sign in sign up
<<
Home , Psilocybin

Do Not Disseminate Without Permission from the Author Psychedelics in the Treatment of and Substance Use Disorders

Jordan Sloshower, MD, MSc Interprofessional Fellow in Psychiatry Yale University, West Haven VA May 6, 2020 Last Year’s Presentation • Overview of Psychedelics • Overview of studies using psychedelics to treat SUDs • Historical • Recent • Overview of studies in • Introduction to my pilot study: Psilocybin-assisted Neuroplasticity in the Treatment of MDD Today’s Agenda • Study update • Mechanisms of Action • Integration of in psilocybin treatments • AUD (NYU study) → MET • MDD (my study) → ACT Classical Psychedelics

• extracted from the root bark of Tabernanthe iboga plant native to west central Africa • Not a ‘classical psychedelic’ • Interacts with a variety of brain receptors and systems (NMDA, κ and μ , nicotinic, sigma-2) • Observational study on opioid withdrawal and treatment (Kingsley Brown and Alper 2017) • Open-label case series (n=191) of opioid and dependent individuals (Mash et al 2018) • See www.yalepsg.org Mechanisms of Action

Neurobiological • ‘5HT2A ,’ ‘psychoplastogen’

Psychological / Emotional / Interpersonal • ‘psychedelic,’ ‘cognitive tool’

Social / Ecological • ‘empathogen,’ enhancers of connection

Spiritual / Mystical • ‘’ Psilocybin-induced Neuroplasticity in the Treatment of MDD: Study Aims 1. Mechanism • Neuroplasticity (EEG Long Term Potentiation) • Verbal memory (RAVLT) • Emotion processing (affective go/no go task), • Psychological flexibility (ACT measures, qualitative) 2. Efficacy • acute and sustained changes in depressive symptoms (HAM-D and QIDS-SR) and (HAM-A) 3. Safety • Cardiovascular changes • Adverse events • Reinforcing effects Psilocybin-induced Neuroplasticity in the Treatment of MDD: Study Design

• Pilot study, n = 18 • Double-blind, -controlled, within subject crossover design • Inclusion: Moderate to severe MDD, one or more treatment failure • Ten week protocol with 2 dosing sessions four weeks apart, plus 8 preparatory and follow-up sessions • Participants receive two of three conditions in random order: • placebo • low-dose psilocybin (0.1mg/kg) • medium/high dose psilocybin (0.3mg/kg) Study Update

• Screening and recruitment • Phone screens: 230 • In-person screens: 35 • Enrolled: 12 • Completed: 8 • Currently on hold due to COVID • Article describing therapy protocol incorporating Acceptance and Commitment Therapy (ACT) published in JCBS Jan 2020 (Sloshower first author) • 2019: FDA breakthrough status for psilocybin in MDD/TRD • Phase II/III efficacy studies underway Psilocybin-assisted Psychotherapy

• Embed sessions within broader course of psychotherapy • Subjective drug effects have meaning and value • ‘Set’ and ‘Setting’ • Preparation, Support, Integration (PSI) META as Therapeutic Platform in AUD

• Combined a PSI framework with META therapy sessions • Motivational Enhancement and Taking Action (MET + CBT) • Psilocybin sessions enhanced aspects of META

“Ideally, the disorder-specific therapy would be designed to mobilize or reinforce the change mechanisms activated by therapeutic administration of the psychedelic medication” - Bogenschutz & Forcehimes 2017 ACT as Therapeutic Platform in MDD

• Acceptance and Commitment Therapy • 3rd wave of CBT • Treatment target is ‘Psychological Flexibility’ • Transdiagnostic construct Why ACT?

• Hypothesis 1: Psilocybin treatment + ACT therapy are synergistic • Depression ~ psychological inflexibility • ACT interventions → psychological flexibility → fuller values-congruent life → decreased depression • ACT offers a framework for preparatory and follow-up (‘integration’) therapy sessions Why ACT? • Hypothesis 2: Psilocybin dosing sessions can provide experiential contact with ACT processes • Intensity of → present moment awareness • Instruction to “trust, let go, and be open” → acceptance • Altered & sense of self → defusion, self-as-context • Insight → values clarification

11 Dimensions of drug-induced altered states of ACT hexaflex model of psychological flexibility consciousness Psilocybin-assisted Therapy Manual using ACT Psilocybin-assisted Therapy Manual using ACT Acknowledgements

Deepak Cyril D’Souza (Study PI)

SNRGY lab, Patrick Skosnick, Jose Cortes Briones

Ryan Wallace

Jeffrey Guss (NYU)

Therapy team: Robert Krause, Anne Dutton, Stephanie Kilpatrick

Study Participants

Heffter Research Institute and Carey Turnbull Thank you!

Any questions?

[email protected] www.yalepsg.org Safety of the Classical Psychedelics

• Low risk of physical • Primary risk is dependence/addiction psychological harm • No self-administration (dose related) behaviors in animals • • No w/d syndrome • Prolonged • No evidence of • neurotoxicity persisting d/o (HPPD) • No evidence of DNA damage Preliminary Results Depressive Symptoms - HAMD

Depression Severity for Participants 1 & 2 30

25

e

r o

c 20

S

7 1

15

D

- M

A 10 H 5

0 -1 1 7 27 29 35 42 (after dose (after dose 1) 2) Day Dose A - 24 Hours Dose A - 2 Weeks Pre Tetanus

Post EEG Tetanus (LTP) LTP N100 N100

Dose B - 24 Hours Dose B - 2 Weeks

N100 Amplitude (microvolts) Amplitude N100

Time (msec) Discussion Points

• Issues of expectancy and placebo effect, especially in a cross- over design • Issues of participant selection and establishing diagnosis • Overlap of trauma and chronic depression, cPTSD • Separating drug and therapy effects • Future trial design, feasibility and roll-out Future Directions

• Psilocybin granted FDA Breakthrough Status for MDD & TRD • Phase II/III registration trials currently underway • Rescheduling, commercialization, scaling up • Usona trial site at CMHC • Completion of phase II psilocybin trials for AUD, NUD, CUD • Completion of phase III trials of MDMA for PTSD • Expanded Access • Training and Education • Development of Psychedelic Elective Course Mechanisms of Action Neurobiological Mechanisms

• Promotion of structural and functional neural plasticity Effects On Dendritic Arborization Effects On Spinogenesis Depression (Decreased Synaptic Density) Post Psilocybin (Optimum Synaptic Density)

+ + + + - - - -

I Apical Dendrites Apical Dendrites I Apical Dendrites Apical Dendrites - ++ - ++ + -- ++ - ++ + -- II, III -- II, III ++ +++ -- --- + -- - +++ + --- - +++ + --- IV IV +++ ++++ --- +++ ---- ++++

--- +++ ---- ++++ Cortical Layer Cortical V Layer Cortical V

VI VI

Inhibitory Exitatory Inhibitory Exitatory Inputs Inputs Inputs Inputs Neurobiological Mechanisms • Alterations in functional connectivity • Network disintegration and desegregation • Disruption of • Correlates with aspects of mystical-type (ego dissolution) • 5HT2A receptor modulation / downregulation Psychological Mechanisms

• Mystical/transformative Experience/Awe • Insight • Emotional Responsiveness • Increased Psychological Flexibility

Studerus et al 2010