While the potential benefits of psychedelics are increasingly acknowledged, like with any activity or substance that affects perception, there are still risks, and they may be inappropriate or even dangerous for some people and in some contexts. Knowing the potential risks makes it easier to avoid them, and to reduce their harmful effects if they occur for you or others.

General Points for Consideration

• If you’re considering using psychedelics, it’s vital to educate yourself on responsible use. Knowing the potential risks makes it easier to avoid them, and to reduce their harmful effects if they occur in you or others. People with bipolar disorder, schizophrenia, or other forms of psychosis, or people predisposed to these disorders (e.g. having close family members with the disorders) are strongly advised to avoid psychedelics.

• General risks of risks from psychedelics can include:

  • Psychedelic crisis

  • Psychosis and other related long-term mental health issues

  • Hallucinogenic perception persistence disorder (HPPD)

  • Psychological addiction

  • Harmful drug interactions

  • Dangerous behaviours and engaging in dangerous situations during a trip

• Knowing the potential risks makes it easier to avoid them, and to reduce their harmful effects if they occur in you or others.

• Whilst drugs remain illegal in many parts of the world, harmful black market practices continue which increases the risk of substances being mis-sold or adulterated. These risk can be effectively reduced, though not eliminated, using easily obtainable testing kits such as those available through https://www.reagent-tests.uk

Our Harm Reduction Resources are split over overall guidance to risks and harm reduction, as well as specific information on each of the most common psychedelic substances. We recommend reviewing general guidance first. Click the icons below to skip to the relevant section.

Follow the links below to learn more about specific substances, or read on for general harm reduction and key emergency response advice on psychedelics.

A psychedelic crisis is commonly known as a “bad trip, ” and typically involves unpleasant hallucinations, thought loops and distressing emotions in relation to an altered sense of reality. Although these experiences normally disappear once the drug has worn off, experiencing a psychedelic crisis can be traumatic for some people and can have long-lasting consequences.

If properly managed however these experiences have the potential to provide opportunities for personal growth and development. Often the psychological material that arises during these difficult experiences is of great significance and insight into it can lead to opportunities for positive change that may influence, for example, personal relationships, behaviours, or relationships with other drugs such as nicotine and alcohol.  

How To Reduce the Risk of a Psychedelic Crisis

Set and Setting

The risk of a psychedelic crisis can be decreased by taking psychedelics in the right set and setting. 

Set refers to your mood, recent experiences, and intentions prior to going into the trip. If you are feeling anxious or in a low mood then taking psychedelics may not be a good idea as there may be a chance these emotions could be amplified to an unpleasant degree. 

Setting refers to the physical environment in which the drug is taken.  This should be a quiet, safe, and familiar environment that doesn’t have negative associations. 

It is also important to plan ahead for things you may want during the course of your experience. This may include food, creative activities, a place to lay down, music, and access to the bathroom. 

Whilst some people do have positive experiences of using psychedelics in highly stimulating environments, like festivals, these environments are much less predictable and controllable. In taking psychedelics in party and festival environments, it would be advisable to have prior experience, to use a low dose, and test the drug’s purity before consumption if this is an available option.

Having a Trip Sitter

Taking psychedelics with other people can be a positive experience. However, taking psychedelics with strangers or people you feel uncomfortable around can increase the risk of experiencing anxiety or a psychedelic crisis. 

It can be best practice to have a “trip-sitter” present, especially for first timers and high-doses. The trip sitter is somebody who you feel comfortable around who has previously used and is knowledgeable of the drug the user is taking but remains sober throughout the trip. Their role is to provide a stable reference point and to keep the user safe whilst avoiding “guiding” the psychedelic experience. 

More information on the role of a trip-sitter can be found here.

Preparing for a Trip

Preparation prior to the trip can reduce the risks of a bad trip. Preparation advice includes:

• Cleaning and clearing the room or environment the user is taking psychedelics in

• Having comforting and meaningful objects nearby 

• Setting an intention for the journey

• Planning ahead for things you may want access to during the experience 

During the Trip

During the experience, techniques that help return the experience to the present moment such as focusing on the breath or using a mantra (repeated sound/phrase) can be useful for managing distressing experiences. Psychedelic guides normally suggest that whatever arises during the trip, you should try and “let go” and surrender to the experience non-judgmentally, knowing that the effects will wear off.

