PSI Epidemiological Report

Epidemiological Report

Research Summary

Psychedelic Public Health & Safety

Epidemiological Profile

Research Summary

Contents

Contents

Epidemiological Review of Psychedelic Use: Patterns, Contexts, and Adverse Events

1 Introduction

1.1 Summary

1.2 Definitions

2 Methods

2 1 Data sources

2.2 Limitations of the data

3. Patterns of Use

3 1 Prevalence

3 2 Demographic Trends

3.3 Geographic Distribution

3.4 Motivations for Use

3 5 Microdosing

3 6 Integration and Preparation

3.7 Polysubstance Use

3.8 Where & How Users Learn About Psychedelics.

4 Settings & Social Contexts of Psychedelic Use

4 1 Overview of Settings & Social Contexts

4 2 Recreational Contexts

4.3 Clinical Contexts

4 4 Unregulated Facilitated Contexts

4 5 Ceremonial Contexts

5 Adverse Events and Risks

5.2 Population-Level Risk Factors

5 3 Population-Level Adverse Events

6 Interventions & Harm Reduction Strategies

6 1 Psychedelic Users' Knowledge of Harm Reduction Practices

6.2 Use of Medical, Psychiatric, or Psychological Assistance

6 3 Population-Level Efficacy of Interventions

6 4 Influence of Demographic Factors on Interventions and Harm Reduction

References

Epidemiological Review of Psychedelic Use: Patterns, Contexts, and Adverse Events

1. Introduction

1.1 Summary

This report provides a comprehensive epidemiological review of psychedelic use within the United States, focusing on patterns, contexts, and adverse events Psychedelic substances, including psilocybin, LSD, MDMA, DMT, and ayahuasca are experiencing increased visibility and use, both recreationally and, increasingly, in therapeutic settings (Viña and Stephens 2023). However, it's crucial to note that the majority of psychedelic use in the U S still occurs outside of controlled medical environments (Davis et al 2022)

The prevalence of psychedelic use varies significantly across different demographic groups Young adults and veterans, for instance, exhibit higher rates of use (Jahn et al. 2021; Davis et al. 2024). Motivations for use are diverse, ranging from personal growth and spiritual exploration to the self-treatment of mental health conditions (Davis et al 2024; Lake and Lucas 2024) These substances are used in a variety of settings, from strictly controlled clinical trials to less supervised recreational environments

While psychedelics are generally considered well-tolerated in controlled clinical or research settings, adverse events can occur. "Set and setting," referring to psychological factors and the immediate environment, are critical determinants of the psychedelic experience and its outcomes (Leary et al 1963; Carhart-Harris et al 2018)

Common adverse events include anxiety, headaches, nausea, and transient increases in heart rate and blood pressure (Schlag et al. 2022; Thakur et al. 2022; Breeksema et al. 2022) . Though rare, serious adverse events such as psychosis, suicidal ideation, and hallucinogen persisting perception disorder (HPPD) necessitate careful monitoring (Evans et al 2023; Bagggott et al 2011 Pre-existing neuropsychiatric disorders, high doses, unsafe environments, and a lack of proper preparation and support are significant risk factors for adverse events, and polydrug use is frequently observed in the most severe psychedelic-related incidents (Kopra et al. 2022).

Epidemiological data for this report is derived from various sources, including national surveys such as the annual National Survey on Drug Use and Health (NSDUH), emergency department data, and online surveys Limitations within these data sources, such as reliance on

self-reporting, the exclusion of specific populations (e g , military personnel), and the potential for underreporting of adverse events are acknowledged.

To better understand the risk-benefit profiles of psychedelics, ongoing and improved drug safety monitoring, systematic detection, and transparent reporting of adverse effects are essential

1.2 Definitions

● Psychedelics: Psychedelics are psychoactive substances that include compounds such as psilocybin, LSD, MDMA, DMT, and mescaline. These substances are known for inducing altered states of consciousness, affecting perception, cognition, emotion, and self-awareness

● Hallucinogens: Hallucinogens are psychoactive substances that can cause hallucinations, perceptual distortions, and altered states of consciousness The term "hallucinogen" is sometimes used interchangeably with "psychedelic," but there are some key distinctions. Hallucinogens are typically defined by their ability to produce hallucinations, while psychedelics are characterized by their ability to induce a broader range of subjective effects, including changes in perception, thought, and emotion

● Types of psychedelics:

○ Psilocybin is a naturally occurring compound found in certain mushrooms, often used in religious and divinatory contexts. It is a classical serotonergic psychedelic that primarily interacts with serotonin receptors in the brain.

○ LSD (Lysergic acid diethylamide) is a classical serotonergic psychedelic known for its potent effects on perception, cognition, and consciousness It primarily acts as an agonist at serotonin (5-HT2A) receptors, leading to altered sensory experiences, changes in mood, and heightened introspection

○ MDMA (3,4-methylenedioxymethamphetamine), sometimes called "ecstasy" or "Molly,” is a psychoactive compound that exhibits both stimulant and empathogenic properties Unlike classical serotonergic psychedelics such as LSD and mescaline, MDMA primarily enhances the release of serotonin, dopamine, and norepinephrine, leading to increased feelings of emotional openness, empathy, and well-being While it acts on serotonin systems, it is not considered a classical psychedelic.

○ DMT (N,N-Dimethyltryptamine) is a naturally occurring tryptamine found in various Amazonian plant species such as ayahuasca, and is also produced endogenously in mammalian brains

○ Mescaline is a classical serotonergic psychedelic alkaloid found naturally in several cacti species, including peyote (Lophophora williamsii), San Pedro (Echinopsis pachanoi), and Peruvian Torch (Echinopsis peruviana).

2. Methods

This section details the methodological approach employed to analyze psychedelic use trends, encompassing data sources, their limitations, and areas where further research is needed.

2.1 Data sources

This report draws on a variety of data sources, including surveys, clinical trials, population studies, and ethnographic data

● General Data Sources: Epidemiological data on psychedelic use trends were gathered from various sources, including:

○ Nationally representative surveys such as the National Survey on Drug Use and Health (NSDUH)

○ Online surveys

○ Emergency department visit data

○ Online forums and communities

○ Clinical trials and research studies.

● Databases: Databases such as Scopus, MEDLINE, PsycINFO, Web of Science, EMBASE, PubMed, Google Scholar and ClinicalTrials gov were reviewed to identify relevant studies

2.2 Limitations of the data

● Limitations: The National Survey on Drug Use and Health (NSDUH) is a crucial source of data on substance use in the United States. However, it's important to be aware of the limitations of this, and other studies cited in this report, particularly in the context of psychedelic use:

○ Reliance on self-reported data, which may be subject to recall and response bias

○ Exclusion of specific populations, such as those in the military or who are institutionalized

○ Potential for selection bias due to recruitment methods.

○ Variability in study designs and data collection methods across included studies.

○ Underreporting of adverse events

○ Challenges in establishing causality between psychedelic use and long-term outcomes

○ Difficulty in obtaining accurate information on drug purity, potency, and dosage in naturalistic settings.

○ Language bias, as the search was limited to articles published in English.

● Representative vs. Non-representative Studies:

○ Primary Representative Group: The standard population-level, representative group surveyed in the available materials is defined as civilian, non-institutionalized individuals aged 12 or older in the United States

■ NSDUH Data: Many of the sources used to prepare this report rely on data from the National Survey on Drug Use and Health, which is designed to be representative of the civilian, non-institutionalized population aged 12 or older in the United States

■ Sampling and Weighting: NSDUH data uses weighting to reflect the characteristics of this population This ensures that the data is consistent with population totals obtained from the U S Census Bureau

■ Exclusions: Specific exclusions of this representative group include those experiencing homelessness (not in shelters), active military personnel, and residents of institutions (e g , correctional facilities, hospitals)

○ Non-representative samples: Many of the sources used to prepare this report are considered “non-representative” and are noted as such

■ Sampling Bias: Some of these studies recruit participants through online forums, social media, or psychedelic advocacy events. These samples often over-represent white, highly educated individuals with positive attitudes toward psychedelics Studies focusing on specific experiences, such as negative psychological responses, also introduce bias

■ Demographic Limitations: Many samples are largely White, North American, and/or male This limits the generalizability of findings to other ethnicities, nationalities, and gender identities.

■ Anglophone Regions: A significant number of studies are conducted in English-speaking countries, such as the United States, Canada, the UK, Australia, and New Zealand Findings from these regions may not generalize to non-English speaking populations or other cultural contexts

● Recommendations for Further Research: Both use patterns and legal guidelines for psychedelics are rapidly changing, and future data collection systems will be needed to better understand usage within these new contexts.

○ Adverse Event Tracking: Collect detailed data on adverse events, including emergency room visits, hospitalizations, and negative health outcomes associated with hallucinogen use

○ Mental Health Comorbidity: Conduct studies to explore the co-occurrence of mental health conditions and hallucinogen use, including longitudinal studies to assess causality

○ Longitudinal Studies: Implement longitudinal studies to track changes in hallucinogen use patterns, user characteristics, and long-term health outcomes

○ Specific Hallucinogens: Gather more detailed data on the use of specific hallucinogens, especially those for which data is limited

○ Poly-drug Use: Examine the patterns of poly-drug use among hallucinogen users, including combinations of substances, and related consequences.

○ Socioeconomic Factors: Investigate the socioeconomic factors associated with hallucinogen use

3. Patterns of Use

This section examines the prevalence of psychedelic use, focusing on data from the United States. The primary source for this data is the 2023 National Survey on Drug Use and Health (NSDUH), a representative, population-level study. Some prevalence data such as that drawn from voluntary online surveys is not considered representative and is noted as such.

3.1 Prevalence

Lifetime Prevalence:

● Overall Psychedelic Use: A study of multiple years of NSDUH data estimated that 15.9%, or approximately 52 million Americans aged 12 or older had used a psychedelic drug in their lifetime (Jahn et al 2021) This appears consistent with an earlier analysis of NSDUH data which estimated that 13.6% Americans had used psychedelics in their lifetime (Johansen and Krebs 2015)

● Psilocybin: Representative studies found that approximately 11 8% of Americans between 16 and 34 years old have used psilocybin (Forstmann and Sagioglou 2021). Among a non-representative group of psychedelic users from an online survey, 61.5% reported having used psilocybin (Krebs and Johansen 2013) Other non-representative studies found that rate to be higher, with up to 92 1% (Glynos et al 2023) of psychedelic users reporting having used psilocybin

● LSD: An analysis of NSDUH data from between 2015-2019 estimated that 27 million people in the United States had used LSD at some point in their life according to representative studies (Weleff et al. 2024).

● Mescaline/Peyote: In a representative survey, researchers estimated that 8 million individuals in the US had used Mescaline/Peyote in their lifetime (Uthaug et al 2022)

● MDMA: MDMA is often tracked separately from classical psychedelics which can create challenges for researchers. According to one study, 9% of Americans aged 18 and older, or approximately 30 million people, reported using MDMA (YouGov). This data is non-representative as YouGov polls generally rely on self-selected participants

● Other Psychedelics: In a sample of 1,295 participants (non-representative; self-selected sample of individuals with prior psychedelic experience) the following lifetime prevalence of use was noted (Raison et al 2022):

○ Ayahuasca: 5.8%

○ DMT: 3.2%

○ Ketamine: 2.7%

○ Mescaline/peyote/San Pedro/other mescaline-containing cacti: 2.0%

○ 5-MeO-DMT: 1.7%

○ Other designer/synthetic: 1.8%

○ Salvia: 0.4%

○ Iboga/Ibogaine: 0.3%

2C-B: 0 3%

Past Year Prevalence:

● Overall Psychedelic Use: In 2023, approximately 8.8 million Americans aged 12 or older reported using psychedelics in the past year, representing 3 1% of the population Research indicates a substantial gap between lifetime use and recent use, suggesting many people experiment with hallucinogens at some point but do not continue regular use (NSDUH 2023).

● Young Adults (ages 19-30 in the US):

○ The prevalence of using both LSD and non-LSD hallucinogens during the past 12 months was 2 0% overall (Keyes 2023) This data is representative of US young adults aged 19-30, and came from a longitudinal cohort study among young adults aged 19–30 years from the US general population interviewed between 2018 and 2021.

Comparisons to Other Drug Categories:

● Marijuana: In 2023, 21 8 percent of people aged 12 or older (or 61 8 million people) used marijuana in the past year (NSDUH 2023). Psychedelic users in particular commonly use cannabis, with one non-representative study finding that as many as 97.8% of psychedelic users had used cannabis. In comparison, the study found 36% of those who had never used psychedelics had used cannabis (Johansen and Krebs 2015)

● Cocaine: 71 3% of psychedelic users (non-representative) have used cocaine, compared to 7.5% of non-psychedelic users (Johansen and Krebs 2015).

● Opiates: 49.7% of psychedelic users (non-representative) have used opiates, compared to 9.5% of non-psychedelic users (Johansen and Krebs 2015).

● Tranquilizers and Sedatives: 43 5% of psychedelic users (non-representative) had used tranquilizers and sedatives, while only 5 6% of non-psychedelic users had used them (Johansen and Krebs 2015)

● Alcohol: In the Global Psychedelic Survey (GPS), a non-representative online survey of adults ≥21 years old, 31.5% of respondents reported using alcohol in conjunction with psychedelics. The study also found that among those who co-used at least one psychedelic, 57 1% reported using alcohol as a secondary substance (Lake and Lucas 2024)

● Tobacco: In the GPS, 15 4% of respondents reported using tobacco in conjunction with psychedelics Among those who co-used at least one psychedelic, 28 0% reported using tobacco as a secondary substance. (Lake and Lucas 2024)

● Benzodiazepines In a non-representative sample, 52.0% of psychedelic users reported lifetime use of illicit benzodiazepines and barbiturates (Honk et al 2024)

● Amphetamines 59 0% of psychedelic users (non-representative) reported lifetime use of major stimulants (Honk et al 2024)

● Frequency of Use: The 2023 NSDUH survey provides data that illustrates the frequency of use of several specific hallucinogens.

○ LSD: Lifetime use: 30.2 million, past-year use: 1.7 million, past-month use: 315,000

○ PCP: Lifetime use: 5 9 million, past-year use: 135,000, past-month use: 21,000

○ Ecstasy: Lifetime use: 22 3 million, past-year use: 2 2 million, past-month use: 471,000

Trends in Prevalence of Psychedelic Use

● Multiple studies indicate an overall increase in hallucinogen and psychedelic use among adults in recent years Data from the representative Monitoring the Future (MTF) study showed recreational use of hallucinogens increased from 5% to 9% among college students between 2019 and 2020 (Viña and Stephens 2023).

