EDITORIAL NOTE: I think it is vital that Oregonians be involved in implementing M109 in our state. I have decided to focus on specific topics relevant to the implementation of psilocybin services in Oregon. This newsletter issue is on what may be the most critical challenge facing the program—affordability.
I hope you will subscribe.
Yeoman's Work by the Oregon Psilocybin Advisory Board
When voters approved Measure 109 last November, they created the Oregon Psilocybin Advisory Board to advise the Oregon Health Authority on the regulatory structure for the supervised use of psilocybin products.
Over the last 3-months, the all-volunteer board has held over 30 meetings on a wide variety of issues. They have focused on:
- Training programs
- Research on the safety and efficacy of psilocybin use
- Licensing facilitators, service centers, and producers
- Production and testing of psilocybin products
- Equity issues around the entire program
The board's collective breadth and depth of experience is deeply impressive, and all Oregonians should thank them for their countless hours of hard work for our state.
One thing that has become clear in the last few months is the huge challenge that the board and OHA will have in developing a program that fulfills Governor Brown's charge that this promising treatment is made available to all Oregonians regardless of circumstance.
The Economics of Psilocybin Services Under M109
Before we get too much into the weeds on the issue of affordability, it is important to understand a few essential points.
Insurance Won't Pay for Psilocybin Services
The language in M109 is clear; the state can't "require a government medical assistance program or private health insurer to reimburse a person for costs associated with the use of psilocybin products."
Even if an insurance company wanted to cover psilocybin services, it is unlikely it could do so anytime soon as psilocybin is still a Schedule I drug under the Controlled Substances Act.
This means that, unlike other health interventions, consumers will bear all the costs associated with psilocybin services.
Psilocybin Services are Time-Consuming for the Provider
Few expect the mushrooms themselves will be the main cost driver; instead, it will be the labor of facilitators. These trained sitters will likely need to:
- Answer many questions from prospective clients
- Screen each client for contraindications
- Hold a preparation session to explain the process
- Observe the client during the trip for up to 8 hours
Most Oregonians Can't Afford to Pay Thousands of Dollars for Psilocybin Services
Oregon is not a particularly wealthy state. Our median income is close to the national average. According to a recent poll, just 39% of Americans could pay for a $1,000 emergency medical expense.
Proposed Regulations Threaten Affordability
Members of the Oregon Psilocybin Advisory Board are rightly concerned about the safety of clients using psilocybin services under M109. However, it is potentially problematic that some board members seem to use the rules and regulations faced in the medical world as a template for a regulatory framework for psilocybin services.
While undoubtedly well-intentioned, some of the proposed regulations (if enacted) will make it impossible for psilocybin services to be affordable to the average Oregonian.
There have been countless discussions about possible rules for the program. These proposals run the gamut from the somewhat pedantic—parking space regulations for service centers to much more weighty issues of whether there will need to be more than one facilitator during a psilocybin session.
I hope to address these questions more in-depth in the future, but in this issue, I would like to focus on two matters in particular:
The text of M109 states that the board shall make recommendations on if group administration sessions should be available.
I had assumed this was just a formality; after all, this is how many indigenous groups have traditionally used psychedelics. Moreover, recent research has found group therapy can help individuals such as veterans connect more deeply than one-on-one therapy.
Group sessions could also significantly reduce costs.
However, some members of the board have expressed concern over allowing group sessions. Honestly, not allowing Oregonians this option smacks of medical paternalism. But setting aside that concern, it would be hard to imagine psilocybin services costing anywhere close to south of one thousand dollars outside of group sessions.
A recent global drug survey found that of the more than 10,000 people who reported taking magic mushrooms, just 0.2% of them needed emergency medical treatment. That figure is less than a fifth of the rate for alcohol users.
Still, there are some risks associated with psilocybin use. Therefore, M109 requires potential clients to be screened before an administration session to identify these risk factors and contraindications.
The specific details of the screening process are still very much undetermined. A simple checklist seems reasonable. However, some on the board have suggested medical screenings might be in order. It is not yet clear who would be allowed to do such a screening, but if psilocybin service centers had to hire a psychiatrist or a psychiatric-mental health nurse practitioner, it would add considerable costs.
Another issue with screening is to decide if clients with certain conditions will have to see medically trained facilitators (as opposed to regular facilitators who must go through a training program but don't need to be medical professionals).
It is still very much unclear who might be required to see medically trained facilitators. For example, would only clients with extreme and rare psychiatric conditions be made to see these practitioners? Or would anyone currently showing signs of depression be required to be treated by them as well?
Would a licensed clinical social worker suffice, or would clients be required to see a psychiatrist or psychologist?
Moreover, given that insurance won't pay for psilocybin services, such a process could mean wildly differential pricing for those with mental health issues as medically trained facilitators will charge much higher rates than less credentialed providers.
Would this violate the spirit of mental health parity laws? More importantly, doesn't this fly in the face of the messaging of the M109 campaign whose raison d'être was to help Oregonians deal with our mental health crises.
True Access Does Not Exist Without Affordability
Most of the proposed rules the board members are making have merit. However, the combined effect of these proposals may make psilocybin services unaffordable for all but the affluent.
With the passage of M109 and M110 (Drug Decriminalization and Addiction Treatment Initiative), Oregonians clearly rejected the failed war on drug laws of yesterday. A new approach that treats people as adults and leverages policies of informed consent and harm reduction is a better way forward than a hyperregulatory framework that results in de facto prohibition.
When a new building code is proposed, housing affordability advocates look at the "incremental cost" that this new regulation will add to the cost of housing.
This doesn't stop new building codes from being developed, but it does help regulators decide if the benefits of the new regulation outweigh the costs.
Recently the equity subcommittee of the OPAB asked that before the board and/or OHA voted on any proposed rules that they first get a cost estimate from health economists.
Making costs visible can not be optional. Oregonians deserve to know how much psilocybin services will cost them before any rules are approved.
The board should adopt this common-sense proposal immediately. I also hope advocates demand that affordability be the central concern of those in charge of setting up psilocybin services.
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