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‘He who dies before he dies does not die when he dies.’ – Siddhartha Gautama

Psychedelic drugs are agents that mayassist a person in approaching existentialissues. They enjoy a rich history in

ancient, non-Western cultures and, morerecently, in psychiatric research of the 1960s.After a 40-year hiatus, international trials arenow underway to revisit the role of psychedelicdrugs in assisting patients with terminal cancerto explore – and resolve – anxiety-inducingexistential issues surrounding their illness.

What are psychedelic drugs?Classical psychedelic (hallucinogenic) drugsinclude the agents D-lysergic acid diethylamide(LSD) and psilocybin (the active component in

‘magic mushrooms’). Another class of drugs,the entactogens, includes the agent MDMA(ecstasy). Contemporary researchers are askingwhether the unique psychotropic qualities ofthese drugs can be useful as adjuncts topsychotherapy in reducing the burden ofanxiety and pain for palliative care patients.

The classical hallucinogens are non-addictive, physiologically non-toxicsubstances, which may offer the user anexperience of self-reflection through exposureto personal existential issues. They facilitate adeeper access to repressed parts of the psycheand were studied extensively in the 1950s and1960s.1 They were subsequently shelved forsocio-political reasons, in the wake of the1960s drug culture that grew out of theirmainstream use.2

MDMA (3,4-methylenedioxymethampheta-mine), better known as the street drug ecstasy,has been well known for the past 20 years,through its association with the rave dancescene. Like LSD, MDMA began its life inmedicine, when used in the early 1980s as adrug to enhance the psychotherapeuticprocess. MDMA promotes relaxation, loosensthe ego and encourages increasedcontemplativeness.3 These effects can producea state of improved insight and aid a greaterexploration of otherwise painful memories, by‘inhibiting the subjective fear response to anemotional threat’.4 This makes MDMA aparticularly useful drug for patientsexperiencing anxiety associated with theprocess of dying.5

Contemporary research consistentlydemonstrates that the classical psychedelicdrugs (LSD and psilocybin) present with nodemonstrable physiological concerns and norisk of dependency.6,7 Although debate still goeson about the relative risks of using frequent

Can psychedelic drugs play a role in palliative care?Ben Sessa believes it is a good thing that, after a 40-year hiatus, international trials

are revisiting the role of psychedelic drugs in assisting patients with terminal cancer to

explore – and resolve – anxiety-inducing existential issues surrounding their illness

l Contemporary researchers are asking whether the uniquepsychotropic qualities of psychedelic drugs can be useful asadjuncts to psychotherapy in reducing the burden of anxietyand pain for palliative care patients.

l The classical hallucinogens D-lysergic acid diethylamide (LSD)and psilocybin (the active component in ‘magic mushrooms’)may offer the user an experience of self-reflection throughexposure to personal existential issues.

l MDMA (3,4-methylenedioxymethampheta-mine), betterknown as ecstasy, is a particularly useful drug for patientsexperiencing anxiety associated with the process of dying.

l Currently, four scientific studies into psychedelic agents areunderway, in the USA and in Switzerland.

l Today’s medical psychedelic community looks beyond thesensationalist stories of the past to a more balanced,objective and evidence-based approach to psychedelic drugs.

Key points

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psychedelic drugs may provide a symbolicexperience of what it is to die, thus ‘giving onea realisation of life’s impermanence, andproviding an insight into the transcendentnature of consciousness’.13 In this context, theshaman can be seen as a ‘psychopomp’, anagent assisting the process of dying. A recentstudy at Harvard University explored thespiritual phenomenon frequently reported byusers of psychedelic drugs.14 In a double-blindstudy, participants were given psilocybin or aplacebo and rated their experience of spiritualfeelings, giving a fascinating objectivity to thewell-established existential experiencesdescribed by users of psychedelic drugs.

