How Should We Do Drugs Now?

After a half century spent waging war on drugs, Americans seem ready to sue for peace. The 2020 elections brought plenty of proof that voters have leapt ahead of politicians in recognizing both the failures of the drug war and the potential of certain illicit drugs as powerful tools for healing.

Ballot initiatives in five states — four of them traditionally red — legalized some form of cannabis use. By substantial margins, Oregon passed two landmark drug reform initiatives: Fifty-nine percent of voters supported Measure 110, which decriminalized the possession of small quantities of all drugs, even hard ones like heroin and cocaine. A second proposal, Measure 109, specifically legalized psilocybin therapy, directing the state’s health department to license growers of so-called magic mushrooms and train facilitators to administer them beginning in 2023.

In the past two years, a new drug policy reform movement called Decriminalize Nature has persuaded local governments in a half dozen municipalities, including Washington, D.C., to decriminalize “plant medicines” such as psilocybin, ayahuasca, iboga and the cactuses that produce mescaline. Last month, the California State Senate passed a bill that would make legal the personal possession, use and “social sharing” of psychedelics, including LSD and MDMA, a.k.a. Ecstasy or Molly. Political opposition to all these measures has been notably thin. Neither party, it seems, has the stomach for persisting in a war that has achieved so little while doing so much damage, especially to communities of color and our civil liberties.

But while we can now begin to glimpse an end to the drug war, it is much harder to envision what the drug peace will look like. How will we fold these powerful substances into our society and our lives so as to minimize their risks and use them most constructively? The blunt binaries of “Just say no” that have held sway for so long have kept us from having this conversation and from appreciating how different one illicit drug is from another.

That conversation begins with the recognition that humans like to change consciousness and that cultures have been using psychoactive plants and fungi to do so for as long as there have been cultures. Something about us is just not satisfied with ordinary consciousness and seeks to transcend it in various ways, some of them disruptive (as psychedelics were in the West in the 1960s) and others generally accepted as productive, like caffeine. Hence the ritual of the coffee break, in which employers give employees both the drug and paid time off in which to enjoy it.

But context is everything: In many Native American communities, peyote, a psychedelic, is not at all disruptive; to the contrary, its ceremonial use promotes social cohesion and heals trauma. Timothy Leary’s notion of the importance of “set and setting” — that is, expectation and context — probably applies to all drugs, not just psychedelics, something worth keeping in mind as we navigate this new world.

In the case of psychedelics, decriminalizing these powerful compounds is only the first step in a process of figuring out how best to safely weave their use into our society. The main model we have for resocializing a formerly illicit drug is the legalization of cannabis, now the new normal in 18 states, and many in the cannabis world look to psilocybin as the next cannabis. But the prospect of magic mushrooms being commercialized like cannabis — advertised on billboards and sold next to THC gummy bears in dispensaries — should fill us with trepidation. Microdoses perhaps, but a macrodose of psilocybin is a powerful, consequential and risky experience that demands careful preparation and an experienced sitter or guide. We will need to look elsewhere for models of safe and sane psychedelic use.

But where? The straightest and least controversial path to folding psilocybin, as well as MDMA, into society is the medical route, which passes through the Food and Drug Administration drug approval process. These drugs are already well along in that process, and both should be approved for use in psychotherapy within a few years — MDMA to treat post-traumatic stress disorder and psilocybin to treat depression and addiction. After that happens, doctors will be able to prescribe these compounds, though not willy-nilly. The agency is expected to issue regulations stipulating exactly how and by whom they can be administered, probably with a trained facilitator in a safe place, in order to maximize the value of the therapy and minimize the chances of a bad trip.

But what about the rest of us — healthy people without a psychiatric diagnosis who want to use psychedelics for therapy, self-discovery or spiritual development? A small handful of religious organizations have marked out a second path to normalization. Since 1994, the Native American Church, now with an estimated 250,000 members, has had the constitutional right to use peyote as a sacrament. Since then, two other churches have secured the right to use ayahuasca. Today, new churches organized around the use of psilocybin, LSD and other so-called entheogens are springing up, with plans to seek legal recognition. Some legal experts expect them to prevail. This Supreme Court’s expansive jurisprudence on religious freedom has created a wide opening through which a parade of new psychedelic churches may be able to march. The same majority that ruled that the religious beliefs of a corporation, Hobby Lobby, exempted it from provisions of federal law may find it impossible to rule against the right of the Church of Lysergic Acid to use its chosen sacrament. Americans could soon be able to go to a church to have a ritualized psychedelic experience.

