Minorities’ diminished psychedelic returns: Cardio-metabolic health

Abstract

Although there is a growing support for the protective factor of psychedelics to improve mental and physical health, these effects may differ across racial and ethnic groups. Race differences remain a critically understudied gap in psychedelic literature. Recent empirical research into Minority Diminished Psychedelic Returns suggests that Black Americans may gain little health benefits from psychedelic use. This study tests race differences in the association between Lifetime Classic Psychedelic Use and multiple indicators of cardio-metabolic health including cardiovascular disease, hypertension, and Body Mass Index. This project uses pooled data of Black and White adults respondents from the National Survey of Drug Use and Health (NSDUH) (2005 to 2019) (N = 421,477). The analysis includes a series of logistic and ordinary least square regression models conducted in Stata 18. Results demonstrate that Lifetime Psychedelic Use is associated with better cardio-metabolic health. However, regression models by race find that there is no association between LCPU and cardio metabolic health for Black people, while the positive associations remain significant for white people. Overall, results lend support for the MPDR theory.

Keywords

Psychedelics inequality health outcomes

Introduction

Ever-expanding research analyzes psychedelics as a viable option for treating health problems, including depression, anxiety, suicidality, PTSD, drug dependency, and other behavioral addictions (Barnett, Parker et al., 2022; Davis, Barrett et al., 2021; dos Santos et al., 2018; Mithoefer et al., 2019; Peck, 2021; Penn et al., 2021; Roseman et al., 2018; Yaden et al., 2021; Zeifman et al., 2021). Populations studies have also confirmed clinical trials finding psychedelic use is associated with better mental health, as well as finding positive association with better physical health including obesity, hypertension, and cardiovascular disease (Barnett, Ziegler et al., 2022; Hendricks et al., 2014, 2015, 2018; Jones & Nock, 2022a; Mellner et al., 2022; Sexton et al., 2019; Simonsson et al., 2022; Simonsson, Hendricks et al., 2021; Simonsson, Osika et al., 2021; Simonsson, Sexton et al., 2021; Walsh et al., 2016).

Although previous research has found a strong association between psychedelic use and cardiovascular health (such as obesity, hypertension, and cardiovascular disease), the exact mechanisms explaining the pathways between psychedelic use and cardiovascular health remain unexplained. While several hypotheses propose a direct biological link between psychedelic use and cardio-metabolic health, including anti-inflammatory and immunomodulatory properties (Flanagan & Nichols, 2018; Nichols, 2009), others suggest that there may be a mediating pathway between psychedelic use and physical health. Specifically, evidence has shown a strong association between mental and physical health; individuals with poorer mental health are more likely to be obese, have unhealthy eating and exercise habits, and are more likely to have cardiovascular disease (Dimsdale, 2008; Sinha & Jastreboff, 2013; Yau & Potenza, 2014). Therefore, because psychedelic use is associated with improved psychological well-being, reduced mental illness, and better stress management, it is possible that individuals who have used psychedelics not only experience less cardiovascular strain but also make better health decisions regarding exercise and diet.

The relationship between psychedelics and physical health—direct or indirect—is promising because of their potential impact groups with disproportionally worse health, especially in relation to ongoing racial disparities in cardio-metabolic disease and mortality. Consistently, evidence suggests that compared to their White counterparts, Black people continue to suffer from higher rates of obesity and cardio-metobolic disease, which has been directly linked to higher rates of all-cause morbidity and lowers life expectancy (Assari, 2017a, 2018b, 2020; Assari, Chalian et al., 2019; Assari, Farokhnia et al., 2019; Assari, Lapeyrouse et al., 2018; Assari & Mistry, 2018; Assari, Preiser et al., 2018). The race disparity in obesity is of particular importance because it increases the risk of a wide range of undesired health outcomes such as heart disease, stroke, hypertension, and diabetes (Thompson et al., 1999). Moreover, obesity is a major gateway to several communicable and non-communicable diseases, including COVID-19, that are disproportionately more common in Blacks (Frühbeck et al., 2020; Frühbeck & Yumuk, 2014). The Black–White differences in obesity may partially explain some of the racial disparity in cardiovascular and all-cause mortality between Blacks and Whites (Daw, 2017).

However, growing evidence finds the protective factor for psychedelics varies across sub-populations. Nationally represented data has found that while psilocybin and MDMA use was associated with better health outcomes for white users, there were little to no association among users who were race or ethnic minorities (Jones, 2023; Jones & Nock, 2022b). Another study found that while those who are employed and use psychedelics have significantly lower levels of psychological distress, non-employed users have higher levels of distress (S. M. Viña & Stephens, 2023b). Another study found that while Black psychedelic users saw no decrease in stress, white psychedelic users saw a significant increase in stress that was further amplified by education (Viña & Stephens, 2023a). Additionally, their study found that criminal history significantly attenuated the positive association of psychedelic for white users, but not black users. Another study documented how religious beliefs can interact with psychedelics affecting mental health. The study found that psychedelics can interact with strong religious beliefs, creating better health outcomes, but only when religious attendance was also high (Viña, 2022). Those who had strong beliefs, but low attendance, had higher levels of distress. The findings suggest that culture (levels of religiosity) and social interactions (amount of religious attendance) alter set-and-setting which affects psychedelics on health. So what other conditions are likely to compromise set-and-setting? On a positive note, research has found that psychedelics significantly moderate the negative effects of ethnic and race-based discrimination on anxiety and distress (Ching et al., 2023; Williams et al., 2021). A follow-up study suggests racial trauma symptoms may be moderated through an increase in psychological flexibility conferred by psychedelic use (Davis, Xin et al., 2021). However, those study populations were mostly Asian with little representation from Blacks.

