Alcohol Is Losing Ground. Psychedelic Medicine Is Gaining It.

Are we becoming healthier, choosing different substances, or changing what we consider medicine?

By the 2CB.com editorial team. Referenced evidence review; not yet medically reviewed. Published quotations are attributed to their original sources.

Summary

Alcohol sales are contracting globally and tobacco use has declined substantially. Meanwhile, psychedelic research is moving into larger trials, pharmaceutical acquisitions, executive orders and formal regulatory pathways. These developments are real, but they do not establish that people who stop drinking or smoking are replacing those substances with psychedelics. Nor do they establish that psychedelic treatments prevent suicide better than conventional care. The more consequential change may be the reclassification of a cultural question as a clinical one: which psychoactive substances, in which patients, under which conditions, can produce a measurable benefit?

• Drinking is at a record low. In August 2026, 54% of US adults said they drank alcohol, tying the lowest reading in a Gallup series that began in 1939, down from 62% in 2023 [1].
• The decline is global, but uneven. Worldwide beverage alcohol volume fell 2% in 2025, a third consecutive fall, while tobacco users fell from 1.38 billion in 2000 to 1.2 billion in 2024 [2, 3].
• Psychedelic use is not simply surging. Past-year psychedelic use among US adults aged 19 to 30 fell from 8.9% in 2024 to 7.2% in 2025, and past-year MDMA use was 2.4%, against 4.2% in 2015 [4].
• The flagship approval failed first. In June 2024, FDA advisers voted 9 to 2 against the efficacy of MDMA-assisted therapy for PTSD and 10 to 1 against its benefits outweighing its risks [5].
• Suicide evidence concerns thoughts, not deaths. Intravenous ketamine produced remission of suicidal thoughts in 63.0% of hospitalised patients at day three, against 31.6% on placebo, but that is not mortality evidence [6].
• 2C-B has entered the controlled laboratory. A randomised crossover study published in April 2026 compared 2C-B with MDMA and psilocybin in 24 healthy adults [7].

The decline is real. The explanation is more complicated.

The familiar social pairing of alcohol and cigarettes is losing ground. IWSR, a commercial alcohol market research organisation, reported a 2% decline in worldwide beverage alcohol volume in 2025, the third consecutive annual fall. Wine volume fell 5% and beer 2%. The same report recorded growth in India and Türkiye, illustrating why a global contraction should not be described as every country becoming sober. These are market volume estimates, not a count of drinkers or a direct measure of health [2].

The American survey evidence points in a similar direction. Gallup's August 2026 report found that 54% of US adults said they drank alcohol, matching the previous year's lowest reading in a series dating to 1939. The proportion was 62% in 2023. Seventeen per cent reported substituting nonalcoholic beverages for alcohol. A substantial part of the change therefore involves a different drink, without necessarily involving another intoxicant [1]. Federal survey data agree. Nora D. Volkow, MD, Director of the National Institute on Drug Abuse, said of the 2025 adult panel data: "It is reassuring to continue to see relatively low smoking rates and a continuing decline in alcohol use among adults" [8].

Tobacco has undergone a longer retreat. WHO estimated that the worldwide number of tobacco users fell from 1.38 billion in 2000 to 1.2 billion in 2024. However, the organisation also estimated more than 100 million e-cigarette users. A reduction in smoking is not equivalent to the disappearance of nicotine consumption [3]. Some of the change is product migration rather than abstinence: nicotine has moved from cigarettes towards vapes and pouches [3, 8], and part of the alcohol market has moved to nonalcoholic drinks [1]. A "low-alcohol" or ready-to-drink product is not necessarily a reduction in ethanol; what matters is how much is drunk, not the format.

The health benefits of stopping smoking are established, including lower cardiovascular and cancer risks over time [9]. Alcohol is also a carcinogenic exposure: WHO attributes approximately 2.6 million deaths to alcohol in 2019 [10]. On 3 January 2025 the US Surgeon General issued an advisory calling for cancer warnings on alcohol labels [11]. Vivek H. Murthy, MD, then Surgeon General, said: "Alcohol is the third leading preventable cause of cancer behind tobacco and obesity" [12]. Reducing harmful drinking and tobacco exposure is therefore meaningful health progress in its own right, without needing a psychedelic explanation. Whether a change in substances improves a particular person's health depends on the new exposure as well as the one removed.