● Hallucinogen use among a representative group of young American adults aged 19–30 years increased, with non-LSD hallucinogen use doubling from 3.4% in 2018 to 6.6% in 2021 (Keyes 2023)

● Past-year use of hallucinogens in 2021 was reported in a representative study by 8% of young adults aged 18-30, representing the highest prevalence since the survey began 35 years ago (Tate et al. 2023). The trend was also consistent across a representative study of adults aged 35–50. This age group reported an increase in psychedelic use from less than 1% in 2012 to 4% in 2022 (NIH, 2023).

Initiation of Use

● A representative study fount that in 2023, 1.5 million people aged 12 or older initiated hallucinogen use (NSDUH 2023).

● A representative study found past year initiation of hallucinogen use is more prevalent among younger adults, aged 18-25 at 1 9%, versus only 0 3% among people aged 26 or older (NSDUH 2023)

● The same study found a substantial percentage (27 9%) of past-year hallucinogen users aged 18-25 were new users, highlighting that younger adults are more likely to begin using hallucinogens (NSDUH 2023).

3.2 Demographic Trends

Prevalence of Psychedelic Use by Age Group:

● Emerging Adults (18-25 years):

○ People in this age bracket are frequently identified as the demographic with the highest rates of psychedelic experimentation and use according to a representative study (Jahn et al 2021)

○ Approximately 13 6% of 18-25 year-olds (non-representative) have used classic psychedelics in their lifetime (Hendricks et al. 2025).

○ In 2022, 8% of US adults aged 19-30 (non-representative) reported past-year usage of psychedelics This is up by 3% since 2012 (NIH, 2023)

● Young Adults (25-35 years):

○ The 26-34 age group, while generally less prevalent in overall usage compared to the 18-25 group, still represents a significant portion of experienced users according to a representative study (Jahn et al. 2021).

○ Past 12-month use of non-LSD hallucinogens increased from 3.4% to 6.6% among young adults aged 19–30 years (non-representative) from 2018-2019 (Keyes 2023)

● Midlife Adults (35-50 years):

○ In 2022, a representative study found that 4% of US adults aged 35-50 reported past-year psychedelic use, compared to less than 1% in 2012 (NIH, 2023).

○ In a non-representative study of naturalistic psychedelic use, the mean age was 36 years old (Kruger et al 2023)

● Older Adults (50+ years):

○ Adults aged 50+ generally report the lowest rates of hallucinogen use in the past year according to a representative study (Jahn et al 2021)

○ The use of hallucinogens seems to decrease with age according to a non-representative study (Bormann 2023).

○ Specific data on psychedelic use among older adults is limited. However, some research includes respondents up to the age of 62 (La Torre et al 2024) The lack of details available for psychedelic use in the 50+ age range may suggest that this group is a small proportion of users, but further research is needed

● General Age-Specific Prevalence:

○ Adolescents (12-17): Lifetime use is reported by 518,000 adolescents, past-year use by 387,000, and past-month use by 110,000 according to a representative study (NSDUH 2023)

○ Young Adults (18-25): 6 7% reported past-year use, and lifetime use was reported by 15 5% of this age group according to a representative study (NSDUH 2023).

○ Adults 26 or Older: Past year use was reported at 2.7% for this age group, with lifetime use at 19.1%, and past-month use at 0.9% according to a representative study (NSDUH 2023)

Age Groups Most Likely to Use Psychedelics:

● Based on a representative survey of available data, young adults (18-25 years) are the most likely to have used psychedelics at some point in their lives (Johansen and Krebs 2015)

● However, past-year use is increasing more rapidly among midlife adults (35-50) than younger adults according to a representative study (NIH, 2023)

● It should be noted that the high representation of individuals in their 20s and 30s in psychedelic research (La Torre et al. 2024; Murray et al. 2022; Palmer and Maynard 2022; Lea et al. 2020; Johnstad 2021) raises questions about the generalizability of findings to other age groups and demographic segments

Growth Patterns of Psychedelic Use Across Age Groups:

● Significant growth in past-year usage is seen across all age groups, but it is more pronounced among midlife adults according to a representative study (NIH, 2023).

○

Past-year use among those aged 35-50 has grown from less than 1% in 2012 to 4% in 2022, demonstrating a four-fold increase (NIH, 2023)

○ Past-year use among young adults aged 19-30 increased from 3 4% in 2011 to 8 1% in 2021 according to a non-representative online survey of individuals who contacted the Fireside Project's psychedelic helpline (Pleet et al. 2023).

● While young adults still have higher lifetime prevalence, the rate of increase is higher in midlife adults, suggesting a shift in usage patterns (NIH, 2023).

● US Americans aged 18-25 who had used LSD in the past year (non-representative) was reported to have increased from 1 22% to 3 37% between 2005 and 2015 (Izmi, Carhart-Harris, and Kettner 2024)

Ethnic and Cultural Differences in Psychedelic Use:

While available data consistently indicate that White/Caucasian individuals report higher rates of psychedelic use, it must be noted that research on psychedelic use and its demographic patterns is limited by sampling biases and underrepresentation of minority groups (Davis et al 2024). Many existing studies disproportionately sample white participants, making it difficult to assess use patterns among other ethnic groups.

At the same time, Black, Indigenous, and People of Color (BIPOC) remain significantly underrepresented in both psychedelic research and professional fields, despite the deep historical and cultural significance of these substances in non-Western traditions (Jones 2023) This may skew study findings, as well as raise concerns about cultural appropriation and accessibility, particularly as psychedelics gain mainstream recognition (Davis et al. 2024). Addressing these gaps in future research is essential for ensuring a more inclusive and accurate understanding of psychedelic use across diverse populations

● White/Caucasian: Approximately 28 7% of White Americans reported lifetime hallucinogen use according to a representative sample (Jahn et al 2021)

● Black/African American: In 2018, 11.7% of Black/African American people reported lifetime psychedelic use in a representative study. For this group, MDMA was the most popular psychedelic The highest rates of past year psychedelic use were reported among the 26–34 year old cohort, differing from the trend in other racial groups (Jahn et al 2021)

● Hispanic Americans: 15 93% of Hispanic Americans have used hallucinogens in their lifetime according to a representative study (Jahn et al. 2021).

● Indigenous/Native American: In 2018, 36.5% of Native Americans reported lifetime psychedelic use according to a representative study (Jahn et al 2021) This percentage is significantly higher than rates reported for White Americans (Bormann 2023) American Indian or Alaska Native people have the highest past-year use rate at 4 3% (NSDUH 2023)

● Asian Americans: An estimated 8.20% of Asian Americans have used hallucinogens in their lifetime (representative) (Jahn et al. 2021).

● Multi-racial Americans: In 2018, 22 95% of Multi-racial Americans reported lifetime hallucinogen use LSD was the most popular hallucinogen for multi-racial individuals (representative), with a reported prevalence of 14 5% (Jahn et al 2021)

Data Limitations and Underrepresentation of Minority Ethnic Groups:

○ Black, Indigenous, and People of Color (BIPOC) are significantly underrepresented in psychedelic research and studies (Morton et al 2023; Wang et al 2024; Pilecki et al 2021; Wells, Fernandes, and Reynolds 2024)

○ One representative study showed that only 3% of respondents were Hispanic, 5% were of mixed ethnicity, and 2% were Asian (Evans et al. 2023).

○ This underrepresentation extends to researchers, therapists, and study participants (Pilecki et al. 2021).

○ This is problematic given that many of these substances have historical and cultural significance in non-Western cultures, and the current trend risks being interpreted as a form of cultural appropriation (Pilecki et al 2021)

○ American Indian/Alaskan Native individuals have shown lower openness to clinical MDMA use compared to other groups (Wang et al. 2024).

Gender

Differences

● Prevalence:

in Psychedelic Use:

○ Men tend to use psychedelics more frequently than women (Ajantaival 2014). This was drawn from representative studies, but the sample may be subject to potential self-reporting biases.

○ In a representative survey, 59% of psilocybin users and 60 1% of LSD users were male (Ajantaival 2014)

○ A non-representative study found that 84 2-86 5% of microdosers were male (Hutten et al. 2019).

○ A non-representative study showed that, among those experiencing a "bad trip", 52.4% were female (Ona 2018).

○ This male-skew is not always consistent across available research and could be attributed to sampling and representation

● Adverse Reactions:

○ There is some indication in a non-representative study that women may be more likely to report negative emotional experiences (Aday et al. 2021), though this is based on self-report and may be influenced by reporting bias.

○ There are some conflicting results as to whether there are sex differences in adverse reactions, and some non-representative research has indicated there are no sex differences in 5-HT2AR (the serotonin 2A receptor) distribution or in the pharmacokinetic profiles of psychedelics (Aday et al 2021)

○ According to the non-representative Global Drug Survey (GDS), male users of both psilocybin mushrooms and LSD consistently experience a higher frequency of common adverse effects compared to female users (Kopra et al 2022; 2024)

● Reasons for Use:

○ Men and women report similar reasons for using psychedelics including personal growth, general well-being, recreation, and spiritual or religious purposes according to the non-representative Global Psychedelic Survey (Lake and Lucas, 2024)

○ In one non-representative study, both men and women reported using psychedelics for spiritual/psychological/personal exploration, personal growth, and to improve general mental health (Glynos et al. 2023).

● Preferred Settings:

○ Group vs. Solo Use: Female-identifying respondents to a non-representative anonymous online survey are more likely to report group psychedelic use, while male-identifying respondents are more likely to report solo use (Byrne et al 2023) This aligns with evidence from non-psychedelic therapeutic settings, where women tend to seek group therapy more often and may experience better outcomes compared to men (Byrne et al 2023)

● Physiological and Psychological Responses:

○ Differential Effects: Male and female users report different effects related to depression, memory, attention, and sociability Analysis of this non-representative study found that both sexes report microdosing improves these conditions, but the degree of change varies (Cameron et al 2020)

○ Memory and Attention: A non-representative study found that a greater proportion of males report improvement in memory with microdosing (43.48% vs. 30% of females), while more females report worsening of memory symptoms (27% vs. 8.15% of males) (Cameron et al. 2020).

● Age:

○ Age Differences: A non-representative study found there is no statistically significant difference in age between males and females who use psychedelics (Johnstad, 2021)

○ Term Preference and Age: Individuals who use the term "psychedelic" are significantly younger than those who use "hallucinogen" or "entheogen" (Johnstad, 2021)

Socioeconomic Status and Psychedelic Use:

● Higher Socioeconomic Status:

○ Higher income and education levels are associated with increased psychedelic use and awareness (non-representative) (Kruger et al. 2023).

○ Individuals with higher education and income tend to answer more questions correctly about psychedelics and related policy (Kruger et al 2023)

○ In one non-representative study, respondents with higher incomes and education levels were more aware of substance testing services (Glynos et al 2023)

○ Access to Care: Individuals with higher socioeconomic status are more likely to have access to psychedelic-assisted therapy if and when these become legal and available (Kruger et al 2023)

● Lower Socioeconomic Status:

○ Non-representative studies suggest lower-income individuals and those with less education may be less likely to be aware of or have access to harm reduction or safe psychedelic use information (Kruger et al. 2023). Lower socioeconomic groups may also experience barriers to psychedelic treatment if it becomes medicalized (Aday et al 2024)

Psychedelic Use Among Veterans and Service Members:

● Prevalence:

○ Approximately 51% of veterans surveyed reported using psychedelics. This rate is significantly higher than estimates of lifetime prevalence of psychedelic use in the general adult population in the US (Davis et al 2024)

● Reasons for Use:

○ Most veterans reported using psychedelics for healing/treatment (70%) and/or spiritual purposes (48%). This contrasts with recreational use patterns often seen in the general population (Davis et al. 2024).

○ Some may use psychedelics in a ceremonial setting in an attempt to process past experiences (Weiss et al 2023)

● Likelihood of Utilizing Services:

○ Veterans who used psychedelics indicated they would be more likely to use VA services (p < .001, d = 0.64) and return to the VA for care (p < .001, d = 0.79) if psychedelic therapy were offered (Davis et al. 2024).

● Additional Considerations:

○ The existing research highlights the need for further investigation into the specific needs and experiences of this population

○ The unique challenges faced by veterans, such as PTSD and other service-related mental health conditions, suggest a potential role for psychedelic-assisted therapies.

3.3

Geographic Distribution

Geographic Patterns Within the US:

● General Trends:

○ National Survey on Drug Use and Health includes approximately 70,000 participants in the United States annually (Ajantaival 2014) However, this data does not break down usage by state or region

● Urban vs Rural Areas:

○ The provided sources do not contain specific statistical data differentiating psychedelic use between urban and rural areas.

○ However, one study indicated that the most common settings for use were at home (81.9%) and outside in a naturalistic environment (65.4%) (Glynos et al 2023) This could imply a diverse range of settings across both urban and rural areas

● Trends Across US States:

○ Several US states and municipalities have moved towards psychedelic decriminalization or legalization

■ Denver, Colorado, was the first city to decriminalize magic mushrooms in 2019 (Bloomberg, 2019)

■ Oregon has proposed and enacted policies to decriminalize or legalize the possession and/or ingestion of psilocybin (Smith & Appelbaum, 2022).

■ California is noted as being likely to approve similar legislation (Glynos et al 2023)

■ One source projects that over half of US states will have legalized psychedelics by 2037 (Kruger et al 2023)

Additional Considerations:

● Data Limitations: The absence of granular geographic data underscores the difficulty of tracking psychedelic use due to its largely unregulated status and varying legality

● Sample Bias: The reliance on convenience samples, often recruited through online forums and social media, can skew results by overrepresenting certain demographics This bias limits the generalizability of the findings.

● Need for Population-Based Studies: There is a need for comprehensive research using representative samples across different geographic areas to provide more accurate usage patterns

3.4 Motivations for Use

Motivations for Psychedelic Use:

● Recreational Use:

○ 52% of participants in a non-representative study that consisted of individuals who reported improvements in substance use after using psychedelics outside of a research or medical setting, cited “recreation” as their reason for use (Garcia-Romeu et al 2020)

○ In a study of a non-representative online survey, a significant number of participants reported that "fun" was a motivation for their first psychedelic experience (Palmer and Maynard 2022).