Minorities’ Diminished Psychedelic Returns Theory has been proposed as an explanation for potentially smaller health gains of psychedelic use by minority population, which draws upon two theories (Viña & Stephens, 2023a). First, using cultural -set and -setting, this theory proposes that because the effects of psychedelics are “fundamentally reliant on context – both in the psychological and environmental sense” (Carhart-Harris et al., 2018, p. 725), cultural conditions can impact the overall effectiveness of psychedelic on health. Specifically, setting refers to the physical and social environment where psychedelics are consumed. In contrast, set “refers to the internal conditions of the person using the psychedelics, including factors such as mood, attitudes, preparation, personal history, personality, expectations, motivations for using, and beliefs about themselves and the use of drugs”(Neitzke-Spruill, 2019, p. 52). According to Hartogsohn (2016), the individual level where the psychedelic is consumed sits “atop of a more fundamental collective level, which frames and gives shape” to set-and-setting available to the (Hartogsohn, 2016, p. 2). To be sure, different social groups (i.e., gender and class) will have access to different types of resources that will affect the setting. Moreover, cultures and subcultures provide “distinct types of environments for hallucinogenic experimentation” (Hartogsohn, 2022, p. 8). Most importantly, cultural set-and-setting, hypothesizes cultural conditions that can affect psychedelic outcomes as sitting on a spectrum from the most optimal to the least optimal. Those with the most optimal set-and-setting have the conditions (i.e., psychological, biological, and social) that create the best sustained health outcomes. Conversely, those with the least optimal set-and-setting have fewer of the necessary conditions to create optimal or sustained health outcomes associated with psychedelic use.

Second, MDPR draws upon the well-established Minorities’ Diminished Returns theory, which finds that because of systemic racism, education and income are not protective factors for Black health Compared to Whites, increased education among Black people is not associated with better mental or physical health, including self-reported health or depressive symptoms (Assari, 2020; Assari, Lapeyrouse et al., 2018), emotional wellbeing (Assari, Preiser et al., 2018), obesity (Assari, 2018a), or chronic obstructive pulmonary disease (Assari, Chalian et al., 2019). Education was also not a protective factor against negative health behaviors, including smoking (Assari & Mistry, 2018) or alcohol binge drinking (Assari, Farokhnia et al., 2019). While education and income can be a huge windfall for the health of White people, education does not improve Black life expectancy (Assari, 2018b), it does not lead to upward mobility for Black people (Assari, 2018c), and it may actually be a risk factor of depression for Black men (Assari, 2017b). Today, the race gap in life expectancy is widening and is widest at the highest level of education and income (Olshansky et al., 2012; Schwandt et al., 2021).

In total, MDPR proposes that systemic or structural inequality will be a major catalyst of set-and-setting, putting people on different ends of the spectrum. MDPR argues that:

Systemic racism will affect the entire relationship that people have with psychedelics, both upstream before use, and downstream after use. More specifically, prior to using psychedelics, systemic racism will affect black people's relationship with, perceptions of, and access to psychedelics, all of which could alter psychedelics health efficacy. Structural racism will also affect the relationship between psychedelics and health post use because of different access to other resources that could affect the efficacy of the drugs, or exposure to trauma that more quickly diminishes the efficacy of the drugs (Viña & Stephens, 2023a, p. 3).

In relation to cardiovascular health, MDPR suggests that systemic racism, which creates higher levels of distress, significantly interrupts the pathways between psychedelic use and cardiovascular health for racial minorities compared to white people. This interruption occurs in three interconnected and potentially addictive ways. Firstly, if there is a direct association between psychedelic use and improved cardiovascular health, persistent and heightened stress will either more quickly diminish those biological benefits in a shorter period of time, or stress will significantly buffer the benefits of psychedelic use, whereby there are less cardiovascular improvements from this medication. Secondly, if psychedelic use leads to better cardiovascular health through improved mental health, racial inequality could more quickly diminish mental health or increase stress, leading to continued poor health behaviors. Thirdly, even if psychedelic use directly improves Black cardiovascular health or mental health, which leads to better behaviors, structural inequality and economic segregation would limit the opportunities for—for example—eating well or exercising due to a lack of access to salient resources. Most importantly, because systemic racism is analyzed through the lens of the fundamental causality of health inequality (Phelan & Link, 2015), black people are likely to experience all of these negative pathways simultaneously, rather than just one or the other.

