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The ‘Last Mile Problem’ for Psychedelic Medicine

There has been incredible scientific, regulatory and policy progress in moving Psychedelics and psychedelic based treatment forward legally and responsibly.

This is due to a network of passionate advocates, therapists, clinicians, researchers, and enthusiasts.

The work of MAPS is probably the most obvious place to start when thinking about the slow, plodding and patient focus required to move MDMA from a schedule 1 drug, illegal to study and impossible to use in a clinical setting, to the brink of FDA approval for Post-Traumatic Stress Disorder.

MAPS was started in 1986 with the vision to usher psychedelic medicine from illegality and disrepute to legitimacy.

And they are on the cusp of success.

While slow, and painstaking, taking place over the course of decades this early and dedicated effort is opening doors for others.

Other organizations, other companies, other scientists, other molecules.

More funding, more possibility, more acknowledgment, more access.

At the time of writing there are no less than 10 incorporated entities that plan to move a psychedelic molecule or extract from a psychedelic plant or compound through the regulatory hurdles required to bring such a compound to market as a prescription pharmaceutical.

Three of these organizations have already received Breakthrough Therapy Distinction from the FDA, the clearest sign of future approval.

This is a sign of progress.

This week the NIH is hosting a presentation by Roland Griffiths on “Psilocybin: History, Neuropharmacology, and Implications for Therapeutics” that I believe is the bellwether to a changing wind of NIH funding of psychedelic science.

Doors are opening and progress is accelerating.

Psychedelic Medicine has reached the Last Mile

But we’re not in the clinic yet.

Patients outside of clinical trials cannot yet receive treatment.

Getting the treatment to patients requires solving the ‘Last Mile Problem’.

The term "last mile" was originally used in the telecommunications field but has since been applied to supply chain management. Transporting goods via freight rail networks and container ships is often the most efficient and cost-effective manner of shipping. However, when goods arrive at a high-capacity freight station or port, they must then be transported to their final destination. This last leg of the supply chain is often less efficient, comprising up to 28% of the total cost to move goods. This has become known as the "last mile problem. - Wikipedia

Air Travel also offers an example of the Last Mile Problem.

Let's say your traveling from New York to San Francisco. While you are in flight you are moving 500 miles per hour. The price to distance to the time ratio is at its maximum. You are covering more ground at less cost in less time.

Once you have landed the cost to time to distance equation goes up exponentially. You cover less ground, over a longer time, at a higher cost. An Uber is a slower, less cost and time-efficient than a jet, it takes 4 minutes to travel the ten miles from the airport to the Mission.

In the air, it took 60 seconds to cover 10 miles.

The Last Mile Problem is a feature of complex ecosystems, not just travel, transport, and telecom and can be applied to science and medicine.

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Last Mile Problem in Medical Science

There is hope, excitement and enthusiasm bursting from the psychedelic community who seek to make whole victims of trauma and those suffering from crippling depression and addiction.

The promise of psychedelic medicine is the relief of an untold amount of human suffering.

As a community hoping to usher in this transformation I think it is important to understand the potential blind spots and try to mitigate the unintended negative consequences as much as we can.

Step one is to curb the enthusiasm and find examples of hyper-optimism that we can learn from.

Psychedelic-optimism Mirrors Techno-optimism

Psychedelic optimism has a parallel in the technophile, data-driven ‘tech will save the world’ techno-optimism salvation narrative.

Perhaps the high chief of this belief system is the drop-out turned entrepreneur turned tech-enabled philanthropist, Mark Zuckerberg.

This week Zuckerberg was joined by Economist Tyler Cowen and Patrick Collison, founder, and CEO of Stripe, an online payment platform company for a conversation about measuring progress for his podcast called Tech & Society with Mark Zuckerberg.

Oh, the irony.

Below is an exchange that captures so well the blind faith of technophiles like Zuckerberg, who can explain why they are right with math and reason and logic and data and Tyler Cowen’s refusal to accept such sterile optimism and chastising the surefootedness of Zuckerberg with clarity and aplomb.

Zuckerberg:

Yeah. So let's go deep on medical research here for a second…The Chan Zuckerberg Initiative (CZI), the philanthropy that I run with my wife, a big focus of it is on medical research…we have this aspirational goal that we wanna help build tools that can help scientists cure, prevent, or manage all diseases by the end of this century… And basically, the math of how you get there is, you know, starting about 100 years ago, call it, you know, there was really this uptick in medical research where we started doing randomized control experiments, treating it more like an experimental science. Since around that time, the average life expectancy has increased by 1/4 of a year every year, relatively… There's no guarantee, of course, that that continues, but if we're able to have that continue, then that would imply that by the end of the century we will generally have had to have either cure, prevent, or be able to manage most if not all of the diseases that we're aware of now. So there's some trend that suggests that this should be reasonable, and the approach that we're taking in the work at CZI is largely about building tools to help compound the rate of science.