● Psychological and Personal Exploration:

○ 60.6% of participants in a non-representative study (Garcia-Romeu et al 2020) cited psychological self-exploration as a reason for psychedelic use

○ 81.6% of participants in a non-representative online survey targeting psychedelic users reported using psychedelics for spiritual, psychological, or personal exploration (Glynos et al. 2023).

○ 72.2% of respondents in a non-representative online survey targeting psychedelic users reported using psychedelics for personal growth (Glynos et al 2023)

● Therapeutic and Mental Health:

○ 63.4% of participants in a non-representative survey reported using psychedelics to improve general mental health (Glynos et al. 2023).

○ 47.2% of participants in a non-representative survey reported using psychedelics either to treat a medical condition or to manage past trauma (Glynos et al 2023)

○ Specific conditions included:

■ Depression (75 4% of those using for medical conditions/trauma) (Glynos et al. 2023)

■ Anxiety (66.8%) (Glynos et al. 2023)

■ Post-traumatic stress disorder (40.6%) (Glynos et al. 2023)

○ In a microdosing context, 37% of respondents to a non-representative online questionnaire reported performance enhancement as a primary motive, while 29% cited mood enhancement and 14% cited symptom relief (Hutten et al 2019).

○ Almost 40% of respondents in a study that used an international online survey reported that improving mental health was their main reason for microdosing (Lea et al 2020)

○ A smaller number of respondents in a non-representative study – 13.5% overall –used psychedelics to reduce or quit using other substances (Garcia-Romeu et al. 2020).

● Spiritual and Religious Purposes:

○ 40.5% of participants in a non-representative study used psychedelics to explore spirituality or the sacred (Garcia-Romeu et al 2020)

○ One non-representative online study found that 25% of users reported "spiritual" motives for using psychedelics (Nichols and Barker 2016).

○ It was noted in a non-representative anonymous online survey that many group-based psychedelic sessions are organized with spiritual intentions (Byrne et al 2023)

● Curiosity:

○ 16.4% of participants in a non-representative study cited “curiosity” as a motivation for psychedelic use (Garcia-Romeu et al. 2020).

○ In microdosing contexts, 15.2% of respondents to a non-representative online questionnaire reported using out of curiosity (Hutten et al 2019)

○ Curiosity was also a common intention for the first psychedelic experience among a group of experienced users in a non-representative online survey (Palmer and Maynard 2022)

● Other Motivations:

○ A smaller percentage of users, 3.2% of those surveyed in a non-representative study reported using psychedelics with no specific intention, or simply because other people around them were also using (Garcia-Romeu et al 2020)

● Some users were motivated by self-knowledge, 42% (Soares, Leite, and Pinto 2023)

● Some users were motivated by enjoyment and pleasure, 47% (Soares, Leite, and Pinto 2023).

● Some users report a motivation to explore art and creative pursuits (St. Arnaud and Sharpe 2023)

Variations by Context:

● Ceremonial Use:

○ Psychedelics used in religious or spiritual ceremonies (e.g., ayahuasca) are often associated with intentions of spiritual growth and self-discovery, according to a non-representative survey (Byrne et al 2023)

○ Some formal group sessions with psychedelics have predominantly spiritual intentions, with mental health benefits viewed as secondary, according to a non-representative survey (Byrne et al. 2023).

● Medical/Therapeutic Use:

○ According to a non-representative online survey, Individuals seeking psychedelic-assisted therapy (PAT) are typically motivated by the goal of addressing mental health conditions or past trauma (Glynos et al 2023)

○ Many individuals also use psychedelics to manage difficult emotions according to study of non-representative online surveys (Palmer and Maynard 2022; St. Arnaud and Sharpe 2023).

○ People using psychedelics to manage PTSD (40 6%), depression (75 4%), or anxiety (66 8%) were more likely to do so in the home rather than medical facilities (Glynos et al 2023)

Additional Considerations:

● Intention is Key: Intentions for using psychedelics play a significant role in the experience and its perceived outcomes according to non-representative online surveys Intentions related to "spiritual connection" are positively correlated with well-being, whereas intentions for "recreation" are negatively associated with mystical experiences (Haijen et al 2018; St Arnaud and Sharpe 2023)

● Mindset and Setting: The context in which psychedelics are used can influence the motivation for use. Whereas, the "set" (mindset) and "setting" (environment) significantly impact the type of experience and perceived outcomes (Haijen et al 2018)

● Overlapping Motivations: It's important to note that individuals may have multiple overlapping motivations for using psychedelics (Haijen et al 2018)

Prevalence

of Psychedelic

● PTSD:

Use Among Individuals with Mental Health Conditions:

○ 17% of a surveyed group of psychedelic users in a non-representative online convenience sample reported having a lifetime diagnosis of PTSD (Cherniak et al 2024)

○ 40.6% of those using psychedelics for medical conditions or trauma management in a non-representative survey specifically cited PTSD as a reason (Glynos et al. 2023).

○ A non-representative survey on ayahuasca found that 40% of its veteran participants had a previous PTSD diagnosis (Weiss et al 2023)

● Depression:

○ 21% of a group of psychedelic users in a non-representative online convenience sample reported a lifetime diagnosis of Major Depressive Disorder (Cherniak et al. 2024).

○ 75.4% of those using psychedelics for medical reasons or to manage past trauma in a non-representative survey cited depression as a reason (Glynos et al 2023)

○ Studies of non-representative online surveys show that individuals with a depression history often use psychedelics to self-medicate (Palmer and Maynard 2022).

● Anxiety:

○ 22% of a group of psychedelic users in a non-representative online convenience sample reported a lifetime diagnosis of anxiety disorders (Cherniak et al 2024).

○ 66.8% of those using psychedelics for medical reasons or to manage past trauma cited anxiety as a reason (Glynos et al. 2023).

○ This study also found that 66.8% of participants used psychedelics to manage anxiety (Glynos et al 2023)

● Other Conditions:

○ 18% of a group of psychedelic users in a non-representative online convenience sample reported a lifetime diagnosis of attention deficit hyperactivity disorder (ADHD) (Cherniak et al. 2024).

○ In the Global Psychedelic Survey, over 16% of respondents reported reducing the use of another substance as a motivation for psychedelic use (Lake and Lucas 2024)

● Comorbidity: 35.7% of individuals in a non-representative online convenience sample with a mental health diagnosis reported having at least one comorbid diagnosis (Cherniak et al. 2024).

● Psychotic Symptoms: While psychosis is not a primary motivation for psychedelic use, 5% of individuals in a study reported experiencing a psychotic episode following psychedelic use (La Torre et al 2024) Additionally, a study showed that among individuals with a mental health diagnosis, those with psychosis reported a worsening of their condition most often from psychedelic use, at 7.7% (La Torre et al. 2024).

Preferred Substances In Naturalistic Settings:

● Psilocybin: 92.1% of participants in a study focusing on individuals who use psychedelics in naturalistic settings reported using psilocybin mushrooms (Glynos et al 2023).

● LSD: 76.8% of participants in the same study reported using LSD (Glynos et al. 2023).

● MDMA: 55.5% of participants in the same study reported using MDMA (Glynos et al. 2023)

3.5 Microdosing

Microdosing:

● Definition: Microdosing involves taking sub-hallucinogenic doses of a psychedelic substance, such as LSD or psilocybin (Anderson et al 2019) The intention is to avoid the perceptual changes usually associated with psychedelics while still achieving benefits (Fadiman 2019)

● Common Doses: A typical microdose is usually between 5-20% of a standard full dose. For LSD, this is typically between 5-20 mcg (Miller et al. 2024). For dried psilocybin mushrooms, a microdose is between 0.1-0.4 grams (Fadiman 2019).

● Frequency: Microdoses are commonly taken 2-4 times per week according to non-representative studies (Rouaud, Calder, and Hasler 2024b) Respondents to a non-representative survey said they microdose every day, every second day, every third day, or on a 7 day cycle (Lea et al. 2020).

Lifetime Microdosing Prevalence in the US:

● While it’s challenging to pinpoint an exact percentage of the entire US population that has microdosed, one study found that 17% of respondents to a non-representative anonymous online survey reported having engaged in the practice of microdosing at some point in their lives (Cameron, Nazarian, and Olson 2020) This suggests that microdosing is a relatively common practice, but this number isn't from a population-level study, and the true percentage of the entire US population may be different

● In the same survey, 13% reported microdosing at some point in their life (Cameron, Nazarian, and Olson 2020).

Past Year Microdosing Prevalence in the US:

● It is difficult to determine an exact percentage of the US population that has microdosed in the past year A non-representative online survey found that 4% of their sample reported current microdosing (Cameron, Nazarian, and Olson 2020).

● Another study, using a non-representative survey of drug and alcohol users, found that 17% of their participants reported microdosing psychedelics at some point in their lives (Rouaud, Calder, and Hasler 2024)

Psychedelic Substances Used for Microdosing:

● LSD:

○ LSD appears to be the substance most commonly used for microdosing, with 48.58% of microdosers in a non-representative online survey reporting using LSD (Cameron, Nazarian, and Olson 2020)

○ In a different sample, 59.7% of microdosers reported using LSD (Hutten et al 2019).

○ LSD is frequently used due to the ability to measure doses using a pipette or by cutting blotter paper into smaller tabs (Hutten et al. 2019).

● Psilocybin:

○ 26.18% of microdosers reported using psilocybin (Cameron, Nazarian, and Olson 2020)

○ In a different sample, 57 8% of microdosers reported using psilocybin (Hutten et al. 2019).

● MDMA:

○ 11.99% of microdosers reported using MDMA (Cameron, Nazarian, and Olson 2020)

● Other Substances:

○ DMT: 1 58% of microdosers reported using DMT (Cameron, Nazarian, and Olson 2020).

○ 1P-LSD: 11.6% of microdosers reported using 1P-LSD (Hutten et al. 2019).

○ Researchers found other substances such as mescaline, 2C-B, 5-MeO-DMT, and NBOMes were also used, but less frequently (Cameron, Nazarian, and Olson 2020; Hutten et al 2019; Miller et al 2024)

Additional Details:

● Motivations: The most commonly reported motivation for microdosing is performance enhancement, with other reasons including mood enhancement, curiosity, and symptom relief (Hutten et al 2019) Many microdosers will microdose while studying or working (Hutten et al 2019)

● Safety: There is a general lack of scientific evidence on the safety and efficacy of microdosing, especially over long periods (Rouaud, Calder, and Hasler 2024b). Dosing accuracy with unregulated substances can also be a challenge (Miller et al. 2024).

3.6 Integration and Preparation

Integration Practices:

● Definition: Integration refers to the process of making sense of psychedelic experiences and incorporating insights into daily life to maximize benefits and minimize harm. It involves working through challenges and adjusting to changes following psychedelic use (Cowley-Court et al. 2023).

● Integration, commonly included in treatment protocols, is considered a vital component of psychedelic-assisted therapy (Robinson et al 2024) While specific percentages of individuals engaging in integration practices are not consistently available across all studies, it is widely acknowledged that integration is crucial for sustained benefits from psychedelic experiences (Bathje et al., 2022; Cavarra et al., 2022; Gorman et al., 2021; Jivanescu, 2022; Walther & van Schie, 2024).

Types of Integration Practices:

● Discussion and Reflection: Many protocols encourage patients to discuss their experience or write reports to consolidate memories and promote integration (Bathje et al., 2022).

● Community and Social Support: Integration is supported by connecting with a community that helps make sense of the experience and provides social support (Robinson et al 2024; Jivanescu 2022) This can take the form of peer-led, community-based integration groups (Gezon 2024)

● Personal Practices: Individuals often use personal practices like meditation, prayer, exercise, or increased social engagement to support integration (Pilecki et al. 2021).

● Ongoing Process: Integration is not limited to specific sessions but is an ongoing process of incorporating insights into daily life (Gorman et al 2021; Jivanescu 2022; Robinson et al 2024)

● Formal Integration Support: A non-representative study found that only a small percentage of people use psychedelics with a therapist, at 4.4% (Glynos et al.

2023) Of those, most (71 4%) found the presence of a therapist or healthcare professional important to the success of the experience (Glynos et al. 2023).

Challenges with Integration:

● A significant number of individuals, even those who experience transformative effects, face challenges in integrating their psychedelic experiences into daily life (Jivanescu 2022; Lutkajtis and Evans 2023).

● There is a recognized need to develop more structured and evidence-based integration practices (Wells, Fernandes, and Reynolds 2024).

Preparation Practices:

● Definition: Preparation involves steps taken before a psychedelic experience to ensure safety, well-being, and maximize positive outcomes (Schlag et al. 2022).

● Importance of Preparation: Preparation is considered essential for the safety and well-being of individuals using psychedelics, and helps to maximize positive outcomes (Pilecki et al 2021; McAlpine et al 2024)

● Prevalence of Preparation: Data regarding the specific proportion of individuals who prepare for psychedelic experiences is limited (McAlpine et al. 2024). Many people using psychedelics with self-direction do not have the benefits of structured preparation.

● Types of Preparation Practices:

○ Psychological Preparation: This involves understanding psychedelic substances, clarifying expectations, and ensuring mental readiness (McAlpine et al 2024) This includes setting intentions for the experience (Campo and Yali 2024; McAlpine et al. 2024).

○ Physical Readiness: Preparation also includes ensuring physical readiness to navigate the experience (McAlpine et al. 2024). This can include rest (getting adequate sleep before the experience); exercise (engaging in physical activity); hydration (drinking enough water); nutrition; (eating a nutritious meal) (Karoly et al 2024)

○ Safety Planning: This involves creating safe and supportive environments for the psychedelic experience (McAlpine et al. 2024; Palmer and Maynard 2022).

○ Educational Resources: Some preparation programs include educational resources like reading, videos, and podcasts (McAlpine et al 2024)

○ Mindfulness Practices: Meditation and breathing exercises are also used to prepare for psychedelic experiences (McAlpine et al 2024)

● Self-Directed Preparation: Most individuals using psychedelics naturalistically do not have the benefit of structured support. There is growing interest in using self-directed preparation strategies for psychedelic experiences, and digital interventions are being developed to deliver standardized, accessible preparation outside clinical settings (McAlpine et al 2024)

● Standardized Preparation: A large portion of preparation strategies can be standardized, but they should be tailored to individuals’ needs (McAlpine et al. 2024).

