Substance use disorders (SUDs) — alcohol use disorder (AUD), opioid use disorder (OUD), tobacco use disorder, cocaine use disorder, cannabis use disorder, and others — affect roughly 1 in 5 Canadians in their lifetime (Statistics Canada CCHS). Canada is in an ongoing opioid-toxicity crisis driving substantial mortality and morbidity. Standard-of-care treatments — OAT (opioid agonist therapy; methadone, buprenorphine/naloxone) for OUD; naltrexone, acamprosate, disulfiram for AUD; varenicline, NRT (nicotine replacement therapy) for tobacco use disorder; CBT (cognitive behavioural therapy), contingency management; 12-step programs — are foundational. This article is a Canadian evidence-and-pathway guide to psychedelic-assisted therapy as an emerging adjunct or alternative: psilocybin for alcohol use disorder with Bogenschutz 2022 JAMA Psychiatry as the pivotal phase 2 evidence; ketamine for AUD and cocaine use disorder with growing real-world use; MDMA-AT for AUD with smaller emerging evidence; and the SAP-investigational pathways and insurance realities. Importantly, psychedelic-assisted therapy does NOT replace standard-of-care addiction treatment — particularly opioid agonist therapy for OUD.
Key takeaways
- Substance use disorders affect ~1 in 5 Canadians lifetime. Canada is in an ongoing opioid-toxicity crisis.
- Standard-of-care treatments are foundational: opioid agonist therapy (methadone, buprenorphine/naloxone) for OUD; naltrexone, acamprosate, disulfiram for AUD; varenicline, NRT for tobacco; CBT, contingency management; 12-step programs.
- Psilocybin for AUD has the strongest published evidence: Bogenschutz et al. 2022 JAMA Psychiatry phase 2 RCT showed significant reduction in heavy drinking days at 32 weeks (n=93; psilocybin + therapy vs diphenhydramine + therapy).
- Garcia-Romeu 2014 / Johnson 2014 tobacco: open-label psilocybin-assisted smoking cessation showed high abstinence rates at 12 months.
- Ketamine for AUD: Krupitsky 1997, Krupitsky 2002, Dakwar 2019 — emerging but evidence-base smaller than TRD.
- Ketamine for cocaine use disorder: Dakwar 2019 RCT showed signal.
- MDMA-AT for AUD: smaller emerging evidence.
- No psychedelic-assisted therapy is Health Canada-approved for SUD.
- Psychedelic-assisted therapy does NOT replace OAT for OUD — particularly important given opioid-toxicity crisis context.
- Insurance: SUD-specific psychedelic coverage is essentially non-existent. Provincial public addiction services funding the standard-of-care treatments.
Defining substance use disorders
DSM-5 SUD criteria (severity rated by number of criteria met):
- Mild: 2-3 criteria
- Moderate: 4-5 criteria
- Severe: 6+ criteria
Specific SUDs include AUD, OUD, cocaine use disorder, tobacco use disorder, cannabis use disorder, stimulant use disorder, hallucinogen use disorder, and others.
The SUD evidence map for psychedelic-assisted therapy
Psilocybin — strongest SUD evidence is in AUD
- Bogenschutz MP, Ross S, Bhatt S, et al. 2022 (PMID 36014054). JAMA Psychiatry, 79(10):953-962. Phase 2 RCT of psilocybin-assisted therapy for AUD; n=93; psilocybin + therapy showed significantly fewer heavy drinking days vs diphenhydramine + therapy at 32 weeks.
- Bogenschutz 2015 (PMID 25586396): open-label phase 2 in AUD showed feasibility signal.
- Garcia-Romeu A, Johnson MW, Griffiths RR. 2014 — open-label psilocybin-assisted smoking cessation; 80% biologically confirmed 6-month abstinence in small sample (n=15).
- Johnson 2014, Johnson 2017 (PMID 28447925): tobacco cessation 12-month follow-up showed sustained signal.
Ketamine — emerging SUD evidence
- Krupitsky 1997, 2002 (Russian trials): ketamine-assisted psychotherapy for AUD/heroin
- Dakwar et al. 2019 (PMID 31272208): RCT of single-dose IV ketamine + motivational enhancement therapy in cocaine use disorder
- Dakwar et al. 2020 (PMID 32340401): RCT of IV ketamine for AUD
- Real-world Canadian KAP: increasing use in TRD patients with comorbid AUD
MDMA — emerging SUD evidence
- MDMA-AT for AUD: smaller emerging signal; investigational
- MDMA-AT for PTSD with comorbid SUD: relevant given high PTSD-SUD comorbidity
Spravato — NOT for SUD
Spravato (esketamine) is Health Canada-approved for treatment-resistant depression (TRD) only. Not approved for SUD.
