We should study psychedelic-assisted therapy apart from its potential clinical value. It offers important lessons on the adoption of healthcare practices. Scientific progress often follows a circuitous path, but the journey taken by this reborn therapy is stunning. Most people still think of psychedelics as dangerous drugs, not therapeutic agents. Yet their growing medical support is worth understanding.
Changes in the practice of medicine are like other instances of social change. There are formal and informal components. For example, the FDA approves medicines, but doctors freely prescribe them “off-label,” or as they choose. Doctors are influenced by social forces. Fen-Phen’s use for weight loss ended due to heart damage. Its meteoric rise had been based more on popular than medical support.
There are oddities at both extremes in the adoption of clinical practices. Some practices are embraced widely despite limited clinical evidence. Others take years for adoption despite definitive evidence of effectiveness. For example, researchers reviewed studies for 3,000 different medical treatments being used a decade ago and found the effectiveness for half of them was unknown.
This may be partly explainable. Many unproven treatments will ultimately get validated, and experimental ones are used for serious conditions without better alternatives. Yet we clearly endure needless waste and disappointment with ineffective care. The opposite frustration also exists. Our “research to practice gap” often means years can elapse before valid treatments are widely adopted.
How did psychedelics and other mind-altering drugs become acceptable therapeutics? Advocates (like MAPS) persisted. They garnered support for research, education and pharmaceutical development. Several esteemed medical institutions now have programs to study psychedelics for treating behavioral disorders. Once-feared chemicals, like J&J’s ketamine-like nasal spray, are now used for depression.
Waiting for all the evidence to emerge may be principled and impartial, but for better or worse, other judgments and pressures impact the adoption of medical practices. Stories of progress in science are often simplified. Progress is usually messy and may depend on strong supporters as much as a strong rationale. Tidy stories of progress often hide confusion, conflict and influence.
This is good to know when pursuing innovation and change. Proponents must be realistic. There are times when medical practices are steadily adopted as evidence builds, and yet practices may be quickly or slowly embraced, despite existing evidence. We extol evidence-based practice today, but clinical products and practices have had widely inconsistent timelines for their conception, validation and use.
These thoughts are relevant to my advocacy for changing the delivery of behavioral healthcare. It seems quixotic to some. While we have always been an isolated specialty, our field strikes me as quintessential primary care. We could disseminate our services more widely within the non-stigmatized primary care setting and also help PCPs with their biggest challenges. Are these ideas sufficiently validated?
Examples like psychedelics are helpful. The moral is that people must fight for ideas. They rarely succeed on their own. Adoption often requires campaigns for support. Empirical validation varies for every solution. Other factors help drive adoption, and opponents can be crafty. Closed minds can hide behind endless demands for evidence. Implementations can be delayed with timid, stepwise measures.
Gradual implementation can damage valuable treatments. Consider buprenorphine. Its history might be described as the progressive expansion of prescribing practices. The number of patients able to get treatment in outpatient settings increased over time. It is also a story of how restrictions and evolving regulations contributed to damaging the reputation and availability of a lifesaving treatment.
The design of healthcare delivery has similarities. Delivery systems cannot be fully tested in clinical trials. For example, combining PCP and psychotherapy services has not been fully researched, even though each involves well validated treatments. Moving therapists into the primary care setting may seem odd to the tradition-bound. What level of proof can justify it? No level of proof dictates action.
New practices are often not adopted due to a preference for tradition or a fear of change. Delay may seem prudent, an effort to be surer, when the driving force is resistance. Critical decisions frequently must get made with information lacking on key issues. Plenty of evidence may be available for big decisions, but never enough for complete certainty. Clarity often emerges only in the rear-view mirror.
It is a fallacy to think answers to big questions will all emerge from research. Practical decisions about healthcare delivery draw on research, but good judgment must always be part of the equation. People with knowledge of psychedelics have persisted in their agenda. This too is part of science. It advances not just on well-designed studies, but also when people have the courage of their convictions.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.