Some people are still apprehensive to solicit the use of cannabis because of stigma and taboo. With psychedelics, given what the layperson likely knows about them, people who might significantly benefit from clinical psychedelic treatment may be even more fearful or at least skeptical of what’s going to happen to them.
I spoke with Devon Christie, MD, Medical and Therapeutic Services Director at Numinus, a company dedicated to building a “global movement that empowers everyone to connect – with ourselves, each other, and the planet – and that brings health and wellness to all.” Dr. Christie offered her insights into the use of psychedelics in the context of safe, evidence-based protocols for psychedelic-assisted psychotherapy.
T&T: If you were speaking with someone who knew nothing about psychedelics, what would you tell them regarding how substances like psilocybin, MDMA [3,4-methylenedioxymethamphetamine], DMT [dimethyltryptamine], and mescaline work? How are they similar and how are they different?
From what we are learning scientifically, psychedelics cause a change in the resting state of your brain. [1] Psychedelics enable a different repertoire of connections to be made between regions in your brain, while at the same time, temporarily suspending certain well-rehearsed connections that comprise much of your ordinary waking state. This leads to a state shift that is theorized to engender new experiences, new sensations, and opportunities for deep insights and new meaning to emerge. The safety and healing benefit may be greatly enhanced when these substances are taken in the context of a psychedelic-assisted psychotherapy protocol with trained therapists. All the substances variably interact with receptors in the brain and elicit varying changes in neurotransmitter levels such as serotonin and dopamine.
T&T: Could you describe some of the reported patient experiences via psilocybin, MDMA, DMT, and mescaline? What do patients report having been through from a mental and physical state? Are there commonalities between each substance?
There are many factors that contribute to a person’s experience under a psychedelic substance, beyond the molecule itself, that comprise the ‘context’ or ‘set’ and ‘setting’. This has been recognized within clinical research, and also draws from the wisdom of people who have used these substances ceremonially and/or medicinally for hundreds, if not thousands, of years. The ‘set’ refers to the mindset of the person, including examples such as fears, expectations, any previous experience with altered states of consciousness, aspects of preparation that have been done in advance with their therapist or therapy team, and their overall ‘intention’ for the experience. The ‘setting’ includes elements of the physical environment – lighting, music, décor, and the therapist(s) or others present.
When it comes to the substances, it can be useful to differentiate classical psychedelics (5HT2A receptor agonists) versus empathogens or entactogens like MDMA and 3,4-methylenedioxyamphetamine (MDA). Effects for all are dose dependent. Classical tryptamine psychedelics (psilocybin, DMT) are most well known for their ability to elicit ‘mystical type experiences’, and indeed positive outcomes in research are positively associated with the degree of mystical experience. A mystical type of experience typically involves a sense of unity or connectedness with everything; a sense of dissolution of the notion of ‘self’ or ego identity; a sense of sacredness; a sense of deep meaning or encounter with an ultimate reality; deeply felt positive mood such as joy, peace, awe; ineffability (difficulty putting the experience to words); awareness of paradox; and often transcendence of time and space. These substances can also elicit introspection and insight, as well as open and closed-eye visuals sometimes referred to as hallucinations. Mescaline is also a classical psychedelic but of the phenethylamine class; it may elicit similar effects, while also being known as gentler and more tactile.
MDMA, an empathogen/entactogen, is different insofar as mystical experiences, while possible, are not typical. Rather, MDMA tends to elicit feelings of closeness with oneself and others. There is a stimulating effect, as well as suppression of fear, anxiety and shame, enhanced empathy, relaxation, and euphoria.
T&T: What advice would typically be offered to someone being treated with psychedelics if they were having an adverse experience?
Much is done in the preparatory phase during psychedelic-assisted psychotherapy to help prepare the client or research participant for the experience, which includes informing the client that intense or difficult/challenging experiences may surface. The client is prepared and guided to attempt to stay open to the experience, regardless of whether it is pleasant or unpleasant, and to trust that all aspects of their experience during the session are in service to their healing process. What is often referred to as a ‘bad trip’ in a recreational setting would be considered an opportunity for healing in a psychedelic-assisted psychotherapy setting.
Therapeutically, ‘bad trip’ experiences are often repressed emotional content, implicit or explicit memories and traumas. In the moment, supportive approaches may include reminding the participant/client to trust and remain open to the experience, and to use the techniques they were taught during preparation such as connected or diaphragmatic breathing, or trauma-specific therapeutic skills. In general, the therapist’s consistent attuned, calm, stable, open, and grounded presence is instrumental in promoting the most supportive environment for a client moving through challenging territory in their session.
T&T: What types of medical conditions can psychedelics be useful for?
There has been literature on a range of conditions including depression, anxiety (inclusive of end-of-life anxiety), post-traumatic stress disorder (PTSD), substance use disorder, and obsessive-compulsive disorder, to name a few. There are also pilot studies looking at eating disorders and chronic pain conditions. [2-6]
T&T: What do they offer to terminally ill patients?
Psilocybin has been most studied for terminally ill patients. Research shows that psilocybin-assisted psychotherapy can alleviate anxiety and depression associated with end-of-life existential distress. [7,8] This is an important advancement in the realm of palliative medicine. Currently, patients nearing end of life are primarily offered opiates and sedatives which do not adequately address existential anxiety/distress and have heavy side effects; and in Canada, patients may choose medical assistance in dying (MAiD), which is a terminal solution. From my perspective, the potential for psilocybin to assist individuals nearing end of life is monumental as it helps those in need to come to terms with their relationship with death and/or aspects of their life history or relationships, and to have relief of anxiety and depression to thus die with a greater sense of peace.