For more detail see Psilocybin for Alcohol Use Disorder, Ketamine Therapy for Addiction, and the Ketamine Therapy in Canada guide.
Decision framework — comparing SUD options
| Factor | Standard-of-care | Psilocybin (SAP) | Off-label ketamine |
|---|---|---|---|
| Health Canada approval | Yes (OAT, naltrexone, etc.) | No (SAP investigational) | No (off-label; med approved as anaesthetic) |
| Strongest SUD-specific evidence | Substantial RCT base; many decades | AUD (Bogenschutz 2022); tobacco (Garcia-Romeu/Johnson) | AUD/cocaine (Dakwar 2019, 2020) |
| Insurance coverage | Yes (provincial drug plans, public addiction services) | No | Generally no |
| Coordination with addiction medicine | Foundational | Adjunct only — not replacement | Adjunct only — not replacement |
Critical point: psychedelic-assisted therapy is appropriately considered as an adjunct to standard-of-care addiction medicine, not as a replacement. Particularly for opioid use disorder, opioid agonist therapy (methadone or buprenorphine/naloxone) saves lives in the context of Canada's opioid-toxicity crisis.
Canadian access pathways
Standard-of-care SUD treatment
- Provincial public addiction services: Alberta Addiction & Mental Health, BC Mental Health and Substance Use Services, Ontario CMHA / RAAM clinics, Quebec CIUSSS programs
- Provincial drug plans: cover OAT (methadone, buprenorphine/naloxone), naltrexone, acamprosate, disulfiram, varenicline, NRT
- Private addiction medicine: ASAM-credentialed providers across Canada
Psychedelic-assisted therapy adjunct pathways
- Out-of-pocket: dominant pathway for SUD-indication psychedelic-assisted therapy
- Psilocybin SAP: case-by-case Health Canada approval; SUD-primary indications less commonly approved than for end-of-life distress
- Off-label ketamine: ~$400–$1,500/session out-of-pocket
- Workers' compensation: case-by-case for compensable underlying injury with SUD comorbidity
What the evidence does NOT say
- No psychedelic-assisted therapy is Health Canada-approved for SUD.
- Psychedelic-assisted therapy is NOT a replacement for opioid agonist therapy. OAT (methadone, buprenorphine/naloxone) is foundational for OUD and saves lives. Patients should not interrupt OAT to pursue psychedelic-assisted therapy without close coordination with their OAT prescriber.
- Bogenschutz 2022 JAMA Psychiatry is the strongest SUD-specific evidence to date; phase 3 evidence is not yet complete for any SUD indication.
- Effect sizes: Bogenschutz 2022 showed significant but partial reduction in heavy drinking days, not abstinence in all participants.
- Safety considerations: psilocybin and MDMA require comprehensive screening — psychotic-disorder personal/family history excludes; severe cardiovascular conditions; medication interactions (particularly MDMA + SSRI/MAOI, naltrexone considerations).
- Hallucinogen use disorder: a recognized DSM-5 diagnosis; some patients may have problematic relationships with psychedelic substances themselves. Clinical screening includes this history.
How ATMA CENA works with SUD patients
ATMA CENA's SUD pathway:
- Comprehensive intake: SUD history, prior treatments, current OAT or other medications, comorbid conditions, screening for psychotic-disorder risk
- Three-phase model: preparation + dosing + integration
- coordinated care: addiction medicine specialist remains primary; existing relapse-prevention work continues
- Coordination with addiction medicine: ATMA CENA will work with patient's existing addiction medicine team rather than displacing it
For more detail see Psilocybin for Alcohol Use Disorder and Ketamine Therapy for Addiction.
Frequently asked questions
What's the strongest psilocybin SUD evidence? Bogenschutz et al. 2022 JAMA Psychiatry phase 2 RCT of psilocybin-assisted therapy for alcohol use disorder. n=93; significant reduction in heavy drinking days at 32 weeks vs diphenhydramine + therapy.
What about psilocybin for tobacco cessation? Garcia-Romeu 2014 / Johnson 2014, 2017 open-label trials showed high biologically confirmed abstinence rates at 6-12 months in small samples. Phase 2 RCT data emerging.
What about ketamine for cocaine use disorder? Dakwar et al. 2019 RCT of single-dose IV ketamine + motivational enhancement therapy showed signal for reduction in cocaine use. Effect sizes smaller than for TRD; sustained-effect data more limited.
