Contraindications

Assessing contraindications is a complex process, given the regulated and unregulated health professionals working in the field and the populations undergoing altered states.

Clients will often either not report nor have a formal diagnosis of a mental disorder, or if they do, it may not be accurate, or they may deny its validity.

Note

It is important to recognize that there are those for whom it may never be suitable to work with psychedelic medicines due to psychiatric and medical conditions that would put them at risk. It is essential to have a medical professional with whom you or your client can consult.

Domains for Assessing Contraindications and Risk

Contraindications can vary and depend upon individual factors (both mental and physical health), their social circumstances, the medicine, set, and setting. Formal and structured assessments are more likely to yield useful information and help the health professional avoid missing areas of risk.

The following key categories accrue to risk, falling within the area of mental health and addictions in order to determine suitability for PHRI and psychedelic-assisted therapy (Silveira & Rockman, 2021).

If a client reports any of these symptoms, functional impairments, conditions, or risks, this should trigger a deeper evaluation. If any of the items are a concern, they should be considered a potential contraindication, and if you are a regulated professional, ensure that you document that you asked about these domains.

Domains for Assessing Contraindications and Risk

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Symptoms

May lead to risk to self/other, intentionally, or unintentionally

  • Homicidal thoughts
  • Suicidal thoughts - acute/chronic
  • Disordered thinking
  • Uncontrolled Anger/Violence
  • Hopelessness
  • Delusions
  • Grandiosity
  • Command hallucinations
  • Other Hallucinations
  • Attention Deficits
  • Memory deficits
  • Judgment Impaired
  • Insight Impaired
  • Active Alcohol use/dependence
  • Active Substance use/dependence
  • Impulsivity

Functional Impairments

Decreased function may enhance risk

  • Personal Care (Basic and Instrumental ADLs)
  • Dependents
  • Licenses
  • Relationships
  • Work
  • Education
  • Housing
  • Finances

Conditions

Consider acuity and history

  • Affective/Mood Disorders - (e.g., Bipolar Disorder)
  • Psychotic Disorders (e.g., Schizophrenia, Schizoaffective)
  • Personality Disorders (e.g., Borderline Personality Disorder)
  • Anxiety Disorders (e.g., PTSD, Panic Disorder)
  • Active Substance Use Disorders
  • Active Eating Disorders (e.g., Anorexia Nervosa)
  • Certain medical conditions (e.g., hypertension, cardiac disease, epilepsy)

Material Risks

Concrete potential repercussions

  • Child safety
  • Other dependents
  • Motor vehicles
  • Suicide attempt or completion
  • Homicide attempt or completion
  • Suicide ou homicide
  • Injury
  • Decreased self-care
  • Victimization and elicited - harm from others
  • Work
  • Financial
  • Housing
  • Firearm use

Note

Ingesting any psychoactive substance will have some degree of risk, and it is essential that the client is informed of this.

Absolute Contraindications

The following are considered absolute contraindications for MDMA, psilocybin, and ketamine (Mitchell et al., 2021). There are absolute contraindications associated with other compounds and it is beyond the scope of this document to address these. Please refer to the literature for further information.

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Ketamine

  • Allergic reaction to ketamine
  • History of ketamine abuse
  • History of stroke or brain aneurysm
  • Uncontrolled high blood pressure
  • Acute Angle Glaucoma
  • Uncontrolled thyroid disorder
  • History of mania/bipolar
  • Age 14 and under
  • Current diagnosis of schizophrenia, schizoaffective disorder, major depressive disorder with psychotic features, psychotic disorder
  • Pregnancy (clients who have the potential to become pregnant must use contraception if sexually active)