Declining sales can reflect moderation, abstinence, economic pressure, medical warnings and shifts between products. Some of the newest candidates for reducing drinking are not psychedelics at all. In a 48-person randomised Phase II trial in adults with alcohol use disorder who were not seeking treatment, low-dose semaglutide, a drug used for diabetes and weight loss, reduced alcohol craving, the amount drunk in a laboratory drinking session and drinks per drinking day compared with placebo, although it did not change average drinks per day or the number of drinking days [13]. Aggregate trends cannot identify which explanation accounts for a particular person's behaviour. Before calling this a health revolution, we need to distinguish fewer harmful exposures from a different pattern of exposure [1, 2, 3].

A psychedelic resurgence, not a universal surge

The latest US Monitoring the Future adult report provides an important corrective. Among adults aged 19 to 30, past-year hallucinogen and psychedelic use was 7.2% in 2025, above 4.1% in 2015 but below 8.9% in 2024. MDMA moved differently: past-year use was 2.4% in 2025, compared with 4.2% in 2015. The same report recorded past-month nicotine vaping of 19.3% among young adults in 2025, compared with 6.1% in 2017. These are US age-specific estimates, not global prevalence figures [4].

Other surveys measure a different population. A RAND survey of 10,122 US adults in September 2025 estimated past-year psilocybin use at 4.3%, or about 11.1 million adults [14]. Regulated access accounts for a very small share of that. Oregon's licensed psilocybin services served 5,935 clients in 2025 [15]. On these figures, most psilocybin use in the United States takes place outside any regulated setting.

Ketamine also requires its own analysis. A study of US surveillance datasets reported an increase in past-year nonmedical use among people aged 12 and older from 0.19% in 2021 to 0.34% in 2023. That is a marked relative increase from a small base. Poisonings and diversion increased in several datasets, while reported ketamine-involved deaths did not change significantly from 2020 to 2023 [16].

The defensible conclusion is that some substances and settings have expanded, while others have not. Cultural visibility, recreational consumption, clinic activity and therapeutic efficacy are four different measures. A growing research industry cannot be used as a substitute for a population survey.

Nor do these independent datasets prove substitution. To establish that reduced alcohol use is causing increased psychedelic use, researchers would need to follow individuals over time and measure both behaviours, their motivations and relevant confounders. Reading two trend lines together can generate a hypothesis; it cannot establish the mechanism.

Ancient knowledge and modern prohibition

Psychoactive plant use predates modern pharmaceutical research by millennia. Chemical analysis and radiocarbon dating of archaeological peyote specimens from Texas support use approximately 5,700 years ago [17]. A separate study identified DMT and harmine, among other compounds, in a roughly 1,000-year-old ritual bundle from Bolivia. The latter finding documents access to psychoactive plants; it does not establish that the substances were consumed together as the ayahuasca preparation familiar today [18]. Melanie J. Miller, PhD, the study's lead author, put the claim at its proper scale: "Our findings support the idea that people have been using these powerful plants for at least 1,000 years" [19].

These histories belong to particular Indigenous communities and traditions. They should not be flattened into a claim that every contemporary drug has been used since the dawn of time. For example, 2C-B was first synthesised by Alexander Shulgin in 1974. Its history is chemically and culturally distinct from peyote's. Ancient use is evidence of historical knowledge, not proof of efficacy for a modern diagnosis [7, 17, 18]. Those traditions also have living legal standing: since 1994, US federal law has protected the use of peyote by American Indians for bona fide traditional ceremonial purposes [20]. An Indigenous-led group of practitioners and scholars has warned of cultural appropriation and the patenting of traditional medicines, and has called for fair and equitable sharing of benefits with Indigenous Peoples [21]. Who gains access to these medicines, and who shares in any profit, remain open questions for the field.

The US legal chronology also matters. The 1970 Controlled Substances Act placed LSD, mescaline and psilocybin in Schedule I [22]. MDMA was temporarily placed there in 1985 [23]. 2C-B was temporarily scheduled in 1994 and permanently placed in Schedule I in 1995 [24]. Ketamine took a different route: it became a Schedule III controlled substance in 1999 [25].

