Psilocybin and Ketamine Are Safer Than Xanax, Say US Psychiatrists

Most American psychiatrists view psilocybin and ketamine as safer drugs than alprazolam (Xanax), methamphetamine, or alcohol, according to a new survey.

These attitudes contradict the poor safety profiles of the psychedelic drugs as recorded in current drug scheduling in the US.

Published in the International Journal of Drug Policy, the survey also found that nearly a third of respondents felt that current US drug policies had increased the difficulty of prescribing controlled substances in psychiatric care.

The Ohio State University researchers behind the survey say that these views are largely in agreement with the opinions of other mental health professionals and drug addiction experts. By calling attention to this discordance between scientific views and current drug control, they hope that the latter may become more flexible to reflect expert consensus. 

Drug schedules do not match psychiatrists’ perception of safety and efficacy

In total, 181 psychiatrists from across the United States took part in the survey. The average age of the participants was 49 years and they had been practicing psychiatry for an average of 16 years.

In the first part of the survey, participants were presented with one of four possible scenarios depicting a patient with severe depressive symptoms who had found relief using a non-prescribed drug, and who was now asking for this drug to be incorporated into further treatment.

Each vignette was identical apart from the drug being used: either psilocybin (Schedule I), methamphetamine (Schedule II), ketamine (Schedule III), or Xanax (Schedule IV). For the vignette presented, the psychiatrists were asked to rate their level of agreement with a series of hypothetical clinical decisions and future outcomes.

The survey revealed that psychiatrists were more likely to warn the theoretical patient against the repeated, non-prescribed use of methamphetamine and Xanax compared to psilocybin or ketamine. Ketamine was also significantly more likely to be integrated into the patient’s future treatment plan.

Consistently, the un-prescribed methamphetamine and Xanax use was deemed as more concerning and less acceptable than the use of psilocybin or ketamine, despite this contradicting the scheduling levels for each drug.

Psychedelics deemed less harmful than unscheduled alcohol

In the latter part of the survey, the psychiatrists were asked to rank these four drugs, plus alcohol (which is unscheduled), in terms of their perceived safety, therapeutic potential, and abuse potential.

Generally, the psychiatrists believed psilocybin and ketamine to be equivalent in terms of their safety, with Xanax, methamphetamine, and alcohol all being perceived as less safe than the psychedelics.

Ketamine was viewed as the drug with the highest therapeutic potential and alcohol the lowest. Psilocybin was believed to have the least abuse potential, closely followed by ketamine. Alcohol, Xanax, and methamphetamine were all ranked similarly in terms of their abuse potential, and all were felt to be higher than for the psychedelics.

“Psychiatrists’ perceptions of the drugs in our survey were not congruent with those indicated by the current drug schedule,” first author Adam Levin told Analytical Cannabis. Levin is a third-year psychiatry and behavioral health resident in Ohio State’s College of Medicine.

“These differences were especially pronounced with regard to psilocybin and Xanax. Specifically, psychiatrists viewed psilocybin as safer, as having a higher therapeutic potential and a lower abuse potential than indicated by its Schedule I status,” Levin said.

“With regard to Xanax, psychiatrists rated it as having an abuse potential comparable to methamphetamine and alcohol, and as less safe than ketamine and psilocybin under medical supervision, despite it being in a relatively lower/less restrictive schedule (Schedule IV).”

Indeed, across all three domains of safety, therapeutic potential, and abuse potential, the rankings of the drugs made by the psychiatrists did not match the rankings implied by the drugs’ position in the current drug scheduling system.

Does drug policy affect how psychiatrists treat patients?

Finally, the survey posed several open-ended questions to explore psychiatrists’ attitudes towards current drug policies and its impact on psychiatry training. 

The researchers found that nearly one-third of responses were of the opinion that US drug policy increases the difficulty of prescribing controlled substances in psychiatric care. Nearly one-fourth indicated that US drug policy was limiting learning opportunities in psychiatric training through increasing stigmatization, and around one-fifth of responders also felt that current drug policy was affecting the attitude of trainees towards certain drugs and drug users.

Interestingly, when asked directly about how US drug policy affects professional beliefs about certain drugs, 28% of respondents expressed some form of criticism towards US drug policy. For example, nearly 10% of the total responses said that their own professional beliefs were based more on scientific evidence than federal drug policies.

“In the last 10-15 years, as more evidence for the therapeutic potential of ketamine in treating psychiatric disorders has emerged, the ‘off-label’ prescription rates (ie. prescriptions for non-FDA approved indications) of ketamine have increased significantly,” Levin explained.

“This was reflected in our survey with psychiatrists rating ketamine as the most likely of the four drugs to be used as part of their own treatment plan in the vignettes. So, it does seem that, in some cases, psychiatrists are adjusting their behavior according to clinical and scientific evidence as opposed to drug policy.”

As the body of evidence supporting psychedelic-assisted psychotherapy continues to grow, US drug regulations must be flexible and change accordingly. And according to a recent letter from the US Department of Health and Human Services, the Biden administration may already be taking steps towards this.

The letter recommended the establishment of a new FDA taskforce to examine potential challenges in rolling out MDMA and psilocybin-based treatments for post-traumatic stress disorder and treatment-resistant depression. According to the letter, the agency is expecting “approval [...] within approximately 24 months” for these therapies.

“As several Schedule I drugs approach potential FDA approval in the next few years (MDMA and psilocybin), they will need to be rescheduled per the Controlled Substance Act,” Levin commented. “This rescheduling should adhere closely to the scientific evidence and to expert consensus.”