The issue of spirituality often sitsuncomfortably with many doctors (myselfincluded), as it does not fit readily into themedical model. Nevertheless, the broaderconcept of existential issues, especially whenfaced with imminent death, may be morereadily embraced by scientists within a lessspiritual and wider psychological context. Thepsychedelic drugs can be recognised, therefore,as organic agents, well placed to address thisfundamental psychological need.

The psychedelic researcher Stanislav Grof hasexplored the possibility of improving theWestern approach to death and dying bydescribing how psychedelics can play a role inassisting individuals to better understand these

doses of the recreational ecstasy, there areconsistently no such concerns with theproposed use of MDMA-assisted psychotherapy,as proposed in the studies described here.8

For the past 40 years, there has been a relativeabsence of research into psychedeliccompounds. However, they are currentlyenjoying a renaissance in medical research.

Death as an existential processIt is well recognised that the issue of deathtends to be repressed [OK?] in the Westernculture. We frequently over-medicalise death atthe expense of acknowledging its emotionalaspects, tending to focus more on delaying itrather than on improving the quality of theremaining days of life.9 The risk, for theindividual, of developing a diagnosis-associatedadjustment disorder is significant.10 Using astructured, problem-focused approach, adjuvantpsychological therapy partially addresseselements of depression and anxiety associatedwith adjustment disorder.11 However, to whatextent does this address an individual’s fearsabout the existential issue of death?

In contrast to the Western model, manyindigenous cultures embrace or even celebratedeath as an important existential transition.Some cultures employ psychedelic plants assacraments in a psychotherapeutic context.Examples include the Native Americans’use of the peyote cactus (which containsmescaline), the Mexicans’ use of magicmushrooms, the Amazonians’ use ofthe ayahuasca plant (which containsdimethyltryptamine, or DMT), theWest Africans’ use of the root iboga(which contains ibogaine) and the useof cannabis for religious purposes inIndia, the West Indies and East Africa.These psychedelic-assisted ceremoniesare lead by a shaman – a respectedtribal leader with the combinedstatus of a healer, doctor and priest.Their use is very different from theWestern version of recreationaldrug abuse. Instead, they offer apowerful group experience, which hasa profoundly cohesive and positive effecton the individual and their community.12

Psychedelics and the existential issue A common experience with psychedelic drugsin the non-Western context is that of symbolicdeath or rebirth. The indigenous use of

‘Magicmushrooms’,which contain theactive ingredientpsilocybin

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existential aspects. This has much in commonwith the modern concept of having a deathplan, just as pregnant women often have a birthplan. [I think you need to add a sentence heresaying something about the concept ofMidwives for the Dying].15

The role of psychedelic drugs in palliative careFor 20 years, following the discovery of thepsychedelic properties of LSD in the 1940s byDr Albert Hofmann,16 the newly developed drugwas studied as an adjunct to psychotherapy formany psychiatric conditions on more than40,000 patients [add ref?]. The drug showedparticular promise in treating anxiety disordersand was frequently noted to reduce anindividual’s fear of death.

This latter property was further studied bythe anaesthetist Eric Kast, who was interestedin whether LSD’s ability to distort body imagecould reduce the perception of pain. Hecompared the analgesic effects of LSD withtwo other commonly used opiate analgesicsand found it superior to both in relievingpain.17 In further studies, he went on toexplore LSD’s ability to induce a spiritual-typeexperience that allowed terminally ill patientsto better identify with the emotional aspects of dying, to improve their sleep and reducetheir anxiety for many weeks after the initial treatment.18,19

Contemporary researchContemporary psychedelic research draws onsome of the principles of Kast’s work. Thesestudies have many similarities in their design. l Participants have a diagnosis of cancer

and have developed a secondary anxietydisorder that has been previouslyunsuccessfully treated with traditionalmethods – such as anxiolytic medication ortraditional psychotherapy.

