The Pain Gap

Epistemic Justice in Psychedelic Ethics

Author

Joanna Kempner, PhD, & Emmanuelle A. D. Schindler, MD, PhD

Publish date

The Pain Gap: Epistemic Justice in Psychedelic Ethics
Topic(s): Editorial-AJOB Psychiatric Ethics

This editorial appears in the January 2025 Special Issue on Psychedelic Ethics of the American Journal of Bioethics.

Pain, as Emily Dickinson aptly described, “has an element of blank.” It is perhaps the most universal human experience, yet even in its most visceral and all-consuming forms, pain defies description, resists empathy, and too often fades from collective memory. This erasure reflects a profound epistemic injustice: Medicine, a profession dedicated to healing, has historically neglected pain, treating it as peripheral rather than central to its mission. The systematic tendency to overlook what Dickinson described as an “infinite realm” of suffering perpetuates ignorance about the lived experience of pain and obstructs the development of effective treatments.

This neglect is mirrored in psychedelic medicine, where the focus has historically centered on psychiatric and behavioral disorders. Early researchers emphasized psychedelics’ potential to mimic and alter mental states, exploring their therapeutic applications for conditions like post-traumatic stress disorder (PTSD), depression, and anxiety. Since its reemergence, the field’s focus on psychiatry has only deepened, with prevailing theories, institutional interests, and established procedures reinforcing the centrality of psychotherapy in psychedelic-assisted therapy (PAT). While potentially effective for psychiatric disorders, this model excludes conditions, like those treated by neurologists, where psychotherapy may neither be relevant nor effective.

In psychedelic circles, suggesting that psychedelics might be beneficial on their own—without psychotherapy—often feels transgressive. Neurologists, by contrast, have long embraced this idea, recognizing the pharmacological potential of psychedelics for treating conditions like headaches and migraines. Perhaps this is because Sandoz Pharmaceuticals, where Albert Hofmann synthesized LSD, was a pioneering force in migraine treatment through its development of ergot-derived compounds. Among its notable innovations were dihydroergotamine and methysergide, two drugs that Hofmann helped create. In 1963, Italian neurologist Frederico Sicuteri demonstrated that both LSD and methysergide, a nonhallucinogenic congener of LSD, were effective preventive treatments for migraine. This groundbreaking discovery not only provided a much-needed option for a difficult-to-treat condition but also revolutionized the understanding of migraine pathophysiology by highlighting the role of serotonin. These findings, along with striking structural and pharmacological similarities between classic psychedelics like LSD and psilocybin and migraine therapies such as dihydroergotamine and triptans, suggest a shared mechanism of therapeutic action in headache disorders.

One such disorder is cluster headache, a rare but devastating neurological disease characterized by excruciating pain. Cluster headache attacks occur in cycles—periods lasting weeks or months when patients experience up to eight daily attacks of pain that they consistently describe as more severe than unmedicated labor, pancreatitis, or gunshot wounds. For nearly 25 years, in response to inadequate treatments, cluster headache patients have led a do-it-yourself medicine movement. Their protocol—three low doses of psilocybin mushrooms or LSD over 10 days—does not incorporate psychotherapy. This grassroots approach, refined over decades, has informed formal clinical trials, which adopted the same patient-developed protocol.

To be effective, interventions must be tailored to the needs of the condition. In medicine, we develop treatments to treat diseases and should not be held captive to a discipline’s frameworks or traditions.

Psychedelic protocols to treat other pain disorders further disrupt the assumptions and structures that shape psychedelic medicine. In phantom limb syndrome, psilocybin has been combined with mirror therapy, enhancing the effects of standard treatments for painful sensations caused by cortical reorganization after limb loss. Similarly, in low back pain—a condition that can involve arthritic, muscular, myelopathic, or radicular pain—psilocybin has been paired with physical therapy to augment the efficacy of rehabilitative treatments. While some pain conditions, such as cancer pain or fibromyalgia, may benefit from cognitive, behavioral, or psychotherapeutic interventions to address the psychological burden of chronic pain, many do not. As it happens, some pain disorders may be best served with a combination of psychedelics and physical—rather than psychological—therapy.