Nancy Reagan's prominent "Just Say No" campaign belongs to the 1980s, not the initial 1970 scheduling decision. The presidential archive documents a 1986 proclamation establishing a national campaign week. Scheduling and public messaging formed part of the environment in which these substances were understood, but the historical record does not support attributing every research setback or public belief to one campaign [26].

Researchers have long argued about the cost. In 2013 Professor David Nutt of Imperial College London, a prominent critic of drug scheduling, said: "This hindering of research and therapy is motivated by politics, not science" [27]. That is an advocate's argument, not a settled historical finding, but it describes a view now common among researchers in the field.

Schedule I remains a legal classification with specific statutory criteria. It is not a permanent scientific verdict that a molecule can never become a medicine. FDA's July 2026 guidance describes a development pathway for psychedelic drugs while retaining requirements for reliable evidence, safety assessment and controlled-substance compliance [28].

Why medicine is paying attention again

The most useful clinical question is not whether psychedelics are good or bad as a category. It is whether a particular treatment improves a particular outcome relative to a credible comparator. The category itself is loose: psilocybin, LSD and mescaline are classic serotonergic psychedelics, MDMA is an entactogen and ketamine is a dissociative, so evidence for one does not transfer to the others.

Psilocybin offers a direct connection to the alcohol story. In a 2022 randomised trial, 93 participants received at least one medication session, with psychotherapy offered to both groups. Over the subsequent 32 weeks, heavy drinking days averaged 9.7% in the psilocybin group and 23.6% in the active-placebo group. The comparison was psilocybin plus psychotherapy against diphenhydramine plus psychotherapy, not mushrooms against no treatment [29].

Psychiatrist Michael P. Bogenschutz, MD, described psilocybin therapy as "a promising means of treating alcohol use disorder" in NYU Langone's accompanying release. That is a statement of promise, not an announcement of an approved treatment. This study suggests that a psychedelic intervention might help selected patients reduce an established harmful drug behaviour. It does not explain falling national alcohol sales [30].

Depression research is encouraging but uneven. A 2022 trial involving 233 people with treatment-resistant depression found that a 25 mg psilocybin treatment with psychological support improved depression scores more than a 1 mg control at three weeks. Adverse effects were common, and suicidal ideation, behaviour or self-injury occurred across dose groups [31]. A separate 59-person comparison of psilocybin with escitalopram did not find a statistically significant difference on its prespecified primary depression outcome at six weeks [32].

Larger programmes are progressing. Compass Pathways reported positive primary outcomes in two Phase III COMP360 psilocybin trials and, in July 2026, announced six-month data and an ongoing rolling FDA application. These are sponsor-reported results and regulatory plans. They should not be presented as independent confirmation, FDA approval or a guarantee of commercial launch [33, 34]. Sceptics within psychiatry have said so plainly. Charles B. Nemeroff, MD, PhD, of the University of Texas at Austin, co-editor of the American Journal of Psychiatry's psychedelics issue, said "there is a need for us to bring scientific rigor to a field that is somewhat ahead of its skis" [35].

Other molecules are following. Definium Therapeutics, formerly MindMed, reported in September 2026 that a 100 microgram dose of its LSD formulation improved anxiety scores by 5.1 points more than placebo at week 12 in a Phase III trial in generalised anxiety disorder [36, 37]. That is a company-reported topline result, not a peer-reviewed paper. In March 2026, JAMA Psychiatry published a randomised, double-blind Phase IIb trial of inhaled 5-MeO-DMT (GH001, mebufotenin) in 81 patients with treatment-resistant depression, which reported a 15.5-point greater reduction in depression scores than placebo at day 8 [38]. Both results are short-term, and neither drug is approved.

Trauma, veterans and the FDA's MDMA decision

For PTSD, MDMA-assisted therapy has produced notable trial results. In a 2023 Phase III study of 104 participants, PTSD symptom scores improved more with MDMA and therapy than with placebo and the same therapy. Among participants with endpoint diagnostic data, 71.2% in the MDMA group and 47.6% in the placebo group no longer met PTSD criteria. These percentages are an exploratory diagnostic outcome, not a lifetime cure rate [39].