l The studies employ a combination of non-drug and drug-assisted psychotherapysessions. Initially, there are several non-drugsessions, so that the patient and therapist canbuild up a rapport, and during whichbaseline psychiatric assessment scales arecompleted. Then, two drug/placebo sessionsare conducted – spaced several weeks apart –and followed up by further supportive, non-drug sessions.

l During the drug sessions, the patient isinitially encouraged to lie down, wearing an

eye mask. The psychotherapy is largely non-directed, with the therapist encouraging thepatient to free associations. Music isfrequently employed to assist the process.

l Despite the very low risks involved,physiological data is measured throughoutthe experimental sessions, which take placewithin a general hospital environment whereemergency facilities are available.

l Attention is paid to fostering a favourable ‘setand setting’. That is, participants areadequately informed about the nature of thepsychedelic experience and the environmentfor the sessions is relaxed and comforting.

l Psychological data is collected to measuredepression, pain and anxiety at baseline,during sessions and at several months’follow-up. Most of the studies also include acomponent measuring quality-of-life factors.

Studies now taking placeCurrently, four studies into psychedelic agentsare underway, as described below.

Study into psilocybinThis is taking place at the University ofCalifornia in Los Angeles, USA. The principalinvestigator is Charles Grob [who is he?]. In

The peyote cactus, which contains mescaline, istraditionally used by Native Americans in apsychotherapeutic context

LSD wasfrequentlynoted toreduce anindividual’sfear of death

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this trial, patients with end-stage cancer and secondary anxiety disorder are treatedwith placebo-controlled, psilocybin-assistedpsychotherapy in a double-blind study. The hypotheses are that the psilocybin group, compared to the controls, willexperience a greater reduction in pain, anxiety and depression that will persist beyond the duration of the study and lead to a reduced need for pro re nata anxiolytic andanalgesic medication. A brief video of aninterview with Pamela Sakuda, one of theparticipants, in which she discusses herexperience of psychedelic psychotherapy, can be seen online.20

Study into MDMAA study into MDMA is taking place at theMcLean Hospital, Harvard Medical School, USA. The principal investigator is John Halpern[who is he?]. This study is similar to the abovebut is using MDMA as the adjunct topsychotherapy for patients with anxietysecondary to end-stage cancer.

Study into LSDThis is taking place in Switzerland [do you havemore detail about location of study?] and theprincipal investigator is Peter Gasser [who ishe?]. The design of this study is identical to theMDMA study above but is using LSD as thepsychedelic agent.

Study into psilocybinThis proposed study will take place at the JohnsHopkins University, Baltimore, USA. Theprincipal investigator will be Roland Griffiths[who is he?]. This study, which plans to usepsilocybin-assisted psychotherapy, will differfrom the previous three in that participants willnot have to be suffering from end-stage cancer;it may also include patients with early, non-terminal cancer.

Details of all these studies can be found onthe websites of the MultidisciplinaryAssociation for Psychedelic Studies (MAPS)21

and of the Heffter Research Institute.22

Learning from ancient historyMany of these studies have been decades in theplanning. The ethical considerations restrictingthis kind of research are vast. The past history ofabuse and damage to individuals and societyfrom the misuse of recreational drugs areundeniable. Nevertheless, a lot of water has

passed under the bridge since the ‘turn on, tunein and drop out’ days of the 1960s. Today’smedical psychedelic community looks beyondthe sensationalist stories of the past to a morebalanced, objective and evidence-basedapproach to psychedelic drugs.

It appears that there is a lot the medicalprofession can learn from the ancient history ofnon-Western cultures about improving themanner in which we approach death, andpsychedelic drugs may have an important roleto play in this lesson. If there is a possibility thatthese fascinating chemicals could safely andeffectively relieve the suffering of those withterminal illness, then we owe it to these patientsto carry out this research.

AcknowledgementsThank you to Dr Charles Grob for his encouragement and Mr NorbertLitzinger for permission to include the link to his wife’s interview.