● Intentionality: Meaningful intention is significantly associated with greater psychological flexibility, underscoring the importance of preparation (Campo and Yali 2024)

● Harm Reduction: According to a non-representative online survey, experienced users are more likely to engage in harm reduction practices for their most recent experience compared to their first experience, such as planning for a comfortable setting, setting a purpose, obtaining the drug from a reputable source, measuring the dose, and arranging a time to take the drug (Palmer and Maynard 2022).

3.7 Polysubstance Use

Polysubstance Use:

● Definition: Polysubstance use involves using multiple substances concurrently or in close temporal proximity This can include combining psychedelics with other psychedelics, or with non-psychedelic substances like alcohol, cannabis, stimulants, or depressants (Fernández-Calderón et al 2020)

● Simultaneous vs. Concurrent Use: Simultaneous polysubstance use (SPU) refers to using different drugs during a single session with overlapping effects. Concurrent polysubstance use (CPU) refers to the use of different drugs over a specified period, such as the past year or month (Fernández-Calderón et al 2020)

Combining Psychedelics:

● Prevalence of Mixing Psychedelics: A significant portion of non-representative psychedelic users combine different psychedelic substances. In one small online survey, 31% of respondents reported mixing psychedelics (Bremler et al. 2023). Another non-representative study found that 8% of participants with psychotic experiences reported mixing psychedelics with other psychedelics or MDMA (La Torre et al 2024)

● Specific Combinations: Some users combine LSD and psilocybin, or LSD and ayahuasca (Cameron, Nazarian, and Olson 2020). Additionally, some mix psilocybin with mescaline (Kuc et al. 2022). Ayahuasca and DMT are sometimes analyzed together due to their overlap (Hase et al. 2022).

Mixing Psychedelics with Other Drugs:

● High Prevalence: Polysubstance use involving psychedelics was found to be common in non-representative studies (Kopra et al. 2022; Kuc et al. 2022). One such study found that 67.2% of their sample consumed more than one drug concurrently (Ona 2018).

● Cannabis: Cannabis is the most common secondary drug used with psychedelics, with 24.1% of users in a non-representative study combining them (Ona 2018) Additionally,

39 3% of participants in another non-representative study reported using cannabis during a psychedelic experience (Kuc et al. 2022).

● Alcohol: Alcohol is another commonly used substance alongside psychedelics (Kopra et al 2022) One non-representative study reported that nearly a quarter of participants had consumed alcohol when seeking emergency medical treatment after taking LSD (Kopra et al 2022)

● MDMA: MDMA is frequently combined with psychedelics, sometimes referred to as "candyflipping" when mixed with LSD (Kuc et al. 2022; Chary, Yi, and Manini 2018). 8% of people with adverse experiences reported in a non-representative survey mixing psychedelics with MDMA (La Torre et al 2024)

● Other Substances: Polysubstance use can include combinations with tobacco (6%) (La Torre et al 2024), sedatives, amphetamines, synthetic cannabinoids (Chary, Yi, and Manini 2018; Edwards et al 2023), and other non-psychedelic drugs (Bremler et al 2023). Some users mix psychedelics with prescription medications such as antidepressants, which may increase the risk of serotonin syndrome (Edwards et al. 2023) Additionally, some users report combining psychedelics with reversible MAOIs to enhance effects (Malcolm and Thomas 2022)

Specific Drug Combinations of Note:

● Psychedelics with MAOIs: Combining certain psychedelics like DMT with MAOIs can enhance or extend their effects but may also lead to fatal outcomes with drugs such as MDMA or 5-MeO-DMT (Malcolm and Thomas 2022)

● Ecstasy with other drugs: Roughly two thirds of MDMA/ecstasy related deaths in England and Wales involve another drug that is not alcohol (Edwards et al 2023)

Important Considerations:

● Increased Risk of Adverse Reactions: Polysubstance use can increase the risk of adverse reactions, including severe reactions, seizures, and psychological distress (Kopra et al 2022; Edwards et al 2023; Malcolm and Thomas 2022) Combining ecstasy with other amphetamine derivatives can lead to more severe long term cognitive changes (Edwards et al. 2023).

● Unknown Interactions: There is a lack of clarity about the interactions between psychedelics and other recreational drugs (Edwards et al 2023; Kuc et al 2022)

● Intentional vs. Unintentional Mixing: Some combinations occur intentionally to maximize positive effects or minimize negative effects, while others might be due to contamination or lack of awareness of drug interactions (Chary, Yi, and Manini 2018; Kuc et al. 2022; Nichols and Barker 2016).

● Lack of Quality Control: The quality of drugs is not always known, especially when obtained from unregulated sources (Bremler et al 2023)

● Emergency Treatment: Over a third of participants who sought emergency medical treatment after taking LSD reported mixing drugs as a reason for the incident (Kopra et al. 2022).

3.8 Where & How Users Learn About Psychedelics.

Sources of Information:

● Personal Experience: The most common source of information for psychedelic users is their own experimentation and experiences, with 79.52% of users in a non-representative survey citing this (Kruger et al 2023)

● Internet Sources:

○ Websites: 61.67% of respondents to this survey seek information from internet websites (Kruger et al 2023)

○ Discussion Forums: 57.08% use internet discussion forums . Reddit is also a particularly popular platform (Kruger et al. 2023).

○ Social Media: 45.45% use social media posts, with Reddit, Erowid, and Instagram as common platforms (Kruger et al 2023)

● Community and Peers:

○ Friends: 61 02% get information from friends (Kruger et al 2023)

○ Local Communities: 40.13% utilize local psychedelic communities (Kruger et al. 2023).

○ Psychedelic Nonprofits: 40.05% seek information from non-profit organizations like Multidisciplinary Association for Psychedelic Studies (MAPS) (Kruger et al 2023)

● Traditional Sources:

○ Books: 57% of users obtain information from books (Kruger et al. 2023).

○ Peer-Reviewed Articles: 54.55% use peer-reviewed scientific journal articles (Kruger et al 2023)

● Other Sources:

○ Primary Health Providers: Only 4.83% of users seek information from their primary health/medical care provider (Kruger et al 2023)

○ Family Members: 14.33% get information from family members (Kruger et al. 2023).

○ Conferences/Events: 20.88% learn about psychedelics from conferences or events (Kruger et al 2023)

○ Psychedelic Therapists: 20.07% get information from psychedelic therapists

○ Podcasts: 44.14% use podcasts as a source of information (Kruger et al 2023)

○ Providers of Psychedelics: 26.45% get information from providers of psychedelics (Kruger et al. 2023).

○ Companies involved in psychedelic research and development: 25 47% get their information from companies involved in psychedelic research and development (Kruger et al. 2023).

Informedness and Reliability:

● General Knowledge: Psychedelic users often have a high level of knowledge about legal status, effects, and clinical trials (Wells, Fernandes, and Reynolds 2024; Kruger et al. 2023). They often correctly identify target disorders for which psychedelic therapies have shown efficacy (Wells, Fernandes, and Reynolds 2024).

● Overestimation of Benefits: Users may overestimate the therapeutic potential of psychedelics (Wells, Fernandes, and Reynolds 2024; Kruger et al 2023)

● Trust in Sources:

○ Most Trusted: Articles in peer-reviewed scientific journals are the most trusted source, followed by psychedelic nonprofits and researchers based in colleges or universities (Kruger et al. 2023).

○ Least Trusted: Government agencies and pharmaceutical companies are the least trusted sources of information (Kruger et al 2023)

○ Mixed Trust in Online Forums: Although many users seek information from online forums, they have only a moderate level of trust in the information they find there (Kruger et al. 2023).

● Limited Healthcare Provider Knowledge: Healthcare providers themselves often lack knowledge of psychedelic-assisted psychotherapy, with most having low self-reported knowledge (Wells, Fernandes, and Reynolds 2024)

● Misinformation: There is a large amount of misinformation on psychedelics that can be overwhelming to sort through (Pilecki et al. 2021).

Demographic Differences in Information Seeking:

● Age:

○ Younger users in a non-representative study are more likely to rely on their own experiences, internet discussion forums, social media, podcasts, and friends They are also more likely to use Reddit (Kruger et al. 2023).

○ Older users are more likely to seek information from psychedelic therapists, and may report not seeking information at all They are also more likely to use Facebook Older users also express more trust in government agencies (Kruger et al 2023)

● Other Factors: Those with more education, lower age, identifying as male and as Caucasian/white tend to have better knowledge of psychedelics (Kruger et al. 2023).

● Underrepresented Communities: There is a need for education and outreach in under-represented communities (Kruger et al 2023)

Impact of Knowledge on Use:

● Harm Reduction: Access to accurate information can promote harm reduction practices (Kruger et al. 2023).

● Dosage and Setting: A lack of clear knowledge regarding dosage and the health implications of variations in dosages can lead to dangerous practices (Engel et al 2024)

● Personalized Preparation: Preparation strategies can be standardized, but should be tailored to the individuals needs based on accurate information (McAlpine et al 2024)

● Use in Naturalistic Settings: Individuals who use psychedelics in naturalistic settings may not have the same access to information that is present in clinical settings.

● Discerning Approach: Despite using diverse information sources, many individuals who use psychedelics take a discerning approach, critically evaluating the information and assigning varying levels of trust to different sources (Kruger et al 2023)

In summary:

Individuals obtain information about psychedelics from a variety of sources, with personal experiences, the internet, and community networks being the most common (Kruger et al. 2023) While many users possess considerable knowledge, they may also overestimate benefits and rely on potentially unreliable sources Demographic differences exist in how people seek and access information, which can impact how they use psychedelics and the safety of their practices (Kruger et al. 2023).

4. Settings & Social Contexts of Psychedelic Use

Psychedelic use occurs across various settings, including clinical research, ceremonial traditions, and recreational environments. This section categorizes these settings and examines their influence on user experiences and safety outcomes

4.1

Overview of Settings & Social Contexts

Prevalence of Use Across Settings:

● Recreational Use: Recreational use is most common The majority of psychedelic use occurs in recreational settings (Pestana, Beccaria, and Petrilli 2021; Pflieger 2005). A non-representative survey indicated that most naturalistic psychedelic use takes place in informal settings, with 95% of solo users and 91% of group users using psychedelics informally (Byrne et al 2023)

● Clinical Use: Clinical use is less common Only a small fraction of psychedelic use takes place in clinical settings (Glynos et al 2023; Shaw et al 2023) Only 3% of psychedelic users report using psychedelics in clinical or hospital settings (Glynos et al 2023). Another study found that 4.4% of users have used psychedelics with a therapist or healthcare professional (Glynos et al. 2023).

● Unregulated Facilitated Use: Unregulated facilitated contexts involve the use of psychedelics with guidance and support from facilitators who may not have formal accreditation or qualifications (Byrne et al. 2023). Prevalence data on these contexts is limited, but a notable portion of psychedelic use occurs outside clinical or research protocols (Anderson et al 2019) For example, some seek "underground" therapists, who provide psychedelic-assisted therapy outside legal channels (Lea et al 2020) Additionally, a significant percentage of ayahuasca use happens in non-traditional settings (Bouso et al. 2022).

● Ceremonial Use: While less common than recreational use, ceremonial use is a notable context In one non-representative international online survey, 45 9% of ayahuasca use occurred in religious contexts, 20 2% in traditional shamanic settings, and 25 4% in non-traditional settings (Bouso et al 2022)

Patterns of Use by Context:

● Recreational Settings:

○ Use is often for enjoyment, exploration, or social purposes (Pestana et al , 2021)

○ Settings can include parties, festivals, private homes, or outdoor locations (Ona 2018; Glynos et al 2023)

○ Group use is common, but solo use also occurs (Byrne et al. 2023).

○ Harm reduction practices are often less consistently used in party settings (Palmer and Maynard 2022).

○ There may be less attention paid to mindset (“set”) and setting, which can increase the risk of negative experiences (Ona 2018)

○ 67.2% of users in recreational contexts, according to a non-representative online survey, consume more than one substance at a time.

○ Doses, settings, and social contexts are not as controlled as in clinical or ceremonial settings (Engel et al. 2024).

● Clinical Settings:

○ This refers to cases when psychedelics are used under the supervision of trained professionals, where the goal is typically therapeutic, addressing conditions such as depression, anxiety, and PTSD (Davis et al. 2022; Glynos et al. 2023).

○ In a non-representative study that surveyed healthcare providers recruited through the Johns Hopkins Center for Psychedelic and Consciousness Research website and social media advertisements, 93 9% of healthcare professionals found a specialized clinic to be an appropriate setting for psilocybin administration, and 90 1% for MDMA (Wang et al 2024)

○ According to a non-representative online survey, Dosages in clinical settings are carefully controlled and monitored (Engel et al. 2024).

○ These clinical settings are designed to minimize distractions and promote psychological safety (Byrne et al 2023)

● Unregulated Facilitated Settings:

○ Psychedelic use occurs with guidance from individuals who may lack formal training or accreditation (Byrne et al. 2023).

○ Facilitators operate outside established institutions or regulatory frameworks (Glynos et al 2023)

○ Motivations of facilitators vary, ranging from altruistic intentions to potentially exploitative ones (Kruger et al 2024)

○ Settings range from private homes to retreat centers (Davis et al 2024)

○ Safety and ethical considerations are paramount due to the lack of oversight (Kruger et al. 2024).

○ Ceremonial Settings:

○ Use is often embedded within spiritual or religious practices (Bouso et al 2022)

○ Traditional shamanic settings, and non-traditional settings may be used (Bouso et al 2022)

○ The focus is on personal growth, spiritual insight, or healing (Glynos et al. 2023).

○ Ayahuasca use is often in a religious context, where there is a lower frequency of anxiety and depressive disorders compared to non-supervised settings (Bouso et al 2022)

○ The age of ayahuasca use onset is lower in religious contexts compared to other contexts of use (Bouso et al 2022)

○ Religious contexts have lower frequency of substance use disorder compared to non-supervised contexts (Bouso et al. 2022).

○ Non-US ceremonial sites such as the ayahuasca retreat centres in Peru offer individuals the opportunity to seek insight or healing that might be restricted in the US due to regulatory barriers However, caution is essential, as not all retreat centres have reputable practices The motivations of facilitators or shamans may not always be altruistic, posing potential risks to participants' safety and well-being such as sexual assault, exploitation and cultic dynamics (Evans & Adams, 2024)

Other Contextual Factors:

● Home Use: 81.9% of psychedelic users in a non-representative survey report using psychedelics at home, which is seen as a common and acceptable practice among psychedelic users (Glynos et al. 2023).