Jennifer Mitchell, PhD, the first author, said in UCSF's 2023 coverage: "We are nearing the tipping point in establishing the benefits of psychedelic therapy for mental health conditions." That optimism is part of the historical record [40]. The regulatory story then turned. On 4 June 2024, FDA's advisory committee voted 9 to 2 that efficacy had not been shown and 10 to 1 that the benefits did not outweigh the risks [5]. Its concerns included functional unblinding: participants can usually tell whether they have received a powerful psychoactive drug, which weakens the double-blind design on which efficacy estimates depend. About 40% of participants had taken MDMA before the trials. Tiffany Farchione, Director of FDA's Division of Psychiatry, said: "The fact is you just can't blind these studies" [5]. The National Institute of Mental Health has since named the same problems as obstacles to interpreting psychedelic trials: subjective effects that make blinding difficult, no agreed placebo, psychotherapy that varies between studies, and strong participant expectations [41].

FDA issued a Complete Response Letter in August 2024 and asked for a further Phase III trial [42]. In the same month the journal Psychopharmacology retracted three papers based on MAPS-funded Phase II trials, citing protocol violations amounting to unethical conduct at one study site, which the authors had known about and not disclosed [43]. In August 2026, MAPS reported that Resilient Pharmaceuticals, formerly Lykos, had resubmitted the application. Its statement relied on a reported resubmission and is an interested organisation's account, not an FDA approval notice [44].

The unmet need behind these trials is real. Rachel Yehuda, PhD, Director of the Mount Sinai Center for Psychedelic Psychotherapy and Trauma Research, said in 2022: "Between the side effects of antidepressants and the distress of reliving traumatic memories in therapy, dropout rates are high" [45]. Federal agencies have begun to fund the question directly. In December 2024 the Department of Veterans Affairs announced its first funded study of psychedelic-assisted therapy since the 1960s, testing MDMA-assisted therapy for veterans with PTSD and alcohol use disorder [46]. Congress had already, in December 2023, directed the Department of Defense to fund research on MDMA, psilocybin, ibogaine, 5-MeO-DMT and plant-based therapies for service members with post-traumatic stress or traumatic brain injury, and authorised $10 million for the work [47].

Ketamine should not be treated as interchangeable with MDMA or psilocybin. It is a dissociative anaesthetic with a different principal pharmacological target. FDA-approved intranasal esketamine, sold as Spravato, is indicated for adult treatment-resistant depression, either alone or with an oral antidepressant; the monotherapy approval was announced on 21 January 2025 [48, 49]. Its separate indication for depressive symptoms in adults with major depression and acute suicidal ideation or behaviour requires an oral antidepressant. Neither indication is an approval to treat PTSD [48].

PTSD-specific ketamine findings are mixed. A small randomised trial of 30 patients found improvement compared with midazolam [50]. A larger trial involving 158 veterans and active-duty service members who had not responded to prior antidepressant treatment did not find a significant ketamine treatment effect on PTSD symptoms [51]. The VA's guide to the 2023 VA/DoD guideline suggests against ketamine for PTSD. Benefits for comorbid depression and benefits for PTSD itself should be distinguished [52].

It would also be inaccurate to write that conventional prescriptions have never helped. A large synthesis of 522 trials found that the 21 antidepressants examined were more efficacious than placebo for acute adult major depression. This does not resolve long-term outcomes or treatment-resistant illness. It does establish that unmet need cannot be equated with universal treatment failure [53]. For PTSD, VA guidance prioritises specific trauma-focused psychotherapies and supports sertraline, paroxetine and venlafaxine [52].

Suicide: promising findings are not mortality evidence

Suicidal thoughts, suicide attempts and suicide deaths are separate outcomes. Improvement in one cannot automatically be reported as improvement in all three.

In a French randomised trial of 156 hospitalised patients with severe suicidal ideation, intravenous ketamine plus usual treatment produced remission of suicidal thoughts in 63.0% at day three, compared with 31.6% with placebo plus usual treatment. Results differed by diagnosis, and the difference at six weeks was not statistically significant. This was an acute ideation trial, not evidence that ketamine reduced suicide mortality relative to antidepressants [6]. Madhukar H. Trivedi, MD, of UT Southwestern, writing on the earlier ketamine evidence, concluded that "routine clinical use of ketamine infusion as an acute treatment for suicidal patients would be premature" [54].