To better understand sub-population heterogeneity in the protective effects of psychedelics on cardiovascular disease, this study used a nationally represented sample to examine racial differences in the association of psychedelics on cardiovascular disease and BMI in the United States. The analysis uses pooled data from the National Survey of Drug Use (2005 to 2019), which is reduced to only White and Black adult respondents (n = 421,477). Results demonstrate that Lifetime Psychedelic Use is associated with better cardio-metabolic health. However, regression models by race find that there is no association between LCPU and cardio metabolic health for Black people, while the positive associations remain significant for white people. Overall, results lend support for the MPDR theory.

Data and methods

This present study replicates research using pooled data from the National Survey of Drug Use and Health (NSDUH) (2002 to 2019) (Simonsson et al., 2022; Simonsson, Osika et al., 2021; Simonsson, Sexton et al., 2021). The NSDUH is an annual survey designed to measure the prevalence of substance use and mental health issues in the United States, conducted in all 50 states and the District of Columbia. The data was weighted to reflect the civilian noninstitutionalized population. There are three key variables which are asked at different periods of the; hypertension and heart disease were measured in 2005–2014, and BMI was measured in 2013–2019. This analysis focuses on differences between White and Black people. Thus, all other race/ethnic groups and those young than 18 years of age were also dropped for a final sample size (n = 421,477). Table 1 shows the descriptive statistics for dependent, independent, and control variables. All variables are derived from responses to publicly available data. Full sampling techniques can be found at their website: https://nsduhweb.rti.org/respweb/about_nsduh.html.

Table 1.

Descriptive statistics for dependent variables, independent variables, and controls (2008–2019) (weighted).

	Mean	SD	n	% / min-max
Dependent Variables
Heart Disease in Past Year	9.49	6.06	122,633	0–24
Hypertension in Past Year			69,745	14.22
BMI	28.35	6.22	200,952	9.37–68.55
Key Independent Variables
LCPU			64,610	15.33
Black			62,500	14.83
Control Variables
Women			219,805	52.15
Age	14.93	2.02	421,477	8–17
Education	2.81	.99	421,477	1–4
Marital Status
Single, never Married			102,082	24.22
Married			229,613	54.48
Widowed			28,653	6.80
Divorced/Separated			61,127	14.50
Religious Attendance	1.96	1.90	419,044	0–5
Religiosity	4.95	2.58	413,219	0–9
Lifetime Drug Use
Cocaine			73,554	17.45
Marijuana			209,184	49.63
MDMA/ecstasy			29,474	7.00
PCP			12,555	2.98
Inhalants			40,807	9.69
Stimulants			45,849	10.88
Sedatives			35,348	8.39
Tranquilizer			70,450	16.72
Heroine			8743	2.07
Pain Relievers			142,862	33.90
Tobacco			266,963	63.34
Age of First Alcohol Use	2.76	1.10	421,477	1–5
Self-Reported Risky Behavior	1.65	.74	420,604	0–3

Source: 2005–2019 National Survey of Drug Use and Health, n = 421,477.

Key dependent and predictor variables

This analysis includes three dependent variables that were provided by the NSDUH and which were used in previous research on psychedelics and health (Simonsson, Hendricks et al., 2021; Simonsson, Osika et al., 2021; Simonsson, Sexton et al., 2021). The analysis includes two binary variables; heart disease in the past year and hypertension in the past year are binary variables, (yes vs no). BMI is a continuous variable that ranges from 9.37 to 68.55. While the research this paper is replicating coded BMI into categories based on National Institute of Health (NIH) guidelines, this analysis follows guidelines from other research that finds while BMI is a good indicator of health outcomes including cardiovascular disease and both mortality and morbidity risk, BMI is insufficient in predicting obesity because of variations in body types (Gutin, 2018; Khanna et al., 2022). Thus, this analysis keeps the variable as a continuous variable that could indicate other major health concerns.¹

These variables were specifically chosen due to their direct link to race disparities in social determinants and early mortality rates. Evidence suggests that high blood pressure, heart disease, and obesity are three of the strongest predictors of race disparities in early mortality rates (Dimsdale, 2008; He et al., 2023; Kyalwazi et al., 2022). Additionally, research shows that early mortality rates associated with higher blood pressure and obesity have increased significantly among Americans compared to Whites between 1999 and 2020 (Kyalwazi et al., 2022). However, studies have found that adjusting for social determinants of health, including food insecurity, lack of home ownership, lack of leisure time, and lack of sleep, eliminates race disparities in cardiovascular disease mortality. These social determinants are strongly linked to racial/structural inequality. Therefore, if the analysis reveals evidence of smaller health gains among psychedelic users who are Black, the results would support the MDPR.

Key independent variables

This analysis includes two key independent variables. First, the paper replicates previous research and created a measure of lifetime classic psychedelic use (LCPU): classic psychedelics are a subclass of psychedelics that have little toxicity (dos Santos et al., 2018). Classic psychedelics include N-dimethyltryptamine (DMT), the DMT-containing admixture ayahuasca, psilocybin, lysergic acid diethylamide (LSD), mescaline, and the mescaline-containing cacti peyote. Respondents reported if they had ever used, even once, the following drugs: DMT, ayahuasca, psilocybin, LSD, mescaline, or peyote. Consistent with previous (Simonsson, Osika et al., 2021; Simonsson, Sexton et al., 2021), the six variables were used to create a dummy variable indicating any lifetime classic psychedelic use (LCPU) (yes vs. no).² Second, race is a binary variable with Black = 1 and white as the reference category.

