Do not conflate debates on regulating therapeutic use of psychotropic substances with those on the legalization of their non-therapeutic use

Abstract

Andrews et al. [1] discuss the development of regulatory policies for psychedelics by drawing parallels to the recent history of cannabis legalization. Although they address the distinction between therapeutic and non-therapeutic substance use, this aspect deserves more emphasis because it underlies many of the challenges and criticisms highlighted in the paper. Separating the debates on regulating psychedelics for therapeutic use and legalizing them for non-therapeutic use is crucial. The two modalities differ considerably in purpose, regulation and decision-making processes.

Therapeutic use treats medical problems under professional supervision. Non-therapeutic use seeks pleasure, relaxation or mind alteration without medical supervision, chosen for psychoactive effects and often used socially or in cultural rituals. However, even more important, regulating these domains follows distinct logics: scientific rigor for therapeutic use versus political and social consensus for recreational use.

Science is an organized body of knowledge derived from observation, experimentation, analysis and methodical research, aimed at minimizing personal biases. Politics, however, aims to realize societal values through policies, sometimes ignoring scientific evidence. In democracies, this involves public debates and consultations, with citizens supposed to influence government decisions. Therefore, non-therapeutic legalization is less based on scientific evidence and more influenced by political, social and economic considerations. The intermingling of these two spheres leads to major problems in both: in particular to a de-scientification in therapy development, but also to a pseudo-medicalization, to a medical bureaucratization in the area of recreational consumption, in a field that concerns primarily civil rights.

Therapeutic drugs might be marketed without robust evidence because of public pressure, as Andrews et al. [1] emphasize. Premature marketing based on uncertain evidence certainly is problematic. However, the risks from blurring the boundaries between therapeutic and recreational use will persist even with stronger evidence.

One expression of this de-scientization, which will persist, is the ominous tendency to adopt untested traditional rituals, like shamanistic practices, into therapy, which undermines credibility and risks patient safety. Involving non-professionals, such as shamans or healers, also compromises the field's credibility. Additionally, public pressure on regulatory authorities can hinder or contradict the search for scientific evidence.

Moreover, the medicalization of recreational use of psychedelics risks bureaucratizing a civil rights issue. Recognizing the consumption of psychedelics as a civil right requires regulation rather than medicalization. Restricting access to the medical framework compromises individual freedom, creating financial and administrative barriers that exclude some people and leading to inequalities in access. Medical bureaucratization would finally also oversimplify psychedelic experiences, neglecting the diversity of individual motivations and cultural contexts. Finally, the scientific support for the therapeutic efficacy of psychedelics cannot in itself be an argument for the legalization of non-therapeutic use.

The current hype is certainly problematic, as emphasized by the authors, but again only to the extent that no distinction is made between the two domains and their two inherent logics. Hyping itself is not necessarily the problem, as long as it serves to dynamize research and does not substitute research with public pressure.

Daniele Zullino: Conceptualization (equal); writing—original draft (equal).

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