As for other Americans who want to use psychedelics in a more secular setting, it’s easy to imagine spa-like retreat centers popping up across the country. Indeed, a prototype already exists: Field Trip Health has opened a half dozen lavishly appointed clinics (with more on the way) offering ketamine-assisted therapy for depression, which is already legal, in anticipation of Food and Drug Administration approval of MDMA and psilocybin. A psychiatrist on staff screens “patients” — i.e., customers — and then a doctor or nurse practitioner administers the drug; trained facilitators prepare the clients for what to expect and then sit with them during the experience, afterward helping to “integrate” — make sense of and apply — whatever they have learned.

Different as they sound, the medical, religious and, for lack of a better term, retreat-center uses of psychedelics are all highly formalized, which is important. When psychedelics first burst upon the West in the middle of the last century, they arrived without an instruction manual and so were sometimes used recklessly, without regard for set and setting. People thought nothing of dropping acid at festivals and protests or of spiking punch bowls with LSD, a practice that seems crazy, if not cruel. It’s no wonder the bad trip became such a powerful meme and the culture turned against psychedelics.

In fact, a user’s manual for the safe and constructive use of psychedelics did exist, even then; most of us just weren’t aware of it. I’m thinking of the use of psychedelics by Indigenous peoples, which suggests a model we would do well to keep in mind as we figure out how best to handle these substances. There are numerous examples of Indigenous peoples that have successfully incorporated psychedelic compounds into their cultures as a sacrament, medicine or medium of communication. Surveying these cultures, you find a few common denominators. People seldom, if ever, use a psychedelic alone and never casually: They are taken for a specific reason, with an intention. There is almost always an elder presiding, someone who knows the psychic terrain and can create a suitable container for the experience. And invariably the experience takes place within a structure of ritual.

Dr. Andrew Weil was one of the first to recognize the value of ritual in drug use. In his 1972 book, “The Natural Mind,” he writes:

Ritual seems to protect individuals and groups from the negative effects of drugs, possibly by establishing a framework of order around their use. At least, people who use drugs ritually tend not to get into trouble with them, whereas people who abandon ritual and use drugs wantonly seem to have problems.

Simply borrowing a ritual ceremony from any Indigenous group probably wouldn’t fly in 2021 America and, even if it did, would be an act of cultural appropriation. In my interviews with Native Americans, I encountered a deep reluctance to share with a white journalist exactly what happens during a peyote ceremony. “The great spirit gave us this plant a long time ago,” Steven Benally, a Diné leader of the Native American Church, explained when I asked him simply to describe a peyote ceremony. “I’m guessing you’re white, yes? All this information you want, what’s in it for me?” So much has been taken from Native Americans that they are determined to safeguard their peyote and the rituals that accompany it. We non-Natives will need to design our own culturally appropriate containers for the secular, nonmedical psychedelic experience. But that process should be informed by the principles guiding these Indigenous practices, since they are the product of deep experience with these molecules going back thousands of years.

The end of the drug war will confront us with cases more challenging than the psychedelics, several of which have been investigated by scientists as effective treatments for various forms of mental illness. They are also not habit-forming. But what about the so-called hard drugs, like heroin, cocaine and methamphetamine — drugs that people ostensibly take for pleasure? Is there a safe way to fold these more addictive molecules into our lives?

This is uncomfortable territory, partly because few Americans regard pleasure as a legitimate reason to take drugs and partly because the drug war (with its supporters in academia and the media) has produced such a dense fog of misinformation, especially about addiction. Many people (myself included) are surprised to learn that the overwhelming majority of people who take hard drugs do so without becoming addicted. We think of addictiveness as a property of certain chemicals and addiction as a disease that people, in effect, catch from those chemicals, but there is good reason to believe otherwise. Addiction may be less a disease than a symptom — of trauma, social disconnection, depression or economic distress. As the geography of the opioid and meth crises suggests, one’s environment and economic prospects play a large role in the likelihood of becoming addicted; just look at where these deaths of despair tend to cluster or the places where addiction to crack cocaine proliferated.

Two findings underscore this point, both described in Johann Hari’s 2015 book on drug addiction, “Chasing the Scream.” Much of what we know, or believe we know, about drug addiction is based on experiments with rats. Put a rat in a cage with two levers, one giving it heroin or cocaine, the other sugar water, and the rat will reliably opt for the drug until it is addicted or dead. These classic experiments seemed to prove that addiction is the inevitable result of exposure to addictive drugs, a simple matter of biology. But something very different happens when that experimental rat is sprung from solitary confinement and moved to a larger, more pleasant cage outfitted with toys, good food and companions to play and have sex with. This is the so-called rat park experiment, devised by a Canadian psychologist named Bruce Alexander in the 1970s. He and his colleagues found that in this enriched environment, rats will sample the morphine on offer but will consume a small fraction of the amount consumed by rats living in isolation, in some cases five milligrams a day instead of 25. Dr. Alexander came to see that drug abuse isn’t a disease; it’s an adaptation to one’s environment and circumstance — to the condition of one’s cage.