MDMA

  • Ongoing use of a medication that has a potential interaction with MDMA, including most types of psychiatric medications, where the medication cannot be tapered.
  • Present suicide risk that makes MDMA-assisted psychotherapy unsafe (though history of suicide attempts may not be an exclusion).
  • Current substance use disorder (screening physician should evaluate on a case-by-case basis).
  • Current eating disorder with active purging.
  • Unwillingness to abstain from use of psychoactive substances 24 hours prior to treatment.
  • First-degree relatives with any psychotic disorders or bipolar disorders.
  • History of (or a current) primary psychotic or mental health disorder, which may include bipolar affective disorder type 1, major depressive disorder with psychotic features, or current dissociative identity disorder.
  • Have a history of ventricular arrhythmias at any time (other than occasional premature ventricular contractions in the absence of ischemic heart disease within past 12 months.
  • Have Wolff-Parkinson-White syndrome or any other accessory pathway that has not been successfully eliminated by ablation.
  • Have a marked baseline prolongation of QT/QTc interval or additional risk factors for Torsade de pointes (e.g., heart failure, hypokalemia, family history of Long QT Syndrome).
  • Have a diagnosis of uncontrolled essential hypertension (blood pressure values ≥135/85mmHg on three separate occasions).
  • Have a history of significant hyponatremia or hyperthermia.
  • Any additional medical condition that could make receiving a stimulant medication harmful because of increases in blood pressure, heart rate, or other concerns, such as liver, heart, or kidney disease, or uncontrolled hypertension (to be determined by the screening physician).
  • Clients who are pregnant, breastfeeding, or planning/attempting to become pregnant during treatment period and are not practising an effective means of contraception.
  • Breastfeeding clients are encouraged to abstain from breastfeeding for a minimum of 48 hours (and up to 96 hours) following treatment (~4-5 half-lives though this is an estimate based on a half-life of ~7-8 hours. Depending on the acidity of a mother’s urine, elimination can be delayed substantially.

Psilocybin

  • Ongoing therapy with a medication that has a potential interaction with psilocybin, including most types of psychiatric medications, where the medication cannot be tapered (see concomitant medications)
  • Present suicide risk that makes psilocybin-assisted psychotherapy unsafe (though history of remote suicide attempts may not be an exclusion)
  • Active or unstable substance use disorder that is not the indication for treatment will be evaluated on a case-by-case basis by the screening physician
  • Have received Electroconvulsive Therapy (ECT) within 12 weeks
  • Unwillingness to abstain from use of psychoactive substances (with the exception of nicotine and caffeine) for 24 hours prior to treatment
  • Unwillingness to abstain from the use of any non-prescription medicines or herbal supplements not approved by the treating care provider
  • First-degree relatives with any psychotic disorders or bipolar disorders
  • History of (or current) primary psychotic or mental health disorder which may include bipolar affective disorder type 1, major depressive disorder with psychotic features, or current dissociative identity disorder (DID)
  • Have a diagnosis of uncontrolled essential hypertension
  • Seizure disorder or history of seizures
  • History of unstable or uncontrolled cardiovascular disease (coronary artery disease, heart failure, clinically significant ECG abnormality)
  • History of significantly impaired hepatic function
  • History of major central nervous system disease (history of cerebrovascular accident, masses, aneurysm)
  • History of uncontrolled obstructive airway disease or significant respiratory compromise
  • History of uncontrolled thyroid disease
  • History of narrow-angle glaucoma
  • Gastrointestinal conditions which may affect psilocybin absorption (i.e., stenosing peptic ulcer, pyloroduodenal obstruction)
  • Clients who are pregnant, breastfeeding, or planning/attempting to become pregnant during treatment period and are not practising an effective means of contraception. Breastfeeding clients are encouraged to abstain from breastfeeding for a minimum of 48 hours (and up to 96 hours) following treatment

Learn More

The Little Book of Psychedelic Substances is also a great beginners guide to learn more about the properties and brief history of each psychedelic medicine.

For a deeper dive into the subjective effects, adverse effects, and contraindications of the various psychedelic medicines covered in Numinus' training programs, consider registering for Molecular Foundations.