Control variables

Key independent variables

The analysis includes several sociodemographic controls. Socioeconomic class is measured by two continuous variables: (1) annual household income (less than $10,000, $10,000–$19,999, $20,000–$29,999, $30,000–$39,999, $40,000–$49,999, $50,000–$74,999, and $75,000 or more) and (2) educational attainment (high school degree, some college, college degree or higher, and less than a high school degree, serving as the reference category). Women is a binary variable with “men” set as the reference category. Age as a continuous measure (18, 19, 20, 21, 22–23, 24–25, 25–29, 30–34, 35–49, 50–64, and 65+) and marital status (married, widowed, divorces/separated, and single-never married serving as the reference category). The regression analysis also controls for the year of the survey, based on previous research using the NSDUH. Previous research has found a strong correlation between drug use, risky behavior, and mental illness. Therefore, this study follows the guidance of similar research that uses the NSDUH by including controls for other drug use (Simonsson, Osika et al., 2021; Simonsson, Sexton et al., 2021; Viña, 2022; Viña & Stephens, 2023b, 2023a) It includes the following binary control variables: lifetime use of cocaine; marijuana use; 3,4-methylenedioxymethamphetamine (MDMA/ecstasy); phencyclidine (PCP); inhalants; other stimulants; sedatives; pain relievers; and tobacco use (i.e., smokeless tobacco; pipe tobacco; cigar; and daily cigarette use). Age of first alcohol use and self-reported engagement in risky behavior are continuous variables. Finally, there are two religiosity variables. First, religious attendance measures how often a person attended religious services in the last year with the following option, (0=) 0 ties, (1=) 1 to 2 times, (2=) 3–5 times, (3=) 6 to 24 times, (4=) 25 to 52 times, and (5=) more than 52 times. Religious salience is an index of the following three variables: (1) my religious beliefs are very important, (2) my religious beliefs influence life, and (3) it's important that my friends are religious (Cronbach's a = 0.83).

Analytic strategy

To address this study's questions, I began by calculating the means of each variable in the sample by LCPU status and race. Then, I conducted a post-estimation LINCOM (non-linear combination) commands, which compute the statistical difference of two subpopulation means (Long & Freese, 2014). Statistical mean difference were calculated of Non LCPU minus (-) LCPU and Black people minus (-) White people. Next a series of logistic regression and ordinary least square regression (OLS) models were used to test the relationship between race LCPU, and health (Tables 3 and 4).³ Table 3 predicts the three health dependent variables among the total sample. There are two models for each health variable, one with and one without an interaction term (LCPU*Race).

Using the intersectional approach that understands different groups have substantially different lived experiences (i.e., Whites vs Blacks), the analysis follows recommendations to run individual models by race to compare substantially meaningful profiles (Long, 2009). Table 4 displays models that predict each health dependent variable by race groups, Black and Whites. To facilitate the analysis of race/gender differences across regression models, the analysis assessed the statistical difference of coefficients by running post-estimation SUEST (seemingly unrelated estimation) commands, which combine regression estimation results and allow for generalized Hausman specification tests (Oberfichtner & Tauchmann, 2021). The post-estimation commands are appropriate when the estimates were obtained on the same or overlapping data. NSDUH created weights by adjusting the single-year weights by a scalar factor (i.e., the number of years of data used) so that the estimated number of individuals reported is representative of the national population. All analyses incorporate the sampling weights provided by the NSDUH and conducted in STATA 18. Finally, as with previous research on psychedelics using the NSDUH, there was no control for multiple comparisons in the present study (Mellner et al., 2022; Simonsson, Osika et al., 2021; Simonsson, Sexton et al., 2021). However, according to Armstrong (Armstrong, 2014), a Bonferroni correction is not needed for this study because the paper meets the following requirements: (1) it does not require a single test of the universal null hypothesis, (2) it does not need to avoid a type I error, and (3) it uses extensive preplanned hypothesis that drives this analysis.

Results

Descriptive statistics

Mean differences by LCPU (Table 2) demonstrate that those who have used classic psychedelics, compared to those who have not, are less likely to have heart disease or hypertension in the past year, have lower BMI scores, and be more likely to be white (p < 0.001). Also, compared to those who are white, Black people are less likely to have heart disease in the past year, but more likely to have hypertension (p < 0.001). Black people also have higher BMI scores than whites (p < 0.001). Among control variable, those who have used classic psychedelics are more likely to be men, have higher income and education, are younger, are more likely to be single, have lower religiosity scores, and are more likely to have used any other drugs, started drinking younger, and have higher self-reported risky behaviors (p < 0.001). Lastly compared to whites, Black people were more likely to be women, have lower income, education, and age, are more likely to be single or divorced, have higher religiosity scores, are less likely to have used any drug—but equally likely to have used heroine—started drinking at an older age, and have lower risky behaviors scores.

Table 2.