Observational psychedelic research is frequently overinterpreted. A 2015 analysis of more than 190,000 US survey respondents associated lifetime classic psychedelic use with lower adjusted odds of past-year suicidal thinking, planning and attempts [55]. A second 2015 analysis of 135,095 adults from the same national survey found no significant association between psychedelic use and suicidal behaviour in either direction [56]. Neither was a treatment trial, neither established causation, and neither compared psychedelic therapy with prescribed antidepressants. Differences in who uses psychedelics, reporting and other exposures can influence the association. A 2025 systematic review of 39 articles, with searches run to November 2024, concluded that the effect of psychedelic therapies on suicide-related outcomes "remains inconclusive" [57].

The regulatory wording is particularly clear. Spravato's prescribing information states: "The effectiveness of SPRAVATO in preventing suicide or in reducing suicidal ideation or behavior has not been demonstrated." Its depression indication for patients presenting with acute suicidality does not mean it is approved as a suicide-prevention treatment [48].

Antidepressant warnings about suicidal thoughts and behaviours in younger patients require monitoring, but the Spravato label also carries that warning. Together with suicidality observed in psilocybin trials, this undermines a simple narrative of conventional medicines causing harm while psychedelics remove the risk. The evidence supports careful investigation and clinical vigilance, not a claim of established superiority for preventing suicide deaths [31, 48].

If you are thinking about suicide, help is available now: in the US call or text 988; in the UK call Samaritans on 116 123.

Pharmaceutical money and federal policy

The pharmaceutical industry's involvement is no longer confined to speculation. In September 2023, Japan's Otsuka announced an agreement to acquire Mindset Pharma for approximately CAD 80 million, building on a collaboration developing novel serotonin 5-HT2A receptor agonists [58].

AbbVie announced an agreement in August 2025 to acquire Gilgamesh's bretisilocin programme for up to US$1.2 billion, including an upfront payment and development milestones. It announced completion in October. "Up to" matters: this is a maximum deal value incorporating conditional payments, not a disclosed US$1.2 billion cash payment on day one. Bretisilocin is an investigational, short-acting serotonergic compound, rather than an acquisition of a retail mushroom business [59, 60].

AbbVie's chief scientific officer, Roopal Thakkar, MD, described the aim as reaching "patients for whom other treatments have been ineffective" [59]. Johnson & Johnson's 2025 annual report separately attributed Spravato growth to increased physician and patient demand [61]. The company reported worldwide Spravato sales of US$1,696 million in 2025, up from US$1,077 million in 2024 [61, 62]. An approved esketamine product provides a commercial precedent, although it does not validate the efficacy of every psychedelic candidate.

A treatment also has to work outside the trial. Spravato must be given under the direct supervision of a healthcare provider, with monitoring for at least two hours at each session, through a restricted distribution programme [48]. Generic ketamine is a different matter: FDA states that ketamine is not approved to treat any psychiatric disorder and that compounded ketamine products are not FDA approved, and in June 2026 it warned an online seller of ketamine troches and nasal spray [63, 64]. A clinic offering ketamine is therefore not evidence that its psychiatric claims have regulatory approval. Screening, supervision, repeat visits and cost are part of a treatment's real-world value, not details to settle after efficacy.

Federal policy has moved faster than the evidence base. Executive Order 14401, signed on 18 April 2026, directs FDA to grant Commissioner's National Priority Vouchers to psychedelic drugs with Breakthrough Therapy designation, directs FDA and DEA to establish a Right to Try pathway for psychedelic drugs including ibogaine, and allocates at least $50 million from existing funds to partnerships with states. It also orders a rescheduling review of any Schedule I product that completes Phase III trials for a serious mental illness. The order did not legalise, reschedule or approve any drug [65]. In July 2026, HHS and the Department of Veterans Affairs signed a five-year memorandum of understanding to prepare research, training and clinical protocols for psychedelic treatments, contingent on FDA approval [66]. Jay Bhattacharya, MD, PhD, Director of the National Institutes of Health, nonetheless cautioned that "we still have much to learn about long-term benefits and risks, including the potential for misuse" [67].

