Commentary on Keyes and Patrick: Changes in psychedelic use in the United States may require changes in our narrative of psychedelic harms

Given the shifting public perception of psilocybin and associated legal changes, the increase in use observed by Keyes and Patrick is not surprising. The conclusion that this is a rising health concern is not justified by the data, particularly as in this sample non-lysergic acid diethylamide hallucinogen use seems to have increased in a white, educated, relatively higher socio-economic status group in whom drug use is associated with less risk. Keyes and Patrick present data from the Monitoring the Future survey from 2018 to 2021 showing stable use of lysergic acid diethylamide (LSD), but a near doubling in the use of ‘non-LSD’ hallucinogens over this period in 19 to 30 year olds [1]. Given recent scientific, media and corporate interest in psychedelics, the so-called psychedelic renaissance [2], the increase in non-LSD hallucinogen use is perhaps unsurprising. The authors interpret this as being driven by drugs such as psilocybin, the benefits of which have been much hyped in both the popular [3] and scientific [4] literature. Phencyclidine (PCP) is also suggested to contribute, but is much less prevalent [5], although increases may also be driven by growing use of PCP's weaker congener, ketamine, consistent with other surveys of drug use over this time frame [6]. It is important to track trends in drug use over time, but the authors interpret this rise in non-LSD hallucinogen use as a concern for health. This conclusion seems at odds with multiple sources of evidence that suggest that infrequent hallucinogen use, of the variety observed in this sample—which had a stable mean incidence of between two and three occasions of use in a year—rather than having damaging consequences for health, may indeed have beneficial effects. For example, both cross-sectional [7] and longitudinal [8] surveys of users of hallucinogens during the coronavirus disease pandemic have shown greater well-being and lower scores on measures of psychopathology than people who do not use hallucinogens. Keyes and Patrick's conclusions appear negatively biased in the face of a now large body of evidence that suggest increases in well-being and improvements in psychopathology following infrequent hallucinogen use [7, 8]. This is coupled with the fact that in this sample, increases in hallucinogen use were greatest in a group of white males of higher socio-economic status. There is good evidence that harms from drug use are disproportionately greater both in people of colour and those of lower socio-economic status [9, 10]. Therefore, the observed change in drug use may actually produce an improvement in well-being and also occurred in a group that is relatively protected from harm. Legal changes in the United States [11] and other countries, for example, Australia [12], mean that psychedelic use may become even more widespread in this age group, and this is a pattern that needs monitoring. However, given data that suggest positive consequences of the use of these substances, it may also be important to address structural factors producing racial and socio-economic disparities in their use. Further, it may be time to abandon tired narratives of the harms associated with these drugs, in favour of more positive conclusions that align with a now consistent body of evidence suggesting modest mental health benefits of infrequent hallucinogen use. None. There are no funders to report. C.J.A.M. has received contract research funds from Awakn Life Sciences, MRC and NIHR.