Psychedelics Present Unique Ethical Challenges

In an interview with Pharmacy Times, Sa’ed Al-Olimat, PharmD, co-founder of the Psychedelic Pharmacists Association, discussed the future of psychedelic medicines and the unique ethical challenges they present. He also discussed the roles pharmacists will play in these treatments.

Q: What ethical considerations are raised with psychedelic medicines?

Sa’ed Al-Olimat, PharmD: Oh, yeah, there are many, and it would also depend on the psychedelic we're talking about. So, first, one topic is deciding the consent process, specifically navigating therapeutic touch. So, many clinicians, and I'll even speak to pharmacists on this front, we don't really have a lot of experience holding hands with our patient or knowing when it's appropriate to hug, if it's even appropriate when the patient is really working through something challenging or something enlightening. So, just the conversation of ethical touch is a very important consideration so that there is no abuse of power during this experience. Patients or clients that do take a psychedelic, during that state of being they're in a very vulnerable state and it's a very delicate state to work with. I guess what this translates to is proper training of clinicians, whether it be before and after the experience, but especially during the session itself, what to do what not to do. So, I would say that would be a big consideration, an ethical consideration, that should be raised in psychedelic medicines.

Another important ethical consideration to bring up, specifically when talking about entheogens or naturally occurring psychedelics such as psilocybin, would be the idea or the topic of sacred reciprocity. And I'm not sure how familiar the audience is on the history or the historical context that brought psilocybin to the Western nations, but it was very extractive toward the Mazatec people, specifically the city that Maria Sabina grew up in, and it was Huatla de Jiménez. And it was very extractive, and it really led to a lot of tourist-like approaches to psychedelic access from the Western world down to this city in Mexico, and it destroyed that that community. And now we are profiting off of their expense. We are synthesizing a molecule from the mushrooms that she shared with Gordon Watson and many others. And the question comes up is, how can we provide reciprocity to that community, but also the other communities that have practiced the ceremonial and sacred, safe consumption of psilocybin for the millennia before it started popping up on TikTok and Reddit threads? So, I really believe that we should be aware of this ethical consideration and see what we as practitioners, as people here in the States and beyond, what can we do to practice sacred reciprocity?

There's a lot of other ethical considerations and I'll speak a lot about a lot of these during the presentation at APhA, but the last thing I want to bring up is this topic of healer inclusivity. So, again, like I brought up the use of psychedelics in a community setting for therapeutic reasons, even that has been around for a long period of time, well before you and me, well before APhA, well before all of this. And this topic of healer inclusivity is something I really care about because it's like who are we as clinicians to be able to be the ones to solely gatekeep the use and access to these? And of course, yes, safety and FDA approval and legal landscape regulations, all that stuff. But you can look at the multitude of ways, one being [that] no one's advocating for the inclusivity of pharmacists to really take an active role in this space, aside from the low hanging fruit being specialty pharmacy because manufacturers are going to find someone to ship these compounds out to the clinicians’ offices. But are pharmacists really just the logistical coordinator of drug delivery services? I think we're much more than that. So, how can we be included in this space and be able to really practice at the level of our training, and receive more training to practice even higher? So, that's one topic within healer inclusivity.

The other topic, too, is even broader than that. If someone is extremely compassionate, caring, maybe they don't even have a high school diploma, but they've done the work, they are able to learn and care about this experience, can they not take an active role in this in this space to some degree? So, I don't have the answer to that question and of course, there's a lot of a lot of nuances in that discussion. But if we really care about the sustainability of community practice and the accessibility to care for those that are suffering and struggling and meeting those that have unmet needs that have a deep distrust and mistrust to the medical system, how can we or should we even consider the inclusion of others outside of the medical field into this landscape?

Q: How are pharmacists involved in this research, and how do you predict they’ll be involved in these treatments?

Sa’ed Al-Olimat, PharmD: Yeah, so pharmacists are actively involved in this research right now, from pharmacovigilance reporting to being a part of clinical trial design. One of my colleagues, she's a part of the Psychedelic Pharmacists Association, she's brilliant and her name is Dr. Allie Kaigle, and she's a board-certified psychiatric pharmacist. And I believe she was actually, I think, the first female practitioner to really be the first practitioner to bring MDMA to the VA, so she's not very highly spotlighted because there's other players, other very successful and vocal professionals in the space that are doing something very similar. But her and her colleague…they've conducted MDMA-assisted therapy at the VA for quite some time now. So, pharmacists are taking an active role in what Allie does. She actually sits as a co-monitor or co-therapist during the sessions, and she works closely with the psychotherapist and an interpreter in professional discipline to take a much, much more active role from the preparation to the dose day support and the integration for those at the VA. So, that's one way that pharmacists are involved in this research, is actually being a co-therapist utilizing MDMA and supporting her clients, who are participants in those studies.

Another cool example would be what Doctors Kellen Thomas and Ben Malcolm are doing or have published. So, [they’ve published] a lot of amazing research and overviews on the drug interactions among a variety of psychotropics that are being used now, but also a lot of the psychedelic compounds that we've spoken about and much more. So, they’re really laying the groundwork and really trailblazing what pharmacists can do, and supporting not just the pharmacy profession, but all the professions and enhancing what type of what type of knowledge is out there as we begin needing to navigate these very elaborate and complex drug interaction mechanisms for those that wants to pursue psychedelics and who are on XYZ medication for, you know, ABC indication. So, yeah, a lot of clinical research supports being able to serve as a co-therapist and really just raising the standard of education and knowledge we understand right now in the space.

Q: Is there anything you’d like to add?

Sa’ed Al-Olimat, PharmD: I think the second part of your question, I'm not sure if I actually acknowledged it or answered it, would be how I predicted pharmacists to be involved in this space and in these treatment systems. So, of course, I think what is going to happen for sure is specialty pharmacies will help handle the logistical coordination and, of course, provide some level of patient care, whether it be through some type of phone conversation, touching base with clinician and patient. But I'm not sure how much of that will be inclusive of some level of motivational interviewing or non-directive support, some practice of key or core psychotherapeutic teachings when it comes to these medicines. So, again, we're going to see specialty pharmacy.

But I do think that pharmacists may be able to begin doing more and, you know, to what Dr. Allie Kaigle is doing, being able to really open up access to care by working through some type of collaborative arrangement with a psychiatrist or a physician to be able to be trained and then support patients from screening, preparation, dose, day support, and integration. Now, that's a bit more of the higher hanging fruit, being that dose day facilitation, because there's a lot that someone needs to be trained on when it comes to that. With that said, I personally have taken the MDMA-assisted therapy training program offered by MAPS, which is about a 100-hour-long course with 60 hours online, 40 hours in person. And upon taking that course, it was me in a room of, I think, maybe 70 other clinicians, all of whom were therapists or psychotherapists. And what I recognized was that because I have some basic understanding of motivational interviewing through pharmacy school and everything else was just a blank slate, being able to understand how they practice MDMA-assisted therapy, that was really easy for me to grasp. But of course, there was a lot I had to learn and there were some things that I had to really be cognizant of. But the folks at MAPS did an excellent job with the training. And a lot of therapists were shocked that I wasn't a therapist. So, you know, I do think that pharmacists are in a unique position to not only answer drug information-related questions, help with the screening process, but also to be trained and equipped to support these patients or clients, again, from the preparation to the dose day administration, and integration and beyond. So that's my prediction. I do believe that pharmacists will be able to do much, much more.