Psychedelics in Addiction Treatment
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Psychedelics in Addiction Treatment Chris Stauffer, MD UCSF & SFVAMC, Dept of Psychiatry Matthew Johnson, PhD Johns Hopkins, Dept of Psychiatry & Behavioral Sciences Mary Cosimano, MSW Johns Hopkins, Behavioral Pharmacology Research Unit Boston | November 8, 2019 Disclosure • No classic psychedelic (e.g., psilocybin, LSD, mescaline) nor MDMA have a current FDA-approved indication for medical use What is a ”PSYCHEDELIC”? • Classic Psychedelics (5HT2A agonists) • Psilocybin • LSD (lysergic acid diethylamide) • Mescaline • DMT (N,N-Dimethyltryptamine) • Empathogen-Entactogen • MDMA • MDA • Dissociatives • Ketamine Why PSILOCYBIN? Coffee Psilocybe cubensis Psilocybin (+ >200 other species Caffeine of mushroom) Maria Sabina, Mazatec curandera Robert Gordon Wasson Psilocybe mexicana Pharmaceutical Psilocybin 1959: Isolated from P. Mexicana 1960s: Produced by Sandoz, 100’s of legal administrations worldwide Brown RT, et al. Clin Pharmacokinet. 2017;56(12):1543-1554. Passie T, et al. Addict Biol. 2002;7(4):357-364. 1970: Controlled Substances Act Psilocybin - DEA Schedule 1 substance 1980’s: animal work 1990’s: FDA approves human dose-response study (UNM) 2001: First modern-day psilocybin clinical trial (OCD, UArizona) Relative Harm of Drugs of Potential Misuse van Amsterdam J, et. al. Eur Addict Res 2010;16:202–207 Nutt D, et. al. The Lancet 2007, 369:1047-1053 National Survey on Drug Use & Health The Substance Abuse & Mental Health Services Administration (SAMHSA) • Pooled 2008-2012, n > 191,832 (7,550 lifetime psilocybin use) • Respondents ≥18yo Lifetime Hx Psilocybin Use vs No Hx Psychedelic Use Psychological Suicidal Suicidal Suicide distress thinking planning attempt past month past year past year past year .70 (.60-.81)*** .76 (.64-.90)** .54 (.36-.82)** .58 (.35-.94)* weighted odds ratios (95% confidence intervals), *p<.05, **p<.01, ***p<.0001 Hendricks, Johnson, & Griffiths. J Psychopharmacol. 2015; 29(9):1041-1043. Placebo Psilocybin Petri G, Expert P, Turkheimer F, Carhart-Harris R, Nutt D, Hellyer J, & Vaccarino F. (2014) Homological scaffolds of brain functional networks. J. R. Soc. Interface. 11:20140873. PSILOCYBIN –Current Clinical Trials (33) •Major Depressive Disorder •Cancer-related anxiety •Migraine/Cluster Headache •OCD •Anorexia •Substance Use Disorders (Nicotine, Alcohol, Cocaine) Psychedelics in Addiction Treatment Matthew W. Johnson, Ph.D. Associate Professor Behavioral Pharmacology Research Unit Department of Psychiatry and Behavioral Sciences Johns Hopkins University School of Medicine • Psilocybin in >100 mushroom species • “Classic psychedelic” – Psilocybin – LSD – Mescaline (peyote) – DMT (ayahuasca) 1940s – 1970s • Psychedelics were intensely investigated as research tools and therapeutics • Promising findings for: – Cancer-related distress – Alcoholism The Dark Ages • Despite promising preliminary findings, human research with psychedelics became largely dormant • Dormancy largely a reaction to the association of LSD with the 1960s counterculture Abuse liability & Risks 2018 • Can cause harm in people with psychosis or predisposition • For anybody, can cause fear, panic, confusion and potentially dangerous behavior • Moderate elevations in pulse & blood pressure • Headaches in day following use • Persisting perceptual changes • No addiction Safety Guidelines 2008 • Assisted in the approval of psychedelic studies by new scientists and universities • Screening, preparation, monitoring, follow-up Mystical Experiences & Lasting Benefit 2006 & 2008 • Safe in this structured setting • Among the 5 most meaningful life experiences for majority of people • Improvements in mood and quality of life >1 year after sessions Psilocybin Dose Effects 2011 • Increasing psilocybin dose has an orderly effect on mystical experience, challenging experience, and long term positive attribution Mystical Experience • About 60% of participants in both studies met criteria for a “complete” mystical experience • Unity • Noetic quality • Sacredness • Sense of transcending time and space • Positive mood • Ineffability Psilocybin Increases Openness 2011 • First experimental study to change a personality dimension • Driven by mystical experience Driven by Mystical Experience Addiction Treatment • Classic psychedelics can be misused but are not addictive Krebs & Johansen (2012) Across studies, LSD nearly doubled the odds that alcoholic patients would be improved at the 1st follow up (N=536) Smoking Cessation Pilot 2014 • Feasibility and safety Pilot Study Timeline • 15 week protocol with weekly meetings • Cognitive behavioral therapy • 3 psilocybin sessions over 8 weeks (20-30 mg/70 kg) • 1st Psilocybin session on target quit date Success Rates Substantially Higher than Typical (Hughes