This is a critical distinction given ongoing concerns about our system’s capacity to assess, regulate, and safely implement PAT. As the authors of the four articles in this issue have outlined, there are multiple challenges associated with high-dose, psychotherapy-intensive models: heightened suggestibility that increases vulnerability to coercion or manipulation; risks of boundary violations, especially in settings involving altered psychological states or supportive touch; the potential for retraumatization in patients with a history of trauma; the ethical complexities of integrating spirituality into therapeutic frameworks; and the need for robust clinician training to mitigate these risks effectively.

Some ethical challenges discussed in this issue apply broadly across psychedelic medicine, including the difficulties of designing placebo-controlled trials due to functional unblinding and managing patient expectations fueled by media hype. In contrast, other ethical dilemmas, such as risks of boundary violations and the integration of spirituality into therapeutic models, are specific to psychiatric contexts like PAT. Some psychedelic pain protocols may employ lower doses that either do not require an additional therapy or, if they do, the therapy may be governed by well-established physical therapy protocols, reducing these risks.

It is reasonable, of course, for authors to address ethical issues that do not apply universally across the field of psychedelic medicine. However, these discussions would benefit from a more precise framing, emphasizing that certain risks are context specific rather than inherent to psychedelics themselves. Notably, only Nietzke-Spruill et al. and Cheung et al. explicitly frame the risks of psychedelics as tied to specific therapeutic settings, such as PAT, rather than as universal concerns. Cheung et al., in particular, critique “psychedelic exceptionalism,” rejecting the idea that psychedelics require fundamentally different ethical or evidentiary standards compared to other medical interventions. Drawing parallels to deep brain stimulation and anesthesia—treatments that also alter consciousness and perception—they argue for normalizing psychedelics within broader medical frameworks.

Although Cheung et al. do not explicitly address pain, their framework readily extends to this context. Pain management, like anesthesia, often necessitates rapid and pragmatic interventions that do not depend on psychotherapy. Recognizing psychedelics as versatile pharmacological tools rather than inherently extraordinary substances opens the door to their use in diverse applications, including pain. This perspective aligns with principles of epistemic justice, treating pain as a legitimate and urgent therapeutic target. By challenging exceptionalist narratives, Cheung et al. provide a roadmap for integrating psychedelics into new domains of medicine without unnecessary constraints, allowing them to be tailored to the specific needs of different conditions.

Although psychedelic ethicists often overlook pain as a therapeutic target, this area of medicine is far from problem-free. Broadening the focus of psychedelic medicine to include pain management raises important ethical questions, particularly in the wake of the opioid crisis. The opioid epidemic highlights the urgent need for safer, nonaddictive alternatives to conventional pain therapies, while offering a cautionary tale about the dangers of hyperbole and hype when discussing psychedelics. That pain patients must seek care under a cloud of suspicion highlights the ongoing injustices and challenges in addressing pain as a legitimate therapeutic need.

Expanding psychedelic medicine to include pain management not only broadens its therapeutic reach but also aligns with principles of epistemic justice. By addressing the “infinite realms” of suffering, psychedelic therapies have the potential to restore dignity and relief to those for whom unrelieved pain obliterates all else.

Disclosure Statement

JK has received honorarium and travel reimbursements for speaking about psychedelics and pain from universities and nonprofit organizations, including, on one occasion, Clusterbusters. She received an advance payment on royalties from the sales of a book about psychedelics and pain published with Hachette Books.EADS currently receives research funding from National Headache Foundation and Wallace Research Foundation and previously received research funding from Heffter Research Institute, Ceruvia Lifesciences, and Clusterbusters. She serves on the scientific advisory boards for OptoSom, Ceruvia Lifesciences, and Clusterbusters and previously served as a consultant for PureTech Health. She is named inventor on the following patent related to psychedelics in headache disorders: US20210236523A1EADS is an employee of the US Department of Veterans Affairs; any opinions, findings, and conclusions or recommendations expressed in this material are her own and do not necessarily reflect the views of the US Department of Veterans Affairs.

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