Mean difference of dependent, independent, and control variables by lifetime class psychedelic use (LCPU) (Weighted).

	Mean		Mean Difference^a		Mean		Mean Difference^a
	Non-LCPU	LCPU	Mean Difference^a		Black	White	Mean Difference^a
Heart Disease in Past Year	.05	.02	.02	***	.03	.05	−.02	***
Hypertension in Past Year	.22	.13	.08	***	.25	.20	.05	***
BMI	28.50	27.56	.94	***	29.87	28.08	1.78	***
	(.025)^b	(.042)	(.047)		(.058)	(.025)	(.067
LCPU					.04	.17	−.12
White	.83	.95	−.12	***
Black	.16	.04	.12	***
Women	.54	.37	.16	***	.55	.51	.03
Family Income	5.02	5.13	−.10	***	4.06	5.20	−.14
	(.006)	.014)	(.013		(.016)	(.007)	(.018)
Education	2.80	2.87	−.07	***	2.50	2.87	−.36
	(.003)	(.007)	(.007)		(.007)	(.003)	(.007)
Age	14.99	14.62	.37	***	14.55	15.00	−.44
	(.005)	(.010)	(.010)
Marital Status
Single, never Married	.22	.31	−.08	***	.41	.21	.20	***
Married	.55	.47	.08	***	.33	.58	−.24	***
Widowed	.07	.02	.05	***	.06	.06	−.01	**
Divorced/Separated	.13	.18	−.05	***	.18	.13	.04	***
Religious Attendance	2.09	1.02	.86	***	2.32	1.91	.42	***
	(.005)	(.012)	(.012)		(.011)	(.005)	(.013)
Religiosity	5.16	3.80	1.36	***	5.91	4.78	1.13	***
	(.006)	(.017)	(.017)		(.016)	(.006)	(.017)
Lifetime Drug Use
Cocaine	.07	.71	−.63	***	.11	.18	−.07	***
Marijuana	.40	.98	−.57	***	.44	.50	−.06	***
MDMA/ecstasy	.02	.33	−.31	***	.04	.07	−.03	***
PCP	.00	.17	−.16	***	.02	.03	−.01	***
Inhalants	.04	.39	−.35	***	.03	.10	−.07	***
Stimulants	.06	.36	−.29	***	.04	.12	−.07	***
Sedatives	.06	.22	−.16	***	.03	.09	−.05	***
Tranquilizer	.12	.41	−.29	***	.08	.18	−.09	***
Heroine	.00	.11	−.10	***	.01	.02	−.00
Pain Relievers	.29	.59	−.30	***	.26	.35	−.09	***
Tobacco	.58	.90	−.32	***	.47	.66	−.18	***
Age of First Alcohol Use	2.90	1.98	.91	***	3.20	2.68	.52	***
	(.003)	(.004)	(.004)		(.007)	(.002)	(.008)
Self-Reported Risky Behavior	1.58	2.01	−.42	***	1.41	1.69	−.27	***
	(.001)	(.004)	(.005)		(.004)	(.001)	(.004)

Source: 2005–2019 National Survey of Drug Use and Health, n = 421,477.

Calculate using post-estimation LINCOM (non-linear combination) commands, which compute the statistical difference of two subpopulation means.

Standard deviations in parentheses.

*p < 0.05, **p < 0.01, ***p < 0.001 (two-tailed).

Regression analysis – full models

Table 3 presents results from the regression analysis which includes all controls. Like previous studies that this research is replicating, LCPU is associated with less heart diseases (Model 1) (b = -0.229, p < 0.05) and less hypertension (Model 3) (b = -0.138, p < 0.001). LCPU is also associated with lower BMI scores (Model 5) (b = -0.386, p < 0.001). Interestingly, while Black people have less heart disease (Model 1) (b = -0.346, p < 0.001), they also have higher hypertension (Model 1) (b = 0.508, p < 0.05) and body mass index scores.

Table 3.

Weighted logistic regression predicting using classic psychedelics with interaction terms.

	Heart Disease		Hypertension		Body Mass Index
	Model 1	Model 2	Mode 3	Mode 4	Mode 5	Mode 6
Explainer Variables
LCPU	−0.229*	−0.249**	−0.138***	−0.160***	−0.386***	−0.361***
	(0.0881)	(0.0914)	(0.0350)	(0.0363)	(0.0604)	(0.0625)
Black	−0.346***	−0.362***	0.508***	0.493***	1.826***	1.853***
	(0.0666)	(0.0667)	(0.0244)	(0.0256)	(0.0716)	(0.0724)
Interaction Terms
LCPU*Black		0.313		0.281*		−0.518*
		(0.254)		(0.114)		(0.223)
Constant	−17.70***	−17.68***	−10.46***	−10.44***	25.27***	25.26***
	(0.447)	(0.447)	(0.155)	(0.155)	(0.194)	(0.193)
Observations	263664	263664	263589	263589	196948	196948
R ²					0.043	0.043

Source: 2005–2019 National Survey of Drug Use and Health, n = 421,477.

Standard errors in parentheses.

p < 0.05, ** p < 0.01, *** p < 0.001.