The second phenomenon Mr. Hari recounts took place at the end of the Vietnam War. Some 20 percent of U.S. troops became addicted to heroin while in-country. With the war coming to an end, experts worried about tens of thousands of addicts flooding America’s streets. But something unexpected happened when the addicted service members got home: Ninety-five percent of them simply stopped using. It made no difference whether or not they received drug treatment. This is not to minimize the harm done by heroin to those who couldn’t quit; it is only to suggest that there is much more to addiction than exposure to an addictive drug.

The problem of drug addiction will be with us as long as unhappiness is; waging war on drugs did little to stem it, and it will not vanish with the peace. So what to do about it? Harm reduction is the approach embraced by the voters of Oregon as well as those nations that have legalized drugs, including Portugal and Switzerland. That might mean drug treatment, instead of incarceration, to help addicts break their habit, or in some places, actually giving them heroin (and clean needles) to maintain it. This reduces the harm that comes from using street drugs, which are of unknown purity (and nowadays often laced with fentanyl, which has contributed heavily to a rise in opiate overdoses), and from the crimes committed to obtain them. Switzerland has perhaps the most ambitious approach to treating heroin addiction. The government gives you a prescription for heroin but then makes sure you have a job, decent housing and therapeutic support, on the theory you will no longer need the drug after your circumstances improve. The abuse of opiates unquestionably does a tremendous amount of damage to individuals as well as to society. But contrary to the stereotype of spiraling chemical enslavement, some people manage to use opiates habitually while leading productive lives. Many, if not most, of the harms of the practice stem from its prohibition.

We shouldn’t forget that two of the most destructive drugs in use today — alcohol and tobacco — have long been perfectly legal. Having wisely given up on prohibition, we’ve worked hard as a society to regulate their use, deploying both laws and customs. Recognizing the dangers of tobacco, we’ve desocialized its use over the past 50 years, devising rules and taboos about when and where one may smoke. Along with high taxes, these expressions of cultural disapproval have substantially reduced tobacco use. (It’s worth remembering that in many traditional New World cultures, tobacco is used ritually without the harms associated with smoking in the West.)

The uneasy peace our culture has made with alcohol may point to a way drugs like heroin and cocaine might someday be used in the post-war-on-drugs era. As a society, we accept that some people will end up in an unhealthy relationship with alcohol and that tens of thousands will die each year from abusing it. But a great many more will use the same drug with pleasure and without harm, either to themselves or society. Here, too, the rituals we’ve developed around drinking play a protective role and suggest a model, however imperfect. Most of us don’t drink before a certain hour in the day. We drink only in the company of others. We eat food with alcohol; after drinking, we don’t drive — a practice codified in law. The people who follow these rules and rituals are by and large not the people who get into trouble with alcohol.

The drug war’s blunt, black-and-white approach at least had the virtue of simplicity. “Just say no” is certainly easier to follow than “yes, but only this way and not that.” With all illicit drugs lumped together in the drug war, there was no need to take account of their different properties and powers, what they are good for and what they are bad for. Nor did we need to figure out the best cultural container for each of them, the set of rules and rituals and taboos that might allow us to use them safely, productively and, yes, with pleasure.

But if we’re going to end the drug war, figuring that out is precisely the work we’ll need to do. It won’t be easy or simple or quick; indeed, we’re still figuring out how best to manage alcohol and tobacco, striking the right balance of formal regulations, social norms and taxes. (Taxation is important for two reasons: to discourage use and to pay for the associated health costs to society.) And while it is surely the case that the burden of drug abuse (including that of alcohol and tobacco) will fall most heavily on the poor, that argues not for a war on the drugs so much as for a war on poverty — on the conditions of life that make using drugs seem like a reasonable solution or means of self-medication.

The long history of humans and their mind-altering drugs gives us reason to hope we can negotiate a peace with these powerful substances, imperfect though it may be. We have done it before. The ancient Greeks grasped the ambiguous, double-edged nature of drugs much better than we do. Their word for them, “pharmakon,” means both “medicine” and “poison” — it all depends, they understood, on use, dose, intention, set and setting. Blessing or curse, which will it be? The answer depends not on law or chemistry so much as on culture, which is to say, on us.

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