, his 48 hours of insomnia and deteriorating psychological state would certainly have been considered as SAE. 

In 2022, we (Raison et al.) reported on a large (n=2,510) survey of psychedelics users, seeking to understand both benefits and adverse events associated with psychedelic use (Psychedelics and Wellness Survey – PAWS). In these naturalistic (i.e., non-clinical setting) uses of psychedelics, there is no screening of who can and cannot take psychedelics and support structures may vary considerably. The good news was that 87% of those surveyed in PAWS reported no adverse events. Only 1.4% of respondents reported feeling aggressive or violent during a psychedelic experience. Specifically querying 1993 people who reported a difficult experience on psilocybin, Carbonanro et al. (2016) reported that 2.6% of this subgroup reported violence or aggression during their drug session.

In our PAWS study the vast majority of people report these substances helped improve their sense of wellness, reduced their anxiety, and diminished their depressive symptoms. This reflects much of what we have seen in research studies in depression, PTSD, and substance use disorders: that these compounds, when used thoughtfully, hold great promise for treating some of our most vexing psychiatric problems (Ko et al., 2023).

The incidence of adverse events for psychedelics appears reasonably low. This is encouraging, but it is not zero, and we are still learning who may be most vulnerable. When psychedelic use was relatively uncommon (until 2015, the Monitoring the Future report found a rate of about 4% of people between 18-35 reporting past year psychedelic use and about 1% of those between 35-50 reporting psychedelic use in the last year. By 2022 it had increased to 8% and 4.1%, respectively), it was unlikely one would hear about someone having an adverse event on a psychedelic. However, as psychedelics become increasingly acceptable outside of clinical settings, the sheer number of people impacted by these negative effects will increase – even if the incidence remains low.

In general, studies indicate that even naturalistic psychedelic use likely incurs a net benefit towards well-being, depression, and anxiety (Johnson & Krebs 2015). But there is risk for harm, and we need to be able to better identify who is most vulnerable. Identification of potentially at-risk users should not be limited to clinical trial participants, but should also be a part of harm reduction education efforts for people planning naturalistic psychedelic use. People with personal or family histories of psychosis or mania and those experiencing difficult emotional stressors should be discouraged from using psychedelics in these uncontrolled settings.

So how do we recover from Post Prohibition Trust Disorder?

First off, we have to stop lying, both to each other and to ourselves.

The credibility of the authorities (which includes the medical establishment in addition to government agencies), psychedelic enthusiasts, and the media is on the table to be reclaimed. Agencies like NIDA and law enforcement need to stop painting all drugs with the same brush and exaggerating the harms of drugs. Additionally, clinicians need to stop parroting half-truths from prohibitionists and become more honest brokers of information for our patients.

Psychedelic enthusiasts must grow into the responsibility of being taken seriously and stop pretending these compounds are without risk. Like my old therapist encouraged, we need to start initiating the difficult conversations about risks rather than waiting for others to begin them. We need to start aggregating and disseminating deidentified reports of these harms in places like Oregon where supervised adult psilocybin use is legal, so that we can begin to identify and mitigate liabilities.

The media needs to be better informed on the nuances of drug use and drug effects. A recent headline calling the pilot’s behavior a “bad trip” clearly demonstrates the reporter’s lack of understanding of the difference between acute effects of the drug and later negative sequelae that occurring in the days following. Since most of the public gets its information from news media and not scientific journals, it is critical that reporters better understand what they are writing about.

We need to be willing to acknowledge the gaps in knowledge and do the studies to gather the information that will fill them. As I recently wrote with Rachel Yehuda, “Asking and answering the important scientific questions will take longer, but eventually will yield useful tools for mental health, along with appropriate attendant regulation. Failure to first advance scientific and medical interests may yield a backlash due to adverse events, even if the negative outcomes are uncommon, especially if these adverse events are highlighted by the same popular press that is currently championing these drugs.” (Penn & Yehuda, 2023)

Put more succinctly: imagine where the narrative of psychedelic research would be right now if that plane had crashed?

Finally, we all need to be willing to learn and adjust to changing information. If a particular population is found to be more vulnerable to harm, we need to make that known without losing nuance and insinuating that everyone is vulnerable to this harm. It is incumbent upon psychedelic enthusiasts to be part of the effort to educate the public about the known hazards of psychedelics and to teach how to best mitigate these risks. With both advancing research and increasing use, we will continue to gather information about both the benefits and the risks of psychedelics. The question then will be, “Will we be able to change our minds?”

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