Note: All models control for gender, age, education, family income, marital status, religiosity, drug history, risky behavior, psychological distress, and survey year. See online supplemental table 1 for full models.

Interaction terms and regression models by race

Interaction terms and the regression models that were run by race groups reveal important relationships between LCPU and race on health outcomes. First, while there was no significant interaction between race and LCPU on heart disease (Table 3, Model 2), the association between LCPU and hypertension was significantly attenuated for Black people (Model 4) was significantly attenuated for (b = 0.281, p < 0.05). Interestingly, Model 6 reveals that association between LCPU and Body mass index was significantly enhanced for Black people (b = -0.518, p < 0.05). However, when the analysis is run by race (Table 4), there is no association between LCPU and heart disease, hypertension, or BMI for black people. On the other hand, LCPU remains significantly negatively correlated for white people for all three variables (Model 1, 3, and 5). Overall results both replicate previous studies on the positive relationship between LCPU and cardio-metabolic disease, as well as confirm the Minorities’ Diminished Psychedelic Returns Theory.

Table 4.

Weighted logistic regression predicting using classic psychedelics with interaction terms.

	Heart Disease		Hypertension		Body Mass Index
	White	Black	White	Black	White	Black
	Model 1	Model 2	Model 3	Model 4	Model 5	Model 6
Explainer Variables
LCPU	−0.186*	−0.223	−0.149***	0.107	−0.441***	−0.508
	(0.0896)	(0.256)	(0.0373)	(0.135)	(0.0668)	(0.303)
Constant	−18.11***	−15.59***	−10.50***	−9.742***	26.12***	23.95***
	(0.479)	(1.180)	(0.170)	(0.341)	(0.203)	(0.483)
Observations	222028	41636	221960	41629	164515	32433
R ²					0.038	0.057

Source: 2005–2019 National Survey of Drug Use and Health, n = 421,477.

Standard errors in parentheses.

* p < 0.05, ** p < 0.01, *** p < 0.001.

Note: All models control for gender age, education, family income marital status, religiosity, drug history, risky behavior, psychological distress, and survey year. See online Supplemental Table 2 for full models.

Discussion

This study examined racial differences of psychedelic use among the general population. As discussed above, research has shown that psychedelics may be beneficial for health and wellbeing. Unfortunately, the relationship that marginalized groups have with psychedelics is largely unexplored with a lack of diversity extending into current clinical psychedelic research. Pooled analyses of contemporary clinical trials on psychedelics have found that White individuals comprise over 80% of study participants, substantially underrepresenting BIPOC, and according to Thrul & Garcia-Romeu (2021), calls into question the generalizability of findings to non-White populations (Garcia-Romeu et al., 2021; Michaels et al., 2018). For instance, in one phase 2 trial on the effects of psilocybin on treatment-resistant depression that was concluded in 10 countries in Europe and North America, 215 (92%) of the 233 participants were White (Goodwin et al., 2022). In another study on the effects of MDMA on eating disorders, about 90% of participants were White (Brewerton et al., 2022). Even in research trying to analyze the efficacy of these drugs for marginalized people, results may not paint an accurate picture of marginalized peoples’ experiences. In their study of the effects of ethno-racial differences of MDMA therapy on PSTD, not only was the sample size of BIPOC sample (29%) admittedly too small to detect “ethno-racial group differences” (Ching et al., 2022, p. 984), their entire ethno-racial sample was a combination of all non-Whites whereby Asians (mostly middle and upper class) were overrepresented. Additionally, blacks and indigenous—two race groups with consistently the worst mortality and morbidity rates—were underrepresented. As demonstrated by scholars who study the intersectionality of race and gender (Collins & Collins, 2015), the lived experiences of marginalized people vastly differ. Thus, results from a sample of mostly class-privileged Asians are probably not applicable to Black and Indigenous people's lives.

The need to study marginalized groups is all the more important because of the dramatic legal and cultural shifts around psychedelic use. Results from the latest wave of the Monitoring the Future (MTF) panel study found recreational psychedelics use increased from 5% to 9% among college students between 2019 and 2021 (NIH, 2021). A 2022 NPR report found that thousands of mothers across the U.S. are microdosing with “magic mushrooms” to cope with parent-related stress (Sherry, 2022). On the legal front, the US Food and Drug Administration (FDA) has designated psilocybin and MDMA with the “breakthrough” therapy designations, which fast tracks further federally funded research (Lamkin, 2021). In 2020, Oregon became the first state to legalize psilocybin for medical usage (Ollove, 2022). Other states and jurisdictions—including Connecticut, New Jersey, Colorado, California, Washington, Utah, and Texas—have followed suit by passing various legislative or ballot initiatives on a broad spectrum of decriminalization from personal use to state-funded research (Marks, 2023).

Despite a lack of research, some researchers have made the argument that psychedelics could positively impact BIPOC's health. They may even be a viable solution to ameliorate the negative psychological effects of racism itself. According to Smith et al. (2022, p. 11), the “trauma and PTSD caused by racism are serious and widespread psychological issues,” and psychedelics can be a viable solution in addressing consequences of negative race-based experiences. Drawing on the need for inclusivity, a MAPS Bulletin documents two events that provided MDMA therapy training for communities of color (Carlin, 2020). Although the program faced many challenges, they believe that programs like theirs are key to making psychedelic therapy more accessible to people of color (Carlin, 2020, p. 15).