T&T: Which medical conditions is Numinus seeking to treat with psychedelics?
Numinus will be running Compassionate Access studies for MDMA-assisted psychotherapy for PTSD and psilocybin-assisted psychotherapy for substance use disorder. We are also establishing psychedelic-assisted psychotherapy protocols with ketamine and psilocybin for depression and anxiety. We also anticipate that we will support patients with Special Access Programme applications for MDMA- and psilocybin-assisted psychotherapies while we await formal drug approval for these substances in Canada.
T&T: What level of acceptance have you seen regarding psychedelics in Canada versus other geographies?
I’m unable to comment on other jurisdictions as policy and regulation is not my area of focus, but I can say that the Canadian landscape appears to be moving in a positive direction regarding regulatory changes that will start to open up access to psychedelics. Until very recently, in Canada, only MDMA was accessible through very small research studies being conducted in Vancouver, Montreal, and Toronto. Other substances remained restricted through the Controlled Drugs and Substances Act (CDSA).
In response to advocacy efforts from many groups, including a briefing note submitted by Numinus in December 2020, Health Canada has recently signaled its intention to restore both MDMA and psilocybin to the Special Access Programme which enables medical applications for access while they are still in the final stages of drug approval. In addition, the federal government has granted Section-56 exemptions to the CDSA for medical use for psilocybin to a number of Canadians in recent months for end-of-life anxiety and depression. Other efforts outside of a medical context, such as decriminalization, are also underway; in November 2020, Vancouver, British Columbia, became the first city in Canada to decriminalize all drugs.
T&T: If you traveled in time perhaps to 5 or 10 years from now, what do you think humankind looks like if we’ve continued to use psychedelics for medicinal and personal growth? How might we benefit from these substances as a globe?
I think there is tremendous potential for psychedelics to positively influence individuals and communities when accessed in a safe and supportive context. In general, psychedelics elicit pro-social attitudes, including enhanced compassion for self and others and an enhanced sense of connection not just to other people, but to everything – including the earth. This couldn’t be more important as we are facing a global climate crisis, and the human-caused 6th mass extinction; our collective priorities must shift from unchecked economic growth to protecting what is truly valuable to us as humans, and I believe psychedelics have the potential to contribute to this shift in consciousness.
Psychedelics have the potential to serve as a powerful medicine in the context of therapy to help lessen the burden of our current mental health crisis, with recent cost-benefit analysis showing their potential to save billions of dollars currently spent to address the societal impact of this crisis. In 5-10 years, I think we will see training in these therapies as part of routine physician and therapist education, and we will have an adequate number of trained professionals to meet the need in society. The current stigma associated with mental health conditions including substance use disorders will no longer be present. I anticipate we will see these therapies adopted into our public health system, considered as “psychological surgeries” to cure mental health conditions which have come to be understood as “psychological injuries” similar to how our system supports surgeons to perform routine appendectomies and other everyday procedures to cure patients’ physical ailments. There will be a deeper understanding of mental health in general as we better understand the mechanisms of these therapies, including acknowledgment of the false dichotomy between mind and body and the negative impacts of traumatic stress in early childhood development on human flourishing. It is my hope that together as a society we will take better care of one another and our precious earth.
References
[1] Carhart-Harris RL, Leech R, Hellyer PJ, et al. The entropic brain: a theory of conscious states informed by neuroimaging research with psychedelic drugs. Front Hum Neurosci. 2014;8:20. [journal impact factor = 2.673; times cited = 378] [2] Griffiths RR, Johnson MW, Carducci MA, et al. Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial. J Psychopharmacol. 2016;30(12):1181-1197. [journal impact factor = 3.121; times cited = 401] [3] Jerome L, Feduccia AA, Wang JB, et al. Long-term follow-up outcomes of MDMA-assisted psychotherapy for treatment of PTSD: a longitudinal pooled analysis of six phase 2 trials. Psychopharmacology (Berl). 2020;237(8):2485-2497. [journal impact factor = 3.130; times cited = 2] [4] Feduccia AA, Jerome L, Yazar-Klosinski B, Emerson A, Mithoefer MC, Doblin R. Breakthrough for trauma treatment: Safety and efficacy of MDMA-assisted psychotherapy compared to paroxetine and sertraline. Front Psychiatry. 2019;10:650. [journal impact factor = 2.849; times cited = 9] [5] Dakwar E, Nunes EV, Hart CL, et al. A single ketamine infusion combined with mindfulness-based behavioral modification to treat cocaine dependence: A randomized clinical trial. Am J Psychiatry. 2019;176(11):923-930. [journal impact factor = 14.119; times cited = 17] [6] Spriggs MJ, Kettner H, Carhart-Harris RL. Positive effects of psychedelics on depression and wellbeing scores in individuals reporting an eating disorder [published online ahead of print, 2020 Sep 8]. Eat Weight Disord. 2020;10.1007/s40519-020-01000-8. [journal impact factor = 3.634; times cited = 1] [7] Grob CS, Danforth AL, Chopra GS, et al. Pilot study of psilocybin treatment for anxiety in patients with advanced-stage cancer. Arch Gen Psychiatry. 2011;68(1):71-78. [journal impact factor = 17.471; times cited = 480] [8] Ross S, Bossis A, Guss J, et al. Rapid and sustained symptom reduction following psilocybin treatment for anxiety and depression in patients with life-threatening cancer: a randomized controlled trial. J Psychopharmacol. 2016;30(12):1165-1180. [journal impact factor = 3.121; times cited = 348]
