During the November election, Oregon voters approved a measure allowing licensed centers to provide psilocybin, the substance found in “magic mushrooms,” to help treat people experiencing a range of mental health issues. Oregon is the first state to approve such a program—and with that, eyes will now be on the state to see how it fares moving a substance that remains federally illegal into the sphere of reputable treatment.
According to a study published in November 2020 in the Journal of the American Medical Association, major depressive disorder affects more than 300 million people worldwide. In the U.S., about 10% of the adult population has been diagnosed with major depressive disorder in the past 12 months.
Gov. Kate Brown’s 2021-2023 budget includes $5.6 million to start implementing Ballot Measure 109, which directs the Oregon Health Authority to create a state-licensed, psilocybin therapy program for the treatment of mental illnesses including depression, end-of-life psychological distress and post-traumatic stress disorder.
Starting Jan. 1, the state entered a “two-year program development period,” during which the OHA will work with the Oregon Psilocybin Advisory Board on implementing the new program. Applications for the Advisory Board closed last week, and the selection process for its 14 to 16 members is underway. Measure 109 Campaign Manager Sam Chapman says he’s spoken to a variety of candidates.
“There's obviously doctors, psychiatrists, veterans, representatives of tribal nations and communities, harm reduction specialists, local health officers—I’ve talked with three or four people for every slot on the board.” Chapman told the Source. “It’s incredibly encouraging that so many people are ready to dig in and be part of this really important process over the next two years.” A veteran’s experience with psilocybin
Oregonian Chad Kuske—a Navy SEAL who participated in psilocybin therapy for PTSD—says he applied for the Advisory Board. He received psilocybin services with the help of the nonprofit Veterans Exploring Treatment Solutions, or VETS.
Kuske served as a Navy SEAL for 18 years.
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Courtesy of Chad Kuske
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Chad Kuske served as a Navy SEAL for 18 years before retiring in 2017. He sought psilocybin therapy for PTSD with the help of the nonprofit Veterans Exploring Treatment Solutions.
“I did about 12 combat deployments, and then I was medically retired in 2017,” Kuske told the Source. “Basically, due to a variety of things that all fall under the purview of PTSD.”
Kuske said he was struggling to live after his military service and learned about psilocybin therapy from a friend.
“It immediately stood out to me as one of the only things I hadn't tried,” he said. “I was fortunate that the way I learned about it was through reputable sources that stressed the importance of [mindset] and setting and being prepared and undertaking it with skilled and trained people.”
Kuske says there were three pillars to the services he received: mindset, setting and integration. After a medical screening by a doctor for contraindications, Kuske said he set to work on his mindset with an integration coach who got to know his background and what he hoped to gain from the experience.
“They also start coaching you on formulating intentions and thinking about things you want to let go of that no longer serve you,” he said.
He says the psilocybin experience typically lasts four to six hours, but up to about eight. He described it as an “inward” experience, and for the most part, the coaches try to help the participant feel safe but try not to interfere. After the psilocybin ceremony, he says the work continues.
“These experiences are powerful healing opportunities,” Kuske said. “Amazing insights and lessons can be learned, but they’re only as effective as we allow them to be. You have to integrate everything that you receive from the medicine into your life after the experience. In the absence of that, this amazing gift can dwindle.”
Veterans of War, another veterans' nonprofit, follows a similar format—providing a six-month fellowship for “guided psychedelic therapies that offer hope and a proven path towards recovery” for veterans at risk of suicide, as founding director and U.S. Marine Wyly Gray told the Source. The program treats veterans in groups of four.
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Courtesy of Wyly Gray
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Veterans of War Founding Director and U.S. Marine Wyly Gray
“It's built on four pillars,” Gray said. “The pillars are education, preparation, integration and support.”
For the first month and a half, the veterans attend biweekly, guided group therapy. For the actual ceremony, participants travel to Peru.
“Because it's not only legal there,” Gray said, “but it's also a revered part of their culture outright.” The veterans then have a two-week window for up to four ceremonies, usually with ayahuasca made from the Banisteriopsis caapi vine. Afterward, the participants spend four months on integration and support.
Measure 109 defines psilocybin services as those services provided before, during and after a client’s consumption of psilocybin, which can include “a preparation session, an administration session and an integration session.” Centers in Oregon could look to services like those Kuske found through VETS and that are offered through Veterans of War for guidance.
Chapman, the measure’s campaign manager, expects variation between centers—for example, palliative care and hospice patients may prefer a hospital, he said.
“There are going to be people who would only access psilocybin therapy though that type of context,” Chapman said. “They want to be in a hospital. That is an environment in which they feel safe, that they trust and therefore creates an easier access point for them. So, there may well be medical environments in which psilocybin therapy is administered.”
People on the other end of the spectrum might favor “more of a retreat model,” he said. “Where you could go to a psilocybin services center that provides multiple services from acupuncture to talk therapy to massage and yoga and meditation.” He thinks somewhere in between may look like a therapist’s office.
“There're no crazy bells and whistles or anything of that nature,” he said. “It's just a safe place for psilocybin services to be administered that's comfortable and provides what the clients need.” How can access remain equitable?
Chapman echoed sentiments from veterans Kuske and Wyly regarding an important first step for implementing the psilocybin services program: supporting equitable access.
“The most important part of the rulemaking process is ensuring that we can strike a very important balance between client safety and responsibility, while also ensuring that as many people that stand to benefit as possible have access,” Chapman said. “So, we're talking about equitable access, especially for populations that traditionally don't have access to regular health care.”
He currently sees two opportunities: one in educating health care providers and insurance companies on how people may benefit from psilocybin therapy.