Despite those claims, very little research has tested whether marginalized people actually benefit from psychedelics. This paper attempted to fill that gap by testing the effects of psychedelics on race by drawing on theory of Minorities Diminished Psychedelic Returns to argue that psychedelics will not be a windfall for race/ethnic health disparities. This study successfully replicated previous research using the NSDUH and analyzing health associated with psychedelic use, but it furthered the scholarship by finding evidence of Minorities’ Diminished Psychedelic Returns. First, both Black and White psychedelic use was associated with overall lower BMI scores. Moreover, because Black people had, on average, higher BMI scores, their use was associated with a larger decrease. Unfortunately, Black psychedelic use was not associated with better cardio-metabolic health. In total, like the body of scholarship on MDR, another important health resource—psychedelics—is not associated with improved cardiovascular health for Black people while white people continue to gain some benefits.

Why isn’t psychedelic use associated with better Black cardiovascular health despite its apparent association with lower BMI? In short, “racism is considered a fundamental cause of adverse health outcomes for racial/ethnic minorities and racial/ethnic inequities in health” (Williams et al., 2019, p. 105). Using sophisticated scales measuring levels of discrimination (Williams et al., 1997), ample research has demonstrated how discrimination leads to diminished physical health outcomes for minorities. Black people are more likely to experience both pervasive and everyday mistreatment (i.e., experiencing less courtesy or receiving poor commercial services), which is associated with a worse allostatic load, (Ong et al., 2017; Van Dyke et al., 2020),⁴ poorer sleep duration and efficiency (Slopen et al., 2016), greater systemic inflammation (Ong & Williams, 2019), a greater prevalence of distress and mental illness, worse negative coping behaviors such as smoking (Agunwamba et al., 2017), and worse late life cognitive function (Zeki Al Hazzouri et al., 2011). Research on fundamental causality demonstrates that there are many structural conditions that not only affect the efficacy of any one health intervention, but it emphasizes why health inequality associated with social fault lines (race, class, and gender) persist despite new interventions (Harder & Sumerau, 2018; Link & Phelan, 1995; Phelan & Link, 2015). Psychedelics are but one intervention while social stratification affects innumerable diseases, disease risk factors, and access to resources that can assist in avoiding health risks. Even with lower BMI scores, everyday racism and structural discrimination will still have cumulative negative impact on Black health. Since psychedelic benefits depend on set-and-setting, which is informed by psychosocial conditions, we should expect that the same conditions that diminish Black cardiovascular health across will remain persistent even if there are some health benefits (mental or physical) to psychedelic use.

One puzzling result was that Black people were less likely to be diagnosed with heart disease in the past year, which appears to go against all the literature. However, a follow-up analysis of the NSDUH found that Black people were more likely to be diagnosed with heart disease in their lifetime. This disparity is likely explained by the lack of healthcare options (Shippee et al., 2012; Togioka et al., 2022). Because Black people are less likely to use healthcare for a variety of reasons, they are less likely than white people to have the annual checkups that could catch heart disease. The NSDUH data is likely capturing the ability of White people to take advantage of health care and get an early diagnosis.

Limitations and future research

While this study reveals important associational relationships between race, psychedelics, and health, it also has several limitations. First, the primary limitation is the data. It is possible that minorities gain some benefit from psychedelics in the short term that are simply diminished over time. Longitudinal data that has the time of drug use would better indicate the decline in psychedelic efficacy. Second, unmeasured endogenous factors could also be driving the association among race, psychedelics, and distress. This study included a host of standard control sociodemographic control variables, but this is likely not an exhaustive list. In particular, common findings in the psychedelic clinical trial literature suggest other variables could affect outcomes, including personality traits, presence of peak experience, response to peak experience, and dosage. Other SES indicators including family structure, household size, employment, and segregation would be of interest in other research. And third, one particular limitation of the data is that lack of explanatory variables that illustrate the pathway between psychedelics and cardio-metabolic health. While the literature provides plausible pathways, and the extensive theory of Minorities Diminished Returns demonstrates ample ways in which any one health resources—including psychedelics—will be significantly moderated by inequality for Black people, the analysis cannot determine the causal mechanisms. However, the point of this analysis use a critical social/structural lens to examine potential areas in which psychedelics may be less impactful than previously hypothesis. Previous research has made the claim that psychedelics may lead to better cardio-metabolic health, and this study asks if those findings hold up for all populations. Finally, given the cross-sectional study design, the results cannot be used to make conclusive causal inferences especially because it cannot account for the motivation for use. Those who use psychedelics in clinical setting are likely doing so for health benefits while those who use it in a naturalistic setting will have many different motivations.