et., 2003; Jorenby et al., 2006; Sykes & Marks, 2001) Mystical Experience in Smoking Cessation 2015 • Greater success in those who had mystical experience • Mystical experience associated with craving reduction Alcohol Dependence Pilot • 10 alcohol-dependent participants • Motivational Enhancement Therapy • 2 sessions of .3 mg/kg and .4 mg/kg psilocybin Survey Study of Alcohol Cessation • 343 people claiming to have quit or reduced smoking as the result of a psychedelic experience • 83% no longer qualified as having a alcohol use disorder Randomized Comparative Efficacy Trial • 80 treatment-resistant smokers • Randomized to psilocybin or nicotine patch • Same cognitive behavior therapy • 1 psilocybin session The Dope Slap Effect “Matt Johnson believes that psychedelics can be used to change all sorts of behaviors, not just addiction. The key, in his view, is their power to occasion a sufficiently dramatic experience to ‘dope-slap people out of their story...’ Psychedelics open a window of mental flexibility in which people can let go of the mental models we use to organize reality.’” Acknowledgments Roland Griffiths, Ph.D. Bill Richards, Ph.D. Mary Cosimano, M.S.W. Albert Garcia-Romeu, Ph.D. Brian Richards, Psy.D. Frederick Barrett, Ph.D. Maggie Klinedinst Robert Jesse Annie Umbricht, M.D Chad Reissig, Ph.D. Peter Hendricks, Ph.D. Katherine MacLean, Ph.D. Haley Sweet Samantha Gebhart Toni White https://hopkinspsychedelic.org Fred Reinholdt, M.A. Leticia Nanda, N.P. Email: [email protected] Eric Richter Grant Glatfelter Janna Bonesteel Crystal Barnhouser Theresa Carbonaro, Ph.D. Patrick Johnson, Ph.D. Jenna Cohen Marylyn Clark Daniel Emory Eric Jackson Heather Cronin Una McCann, M.D. Debbie Allan Kim Nelson T. Cody Swift, M.A. Lilian Salinas Laura Doyle Nathan Sepeda John Clifton Nora Belblidia Dan Evatt, Ph.D. David Nichols, Ph.D. Charles Nichols, Ph.D. Tehseen Noorani, Ph.D. Funding Heffter Research Institute Beckley Foundation Counsel on Spiritual Practices Betsy Gordon Foundation William Harrison National Institute on Drug Abuse Psychedelics in Addiction Treatment Mary Cosimano, MSW Behavioral Pharmacology Research Unit Department of Psychiatry and Behavioral Sciences Johns Hopkins University School of Medicine Johns Hopkins Center for Psychedelic & Consciousness Research Conducting Psychedelic-Assisted Treatment Mary Cosimano, MSW Director of Clinical Services Are Psychedelic Drugs a Panacea? • Smoking cessation, end-of-life, depression, beginner and long-term meditators • Tom Insel former director of NIMH • Different symptoms - Same mental formations • Excess rigidity in brain • Destructive narratives • Psychedelics work on locked-in conditions The Role of the Guide • Similar for all studies • Each participant assigned 2 guides • Preparation meetings • Psilocybin sessions • Integration meetings Preparatory Meetings • 6 to 8 hours - few days to weeks • Developing trust and rapport • Session logistics • Managing high-dose psilocybin sessions • Set: participant’s internal mental state • Setting: external environment Volunteer on Value of Preparation “Had it not been for the two experienced researchers in the room, I probably would have had a full- blown panic attack and lost the larger experience.” Psilocybin Session ⚫ 8 hour day – Lying on sofa – eyeshades - headphones ⚫ Relax and Let go - Expansion of Consciousness ⚫ The onset of revelatory experiences seems to correspond to my success in remaining relaxed.” ⚫ Majority have Mystical Experience - Interconnectedness ⚫ Difficult experiences not uncommon ⚫ Important and meaningful Integration Meetings • Incorporate experiences into daily life • Key Component of Studies • Easy to dismiss • “Integration is weaving the mystical into the practical.” My Perspective as Guide • Who am I? What is meaning of my life? • Our Connections – to everything – to life • Love is connection - relationships • Love: true nature, authentic self • Guide – exploration with participant • Each a unique exploration – same method Personal Belief • I believe this exploration in combination with the psilocybin sessions and integration, is what leads to reconnection to our true, authentic self— and that helps to find meaning to our lives- • THAT appears to me to be one of the main outcomes of our psilocybin studies. Volunteer Quote • “My single strongest memory will be from the first session when I found myself chasing something that had been eluding me. When I caught it, I discovered that it was me. The subsequent embrace and rejoining seems to me to be the single most powerful event in my life. I feel whole for the first time and able to cope with anything. Apart, “I” was weak and directionless. Listless, really. But together, I’m strong, capable of anything, and just happier.” Tom “Comfortable and Cozy” • 59 year old male • Professional