● Natural Environments: 65 4% of users in a non-representative survey report using psychedelics outside in a naturalistic environment (Glynos et al 2023)

● Group vs. Solo: While both group and solo use are prevalent, a non-representative survey found that using psychedelics in a solo setting was more common when the goal was to improve mental health. Solo use was also associated with greater subjective symptom improvement (Byrne et al. 2023).

Important Considerations:

● Safety: The risk of adverse events may be higher in recreational settings, where there may be less planning, harm reduction strategies, and support (Ajantaival 2014).

● Therapeutic Benefits: A non-representative survey found that while clinical settings are designed for therapeutic use, users in other contexts can also experience positive outcomes, particularly in spiritual or personal growth (Glynos et al 2023)

● Access: Access to clinical settings is not always easy, as many individuals find that their healthcare providers lack knowledge or are not open to discussing psychedelics, and according to a non-representative survey, many individuals are interested in receiving psychedelic therapy if it is available (Glynos et al. 2023).

In Summary:

Recreational use is the most prevalent context for psychedelic use (Dollar 2021), followed by ceremonial use. Clinical use remains much less common (Glynos et al. 2023). The intentions behind use vary considerably between contexts (Dollar 2021), with clinical settings emphasizing therapy and safety, ceremonial settings prioritizing spiritual experience, and recreational settings focused on enjoyment, personal growth, and exploration Each setting presents different benefits and risks based on the level of structure, supervision, and the goals of the user (Lake and Lucas 2024)

4.2 Recreational Contexts

Solo vs. Group Use:

● Solo Use: 41 7% of psychedelic users report using psychedelics alone according to a non-representative survey (Glynos et al. 2023). Additionally, in a non-representative online survey of individuals who contacted the Fireside Project's psychedelic helpline, 39.9% of callers who were in the midst of a psychedelic experience had taken the substance alone (Pleet et al 2023)

● Group Use: 35.1% of psychedelic users in a non-representative survey report using psychedelics with a group of two or more companions (Glynos et al 2023)

● Combined Use: A study found that 357 out of 578 participants had experience with psychedelics in both group and solo settings (Byrne et al. 2023).

Additional Contextual Factors

● Informal Settings: A non-representative survey found that the majority of naturalistic psychedelic use occurs in informal settings, whether solo or group use. 95% of solo users and 91% of group users reported using psychedelics informally (Byrne et al. 2023).

● Mental Health Intent: When the primary goal is to treat a mental health issue, solo use is more common than group use (Byrne et al 2023)

○ Psychedelics are less likely to be used for mental health purposes in a group setting than in a solo setting (Byrne et al. 2023).

○ Those with the intention of treating mental health issues were about half as likely to use psychedelics in a group setting (Byrne et al 2023)

● Setting Type:

○ Alone in Nature: 26 5% of users (non-representative) report this setting (Raj 2022)

○ Parties: 14.3% of users (non-representative) report using in this setting (Raj 2022).

○ Alone Indoors: 12 2% of users (non-representative) report this setting (Raj 2022)

○ Group Indoors: 8 16% of users (non-representative) report this setting (Raj 2022)

○ The most common settings for use (non-representative) are at home 81.9% and outdoors in a natural environment 65.4% (Glynos et al. 2023).

● Negative Outcomes:

○ Only one individual in a non-representative study reported a negative outcome when using in either a solo or group setting, whereas 10 individuals with experience in both solo and group settings reported an overall negative effect on mental health (Byrne et al. 2023).

○ It's feasible that experience in both solo and group contexts could represent less discriminating or intentional "set and setting," potentially leading to more negative outcomes (Byrne et al 2023)

Important Considerations:

● Intent: The setting (solo vs. group) can be influenced by the user's intent. Those seeking mental health benefits may prefer solo experiences, while those seeking social connection or exploration may prefer group settings (Byrne et al 2023)

● Safety: While negative outcomes in a non-representative study are rare overall, they may be slightly higher in less structured, combined group and solo settings (Byrne et al 2023).

● Therapeutic Impact: Solo use is more frequently associated with subjective mental health symptom improvement (Byrne et al. 2023).

In Summary:

While both solo and group use are common, approximately 42% of psychedelic users report using alone compared to 35% using in a group setting (Nayak et al. 2023). The choice of setting can be influenced by factors such as the user's intentions, therapeutic goals, and the context of the experience There is evidence to suggest solo use is more frequently associated with intentional mental health symptom improvement (Byrne et al 2023)

4.3 Clinical Contexts

State-Regulated Contexts:

● Prevalence: Estimates for the number of people using psychedelics in state-regulated contexts are very limited (Kruger et al. 2023). The legal landscape for psychedelics is rapidly evolving, making it challenging to pinpoint current usage within specific state-regulated frameworks

● Future Trends: It is predicted that over half of the states will have legalized psychedelics by 2037 (Kruger et al 2023) This suggests a significant increase in state-regulated psychedelic use in the coming years.

Clinical Trials:

● A 2022 search of ClinicalTrials gov identified over 400 registered psychedelic studies (Peterson et al 2023) However, the exact number of participants involved in these trials is not specified.

● Many of these studies are in the "recruiting," "enrolling by invitation," "active," or "completed" status, indicating a substantial ongoing effort in psychedelic research (Peterson et al 2023)

● These trials are subject to research ethics review (Peterson et al 2023)

● Limited Availability: Access to clinical trials is limited, and they are not easily accessible for most individuals seeking psychedelic experiences (Byrne et al. 2023).

● Prior Psychedelic Use: A significant proportion of participants in clinical trials have prior experience with psychedelics, with an average of 50% of patients using psilocybin or other psychedelics before study enrollment (Breeksema et al 2022) One study reported an average of 0 8 lifetime experiences with psychedelics among participants (Breeksema et al 2022)

Ketamine Clinics:

● The sources do not specify the exact number of people using psychedelics in ketamine clinics

● Ketamine is legally used in clinics, sometimes along with psychotherapy (Dore et al , 2019).

● Ketamine is sometimes considered a "psychedelic-like drug" (Marguilho et al., 2022), but is not a classic psychedelic.

● Ketamine is a racemic mixture which means it contains two molecules in equal proportion that mirror each other These two molecules are R-ketamine and S-ketamine In 2019, the FDA approved intranasal esketamine (S-ketamine) - the purified version of ketamine containing only the S proportion - for treatment resistant depression (McInrtyre

et al , 2021) It is this purified version (Spravato) that is being administered in FDA approved clinics in the US.

● Ketamine-Assisted Psychotherapy: Research indicates that single or repeated sessions of ketamine-assisted psychotherapy have been used for people with heroin dependence (Gorman et al 2021)

● Therapeutic Benefits: A review of ten years of research on Ketamine for alcoholism suggests it produces therapeutic benefits, including prolonged abstinence and favorable changes in mood and lifestyles (Liu et al. 2016).

● Heroin Addiction: A two-year follow-up study of heroin addiction found a reduced rate of relapse and marginal anti-craving effects in patients receiving a high dose of intramuscular ketamine Repeated KPT sessions produced more favorable outcomes among heroin addicts compared to a single KPT session (Liu et al 2016)

● Home use vs in clinic use: At-home ketamine treatment carries significant risks due to the lack of professional oversight. Self-administering ketamine may lead to incorrect dosages, and patients won’t have immediate medical support if adverse reactions occur. In contrast, clinic-based treatments offer the supervision of trained professionals who monitor vital signs, ensure accurate dosing, and provide immediate intervention if necessary Without medical supervision, patients may also struggle to assess their own mental health progress or navigate the emotional challenges of treatment, which could be better managed with professional guidance. Moreover, the absence of accountability increases the risk of misuse, leading to potential addiction, tolerance, or other harmful effects

Important Considerations:

● Evolving Legal Landscape: The regulatory environment for psychedelics is rapidly changing. The move towards decriminalization and legalization in certain jurisdictions suggests that state-regulated use is likely to increase (Gomez-Escolar et al. 2024).

● Access Barriers: Legal access to psychedelics for therapy is limited to research trials, ketamine clinics, and exceptions for religious groups (Byrne et al 2023; Pilecki et al 2021) This restriction increases risks for those seeking therapeutic use outside these settings (Pilecki et al. 2021).

● Data Limitations: Current data collection systems may not accurately capture the nuances of psychedelic use (Korthuis et al. 2024). State and national regulatory pathways may help define exposed populations, capture health outcomes, and track safety in a more accurate way (Korthuis et al 2024)

In Summary:

While there is growing research activity, precise data on state-regulated psychedelic use and specific numbers for ketamine clinics is currently very limited or unavailable Clinical trials are actively enrolling participants, but access is restricted and the number of participants is not explicitly defined The legal landscape for psychedelics is undergoing rapid change, and future

data collection systems are needed to better understand usage within these contexts (Glynos et al. 2023).

4.4 Unregulated Facilitated Contexts

Prevalence of Facilitated Psychedelic Use

● Low Overall Prevalence: A small percentage of psychedelic use occurs in facilitated contexts Only 4 4% of participants in one non-representative study reported using psychedelics with a therapist or healthcare professional (Glynos et al 2023) A non-representative online study reported 5 3% of experiences occurring in a psychedelic therapy session (Evans et al 2023)

● Clinical Settings: Only 3.0% of users in a non-representative study reported using psychedelics in a clinical or hospital setting (Glynos et al. 2023).

● Traditional Shaman: 20 2% of ayahuasca use occurs in a traditional shamanic context according to a non-representative international online survey (Bouso et al 2022)

● Religious Contexts: 45 9% of ayahuasca use occurs in religious contexts (Bouso et al 2022)

● Non-Traditional Contexts: 25.4% of ayahuasca use occurs in non-traditional contexts (Bouso et al. 2022).

Trip Sitters

● Sober Trip Sitters: While psychedelic harm reduction resources often recommend having a sober trip sitter, this practice is not universally adopted (Palmer and Maynard 2022).

○ Many participants suggest that simply having a sober person present may not always be helpful, especially if that person lacks experience with psychedelics (Palmer and Maynard 2022)

● Experienced Guides: Many users find it more beneficial to have a "guide" who is familiar with the psychedelic experience, rather than just a sober person (Palmer and Maynard 2022).

● Trusted Individuals: Having people present who are deeply trusted (but not necessarily sober) is often preferred (Palmer and Maynard 2022)

○ Some users prefer to use psychedelics alone, especially those with more experience (Palmer and Maynard 2022)

● Remote Sitters: Some users (~21%) communicate their plans to consume psychedelics to someone who is not physically present during the experience (Engel, Thal, and Bright 2022).

● No Sitter: Many posts in online forums indicate that psychedelic care is unnecessary or optional, particularly for LSD and LSA (Engel et al. 2024).

Characteristics of Facilitators

● Types of Facilitators: Facilitators may include therapists, healthcare professionals, shamans, or experienced peers (Golden et al 2022)

● Training and Licensing: The sources indicate a significant lack of standardization or regulation regarding the training and licensing of psychedelic facilitators, especially in unregulated contexts (Pilecki et al. 2021).

○ Most psychedelic users in a non-representative study do not seek information from healthcare providers, and may distrust them (Kruger et al 2023)

○ Many individuals in a non-representative study seek information from their own experience, friends, or alternative sources (Kruger et al. 2023).

○ Formal Training: Some organizations like MAPS, Fluence, and CIIS provide training for individuals delivering psychedelic-assisted therapy (Pilecki et al. 2021)

○ Informal Training: The majority of facilitators are likely untrained or self-trained, lacking formal credentials

● Substances: Facilitators may work with a variety of substances, including psilocybin, LSD, ayahuasca, and MDMA (Engel et al. 2024). 5-MeO-DMT is strongly associated with a perceived need for care (Engel et al. 2024).

Activities in Facilitated Psychedelic Contexts

● Common elements of psychedelic-assisted therapy include preparation with therapists, administration of a psychedelic in a clinical setting, and integration therapy (Kruger et al. 2023).

● Psychotherapy: Psychotherapeutic support before and after dosing is considered best practice and an important component across contemporary psychedelic trials (Palitsky et al , n d )

● Interpersonal Support: The interpersonal components of Psilocybin-Assisted Therapy (PAT) treatment can involve different modalities and amounts of time, expertise, or directiveness (Palitsky et al., n.d.).

● Careful Environment Design: The physical environment is arranged to maximize safety, comfort, and aesthetics (Pilecki et al 2021)

● Screening: Participants are highly screened with exclusionary criteria (e g history of bipolar disorder or psychosis) (Pilecki et al 2021)

● Preparation: Participants receive strategies on how to navigate challenges (Pilecki et al. 2021).

● Therapist Monitoring: In some cases, a third-party person may be present to monitor the therapist and patient (Villiger 2024)

● Specific activities (with limited data):

○ Eye Masks: The sources don't give data on the use of eye masks in facilitated settings. Some laboratory settings have patients with their eyes closed, but it is unknown how common this practice is outside of research settings (Bălăeţ 2022).

○ Meditation: Meditation is frequently used as a component of preparation for and integration after psychedelic experiences, but not in a quantifiable way (Pilecki et al 2021)

○ Creative Therapy & Dance: While these are known therapeutic practices, the sources do not specify the frequency or prevalence of creative therapy or dance in psychedelic-assisted therapy, despite some anecdotal mentions (Pilecki et al. 2021)

● Mindfulness retreats: Mindfulness practices are often combined with psychedelic use to enhance mental health benefits (Aday et al 2021)

● Music: music seems to play a key role in mediating therapeutic outcome with interviews revealing that music had a “welcome” and “unwelcome” influence on individual’s subjective experience (Kaelen et al., 2018). Furthermore, music played during the session was linked to mystical experiences and insightfulness Importantly, the type of music experience predicted a reduction in depression one week after psilocybin, while general drug intensity did not have the same effect (Kaelen et al , 2018)

Important Considerations:

● Lack of Standardization: The lack of standardization in training, qualifications, and practices of psychedelic facilitators represents a significant challenge to ensuring safety and efficacy (Bălăeţ 2022)

● Importance of Preparation: Preparation, support, and follow-up are crucial for avoiding adverse events and increasing beneficial effects (Pilecki et al. 2021).

● Set and Setting: The "set" (psychological factors brought to the experience) and "setting" (immediate environmental context) are critical in shaping the response to psychedelics (Bălăeţ 2022)

● Individual Differences: Responses to psychedelics can vary significantly based on individual traits, such as openness and meditation depth (Aday et al 2021)

4.5 Ceremonial Contexts

Prevalence of Psychedelic Use in Ceremonial Settings:

● Overall, a small percentage of psychedelic use occurs in ceremonial settings according to a non-representative study, with only 2% reporting a recent experience in this context (Byrne et al. 2023). However, it’s important to note that the data specifically focuses on the most recent experience, which might not capture all ceremonial use, as many individuals may have used psychedelics in a ceremonial context at some point in their lives, but not recently.