Integrating the Experience

Psychedelic experiences can be chaotic and large amounts of complex psychological material can arise during the course of a single experience. It is therefore very important to try and integrate the experience, whether positive, negative or neutral, once the drug has worn off as this can help to put the events of the experience into context and reduce the risk of long-term trauma. 

Integration often focuses on reflecting on the experiences and may include writing in a journal and talking about the experience with friends or guides who can support you. This process can take a long time and it isn’t advisable to embark on further experiences if there is still unresolved material from previous trips.

Guidance: The Manual of Psychedelic Support

For more information on managing a psychedelic crisis, the manual of psychedelic support is a comprehensive guide to helping those experiencing psychedelic difficulties. The guide is specifically aimed at music festivals and events but can be applied to individuals taking psychedelics in all settings. This video provided by MAPS is also a useful resource.

Support Resources for those experiencing a spiritual emergency or psychedelic crisis

Reclamation Collective - Reclamation Collective is committed to holding space for folks navigating Religious Trauma and Adverse Religious Experiences. Learn more here.

Psychedelics have the potential to trigger or exacerbate a wide range of mental health conditions if used irresponsibly. Whilst there is a rapidly expanding interest in the potential of psychedelics to improve the lives of people suffering from conditions such as depression, anxiety and PTSD; the risks associated with unregulated use are greatly reduced in the very carefully controlled and highly supported environments used during psychedelic research studies. Most advice about the use of psychedelics in the unregulated setting aims to mimic the safeguards used during these studies.  

Although psychosis-like symptoms usually tend to disappear once psychedelics have worn off, psychedelics and environmental stressors do have the potential to trigger ongoing psychotic symptoms that persist once the substance is no longer in a person's system. The risk of this is small, however, people with pre-existing mental health conditions, such as schizophrenia and bipolar disorder, and those with an underlying mental health condition, are more at risk. 

How to decrease the risk of mental health harms from psychedelics

People with a diagnosis or family history of bipolar and schizophrenia are advised to avoid taking psychedelics. The risks of taking psychedelics in the wrong set and setting increases the risk of a traumatic experience which increases the risk of subsequent long-lasting psychological problems. Having pure and properly-dosed substances is the best way to start to decrease the risks of unwanted psychological reactions due to unexpected drug reactions and effects from contaminated drugs. Testing substances using testing kits is an effective way of reducing the risks of ingesting unexpected substances. Testing kits are available online such as through https://www.reagent-tests.uk/ 

Having an experienced trip-sitter present will increase safety throughout the trip as they can offer support that allows the tripper to remain in the present moment and go with the experience.

Hallucinogenic perception persistence disorder (HPPD)

What is HPP?

This is a rare occurrence where effects of hallucinogenic drugs, mainly the visual hallucinations, remain for a long period of time (from a couple of weeks up to several months, in very rare situations some people even report the effects persisting for years) once the drug has worn off. This can be unpleasant and make people feel detached from reality (1)

Decrease the risk of HPP

As HPP can often occur following a traumatic hallucinogenic experience, ensuring the correct set and setting can help minimise this risk. Risk is also greatly increased with frequent, high dose use of psychedelics. 

Psychological vs. Physical Addiction

Physical addiction is when more of a drug is needed to feel the same effects (tolerance) and when physical withdrawal symptoms occur when people try and stop taking the drug (dependence). Psychological addiction is when somebody has a mental or emotional attachment to a drug and so are strongly driven to find and use this drug. Although research seems to suggest that physically psychedelics are not addictive, people may still feel attached to the experience psychedelics give them so may find themselves becoming psychologically addicted. Classical psychedelics like LSD and psilocybin mushrooms appear to carry a very low risk of any form of addiction. However, drugs like MDMA and ketamine can induce strong psychological dependence with long term harmful effects on 

The risk of dependence varies greatly with different drugs but is generally increased with frequent and high dose use, thus careful, planned and infrequent use of psychoactive drugs is the safest way to reduce these risks.

