Given the emergence of psychedelic policy reform experiments like those in Oregon and Colorado, the proliferation of studies and academic centers devoted to psychedelics, and the media hype about these compounds, it is no surprise that psychedelic use is on the rise in the United States. Unfortunately, the sophistication of our public discourse hasn’t developed nearly as quickly. For a casual observer, it would be easy to miss that “psychedelics” is not one field or industry, but several—with medical, religious, and wellness use each occupying a distinct lane (not to mention the thriving underground scene). The “big tent” of psychedelia has done little to dispel this confusion. Case in point: at the recent Psychedelic Science conference in Denver, medical researchers proudly reported out their p-values on one stage while another simultaneously hosted a deep discussion of “wisdom from the psychedelic underground.”

In the U.S., government now regulates medical, religious, and wellness (Oregon-model) use of psychedelics. Each of these access pathways can be useful, depending on one’s goals and medical history, but they also all have limitations.

The medical access pathway, often called the “medical model,” aims to treat a specific diagnosis by pairing an FDA-regulated psychedelic drug with intensive psychotherapy before, during, and after the patient takes the drug. This model is commonly known as psychedelic-assisted therapy. As research on the clinical uses of psychedelics expands, particularly into non-psychiatric indications, new treatment models that require less psychological support may also emerge. Currently, medical access in the U.S. is only available through clinical trials or the FDA’s woefully limited expanded access program, but the agency is likely to approve both MDMA- and psilocybin-assisted therapy (or perhaps, “psilocybin treatment”) in the coming years. Since laws in all 50 states prohibit the unlicensed practice of medicine and psychotherapy, medical access is the only legal pathway for practitioners who wish to offer treatments for health conditions such as depression or PTSD. Medical access to psychedelics is also by definition limited to patient populations, so “healthy normals” need not apply.

Religious access to psychedelics means the sacramental use of psychedelic substances such as peyote or ayahuasca in the context of sincere religious exercise. Most psychedelics are banned under the Controlled Substances Act of 1970 (CSA), but a patchwork of laws, regulations, and court cases has created narrow lanes for religious groups to obtain exemptions for the sacramental use of psychedelics. So far, only a handful of small religious communities have explicit exemptions from the CSA, and two of these were granted only after suing the DEA. Numerous other sects nonetheless use psychedelics ritually, though they operate outside of government regulation.

Finally, wellness access is a system that allows the public to consume psychedelic drugs under the supervision of a licensed facilitator at a designated location where the administration of the drug and subsequent psychedelic experience or “journey” take place. Wellness access was created through state ballot initiatives in Oregon (2020) and Colorado (2022), setting up a contradiction between state and federal laws. To be clear, wellness psychedelic activity is illegal because federal law has supremacy over state laws, though some observers expect that the feds will deprioritize enforcement in these jurisdictions. Wellness access could make psychedelics widely available to the general public. However, under Oregon’s regulations practitioners can’t offer treatment for any health condition—including mental health and substance use disorders. The final psilocybin services rules issued by the Oregon Health Authority are clear that making health claims or attempting to provide treatment is out of bounds. As wellness access becomes a market reality and researchers begin to collect relevant data, it is possible that this mode of psychedelic use could become a viable alternative or complimentary health practice in the same vein as supplements, massage, and meditation.

Medical, wellness, and religious access are three very distinct regulatory pathways for accessing psychedelics, and BrainFutures believes these differences matter. When psychedelics advocates or media reports blur the boundaries between access pathways, they unnecessarily heighten the risks to participants (users) in terms of both safety and legal exposure.

Unfortunately, the public discourse about psychedelics often paints with a broad brush and conflates one pathway with another.  For instance, advocates for the wellness model in Oregon routinely cite outcomes from clinical trials to justify the program without acknowledging that patients can’t legally be treated for any indication in this context. Many psychedelic churches are also cropping up and offering healing for those suffering from serious mental health concerns. This practice may or may not be protected by the law, but it raises safety questions since the risk of side effects could be heightened in these patient populations. Unlike research clinics, churches might not have quick access to healthcare professionals and medical supplies to assist a congregant in distress. Although psychedelics are usually considered safe—especially compared to more commonly used drugs like alcohol—experts agree they can carry serious physiological and psychological risks. This is one reason why modern human research with psychedelic drugs requires extensive screening and safety measures.

There is space for medical, religious, and wellness access in a thriving psychedelic ecosystem, but as we all know, setting matters. Participants should seek to align their goals with the right access pathway to maintain safety and ensure their specific needs are met. Seeking spiritual transformation? Religious access is probably your best bet. Interested in exploring new dimensions of consciousness? Wellness access might be a good fit, especially if federal laws change to make such access legal. Finally, patients who need treatment for a diagnosed condition should seek medical access. Recognizing that the drug development and approval process is achingly slow, we urge FDA to create additional expanded access slots that can meet patients’ needs in the short run.

Participants should do their research and consult with their healthcare provider (and perhaps a lawyer) before accessing psychedelics in any setting. But journalists and advocates also have a responsibility to make clear distinctions between psychedelic access pathways. Participants deserve to be well-informed about the safety and legal risks they are assuming. Transparent discourse and better public education will go a long way toward ensuring that psychedelics users get the right support in the right setting.

For a deeper dive into each of the three access pathways and BrainFutures’ recommendations for improving the public discourse on psychedelics, download our issue brief, Psychedelic Access Pathways: Differentiating Medical, Wellness, and Religious Access to Psychedelics.