There are many important avenues for future research. Foremost, future research should replicate these findings across other marginalized groups such as Indian Americans, Hispanics, gender, immigrants, and those who are LGBTQ+. Second, future research should ask for more precise indicators of discrimination and motivation of psychedelic use to better understand how structural inequality is negatively impacting Black psychedelic use and outcomes. And finally, it is highly likely that different negative consequences of existing neighborhood/racial segregation (Bower et al., 2014; Sudano et al., 2013) may also play a role in these and other findings related to unequal psychedelic outcomes. In 2021, those in the lower class had a higher risk factor for all the top ten leading causes of death in America, which include heart disease, cancer, COVID, and accidents (Murphy et al., 2020). Those who live in the lower classes have higher rates of stress; are more likely to use harmful substances, including tobacco and alcohol (Bohm et al., 2021); and are less likely to have healthy diets or exercise (Bryan et al., 2021). Those in the lower classes are also more likely to be segregated into neighborhoods with serious structural problems, including crumbling infrastructure, pollution, and a lack of access to healthy foods (Bower et al., 2014; Kwate, 2008; Williams & Collins, 2001; Zenk et al., 2005). In terms of cardiovascular health and obesity, factors such as the density of fast foods, food deserts, and availability of fresh food products may also be impacting these diminished returns findings. Future research into the psychedelic's effects on health should consider that availability of these and other resources. Because poor physical health is consistently associated with worse mental health, it is likely that these factors associated with segregation may also partially explain the diminished mental health returns from psychedelic use.

Importantly, the cardiovascular disease variables were selected foremost for replication purposes. Unfortunately, because the variables were asked at different time periods, they only overlap in two years. Therefore, it is possible that the results are not reflective of the total population. A larger sample may have found that the reduction in BMI found among black participants for years 2015–2019 of the NSDUH did also see an improvement in cardiovascular health. This study contests, however, that overall research on MDR suggests that the probability is low considering other predictors of poor cardiovascular health that Black Americans face.

Conclusion: the importance of population studies

Limitations notwithstanding, this study adds a critical new piece to the burgeoning research on psychedelics and health. One may ask why research should consider race-related results from a population-level approach using a single lifetime use of classic psychedelics rather than those from clinical trials? First, these results represent how a population interacts with drugs in their everyday lives instead of in a controlled clinical environment. As psychedelics become more widely available, naturalistic use will rise faster than clinical treatment, especially in places where mental health treatment is severely underfunded.

Second and directly related, regardless of the motivation (clinical or recreational), psychedelics are associated with less distress (and many other health benefits that are found in nationally represented samples). Population studies are worthwhile so that researchers can investigate whether this holds true among all groups including Black Americans. However, here, results showed that an association does not exist between Black users related to cardio-metabolic health. Drawing on ample research into MDR, this paper argues that racism likely explains why among the regular population, White people have access to the set-and-setting privileges that appear to create some benefits of psychedelic uses while Black users gain little. Thus, in communities with health disparities, not only are they less likely to have access to clinical setting, they also live in a world with a significantly less optimal set-and-setting, leading to few positive outcomes. Given the focus, other confounding variables may explain the race differences there were found, but the results suggest that the difference and reason for the difference (racism) still exist.

Nevertheless, at the same time, future clinical research may find race/ethnic minorities benefit from the treatment in very controlled clinical settings. Furthermore, decriminalization should continue. Even so, MDPR explores why the race-health gap continuously widens and how racism drives the gap. Ultimately, all people live in communities and social situations that directly impact the efficacy of psychedelics, even those used in a clinic, and researchers need to acknowledge the social situation.

Therefore, even if Black people benefit within controlled clinical settings, whether they continue to enjoy those benefits in their everyday lived experiences, which are saturated with racism, remains another question. RDE scholars argue that enforcing civil rights will go further at reducing health inequality because these laws can grant access to social and psychological resources affect marginalized people's sense of self-respect improve affect health (Hahn et al., 2018). RDE scholars also argue that reductions in racial segregation and an enhancement in the availability of healthy foods in Black communities would go further in empowering Black communities and reducing cardiovascular related diseases. Without addressing racism and structural inequality, which plausibly affect all aspects of the psychedelic health career, these drugs are not likely to reshape Black or other marginalized groups health for the better, thus widening already wide health gaps.

Supplemental Material

sj-docx-1-dsp-10.1177_20503245231225756 - Supplemental material for Minorities’ diminished psychedelic returns: Cardio-metabolic health

Supplemental material, sj-docx-1-dsp-10.1177_20503245231225756 for Minorities’ diminished psychedelic returns: Cardio-metabolic health by Sean Matthew Viña in Drug Science, Policy and Law

Footnotes

Authors’ contributions

Sean Vina was the only contributing author to the study. Material preparation, data collection and analysis were performed by Vina. The first draft of the manuscript was written by Vina.

Availability of data and material

This project uses secondary data from the NSDUH which is available for download at

Code availability

STATA coding will be made available upon request by contacting the contributing author.

Consent to participate

This study uses publicly available secondary data. Consent to participate was provided to the NSDUH during their data collection period, and therefore was not needed by this research project.

Consent for publication

This study uses publicly available secondary data. Consent to publication was provided to the NSDUH.

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Ethics approval

This study uses publicly available secondary data. No ethical approval is required for this secondary analysis.

Supplemental material

Supplemental material for this article is available online.

Notes

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