Summary
Massachusetts Question 4 is a citizen petition-driven ballot initiative that would establish regulated access for adults aged 21 and over to certain natural psychedelic substances that show therapeutic potential in mental health, including psilocybin, psilocin, mescaline, dimethyltryptamine, and ibogaine. These substances could be purchased at an approved, state-regulated facility for use by adults under the supervision of a licensed facilitator; the initiative otherwise maintains the current prohibition on the retail sale of psychedelics.
The initiative would create a Natural Psychedelic Substances Commission to guide the facilitated access program and a Natural Psychedelic Substances Advisory Board to develop recommendations for the Commission on related regulatory and taxation policies. It would also remove criminal penalties for limited personal adult use of these substances.
Fiscal Impact
Question 4 is not directly associated with any significant fiscal impact on state or local governments. It would establish a new regulated access program for certain psychedelic compounds, which may have a slight overall net positive revenue impact for state and local governments generated by the combination of a new 15% excise tax on psychedelics sold at licensed facilities, sales taxes, local option taxes (up to 2%), licensing fees and civil penalties, less the costs associated with regulatory rulemaking, the new commission and advisory board, agency oversight, and program administration.
Proponents’ Arguments
Proponents’ primary rationale for Question 4 is clearly stated in Section 1 of the ballot language itself:
“The purpose of this act is to establish a new, compassionate, culturally responsible, and effective approach to natural psychedelic substances by: (a) establishing regulated access for adults 21 years of age and older to natural psychedelic substances that show therapeutic potential in increasing well-being and life satisfaction and improving mental health; and (b) adopting a public health approach to natural psychedelic substances by removing criminal penalties for limited personal use by adults 21 years of age and older. Its intent is to remove the personal use of natural psychedelic substances from the illicit market and to provide supervised, safe access in a therapeutic setting through a regulated and taxed system.” [Emphasis added]
According to the Yes on 4 campaign’s website, operated by Massachusetts for Mental Health Options:
Natural psychedelic medicine is a breakthrough therapy for mental health. Pioneering research from the nation’s top medical institutions shows that natural psychedelic therapies can be effective for PTSD, depressive disorders, severe anxiety, and many other difficult-to-treat conditions. The FDA has designated these promising new treatments as a “breakthrough therapies” due to their improvement over existing tools […]
Question 4 will enable therapeutic access to natural psychedelic medicines that show promise in treating mental health conditions. The measure establishes a compassionate approach grounded in public health and removes criminal penalties for limited personal use of natural psychedelic medicines. Question 4 creates a regulated framework for supervised use with trained facilitators at licensed psychedelic therapy centers. It requires participants to undergo safety screenings prior to receiving psychedelic therapy services and does not legalize retail sales or storefronts.
In a March 2024 legislative committee hearing on the proposed initiative, Sarko Gergerian, a Massachusetts police lieutenant, therapist, and representative of the National Law Enforcement Action Partnership, testified:
“Our citizens, our police officers, and all first responders need access to psychedelics for psychospiritual/religious wellness, self-care, capacity building, resilience expansion and the treatment of mental health challenges.”
Opponents’ Arguments
The Massachusetts Coalition for Safe Communities was organized in May 2024 to oppose Question 4. A spokesman for the coalition commented that the coalition’s opposition was based on the initiative’s home-grow provisions—not expanded access to psychedelics themselves. “We’re not arguing against the therapeutic value,” a coalition spokesman told the State House News Service in May. “We see real danger in the ability to grow at home, especially the square footage it allows.” Question 4 allows home cultivation of natural substances in an up to 12×12 foot area within a home, facilitating individual consumption while maintaining all current laws against illicit sales.
The Coalition also cites three other challenges to Question 4, generally related to safety. First, they argue that DUIs and drugged driving have generally been on the rise in recent years in Massachusetts and imply that expanding legal access to psychedelics could exacerbate the situation. Second, they are concerned that decriminalizing psychedelics and allowing for home-grow will put children and pets at risk of accidental consumption. Lastly, the coalition claims that the psychedelic centers that would be legalized under the state’s regulatory framework established in Question 4 would have several flaws, including the lack of a mandate that licensed psychedelic centers be run by medical professionals and that they would not be prohibited from giving psychedelics to high-risk patients (e.g., pregnant or breastfeeding). According to the Coalition’s website, “It is clear these for-profit centers put corporate profits over public health.”
Discussion
Massachusetts voters are considering Question 4 at a time when many states are considering medical access to psychedelics. After nearly a half-century of criminalization, given the abundant and growing research on the potential of psychedelic compounds in tackling major mental health conditions like PTSD, addiction, treatment-resistant depression, anxiety, and more, federal and state lawmakers are exploring options for creating access for patients.
Today there are dozens of clinical trials underway globally pairing up various psychedelic compounds with various mental health conditions in a quest for therapeutic innovations that outperform existing pharmacological interventions, and practically every top Ivy League and elite university in the country has established a dedicated psychedelic research center digging deep into the neuroscience and mechanisms of action around psychedelics.
Recognizing the re-emergent promise of psychedelics, the U.S. Food and Drug Administration (FDA) put two psychedelic compounds on an expedited path of approval for use in serious mental health conditions. In 2017, the FDA granted a “Breakthrough Therapy Designation” for midomafetamine (MDMA, or “Molly”) for the treatment of posttraumatic stress disorder, and in 2018 and 2019, the agency designated psilocybin as a breakthrough therapy for severe treatment-resistant depression and major depressive disorder, respectively. Earlier this year, the FDA granted a breakthrough therapy designation to a proprietary deuterated psilocybin analog to be used for the adjunctive treatment (e.g., used alongside other existing approved treatments) of major depressive disorder.