So Zuckerberg believes he understands the math and the tools required to cure disease. A noble Moonshot for sure but also a great tool to counter the narrative of how destructive his company has been for the fabric of society. Remember when The Social Network came out, he donated $100 million to Newark Public Schools, money that was awesomely squandered.

The guy believes that you can throw money and tech at an issue, then whatever trend you want to see continue will continue in that manner.

But here comes Cowen:

Here's what worries me, and it should worry you too. So as you mentioned, U.S. life expectancy is basically going up in linear fashion. But if you look at expenditures, we used to spend a few percentage points of GDP on healthcare, and now it's about 18%. So we've gone up to 18%, and we're not even boosting the rate. I'm not saying it's the fault of any one group of people, but something has gone wrong. There's some kind of last-mile problem. You can turn to the newspapers and read all kinds of fantastic stories--new research, new ideas, new tools--but when the rubber hits the road, people living longer, we're spending more and more and more for exactly the same returns. So if that trend continues…the question becomes, you know, where does all the progress go?

Where Does All the Progress Go?

Medical Science is subject to The Last Mile Problem, though it is less obvious, in the form of deceleration of ROI and phase-change of constraints as it exits the lab and diffuses into actual patient care.

Nearly every scientific advance, discovery or new technology, at the time of discovery, is lauded as the key to solving some massive problem, a disease cure, or the missing link to cutting costs, expanding access or some other holy grail.

Electronic medical records is a perfect example.

EMR was supposed to save time and money. It was supposed to make doctors better, more efficient, make fewer mistakes, have better communication with colleagues and streamline a medical system that relied on paper notes and charts.

Show me one doctor who believes the ‘softwarization’ of medicine makes her a better physician.

The same is true when the Human Genome Project announced they had encoded the entire human genome. The headlines and hopes and aspirations at the moment of discovery dwarf any real success made clinically.

After the fanfare of discovery and the prognostication about the future, the work of going from discovery to utility begins.

And this is the hard part.

Very often the excitement is overwhelmed by the challenge, unforeseen roadblocks, unknown unknowns, and other impediments to implementation as envisioned in the excitement of discovery.

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The Last Mile is the First Mile in Psychedelic Medicine

In psychedelic medicine, the Last Mile Problem has the unique feature of also being the First Mile Problem.

Since this phase change marks the advent of a new form of treatment to the healthcare system, the challenge of going from the lab to the clinic is the end of one era and the beginning of the next.

Last Mile/First Mile Issues for Psychedelic Medicine:

The last mile could prove more challenging than the psychedelic community is anticipating because

The compounds in question are combined with psychotherapy and the therapists require additional training and credentialing

The clinics will need to meet certain criteria to be allowed to administer the treatment

Insurance and third party reimbursement is not a guaranteed

The patient population has a condition that makes life more challenging to get out of bed and make it to appointments and keep appointments

The cultural baggage the psychedelics carry

The built-in frenzied enthusiastic community of psychonauts… For all of these reasons, the last mile will not be straightforward.

But Really It's the First Mile Problem.

The inverse way of seeing this problem is as the first-mile problem. Getting started has setbacks, hurtles, obstacles that are tough to see coming.

For all of the above-mentioned reasons why the last mile will prove challenging, they perhaps hold the key to creative thinking, imagination and a different way of doing things.

Because the compounds in question are combined are novel and unique in the manner in which they provoke insight and awakening and because the treatment is done with a guide under a transpersonal framework, this form of treatment will lend itself to alternative forms of payment, reimbursement. Patients who might not be willing or ready to pay for mere pills or mere therapy might find this combination appealing enough to overcome.

Because the training required to participate in psychedelic therapy is new, unique and selects for certain qualities (compassion, insight, experience, etc.), because this training is outside the federally funded tuition assistance programs, people who want to be there will be there and psychedelic medicine will not add to the body count of debt-riddled alternative medicine providers.

Because the clinical infrastructure and staff training are new and unique, efforts can be taken to avoid the pitfalls of the non-profit, shit-hole hospitals and clinics strewn across America that drive up costs and diminish care and value

Because insurance and third-party payers don’t know how to price and reimburse this form of care, there will be an opportunity to step out of the insurance model and create incentives in which patients and providers have skin in the game.

Because these compounds are seeking to address the suffering of trauma, addiction, depression; conditions of self-regulation, conditions that most shy away from, this offers an opportunity to think differently and act differently and deliver care differently.

Because there is a robust and active community of people across the world who have gained so much from these plants and molecules there are resources that can and should be leveraged.

We’re in the midst of a revolution in consciousness, medicine, and health.

The transition, already underway, from underground, illegal and sacred to commercialized, legal and profane is fascinating, scary, hopeful and will only become more so.

If you’re as fascinated by this transition as we are, The Trip Report has you covered.

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