If you feel like you or somebody else has developed psychological addiction to psychedelics or any other drug, helplines are available. A list of free UK helplines can be found here.

As a general rule, mixing any drugs increases risk. A generalised chart for drug interactions can be found here.

Psychedelics and Antidepressants

Mixing psychedelics, particularly phenethylamines and stimulants like MDMA,  and antidepressants can increase the risk of serotonin syndrome (see below). The risk of this is greatest when an individual begins taking a course of antidepressants as this is before their serotonin receptors have been downregulated. Those who have used some types of antidepressants long term report that the effects of psychoactive drugs that exert their effect through serotonin neurotransmission, like psychedelics and MDMA, are reduced. However, there is a wide range of antidepressant pharmacology and it is generally best to avoid mixing drugs as the effects and risks are unpredictable. 

Serotonin Syndrome

Serotonin syndrome refers to a spectrum of toxicity caused by too much serotonin in the central nervous system which can lead to various complications. The symptoms of serotonin syndrome include:

• Autonomic effects- sweating, shivering, increased heart rate (tachycardia), increased body temperature (hyperthermia), nausea

• Somatic effects- tremor, muscle twitching/stiffness, overactive reflexes (hyperreflexia)

• Cognitive effects- headache, agitation, hallucinations, confusion, seizures

Hyperthermia is the most dangerous symptom and a body temperature greater than 38oC should be cause for concern. A temperature greater than 40oC is very high risk and should prompt urgent medical attention. When left untreated these symptoms can lead to coma, cardiac arrest and death, although serious long term harm is rare when treated promptly.

Combining certain drugs increases the risk of serotonin syndrome and this risk increases as more drugs are combined. There is a wide range of drugs that affect serotonin in a range of ways including psychedelics, stimulants, antidepressants, 5-HTP, St. John’s Wort, tramadol, anti-migraine drugs. Particular caution should be paid to herbs containing monoamine oxidase inhibitors including Syrian rue, nutmeg, Yohimbe, as these can have long-lasting pharmacological effects and greatly increase the risk of serotonin syndrome if taken in combination with stimulant drugs like MDMA. However, it should be noted that a monoamine oxidase inhibitor is an essential component of traditional preparations of ayahuasca, required to make DMT orally active. 

Avoiding Serotonin Syndrome

Being aware of which drugs increase the risk of serotonin syndrome will decrease the risk. If symptoms of serotonin syndrome appear then it is essential an ambulance is called. More information about safety regarding various drugs and serotonin syndrome can be found here.
 

Support for people going through spiritual emergencies and/or psychedelic trauma

• Institute of Psychedelic Therapy’s Psychedelic Integration database: A database of UK based counsellors and psychotherapists that offer one to one and group support for integrating psychedelic experiences - https://instituteofpsychedelictherapy.org/psychedelic-integration-database/

• Spiritual Crisis Network: online and peer group support for people going through or recovering from a spiritual crisis, helping support personal transformation (UK) - https://spiritualcrisisnetwork.uk/about

• The International Spiritual Emergence Network (ISEN): spiritual emergency support across various countries globally - http://www.spiritualemergencenetwork.org/

• Emerging Proud: support service and campaigns to reframe mental distress as a catalyst for positive change (UK) - https://emergingproud.com/

General Harm Reduction Information

• Release: contains information for various drugs, harm-reduction advice, legal advice and published reports on drug policy and related issues https://www.release.org.uk/

• Drugs and Me: contains information on dosing/ interactions/harm-reduction/risks and law for different drugs https://www.drugsand.me/en/

• Talking Drugs: contains harm reduction guides for ketamine, MDMA and cocaine https://www.talkingdrugs.org/

• Stanislov Grof: Psychedelic crisis intervention in situations related to unsupervised use of psychedelics http://www.psychedelic-library.org/grof2.htm l

• Erowid: What to do in a psychedelic crisis and includes acute physical dangers by substance: https://www.erowid.org/psychoactives/faqs/psychedelic_crisis_faq.shtml 

References

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3736944/

Credit to Dr Andrew Gibson for contributing his medical expertise and background in harm-reduction to the process of making this content.