In August 2024, the FDA declined to approve the final application by Lykos Therapeautics for MDMA-assisted therapy for PTSD, opting instead to request the applicant conduct additional Phase III clinical trials, in part to address methodological concerns that arose in previous trials to date. While a setback, there are several additional psilocybin-related Phase III clinical trials underway now and in line for potential FDA approval, and media reports suggest that the companies involved are calibrating their approaches based on the lessons learned from Lykos’ experience to date.
As the FDA has been taking cautious steps to open the door to potential limited approval, dozens of local governments nationally began to enact policies to deprioritize psychedelics as a local law enforcement matter. Several local governments in Massachusetts enacted psilocybin decriminalization policies by city council resolution in 2021 and 2023, including Salem, Somerville, Cambridge, Northampton, and Easthampton. City councils in both Somerville and Cambridge enacted resolutions in July and August 2024, respectively, formally endorsing Question 4 as public bodies.
In 2022 and 2023, respectively, Oregon and Colorado launched the nation’s groundbreaking programs authorizing licensed and regulated natural psychedelic medicine therapy. The experience to date of Oregon and Colorado implementing policies substantially similar to those within Question 4 helps to inform what Massachusetts citizens might expect under expanded access to psychedelic therapies. Research by Reason Foundation into the public safety impacts of decriminalized psychedelics in Colorado and Oregon suggests that fears of potential harm under expanded access may have been unfounded.
For example, Reason has not yet identified a law enforcement agency in Colorado that reports psychedelics as a public safety issue. “Psilocybin has not been a significant law enforcement issue in Denver either prior to or following the passage of [Colorado’s facilitated psychedelics access ballot measure],” a Denver Police Department representative told Reason researchers in 2023.
Additionally, Colorado Uniform Crime Reporting data reveal that there has not been a significant increase or decrease in the number of psychedelics-related crime incidents since passage, and data collected from the Colorado Hospital Association show no noticeable increase in psychedelics-related hospital incidences since legal access to psychedelics expanded. Similarly, analysis of hallucinogen-related crime data in Oregon suggests a general downtrend in DUIs, property crimes, and crimes against persons since before voters approved regulated, facilitated psychedelic services.
One thing that sets the Massachusetts measure apart from Oregon and Colorado is that Question 4 would allow individuals to grow natural botanical psychedelics (e.g., psilocybin mushrooms, San Pedro cactus, ayahuasca, iboga) in a space up to 12 feet by 12 feet in total area of an individual home, with a requirement that the space be secured from access by anyone under 21 years old. Home-grow would be limited to personal use and sharing without renumeration, and unlicensed professionals would not be allowed to sell psychedelic products or market their services. Given the availability of legal on-site access under Question 4, the relative difficulty of home cultivation, and the fact that underground cultivation is already happening (given the number of Massachusetts communities that have already decriminalized psychedelics), the likelihood that the home-grow provision of Question 4 will yield a dramatic increase in supply is low. Rather, the more likely outcome is a relief valve that allows people to grow their own therapeutic botanicals without having to engage the illicit market.
One reason that states are experiencing a dramatic uptick in interest in psychedelics policy is due to the advocacy coming from veterans and first responder communities. Veterans organizations like the Heroic Hearts Project, Veterans Exploring Treatment Solutions, and The Mission Within have been making the case that conditions like PTSD and traumatic brain injury affect hundreds of thousands of veterans and drive dozens of veteran suicides every single day. In part this is due to the limited effectiveness of existing therapies and pharmacological approaches. For example, Heroic Hearts Project reports that fewer than 10% of veterans who begin traditional PTSD treatment programs complete treatment and experience marked improvement. By contrast, preliminary research at the King’s College, London into the psychedelic programs operated by Heroic Hearts Project found that over 80% of veterans experience significant improvement after participating in just one psychedelic program.
Question 4 also contains several mechanisms that reflect awareness that expanded access to psychedelics comes with some risks in implementation that the state should monitor and, if necessary, course correct. First, the law mandates that the advisory board includes a subcommittee on implementation and outcomes “to develop recommendations on the requirements, methods, and reporting of information to measure the act’s success, safety, quality, and impact on individuals’ well-being.” Other subcommittees are charged with developing recommendations on public health issues; as well as law enforcement and first responder training. Additionally, the measure contains fairly restrictive limits on allowable amounts of psychedelic compounds for an individual to possess without facing civil penalties; for example, 1 gram of psilocybin or 1 gram of dimethyltryptamine (DMT).
Further, the facilitated access program contains many internal gates and guardrails designed to address risk. Patients are required to attend a preparation session with a facilitator in order to learn about what to expect with the process and what risks they may face. It also includes a complaint/disciplinary process for facilitators engaging in misconduct; as well as recordkeeping, privacy, and confidentiality requirements for facilitators and facilities.
Given the current legal status today, if veterans, first responders, or civilian trauma survivors want to access these compounds, they are either forced to go to the black market and take on major legal risk, or they can take on the high costs of venturing overseas to countries like Costa Rica, Peru, and Bermuda that allow access to psychedelics, having their psychedelic experiences there, and then undertaking the wraparound psychotherapy back here in the United States. Allowing for domestic access to psychedelic compounds under state regulated frameworks would create the opportunity to improve mental health outcomes for a much wider array of citizens.