References1. Grinspoon L, Bakalar JB. Can drugs be used to enhance thepsychotherapeutic process? Am J Psychother 1986; 40: 393–404.2. Sessa B. Can psychedelics have a role in psychiatry once again? Br JPsychiatry 2005; 186: 457–458.3. Vollenweider FX, Gamma A, Liechti M, Huber T. Psychological andcardiovascular effects and short-term sequelae of MDMA (‘ecstasy’) inMDMA-naïve healthy volunteers. Neuropsychopharmacology 1998; 19:241–251.4. Greer GR, Tolbert R. Subjective reports of the effects of MDMA in aclinical setting. J Psychoactive Drugs 1986; 18: 319–327.5. Greer GR, Tolbert R. The therapeutic use of MDMA. In: Peroutka SJ(ed). Ecstasy: the clinical, pharmacological and neurotoxicological effects ofthe drug MDMA. Holland: Kluwer Academic, 1990.6. Hasler F, Grimberg U, Benz MA, Huber T, Vollenweider FX. Acutepsychological and physiological effects of psilocybin in healthyhumans: a double-blind, placebo-controlled dose-effect study.Psychopharmacology (Berl) 2004; 172: 145–156.7. Fantegrossi WE, Woods JH, Winger G. Transient reinforcing effectsof phenylisopropylamine and indolealkylamine hallucinogens inrhesus monkeys. Behav Pharmacol 2004; 15: 149–157.8. Sessa B. Is there a case for MDMA-assisted psychotherapy in the UK? J Psychopharmacol 2007; 21: 220–224.9. Grof S, Halifax J. The human encounter with death. New York: EPDutton, 1977.10. Sellick SM, Crooks DL. Depression and cancer: an appraisal of theliterature for prevalence, detection, and practice guidelinedevelopment for psychological interventions. Psychooncology 1999; 8:315–333.11. Moorey S, Greer S, Watson M et al. Adjuvant psychological therapyfor patients with cancer: outcome at one year. Psychooncology 1994; 3:39–46. [I can’t find this on Pub Med - please check]12. Sessa B. From sacred plants to psychotherapy: the history and re-emergence of psychedelics in medicine. Meeting of the Royal Collegeof Psychiatry’s Spirituality in Psychiatry Special Interest Group, 2006 . http://www.rcpsych.ac.uk/pdf/Ben%20Sessa%20%20From%20Sacred%20Plants%20to%20Psychotherapy%201.5.06.pdf (last accessed30/06/2008)13. Grof S. Beyond death: the gates of consciousness. London: Thames andHudson, 1980.14. Griffiths RR, Richards WA, McCann U, Jesse R. Psilocybin canoccasion mystical-type experiences having substantial and sustainedpersonal meaning and spiritual significance. Psychopharmacology (Berl)2006; 187: 268–283.15. For information on Midwives for the Dying, visithttp://www.soulmidwives.co.uk/index.html (last accessed 30/06/2008)16. Hofmann A. LSD: my problem child. New York: McGraw-Hill, 1980.17. Kast EC, Collins VJ. Study of lysergic acid diethylamide as ananalgesic agent. Anesth Analg 1964; 43: 285–291. 18. Kast E. LSD and the dying patient. Chic Med Sch Q 1966; 26: 80–87. 19. Kast E. Attenuation of anticipation: a therapeutic use of lysergicacid diethylamide. Psychiatr Q 1967; 41: 646–657. 20. http://blip.tv/file/510857 (last accessed 15/07/2008)21. http://www.maps.org (last accessed 30/06/2008)22. http://www.heffter.org (last accessed 30/06/2008)

Ben Sessa, Consultant Psychiatrist, Bristol UniversityDepartment of Psychopharmacology, Bristol, UK

There is a lotthe medicalprofession canlearn from theancient historyof non-Westerncultures aboutimproving themanner inwhich weapproach death