Traditional or Indigenous Ceremonies:

● Ayahuasca in Shamanic Contexts: 20.2% of ayahuasca use takes place within a traditional shamanic context according to a non-representative survey that collected data from participants from more than 50 countries who were at least 18 years old and had used ayahuasca on one or more occasions (Bouso et al. 2022)

● Cultural Significance: Indigenous cultures often view hallucinogenic plants and fungi as divine, with their use tightly controlled by ceremonial guidelines (Johnson, Richards, and Griffiths 2008)

● Ritualized Use: These ceremonies are used for rites of passage, divination, and spiritual or physical healing (Johnson, Richards, and Griffiths 2008)

● Emphasis on Context: Indigenous practices place a strong emphasis on the environment and psychological factors such as intention, ceremony, and ritual (Carhart-Harris et al. 2018)

● Examples:

○ Peyote use by Native American populations in rituals and ceremonies (Nichols and Barker 2016).

○ Ayahuasca use in South American Indigenous practices (Dupuis and Veissière 2022).

○ Use of DMT-containing epená by the Waiká cultures of Brazil and Venezuela, with preparation and consumption occurring in a highly ritualized context (Johnson, Richards, and Griffiths 2008)

Religious Ceremonies:

● Ayahuasca in Religious Contexts: 45.9% of ayahuasca use occurs within religious contexts according to a non-representative international online survey (Bouso et al. 2022)

● Syncretic Religions: Modern syncretic religions, such as Santo Daime and União do Vegetal (UDV), incorporate a high degree of structure and ritual into their use of ayahuasca (Johnson, Richards, and Griffiths 2008).

● Religious Freedom: Some countries have made exemptions for the religious use of psychedelics, and in the US, the Supreme Court has ruled that drug laws may be trumped by freedom to practice religion (Elsey 2017)

Substances Commonly Used:

● Ayahuasca: The most common substance in spiritual practices, ayahuasca, is used both in traditional shamanic and religious ceremonial contexts (Johnson, Richards, and Griffiths 2008; Elsey 2017; Bouso et al. 2022).

● Peyote: Peyote is used in Native American Church ceremonies (Elsey 2017)

● Psilocybin: While not as commonly mentioned in traditional or religious ceremonies, a non-representative online study found that psilocybin mushrooms are used in certain ceremonial settings (Nichols and Barker 2016).

● DMT: DMT is used in various forms (including ayahuasca and epená) in Indigenous ceremonies.

Additional Insights:

● Non-Traditional Contexts: According to a non-representative international online survey, 25.4% of ayahuasca use occurs in non-traditional contexts, which can include spiritual but non-religious settings (Bouso et al. 2022).

● Cultural Appropriation: There are ethical concerns about the appropriation of Indigenous methods by Westerners (Carhart-Harris et al. 2018).

● Contextual Importance: The cultural and contextual factors of psychedelic use are key to understanding their effects (Dupuis and Veissière 2022)

In Summary:

While the overall prevalence of psychedelic use in ceremonial settings is relatively low at 2%, there are significant differences between traditional/Indigenous and religious ceremonial practices. Ayahuasca is a common thread, but the specific rituals and intentions vary Traditional ceremonies emphasize healing and spiritual practices with a focus on mindset, setting, and the psychological factors brought to the experience, while religious ceremonies incorporate a high degree of structure and ritual with a focus on spiritual growth.

5. Adverse Events and Risks

This section reviews documented adverse effects and risk factors associated with psychedelic use By examining population-level risks and common adverse events, we can identify key considerations for safety and harm reduction efforts

5.2 Population-Level Risk Factors

General Population-Level Risk Factors

● Overall Risk: Psychedelics generally have a low potential for health or social harms (Haden, Emerson, and Tupper 2016) They are relatively non-toxic (Haden, Emerson, and Tupper 2016; Schlag et al 2022), and have a very low dependence potential (Haden, Emerson, and Tupper 2016)

● Mental Health Issues: Psychedelic use is generally not linked to mental health problems (Haden, Emerson, and Tupper 2016; Johansen and Krebs 2015), psychological distress, or suicidal behavior (Haden, Emerson, and Tupper 2016; Aday et al 2020) In fact, some studies suggest that psychedelic use is linked to reduced psychological distress and suicidality (Aday et al 2020)

○ Limited Evidence of Psychosis Link: While there is some concern that psychedelics can cause or worsen psychosis, the evidence for a direct causal link is weak (Forstmann and Sagioglou 2021; Lebedev et al. 2021; Sabé et al. 2024). Studies suggest that psychosis induced by psychedelics is rare (Sabé et al 2024) In population studies, the incidence is around 0.002% (Sabé et al 2024)

● Adverse Events: While rare, adverse events do occur, including:

○ Acute Anxiety, Panic, and Confusion: These are the most common symptoms reported when seeking emergency medical treatment (EMT) related to LSD use (Kopra et al. 2022).

○ Psychological Distress: A significant proportion of people treated with psychedelics may experience psychologically distressing outcomes (McIntyre et al 2025)

○ "Bad Trips": A proportion of individuals experience challenging experiences, sometimes referred to as "bad trips," which can include fear, anxiety, and paranoia (Bremler et al. 2023; Palmer and Maynard 2022).

○ HPPD (Hallucinogen Persisting Perception Disorder): Symptoms include visual disturbances and can cause distress in some individuals, but it is relatively rare, with a low prevalence of formal diagnosis (Haden, Emerson, and Tupper 2016; Bremler et al 2023) Only one of 32 survey participants reported a formal diagnosis of HPPD (Bremler et al. 2023).

● Underlying Mental Health Conditions: Individuals with pre-existing mental health conditions, especially personality disorders, may be more susceptible to negative outcomes (Marrocu et al 2024; Ona 2018)

Substance Use Disorders

● Prevalence: A representative study found that 200,000 people had a past year hallucinogen use disorder. This represents approximately 2.4% of those who had a past-year substance use disorder (NSDUH 2023)

● Age: 35,000 people aged 12-17, 121,000 people aged 18-25, and 49,000 people aged 26 or older had a hallucinogen use disorder (NSDUH 2023)

● Diagnostic Criteria: The report states that the criteria for a hallucinogen use disorder excludes the withdrawal criterion, and is based on whether the individual meets at least two other criteria of the DSM-5 (NSDUH 2023).

● Severity: The provided data do not include sufficient information on the severity or prevalence of hallucinogen use disorders

Demographic-Specific Risks

● Age:

○ Younger Age: Younger age is associated with an increased risk of seeking emergency medical treatment due to adverse reactions to LSD (Kopra et al 2022) Increased age is also associated with generally less intense effects, suggesting users may become less sensitive with repeated use (Aday et al 2021).

● Gender:

○ No Strong Predictor: Participant sex is not a robust predictor of drug effects (Aday et al 2021)

○ Male Gender: Male gender is associated with greater knowledge of psychedelics and more favorable views toward their therapeutic potential (Kruger et al. 2023; Wells, Fernandes, and Reynolds 2024).

● Ethnicity:

○ Underrepresentation: Minorities are underrepresented in clinical research with psychedelics (Breeksema et al 2022; Morton et al 2023), limiting the generalizability of findings

○ White/Caucasian: Individuals identifying as white/Caucasian are more likely to answer psychedelic knowledge questions correctly (Kruger et al. 2023).

Socioeconomic and Other Factors

● Education Level:

○ Higher Education: Individuals with higher levels of education are more likely to answer psychedelic knowledge questions correctly (Kruger et al. 2023).

● Socioeconomic Status:

○ Income: Higher annual household income is correlated with greater psychedelic knowledge (Kruger et al 2023)

○ Financial Stability: Those with greater financial stability tend to have more positive experiences with psychedelics (St. Arnaud and Sharpe 2023).

● Geographic Location:

○ Specific Trends: Most participants in studies are from the US (Morton et al. 2023), and Michigan (Kruger et al 2023), which may limit generalizability of findings

● Access to Healthcare:

○ Limited Communication: A large percentage (72.5%) of users never discuss psychedelic use with their primary care provider (Glynos et al. 2023).

○ Stigma and Lack of Knowledge: This lack of communication is often due to stigma, preference for privacy, legal concerns, and the perception that healthcare providers are not knowledgeable about psychedelics (Glynos et al 2023)

Other Notable Patterns

● Prior Psychedelic Use: Increased experience with psychedelics is related to generally less intense effects (Aday et al 2021)

● Polysubstance Use: Polysubstance use is a risk factor for negative outcomes (Bremler et al 2023)

● Dose and Setting: Unsafe environments, high or unknown drug quantities, and poor 'set' and 'setting' increase the risk of negative outcomes (Bremler et al. 2023).

Geographic and Cultural Contexts

● Cultural Differences: Cultural backgrounds and differing socio-cultural norms can influence the intensity of psychedelic experiences, as well as how individuals cope with

challenging events (Breeksema et al 2022) However, the available studies do not offer specific statistical data quantifying differences in risk across cultural contexts.

● Indigenous Knowledge: There is a lack of commentary on the Indigenous history of psychedelics and the role modern research could play in amplifying these voices (Wells, Fernandes, and Reynolds 2024)

Pre-existing Mental and Medical Conditions

● Mental Health Conditions:

○ Personality Disorders: In a non-representative online survey, individuals with a prior personality disorder diagnosis have a 31% chance of experiencing a negative response, and a greater than four-fold elevated risk of adverse psychological responses to psychedelics (Marrocu et al 2024)

○ Psychotic Disorders: A non-representative study found that those with a personal or family history of psychosis are at an increased risk of experiencing psychotic episodes from psychedelics (Haden, Emerson, and Tupper 2016). Individuals with schizophrenia are excluded from psychedelic-assisted therapy due to the risk of triggering or worsening psychosis (Sabé et al 2024) In studies with individuals with schizophrenia, 3 8% developed long-lasting psychotic symptoms, and of those with psychedelic-induced psychosis, 13.1% later developed schizophrenia (Sabé et al. 2024).

○ Bipolar Disorder: Current procedures for psilocybin clinical trials may need to be modified to account for risks specific to bipolar disorder populations Some individuals with bipolar disorder may require monitoring within the facility, especially to ensure adequate sleep takes place after a session (Morton et al 2023).

○ Anxiety and Depression: Anxiety is the most prevalent symptom reported in negative long-term psychological responses to psychedelics (Bremler et al. 2023) 81-93% of participants in a non-represenative online survey reported experiencing anxiety symptoms (Bremler et al 2023)

○ PTSD: In one non-reprsentative study of 608 individuals, 5% reported a sense of going through a psychotic episode following psychedelic drug use (La Torre et al. 2024). The presence of pre-existing PTSD did not increase the chance of adverse events during ayahuasca use (Weiss et al. 2023).

○ General Mental Health Diagnoses: 22 4% of a non-representative sample who had a negative experience had a prior psychiatric diagnosis, but more research is needed to quantify the increased risk this poses (Ona 2018)

Risks Across Different Psychedelics

● Psilocybin:

○ Is generally considered to have a good safety profile (Bennett et al 2023)

○ Headaches have been reported as an adverse event (Breeksema et al 2022)

○ Studies using psilocybin indicate that there was a statistically significant decrease in QIDS-SR16 scores (16-item Quick Inventory of Depressive Symptomatology, Self-Report). A psychometric evaluation of both the clinician-rated (QIDS-C) and self-report (QIDS-SR) versions exists for patients with chronic major depression, from baseline to eight-week follow-up (Bennett et al 2023)

○ There is a very low risk of inducing psychosis with psilocybin, especially in regulated settings (Sabé et al 2024)

● LSD:

○ Is associated with a higher incidence of adverse events, including seeking emergency medical treatment (Kopra et al 2022)

○ Common adverse effects include anxiety, panic, and confusion (Kopra et al 2022)

○ Dosages vary widely according to a non-representative online survey (Engel et al. 2024).

● MDMA:

○ Has some reports of serious adverse events like increased premature ventricular contractions requiring brief hospitalization (Breeksema et al 2022)

○ Commonly associated with nausea, headaches, and anxiety during use (Breeksema et al 2022) Late adverse events included headaches, fatigue, low mood, and anxiety (Breeksema et al. 2022).

● Ayahuasca/DMT:

○ Ayahuasca use is associated with seeking mental health assistance for adverse effects at 11 9% (Robinson et al 2024)

○ Some cases of psychosis are linked to ayahuasca consumption, especially when combined with other factors like concurrent substance use, pre-existing conditions, etc (White et al. 2024).

○ Pharmacovigilance data from the World Health Organization (WHO) shows 61 reports of side effects from Ayahuasca, DMT, and other related substances since 2005 (White et al 2024)

● General Differences: Different psychedelics have differing pharmacological activities, which means that individual agents vary in their receptor affinity and intracellular signaling pathways, which can result in different effects (Baumeister, Tojo, and Tracy 2015).

Dosage, Frequency, and Administration

● Dosage:

○ High Doses: Higher doses of psychedelics increase the risk of adverse events (Bremler et al. 2023).

■ Adverse psychological effects are more likely at higher doses of psilocybin (Baumeister, Tojo, and Tracy 2015)

■ 10 of 15 interviewed participants in a non-representative survey reported either taking an unknown dose or a dose that was unusually high compared to what they had taken previously (Bremler et al. 2023).

○ Microdosing: Even at microdoses, effects on attention suggest there could be individual differences in all cognitive domains (Bălăeţ 2022) Some microdose studies have reported headaches, and other forms of physiological discomfort (Bălăeţ 2022; Petranker et al 2022) However, the long term risks of microdosing are unknown and require further research (Rouaud, Calder, and Hasler 2024).

● Frequency of Use:

○ Increased Risk: More frequent LSD use is associated with an increased risk of seeking emergency medical treatment (Kopra et al 2022)

○ Tolerance: Increased experience with psychedelics is related to less intense effects, suggesting tolerance may develop (Breeksema et al 2022; Aday et al 2021).

● Methods of Administration:

○ Smoking/Vaporizing: The rapid rise in blood concentrations due to smoking or vaporizing can lead to intense effects (Coyle, Presti, and Baggott, n d )

○ Oral Administration: Oral administration is a common method, but the onset of effects is slower and more gradual (Baumeister, Tojo, and Tracy 2015) The studies included did not provide specific statistical relationships between route of administration and adverse events.