States and other countries are acting too. In June 2025, Texas enacted SB 2308, creating a consortium of a drug developer, a university and a hospital to take ibogaine through FDA drug-development trials, with state money released only once matched by non-state funds; the state budget appropriated $50 million for it [68, 69]. In Australia, since 1 July 2023, psychiatrists authorised by the regulator may prescribe psilocybin for treatment-resistant depression and MDMA for PTSD, although no product had been evaluated by the regulator for that use [70].

These investments and policies are evidence that companies and governments see a development opportunity. They are not clinical outcomes. As an editorial inference, the commercial incentives raise questions about ownership, access, treatment costs and the balance between proprietary molecules and existing compounds. Those questions deserve attention alongside efficacy.

What comes next, and where 2C-B fits

The next frontier is already broader than mushrooms and MDMA. Mescaline has contemporary controlled human pharmacology studies [71]. A small randomised ayahuasca trial involving 29 people with treatment-resistant depression reported an antidepressant signal [72]. Neither type of evidence establishes broad clinical effectiveness or predicts which treatment will win regulatory approval next.

Ibogaine is moving into a particularly consequential phase. Stanford investigators reported substantial improvements in a 2024 observational cohort of 30 male special operations veterans with traumatic brain injury who received magnesium-ibogaine treatment in Mexico (Cherian et al.). Without a control group, the contributions of ibogaine, supportive care, expectations and other factors cannot be separated [73]. A 2026 follow-up, the MISTIC 12-month study, assessed 25 of the original participants; longer follow-up does not remove the original design's limitations [74]. On 5 October 2026, FDA sought public input on the design of early ibogaine trials, including cardiac and neurological monitoring. In the announcement, FDA's Michael Davis, MD, PhD, emphasised "important scientific questions as well as serious safety concerns." Encouragement of research, whether by FDA, an executive order or the Texas programme, is not approval of treatment [75].

For 2C-B, there is now a more concrete reason to ask the question. A double-blind, randomised, placebo-controlled crossover study published on 28 April 2026 compared its acute effects with MDMA and psilocybin in 24 healthy adults. At the highest tested 2C-B dose, 30 mg, investigators observed both psychedelic-type effects and increased emotional empathy, with a shorter average subjective duration than psilocybin: 4.9 hours, against 4.8 hours for MDMA and 6.1 hours for psilocybin [7]. It was the first controlled study to compare 2C-B directly with both MDMA and psilocybin, and the first to test 30 mg. It built on a 2023 Maastricht study by Mallaroni and colleagues, a double-blind, placebo-controlled comparison of 20 mg 2C-B with 15 mg psilocybin in 22 healthy participants [76]. Brain-imaging results from the same 22 volunteers, published in 2026, found that 2C-B and psilocybin changed the organisation of brain networks in overlapping but distinct ways [77]. That is acute neuroscience in healthy people, not evidence of a treatment effect.

Those findings make 2C-B an interesting research candidate. They do not establish treatment efficacy for PTSD, depression or addiction, or establish safety in vulnerable patients or with repeated use. Healthy-volunteer pharmacology studies are an early step, not evidence that 2C-B will be the next approved medicine. Its permanent US Schedule I placement dates to 1995 [7, 24].

Public understanding of 2C-B is also distorted by a street product that borrows its name. "Tusi", often sold as "pink cocaine", is a phonetic rendering of "2C" [78]. Of 19 US samples labelled as tusi or 2C-B and tested by DrugsData through 2022, 94.7% contained ketamine as the main ingredient, and, as the same paper reports, the Spanish drug-checking service Energy Control has found ketamine plus MDMA in almost all the tusi samples submitted to it. Joseph J. Palamar, PhD, MPH, of NYU Grossman School of Medicine, wrote that "despite its name, the concoction rarely contains 2C series drugs" [78]. Reports of "2C-B" use from street markets therefore cannot be assumed to describe 2C-B.

Alcohol's retreat and psychedelic medicine's advance are changing the conversation about drugs. The next medicine will be judged by a demanding standard: not whether a compound is ancient, fashionable or profitable, but whether it produces durable benefit with acceptable risk, delivered in a way real health systems can provide. Familiarity, investment and executive orders will not settle that. For readers following that change, 2CB.com brings the legal question back into focus: clinical promise does not determine legality. Consult our cited country-by-country reference at 2CB.com before assuming that a research headline, a federal policy announcement or an overseas clinic makes possession, importation or travel with a substance lawful.

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