There are plenty of other cases (e.g. ultra rare diseases) where we don't do RCTs for various practical reasons. So it's not really a problem of the existing fr

There are plenty of other cases (e.g. ultra rare diseases) where we don't do RCTs for various practical reasons. So it's not really a problem of the existing framework - there's a ton of room for "we can't do an rct because like, duh they know they're tripping." But as other comments pointed out were really hampered by the lack of understanding of how and why these do or don't work - why some people get positive outcomes and why some get negative (preferably we'd like to know before prescribing broadly!) a ton of this basic research/mechanistic understanding etc has not been possible because of the war on drugs. If research had been possible we would be in a much better place of understanding how they could be regulated and used today - even with the more limited technology available a couple decades ago more openness around this could have at least enabled e.g. more and larger observational studies that could elucidate things today but we're stuck with a very fragmented and incomplete picture