Contextual Factors (Setting and Guidance)

● Setting:

○ Clinical Settings: Well-controlled clinical settings with careful screening, preparation, support, and integration show a low incidence of adverse events (AEs) (Aday et al. 2020; 2021; Breeksema et al. 2022; Butler et al., n.d.; Gomez-Escolar et al 2024; Holze et al 2022; Kopra et al 2022; Palmer and Maynard 2022) However, a lack of findings does not necessarily indicate a lack of risk (Gomez-Escolar et al 2024)

○ Recreational/Uncontrolled Settings: These settings present a higher risk due to factors such as unknown drug purity and dosage, lack of preparation, and absence of professional support (Gomez-Escolar et al. 2024; Kopra et al. 2022; Bălăeţ 2022; Bremler et al 2023; Gezon 2024; Pilecki et al 2021; Robinson et al 2024; Sabé et al 2024)

■ 8 9% of lifetime classic psychedelic users report functional difficulties lasting longer than a day in uncontrolled settings (Robinson et al. 2024).

■ 15% of individuals self-medicating with LSD or psilocybin report negative psychological effects lasting beyond the acute effects of the drugs (Robinson et al 2024)

■ Psychedelic-induced psychosis appears to be more prevalent in recreational or uncontrolled settings involving black-market substances (Sabé et al. 2024).

○ Ceremonial Settings: Traditional ceremonial settings may emphasize environmental factors like ritual, song and music in the healing process (Aday et al 2021) However, it is not clear from the provided sources whether this has a statistically significant effect on risks Some data indicates that adverse effects can still occur in ceremonial settings and that 11.9% of ayahuasca users eventually sought professional mental health assistance for adverse effects (Robinson et al 2024)

● Guidance:

○ Therapists/Guides: The presence of trained professionals who can provide support before, during, and after the experience significantly reduces the risk of adverse events (Aday et al. 2021; Breeksema et al. 2022; Pilecki et al. 2021; Cavarra et al. 2022; Kočárová, Horáček, and Carhart-Harris 2021; Walther and van Schie 2024)

○ Trip Sitters: Having a "trip sitter" is a risk management tool and support method used in recreational settings to help manage negative experiences (Pestana, Beccaria, and Petrilli 2021)

○ Absence of Guidance: Lack of proper support and preparation increases the likelihood of negative experiences and long-term psychological issues (Breeksema et al 2022; Bălăeţ 2022; Bremler et al 2023; Pilecki et al 2021)

Longitudinal Risks

● Limited Data: There is a general lack of comprehensive longitudinal studies, which makes it difficult to determine how risk factors evolve over time. Some relevant points:

○ HPPD: There is some concern about the development of Hallucinogen Persisting Perception Disorder (HPPD) (Holze et al 2022; Bremler et al 2023; Raison et al 2022)

○ Enduring Psychosis: Some individuals who experience psychedelic-induced psychosis may later develop schizophrenia, but the statistical data are limited (Sabé et al. 2024). One meta-analysis found that 13.1% of those with psychedelic-induced psychosis later developed schizophrenia (Sabé et al. 2024).

○ Long-term negative psychological responses to psychedelics, while rare, can occur (Palmer and Maynard 2022; Bremler et al 2023; Marrocu et al 2024) A study of Norwegian psychedelic users found that 23% reported persisting adverse reactions lasting longer than a day, with a fifth of those reporting difficulties lasting longer than a year (Robinson et al. 2024).

○ One study reported that 24% of individuals who had a "bad trip" reported negative psychological symptoms lasting one week or more, with 10% reporting negative symptoms a year afterwards (Palmer and Maynard 2022)

● Microdosing: There are few scientific studies on the long-term safety of microdosing and the potential risk of valvular heart disease from chronic use of serotonergic psychedelics (Rouaud, Calder, and Hasler 2024).

Statistical Patterns of Risky Behaviors

● Limited Data: There is limited statistical evidence available from the provided sources on specific risky behaviors associated with psychedelic use, but a few relevant points:

○ Impaired Cognition: Acute cognitive impairments that manifest as impairments in key cognitive domains could mean an inability to function that could be threatening to a person's health (Bălăeţ 2022)

○ One study indicated that 13% of participants reported being harmed by psychedelic use While cigarette smoking and problematic marijuana use were the most frequently endorsed problems, a smaller number of respondents believed that their psychedelic use had contributed to suicidal ideation, aggressive/impulsive behavior and/or misuse of benzodiazepines and opiates (Raison et al 2022)

○ General Awareness: Some psychedelic users are aware of the importance of managing risks, such as being aware of set and setting and calling on trip-sitters for guidance (Pestana, Beccaria, and Petrilli 2021). However, the effectiveness of these practices is not well quantified in the provided sources.

5.3 Population-Level Adverse Events

Hallucinogen Persisting Perception Disorder (HPPD)

● Prevalence:

○ Estimates vary widely across studies, making it difficult to pinpoint an exact percentage (Ford et al. 2022; Ghaznavi et al. 2025; Gomez-Escolar et al. 2024; Müller et al. 2022; Schlag et al. 2022; Simon Melanie 2013).

○ A web-based questionnaire by Baggott et al found that 4 2% of 2,455 surveyed individuals reported persistent visual phenomena post-drug use associated with clinically significant distress, consistent with HPPD (Ford et al 2022)

○ Other non-representative estimates suggest HPPD is very rare, occurring in approximately 1 out of 50,000 hallucinogen users (Ford et al. 2022; Forstmann and Sagioglou 2021). Some studies have documented much lower prevalence rates of the disorder (Schlag et al 2022)

○ It is important to note that many cases reported in the literature are case reports following the use of LSD, psilocybin, MDMA, 5-MeO-DMT, and ibogaine (Ghaznavi et al. 2025).

○ In a recent non-representative study with a sample size of 2,455, 60.6% of the individuals reported at least one drug-free visual experience. Of those reporting

such symptoms, 4 2% found them distressing enough to consider seeking treatment (Simon Melanie 2013).

○ In a study that pooled data from six trials with 142 participants, none met the DSM-V criteria for HPPD (Müller et al 2022)

○ A study of 212 respondents found that 32% reported at least one HPPD symptom, but only 3% of those experiencing any HPPD symptom found them to be distressing (Bremler et al 2023)

● Duration and Impact:

○ HPPD symptoms can last from hours to years, with severity ranging from mild to debilitating (Müller et al 2022)

○ Symptoms can include visual disturbances such as geometric hallucinations, false perceptions of movement, flashes of color, intensified colors, trails of images of moving objects, positive afterimages, halos around objects, macropsia, and micropsia (Bremler et al. 2023).

○ To qualify for a diagnosis of HPPD, the symptoms must cause clinically significant distress or impairment in important areas of functioning, such as social and occupational environments (Bremler et al 2023)

○ HPPD can lead to feelings of isolation and critical judgment, which may be more anxiety provoking than the symptoms themselves (Bremler et al 2023)

○ Difficulties in asking for professional help due to stigma related to psychedelics have also been noted (Bremler et al. 2023).

● Overlap with Other Conditions: HPPD's overlap with drug-induced psychosis, migraine aura without headache, focal epilepsies, visual snow syndrome (VSS), and narcolepsy-cataplexy syndrome makes accurate epidemiological studies challenging (Ford et al 2022)

Extended Difficulties Following Psychedelic Use

● Prevalence:

○ 8.9% of lifetime classic psychedelic users in a non-representative study in Norway reported functional difficulties lasting longer than a day (Robinson et al 2024).

○ 15% of individuals self-medicating with LSD or psilocybin reported negative psychological effects lasting beyond the acute effects of the drugs (Robinson et al 2024)

○ 23% of psychedelic users reported adverse reactions lasting longer than a day (Robinson et al 2024)

○ In a survey of ayahuasca users, 11.9% eventually sought professional mental health assistance for adverse effects (Robinson et al. 2024).

○ A study of individuals experiencing negative psychological responses to psychedelics found that 87% reported anxiety symptoms (Bremler et al 2023)

● Demographic and Contextual Patterns:

○ Younger age may be a contributing factor (Bremler et al 2023)

○ Unsafe or complex environments during or surrounding the psychedelic experience have been linked to negative outcomes (Bremler et al. 2023).

○ Unpleasant acute experiences ("bad trips") are associated with long-term difficulties (Bremler et al 2023)

○ High or unknown drug quantities increase risk (Bremler et al 2023)

○ Lack of social support after a negative experience contributes to longer duration and severity (Bremler et al 2023)

● Duration, Severity, and Resolution:

○ Many report extended difficulties lasting over a year, and approximately 15% experience challenges for more than three years (Robinson et al 2024)

○ Reported extended difficulties can include general anxiety, social disconnection, derealization and depersonalization, perceptual distortions, and existential confusion (Robinson et al 2024)

○ Some symptoms may decrease over time and some individuals experience personal growth after challenging experiences (Bremler et al. 2023).

○ Some participants find psychotropic medications, social support, and lifestyle changes to be beneficial for recovery (Bremler et al 2023)

Functional Impairments

● Prevalence:

○ 8.9% of lifetime classic psychedelic users reported functional difficulties lasting longer than a day (Robinson et al 2024; Ghaznavi et al 2025)

○ In a recent survey, 2.6% of respondents reported seeking medical, psychiatric, or psychological assistance in the days or weeks after a distressing psychedelic experience (Ghaznavi et al. 2025).

○ One non-representative online study found that 4.2% of participants said they experienced continued hallucinations after a psychedelic trip that were troubling for them (Evans et al 2023)

● Variations:

○ Functional impairments can be influenced by factors like substance type, dosage, and setting, but specific patterns are not fully detailed in the provided sources.

○ The co-use of lithium and other mood stabilizers has been found to be associated with the degree of difficulty during respondents’ most challenging classic psychedelic experience and higher odds of overall risk of harm (Ghaznavi et al 2025)

● Recovery and Long-Term Impacts:

○ Some individuals experience a reduction in symptom severity over time, while others continue to struggle with daily tasks and impairments (Bremler et al. 2023).

○ Some individuals may develop new psychiatric diagnoses after psychedelic use, while others experience a worsening of pre-existing conditions (Bremler et al 2023)

○ For some, negative experiences can lead to the use of alcohol (Bremler et al 2023).

○ Some individuals report personal growth after, and as a consequence of, challenging experiences (Bremler et al 2023)

Additional Points

● "Bottom Margin" Analysis: Some research focuses on a "bottom margin" analysis, highlighting the most severe cases of adverse effects, rather than relying on group averages (Marrocu et al. 2024).

● Underreporting: There is evidence of underreporting of adverse events in some studies

● Stigma: Stigma around psychedelic use may make it less likely that individuals experiencing negative effects will seek help or participate in studies, making prevalence data less complete (Bremler et al. 2023).

Challenging Experiences

(e.g., "Bad Trips")

● Prevalence:

○ Unpleasant acute psychological experiences are not rare, even in research settings (Bremler et al. 2023). One study reported that approximately 40% of healthy volunteers experienced moderate to severe anxiety, panic, or distress with high-dose psilocybin (Bremler et al. 2023).

○ Most participants in one study reported having frightening experiences when using psychedelics, and many described these as "bad trips" (Gashi, Sandberg, and Pedersen 2021)

○ In a study of psychedelic users’ most difficult experiences, 39% rated these experiences as among the top five most difficult of their lives (Robinson et al. 2024).

○ A survey found that 23% of psychedelic users reported adverse reactions lasting longer than a day (Robinson et al 2024)

○ The key feature of a "bad trip" is often a feeling of losing oneself, going crazy, or experiencing ego dissolution (Gashi, Sandberg, and Pedersen 2021)

○ A study of 32 individuals who had negative reactions to psychedelics had an average score of 62.1 on the Challenging Experience Questionnaire, which is higher than previously reported average scores (Bremler et al 2023)

● Severity and Context:

○ Experiences can range from fear, anxiety, depression, and paranoia (Palmer and Maynard 2022)

○ These experiences can be profoundly impactful, with some individuals reporting that such experiences were more difficult than most other life challenges (Robinson et al 2024)

○ Challenging experiences may be related to negative sets and settings (Bremler et al 2023; Butler et al , n d ; Holze et al 2022; Kopra et al 2022; Ona 2018)

○ The intensity of drug effects and difficulties appear to be lower and less severe in those with past experience with these drugs (Breeksema et al. 2022).

● Factors Increasing Likelihood:

○ Negative mindset and expectations about the drug can increase the likelihood of a bad trip (Kopra et al 2022)

○ Unsafe or complex environments during the experience can contribute to negative outcomes (Bremler et al 2023)

○ Higher doses of psychedelics increase the risk of adverse events (Bremler et al. 2023).

○ Prior psychological vulnerabilities or mental health conditions can increase the risk of negative experiences (Bremler et al 2023; Marrocu et al 2024)

○ Co-use of other substances or abruptly discontinuing medications can also increase risks (Bremler et al 2023; Ghaznavi et al 2025)

○ Young age is a possible contributing factor (Bremler et al. 2023).

○ Unknown drug quantities or purity is a risk factor (Bremler et al. 2023).

● Additional Insights:

○ Some individuals transform challenging experiences into valuable ones through storytelling (Gashi, Sandberg, and Pedersen 2021)

○ Despite their difficulties, many people report a positive correlation between the degree of difficulty and personal meaningfulness (Palmer and Maynard 2022).

○ Some evidence suggests that challenging experiences do not necessarily foreshadow a worsening of mental health outcomes, and may actually predict improvements (Bremler et al 2023)

Behavioral Adverse Events

● Prevalence and Types:

○ Data on specific behavioral adverse events like self-harm or suicide attempts directly linked to psychedelic use are limited in the provided sources

○ Some individuals believe their psychedelic use contributed to suicidal ideation, aggressive/impulsive behavior, and/or misuse of other substances (Raison et al 2022).

○ In a Phase IIb trial of psilocybin, approximately 5% of patients experienced serious adverse events, including suicidality (Palitsky et al., n.d.).

○ There are case reports of individuals experiencing manic episodes after psilocybin use (Morton et al 2023)

● Contributing Factors:

○ The intensity of the psychedelic experience is not always predictive of long-term outcome (Bremler et al. 2023).

○ A lack of integration following a challenging experience may result in emotional distress (Robinson et al 2024)

● Prevention and Resolution:

○ Careful screening for prodromal hypomanic symptoms before psilocybin administration and monitoring for adherence to prescription medication is important (Morton et al. 2023).

