Microdosing Prescription Medications vs. Psychedelics: A Psychiatrist's Explanation of Efficacy and Risks

This episode clarifies the concept of microdosing, distinguishing its application to psychedelic substances from its potential, and often ill-advised, use with prescription medications. Dr. Tracey Marks explains that microdosing psychedelics like LSD or psilocybin typically involves taking a fraction (1/10 to 1/20) of a recreational dose to achieve cognitive and emotional benefits without dissociative effects. However, she cautions that scientific research on the benefits and safety of psychedelic microdosing is still inconclusive, with some studies showing brain changes but others indicating potential negative impacts on mental functions. A significant point of concern is the illegality of many psychedelics, which complicates reliable sourcing. Dr. Marks then draws a clear line between psychedelics and prescription medications, emphasizing that the latter are engineered with specific pharmacokinetics—how they are absorbed, distributed, metabolized, and excreted. A core pharmacological principle is the minimum effective dose, below which a drug is unlikely to provide therapeutic benefit and may still cause side effects. Individual metabolic differences, influenced by liver enzymes and genetics, play a crucial role in how a person processes medication. She describes slow, rapid, and normal metabolizers, noting that genetic testing can determine metabolic status, though it is often expensive. Slow metabolizers, for instance, might experience more side effects from standard doses and may benefit from lower, but still therapeutically relevant, doses. Practical advice is offered for those considering dose adjustments for prescription medications. For slow metabolizers, taking a slightly smaller dose (e.g., 5-10mg of Prozac instead of 20mg) might be beneficial, but attempting a true "microdose" (1-2mg) is generally ineffective and impractical due to the difficulty of precise measurement from tablets. She recommends seeking medications available in liquid form for accurate small dosing. A critical warning is issued against cutting or crushing extended-release (XR/ER) formulations, as this destroys the controlled-release mechanism, leading to rapid drug release and loss of intended duration. Vyvanse is mentioned as an exception where its internal spansules maintain extended-release properties even if the capsule is opened. The episode concludes by highlighting that while a slow titration schedule may be necessary for some individuals, potentially requiring liquid forms or easily breakable tablets, this will prolong the time needed to achieve desired therapeutic effects. For example, antidepressants typically take 4-6 weeks at a therapeutic dose, but a very slow titration could extend this to several months. The overarching message is that while dose adjustments for prescription medications should always be done under medical supervision, the concept of microdosing, as applied to psychedelics, is generally not appropriate or safe for prescription drugs due to their distinct pharmacological profiles and delivery systems.

"Microdosing usually refers to how to take a psychedelic substance like LSD or psilocybin."

"The idea is to get the cognitive and emotional benefits from the drug without experiencing the dissociative effects."

"But the scientific research is still trying to catch up with these claims."

"Prescription medications are a completely different ballpark."

"A fundamental principle in pharmacology is the concept of the minimum effective dose."

"Doses less than that aren't likely to do much for your symptoms and only subject you to side effects."

"Most of the psychiatric medications are metabolized in the liver and those liver enzymes are controlled by your genes."

"You cannot cut or crush drugs that are an extended release formulation."

"Once you cut that coating, you lose the extended release feature and then a medication that was designed to last for 24 hours may only last in your system for a few hours."

"We expect that antidepressants will take four to six weeks to work when prescribed at a therapeutic dose."