Can psychedelic-assisted therapy replace methadone or Suboxone for OUD? No. Opioid agonist therapy (methadone, buprenorphine/naloxone) is foundational for OUD and saves lives in the context of Canada's opioid-toxicity crisis. Patients should not interrupt OAT to pursue psychedelic-assisted therapy without close coordination with their OAT prescriber.
What about MDMA-AT for AUD? Smaller emerging evidence base. MDMA-AT phase 3 program is for PTSD; AUD studies are earlier-phase.
Should I keep doing AA / 12-step? Yes, if it's been helpful. Twelve-step participation is a foundational community-based addiction recovery resource. Psychedelic-assisted therapy can complement community recovery rather than replace it.
What about Spravato off-label for SUD? Spravato is Health Canada-approved for TRD only. Off-label use for SUD is not appropriate first choice given absence of approved indication and stronger Bogenschutz 2022 psilocybin evidence.
What's the cost?
- Off-label IV ketamine: ~$500–$1,500/session (typically ~$400–$1,000 in coordination with addiction medicine)
- Psilocybin SAP: variable; supply via Filament Health no-charge SAP option exists; clinical hours separate
- Insurance coverage for SUD-specific psychedelic-assisted therapy is essentially non-existent.
Are there Canadian SUD trials I can join?
What about hallucinogen use disorder? Some patients have problematic relationships with psychedelic substances themselves. Clinical screening includes this history. Patients with active hallucinogen use disorder may not be appropriate candidates for psychedelic-assisted therapy without specialized assessment.
Sources
- Bogenschutz MP, Ross S, Bhatt S, et al. (2022). Percentage of Heavy Drinking Days Following Psilocybin-Assisted Psychotherapy vs Placebo in the Treatment of Adult Patients With Alcohol Use Disorder: A Randomized Clinical Trial. JAMA Psychiatry, 79(10):953-962. PMID: 36014054.
- Bogenschutz MP, Forcehimes AA, Pommy JA, et al. (2015). Psilocybin-assisted treatment for alcohol dependence: a proof-of-concept study. J Psychopharmacol, 29(3):289-99. PMID: 25586396.
- Garcia-Romeu A, Johnson MW, Griffiths RR. (2014). Psilocybin-occasioned mystical experiences in the treatment of tobacco addiction. Curr Drug Abuse Rev, 7(3):157-64. PMID: 25563443.
- Johnson MW, Garcia-Romeu A, Griffiths RR. (2017). Long-term follow-up of psilocybin-facilitated smoking cessation. Am J Drug Alcohol Abuse, 43(1):55-60. PMID: 27441452.
- Dakwar E, Nunes EV, Hart CL, et al. (2019). A Single Ketamine Infusion Combined With Mindfulness-Based Behavioral Modification to Treat Cocaine Dependence: A Randomized Clinical Trial. Am J Psychiatry, 176(11):923-930. PMID: 31272208.
- Dakwar E, Levin F, Hart CL, et al. (2020). A Single Ketamine Infusion Combined With Motivational Enhancement Therapy for Alcohol Use Disorder: A Randomized Midazolam-Controlled Pilot Trial. Am J Psychiatry, 177(2):125-133. PMID: 32340401.
- Krupitsky EM, Burakov AM, Romanova TN, et al. (2002). Ketamine psychotherapy for heroin addiction. J Subst Abuse Treat, 23(4):273-83. PMID: 12495781.
- Health Canada — SAP psychedelic-assisted psychotherapy: https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/announcements/requests-special-access-program-psychedelic-assisted-psychotherapy.html
- Canadian Centre on Substance Use and Addiction (CCSA): https://ccsa.ca/
- CRISM Canadian opioid use disorder national clinical practice guideline: https://crism.ca/projects/opioid-use-disorder-national-guideline/
- ASAM (American Society of Addiction Medicine) — clinical guidelines: https://www.asam.org/quality-care/clinical-guidelines
- Public Health Agency of Canada — Opioid- and Stimulant-related Harms: https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/
Related articles
- Psilocybin for Alcohol Use Disorder
- Ketamine Therapy for Addiction
- Treatment-Resistant Depression and Psychedelic-Assisted Therapy
- PTSD and Psychedelic-Assisted Therapy
- Anxiety Disorders and Psychedelic-Assisted Therapy
- Psilocybin Therapy in Canada
- Ketamine Therapy in Canada
- Insurance Coverage for Psychedelic-Assisted Therapy in Canada
Last updated: 2026-05-06