○ The use of social support and lifestyle changes is beneficial for some (Robinson et al 2024)

○ Therapeutic support is vital in guiding individuals through challenging moments to ensure transient distress leads to meaningful insights and lasting benefits rather than further destabilization (Walther and van Schie 2024).

Additional Data on Adverse Events at the Population Level

● General Trends:

○ Approximately 9-13% of non-clinical trial psychedelic users have experienced negative outcomes involving some degree of functional impairment in the days or weeks following dosing (Palitsky et al., n.d.)..

○ About 2.6% of psychedelic users required medical, psychiatric, or psychological assistance in the time since using the psychedelic (Palitsky et al , n d )

● Risk Factors:

○ Prior history of psychiatric disorders increases the risk of negative outcomes (Bremler et al. 2023; Marrocu et al. 2024).

○ Younger age may also be a risk factor (Bremler et al. 2023).

● Differences Across Psychedelics:

○ There are differences in adverse event rates across substances, but more specific data is needed (Morton et al 2023; Blond and Schindler 2023; Malcolm and Thomas 2022)

○ Seizures are reported in 0.78% of psilocybin, 4% of LSD, and 2.2% of ayahuasca cases (Blond and Schindler 2023).

○ Preliminary reports suggest a high rate of seizures (40%) with the N-methoxybenzyl class of synthetic psychedelics (Blond and Schindler 2023)

○ Rates of severe toxicities may be much higher with newer novel psychoactive substances (NPS) such as NBOMe compounds, with seizures reported in 40% (Malcolm and Thomas 2022).

● Additional Points:

○ There is evidence of underreporting of adverse events in some studies (Robinson et al 2024; Breeksema et al 2022)

○ The "set and setting" have a significant impact on the nature of the psychedelic experience (Bremler et al 2023; Holze et al 2022; Kopra et al 2022; Ona 2018)

○ A lack of psychedelic drug education and regulation contribute to adverse events (Bremler et al. 2023).

6. Interventions & Harm Reduction Strategies

Public health initiatives play a critical role in mitigating potential risks associated with psychedelic use. This section reviews existing harm reduction approaches, agency guidelines, and areas for future policy development.

6.1 Psychedelic Users' Knowledge of Harm Reduction Practices

● General Awareness: Many psychedelic users demonstrate a high level of information seeking, often going outside mainstream healthcare for information (Kruger et al 2023) The most common source of information is their own experimentation, but many also use internet websites, discussion forums, friends, books, and peer-reviewed articles (Kruger et al. 2023).

● Knowledge Gaps: There's a demonstrated need for better education and outreach, especially in under-represented communities (Kruger et al 2023)

○ Many users are unaware of the dosages they consume Up to 67% of microdosers in a non-representative online questionnaire reported not knowing the dosage they consume (Hutten et al. 2019).

● Impact of Experience: Those with more experience using a variety of psychedelics, with higher levels of education, lower age, greater frequency of use, identifying as male, and with greater annual household income answer more knowledge questions correctly (Kruger et al 2023)

● Specific Practices: Experienced users report a greater use of harm reduction practices than first-time users (Palmer and Maynard 2022). These practices include being in a comfortable setting, setting a purpose, getting the drug from a reputable source, measuring the dose, and planning the timing of the experience (Palmer and Maynard 2022)

● Differences Across Settings:

○ Users in party settings demonstrate lower use of harm reduction practices (Palmer and Maynard 2022).

○ First-time users are more likely to use psychedelics in party settings, while experienced users tend to use them at home or a friend's home (Palmer and Maynard 2022)

6.2 Use of Medical, Psychiatric, or Psychological Assistance

● General Rates:

○ Approximately 9-13% of non-clinical trial psychedelic users have experienced negative outcomes involving functional impairment in the days or weeks following dosing (Palitsky et al , n d ; Robinson et al 2024)

○ Around 2 6% of psychedelic users require medical, psychiatric, or psychological assistance after using (Palitsky et al , n d )

● Specific Populations:

○ 11.9% of ayahuasca users sought professional mental health assistance for adverse effects (Robinson et al. 2024).

● A study of those self-medicating with LSD or psilocybin reported that 15% had negative psychological effects lasting beyond the acute effects of the drugs (Robinson et al. 2024).

● In a study of psychedelic users' most difficult experiences, 7 6% sought treatment for persistent psychological symptoms (Robinson et al 2024)

● Trends in Support: The sources do not provide detailed data about trends in the types of support needed based on the severity or type of adverse event

Interventions for Psychedelic Adverse Events

● Common Interventions:

○ In cases of acute psychological distress during a psychedelic experience, reassurance is typically sufficient, according to research (Johnson, Richards, and Griffiths 2008).

○ For cases not resolved by reassurance, a benzodiazepine anxiolytic like diazepam is recommended (Johnson, Richards, and Griffiths 2008).

○ Antipsychotic medications should be available, but their use may be problematic and could result in further psychological problems (Johnson, Richards, and Griffiths 2008)

○ Emergency departments should be a "last resort", as personnel inexperienced with hallucinogens can escalate a negative reaction (Johnson, Richards, and Griffiths 2008).

● Efficacy of Interventions:

○ Reassurance has been shown to be effective in the vast majority of cases of acute psychological distress in clinical settings (Johnson, Richards, and Griffiths 2008).

● Benzodiazepines are effective in managing distress, but intravenous routes may exacerbate anxiety (Johnson, Richards, and Griffiths 2008).

● Differential Efficacy: The sources do not provide statistically significant data on whether certain emergency interventions are more effective for specific populations or types of adverse events

Use of Emergency Services

● Prevalence:

○ In 2020, 1 0% of people who consumed LSD, 1 0% who consumed MDMA, 0 6% who consumed ketamine, and 0 6% who consumed psilocybin sought emergency medical care, according to a non-representative online survey of individuals who contacted the Fireside Project's psychedelic helpline (Pleet et al. 2023).

● Analysis of this survey found that 12.5% of callers indicated they might have called 911 and 10 8% said they might have gone to the emergency room, had they not spoken with the helpline (Pleet et al 2023)

● Among those in this survey who have had a challenging experience on psychedelics, 2.7% report seeking help in a hospital or emergency room (Pleet et al. 2023).

● Trends in Use: The sources do not provide detailed data about trends in the use of emergency services based on demographic or contextual trends such as geographic location, age, or setting, however, they do show that younger individuals and those with a prior history of mental health issues are at greater risk of requiring emergency care (Kopra et al 2022)

○ One study noted that 54.5% of those seeking EMT were admitted to the hospital (Kopra et al. 2022).

Use of Peer Support Services

● Prevalence: While specific percentages on the use of peer support services are not available, the sources indicate that peer support is a significant resource for those experiencing difficulties with psychedelics.

○ A study of coping strategies after difficult psychedelic experiences found that seeking support from friends, family, or peer groups was the most frequently used coping technique (Robinson et al 2024)

○ Many individuals value connecting with others who have had similar experiences through integration groups (Robinson et al. 2024).

● Types of Peer Support: Peer support includes various forms:

○ Trip sitters: These are individuals who provide support during a psychedelic experience (Engel et al 2024) According to a non-representative online survey, respondents stated they believed the necessity of trip sitters varies based on the substance, dosage, and route of administration (Engel et al 2024)

○ Harm reduction groups: These groups provide education and support to psychedelic users (Pleet et al. 2023).

○ Community organizations: These may offer a range of services including integration circles and peer support (Robinson et al 2024)

● Sources of Information:

○ Friends are a popular source of harm reduction information, especially for those using MDMA (Edwards et al. 2023). Females are more likely to seek information from friends than males (Edwards et al. 2023).

○ Internet forums are also used to connect with peers and share information about harm reduction and psychedelic experiences (Engel et al 2024; Kruger et al 2023)

Effectiveness of Peer Support

● Mitigating Harm: Peer support can be effective in de-escalating psychological distress (Pleet et al 2023)

○ A peer-support helpline found that 65 9% of callers reported de-escalation of psychological distress due to their conversations (Pleet et al 2023)

○ 29 3% of helpline callers in a non-representative study indicated they may have been harmed without the support of the helpline (Pleet et al. 2023).

● Addressing Challenges: Peer support is effective for those navigating extended difficulties after psychedelic use (Robinson et al 2024)

○ Qualitative research highlights the importance of non-judgmentalism, acceptance, patience, and compassion from support networks (Robinson et al 2024)

○ Peer support is valuable for facilitating the acquisition of information and self-awareness (Robinson et al. 2024).

● Limitations: The effectiveness of specific peer support strategies is not quantified in the provided sources (Robinson et al 2024)

6.3 Population-Level Efficacy of Interventions

● Medical Care vs Peer Support:

○ Medical care is often a last resort when other interventions fail (Johnson, Richards, and Griffiths 2008). Emergency services are used in 1.0% of LSD and MDMA uses, and 0 6% of psilocybin and ketamine uses according to a non-representative survey (Pleet et al 2023; Kopra et al 2022)

○ Peer support services can avert harmful outcomes and reduce the burden on emergency and medical services (Pleet et al 2023)

● Differential Effectiveness:

○ Reassurance is sufficient for most cases of acute psychological distress during clinical trials (Johnson, Richards, and Griffiths 2008)

○ Benzodiazepines may be useful when reassurance is insufficient (Johnson, Richards, and Griffiths 2008)

● The sources suggest that early intervention with peer support can prevent escalation to emergency care (Pleet et al. 2023).

● Specific Events, Substances, Populations: The sources do not offer specific statistical data to determine whether some interventions work better for specific types of events, substances, or populations However, they do highlight:

○ Younger individuals and those with a prior history of mental health issues are at greater risk of requiring emergency care (Kopra et al 2022; Bremler et al 2023)

○ Those using MDMA may benefit more from peer-based harm reduction information (Edwards et al. 2023).

○ A personality disorder may represent an elevated risk for negative responses to psychedelics, indicating a need for increased psychological support (Marrocu et al 2024)

Comparative Effectiveness of Interventions

● Clinical Care vs. Peer-Based Approaches:

○ Clinical care settings often prioritize the use of medications, including benzodiazepines, for managing adverse reactions, with hospitalization as a last resort (Johnson, Richards, and Griffiths 2008).

● Peer support may provide more comprehensive and accessible support and may be useful in preventing escalation to clinical settings (Pleet et al 2023)

● Long-term Harm and Recovery:

○ There is no conclusive data demonstrating one approach as statistically superior in preventing long-term harm. However, both clinical care and peer-based approaches have contributed to positive long-term outcomes (Robinson et al. 2024; Bremler et al 2023)

● Integration is an important aspect of long-term recovery following challenging psychedelic experiences, and may be provided by peers or professionals (Robinson et al 2024; Pilecki et al 2021)

● Setting-Based Differences:

○ Clinical settings have a higher standard of screening, preparation, and support during psychedelic use, and have lower rates of adverse events (Pilecki et al 2021)

○ Recreational settings often lack the structure and support necessary to avoid negative outcomes, increasing the risk of harm (Pilecki et al 2021)

○ Ceremonial settings can vary greatly in safety depending on the group, leadership and practices employed (Gezon 2024).

6.4 Influence of Demographic Factors on Interventions and Harm Reduction

● Age:

○ Younger individuals are more likely to use emergency services after psychedelic use according to a non-representative study (Kopra et al 2022) They are also more likely to trust online forums, researchers based in industry, psychedelic therapists in clinics, and psychedelic start-up companies as sources of information (Kruger et al 2023)

○ Older individuals are more likely to trust articles in the popular media and government agencies (Kruger et al 2023)

● Gender:

○ Females are more likely to seek harm reduction information from friends (Edwards et al. 2023).

○ There are no other specific findings related to gender and intervention effectiveness

● Socioeconomic Status: Individuals in a non-representative study with greater annual household income are more likely to correctly answer questions about psychedelic knowledge (Kruger et al. 2023). However, there is no data on how socioeconomic status directly influences intervention success.

● Other Factors:

○ Individuals with a history of mental health issues, particularly personality disorders, are more vulnerable to adverse outcomes according to a non-representative study (Marrocu et al. 2024).

○ Those with higher levels of education have greater psychedelic knowledge (Kruger et al 2023)

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Section 3 PE Tables Results from the 2023 National Survey on Drug Use and Health: Detailed Tables, SAMHSA, CBHSQ. (n.d.). Retrieved January 27, 2025, from https://www.samhsa.gov/data/sites/default/files/reports/rpt47100/NSDUHDetailedTabs2023/NSD UHDetailedTabs2023/2023-nsduh-detailed-tables-sect3pe htm

Section 4 PE Tables Results from the 2023 National Survey on Drug Use and Health: Detailed Tables, SAMHSA, CBHSQ. (n.d.-a). Retrieved January 27, 2025, from https://wwwsamhsa gov/data/sites/default/files/reports/rpt47100/NSDUHDetailedTabs2023/NSD UHDetailedTabs2023/2023-nsduh-detailed-tables-sect4pe htm

Section 4 PE Tables Results from the 2023 National Survey on Drug Use and Health: Detailed Tables, SAMHSA, CBHSQ (n d -b) Retrieved January 27, 2025, from https://wwwsamhsa gov/data/sites/default/files/reports/rpt47100/NSDUHDetailedTabs2023/NSD UHDetailedTabs2023/2023-nsduh-detailed-tables-sect4pe.htm

Section 5 PE Tables Results from the 2023 National Survey on Drug Use and Health: Detailed Tables, SAMHSA, CBHSQ (n d ) Retrieved January 27, 2025, from https://www.samhsa.gov/data/sites/default/files/reports/rpt47100/NSDUHDetailedTabs2023/NSD UHDetailedTabs2023/2023-nsduh-detailed-tables-sect5pe.htm

Section 7 PE Tables Results from the 2023 National Survey on Drug Use and Health: Detailed Tables, SAMHSA, CBHSQ. (n.d.). Retrieved January 27, 2025, from https://wwwsamhsa gov/data/sites/default/files/reports/rpt47100/NSDUHDetailedTabs2023/NSD UHDetailedTabs2023/2023-nsduh-detailed-tables-sect7pe htm

Section 8 PE Tables Results from the 2023 National Survey on Drug Use and Health: Detailed Tables, SAMHSA, CBHSQ (n d ) Retrieved January 27, 2025, from https://wwwsamhsa gov/data/sites/default/files/reports/rpt47100/NSDUHDetailedTabs2023/NSD UHDetailedTabs2023/2023-nsduh-detailed-tables-sect8pe htm

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