“And the second,” Chapman said, “is working with the community and working with providers and psilocybin facilitators and manufacturers and the service centers to have sliding scales and to work with nonprofits to build equitable coalitions with community partners.”
The veteran community has shown that the strategy can work. For example, Heroic Hearts is a nonprofit that helps veterans already interested in psychedelic therapies. The organization researches providers and offers veterans financial assistance based on donations.
Founder and President Jesse Gould started the organization after being diagnosed with PTSD after three deployments in Afghanistan as an Army Ranger. The program has been growing every year, Gould said.
“I think the first year we probably helped around 10 [veterans], and then I think in the next couple of years we were able to do 20 to 25,” Gould told the Source. “This year we were set to do more than 100 or 150, but obviously COVID put a little bit of a wrench in that.” The organization was still able to assist 20 veterans last year and hopes to help a couple hundred this year.
Along with keeping costs down, Kuske, the Navy SEAL who sought psilocybin treatment, says he hopes to see indigenous wisdom regarding the use of plants and traditional treatments, like psilocybin mushrooms, considered as guidelines are finalized.
“Every time a new article comes out, they explain everything, like it's the first time that we discovered any of this,” Kuske said. “When in reality these safer medicines have been used going back millennia. And I think it's important that we adapt it to our own society, but at the same time that we incorporate it, acknowledge, respect and give honor to the ancestral ways of using these medicines.”
How can officials promote safety?
Dr. Nicole Cirino is president of the Oregon Psychiatric Physicians Association. Both the OPPA and the American Psychiatric Association opposed Measure 109. One reason: as written, the measure allows the use of psilocybin to treat conditions “including but not limited to” addiction, depression, anxiety disorders and end of-life psychological distress. It seems to neither require a specific condition nor a diagnosable mental illness at all, which Cirino suggested is misleading given the therapy focus of the campaign.
In a press release during the general election, the OPPA expressed concern that “neither the safety nor effectiveness has been established according to U.S. Food and Drug Administration guidelines or clinical trials,” which is required for all medications, including those that treat mental illnesses like those listed above. The statement said “the OPPA agrees with the FDA that early limited trials have shown promise” but that safety and efficacy just haven’t been proven yet.
“There are actually a lot of ongoing studies, but they need to be complete,” Cirino told the Source. “We need to analyze the data, and then we need to pull the data together to say what is the effective treatment, where the effective dose is and how we monitor it. It could very well be that in three to four years the FDA has approved psilocybin for a single or maybe two psychiatric conditions.”
Now that the measure has passed, Cirino says OPPA members hope they can help promote safety.
“We have had several of our members with expertise in this area apply to be part of the Psilocybin Advisory Board so that they could set some parameters around everything about the administration of psilocybin, including what sort of psychiatric evaluation and medical evaluation would be necessary prior to accepting a patient into a psilocybin clinic,” Cirino said. She says she’d like to see rules around training for psilocybin administrators as well.
“We're hoping that they have a mental health degree so that they can actually assess the mental health symptoms that are present,” she said. “And we're also hoping that there's going to be some monitoring of both medical and psychological sequelae after the psilocybin is administered to make sure that the adverse effects can be addressed adequately so this is a safe and effective treatment.” Sequelae is a medical term for conditions caused by disease or injury.
Cirino says medications usually come with FDA guidelines that say specifically what psychiatric conditions they treat, the appropriate dose and potential side effects.
“We're not going be able to do that,” she said. “But we might be able to become closer to make it safe and effective for patients.”
As psilocybin services become available in the next few years, Cirino recommends people interested in the option discuss it with their current mental health provider or medical doctor.
Excitement around psilocybin therapy
Unlike Oregon’s Measure 110, which decriminalized possession of small amounts of illegal substances, Measure 109 did not decriminalize psilocybin. Instead, it calls for a regulatory framework for adults 21 and older to receive psilocybin services at licensed centers for issues including mental illnesses like depression—but participants can take it for other reasons, too.
Dr. Peter Sparks, program coordinator and senior psychology instructor at Oregon State University-Cascades, says one reason there’s excitement around psilocybin therapy is that traditional antidepressants must be taken every day for long periods of time.
“And psilocybin therapy, at least in the research, often the way it works, is that you experience one or two episodes of psilocybin, and then the effects of the relief of depressive feelings and the relief of anxiety can last for months,” Sparks told the Source.
He said the therapeutic effect seems to correlate with “the experience of being small” in a large awe-inspiring world.
“There's something about that feeling of awe and the feeling of interconnectedness that causes, or is at least related to, diminishing the symptoms of depression,” he said. “And that seems to make sense because depression is an isolating condition where you feel like you're alone.”
The FDA granted breakthrough therapy designation to COMPASS Pathways’ research of psilocybin as a therapy for treatment-resistant major depressive disorder in October 2018, as discussed in Neuroscience & Biobehavioral Reviews in 2019. And in November 2020, the Journal of the American Medical Association published a randomized clinical trial of 24 adults diagnosed with major depressive disorder. The study found that after four weeks with two psilocybin sessions 71% of participants showed a “clinically significant response” and 54% met the definition for remission of depression.
Measure 109 passed with the support of 1.27 million Oregonians, or about 56% of voters statewide. Most people in Deschutes County supported the measure (53%), but only about 35% of Crook County voters and 41% of Jefferson County voters did. The measure stipulates that cities and counties can “impose reasonable regulations” on the operation of licensed psilocybin facilities and manufacturers—like the location of centers, hours of operation and public access to centers. As of press time, spokespeople for both Deschutes County and the City of Bend said there are no local agenda items related to Measure 109.
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