Abstract:
The Assisted Dying Service1 reflects the
implementation last month of the End
of Life Choice Act (EoLCA) 2019 and
marks a turning point for medical practice
in New Zealand. While we as a profession
grapple with the implications of the new
law,2 it is timely to consider the range of
options that may assist dying patients and
their families.
Although unregistered and currently
illegal in this country, the classical psychedelic
psilocybin has shown encouraging
results in two randomised crossover trials of
patients with terminal cancer and associated
anxiety and depression.3,4 In contrast to
conventional palliative pharmacotherapies,
the clinical effects of psilocybin, including
long-lasting symptomatic and quality-of-life
improvements, are often apparent after a
single supervised psychedelic experience.
If validated in larger studies, these findings
would suggest psychedelics will be an
important addition to current therapeutic
options at the end of life.
Compared to the serotonergic
psychedelics psilocybin and LSD, methylenedioxymethamphetamine
(MDMA,
“ecstasy”) is another unregistered illicit
drug with somewhat different pharmacology
and subjective effects and notably
less hallucinatory. MDMA has been termed
an “entactogen” because of its powerful
tendency to suppress fear responses
and promote feelings of openness and
connection. Recent controlled trial data
indicate the long-lasting efficacy of
MDMA-assisted psychotherapy in relieving
the symptoms of treatment-resistant
post-traumatic stress disorder;5 US Food
and Drug Administration approval for
this indication is currently being sought.
Closer to home, a randomised controlled
trial of MDMA for anxiety and depression
in terminal illness, hosted by the universities
of Auckland and Otago, is due to
start in early 2022. A small, US-based pilot
study has indicated the likely benefit of
MDMA-assisted psychotherapy for this
indication.6
Patients with terminal illness often
encounter a variety of psychological and
physical challenges, and these are generally
well managed in palliative care. Nonetheless,
concerns about the efficacy and
tolerability of conventional palliative treatments
have led patients and their families to
seek additional options, including medically
assisted dying. The future availability of
psychedelic and related medicines may offer
valuable alternatives to patients who might
otherwise opt to pursue the EoLCA.