Psychedelics as medicine iCAAD 2019 New kid on the block or old hat? Dr Sarah Flowers, Addictions Psychiatrist, Life Works Charlotte Parkin, Psychotherapist, Harley Street & Fenchurch Street
Presenter disclosure + Dr Sarah Flowers ̶ Priory Healthcare: Life Works, Visiting Consultant ̶ OneMed Hove, Visiting Consultant ̶ Sussex Partnership NHS Trust, Consultant Psychiatrist + Charlotte Parkin ̶ Priory Wellbeing Centre Fenchurch ̶ Priory Wellbeing Centre Harley Street
Recommended reading
Dr Sarah Flowers - a little about me… + Lewes 1979 – 1997 + London 1997 – 2003 + Addiction 2004 + AA 2006 + NHS Addiction Consultant 2011 + Party Drug Clinic 2013 + NAT AA 2015 + Life Works 2019+
Charlotte Parkin - a little about me… + Northamptonshire 1979 – 1997 + Bristol, Modern History 1997 + Media and Communications 2001 – 2013 + Integrative Counselling 2013 + Priory Hospital North London ATP 2014 + Priory Wellbeing Centre Fenchurch Street 2015 + Harley Street and Fenchurch Street 2018 + Current work 2019+
This session may trigger cognitive dissonance…
Transparency: a sober look at psychedelics + Where I’m approaching this from – represent ambivalence + The 28-day programme and abstinence approach + No current research/clinical involvement in this field + No sponsorship
Contents 1. The definition of a psychedelic drug 2. How psychedelics are being used at present 3. Historical perspective 4. Outline of the psychedelic psychotherapy process 5. Why might psychedelic drugs be suited to recovery from addiction? Proposed mechanisms of action 6. Examples of psilocybin, MDMA and ketamine from 3 doctors 7. The psychedelic-mystical experience as treatment and comparison with 12- step recovery 8. Discussion regarding risks, benefits and attitudes towards their use in the addiction field
1. Psychedelic: ‘mind-revealing’
2. Underground and overground
3. Historical perspective
Second to third wave Psychedelic science The Harvard Psilocybin Humphry Osmond Project + 1990s Johns Hopkins and NYU: + Spring Grove, Maryland psilocybin and end of life cancer 1970s + MAPS since 1986 + 1971 “the most + Many psychiatrists and dangerous man in therapists active in the + UK: Bristol, Imperial and Oxford America” and Schedule 1 field, some to this day + Dr Carhart-Harris: psilocybin for depression. Psilocybin/ escitalopram
2019
4. Psychedelic-psychotherapy A. Selection and preparation B. Session: medicine-guided, psychotherapeutically-supportive C. Integration
A. Selection and preparation Flight instruction Trust and rapport Psychic vulnerability Ego strength In and through difficult Adequate: set, setting, dose experience: Intentions + Ego death “to trust unconditionally Set: “a conscious decision Suggestions: with one’s mind” that in this set, with these people, with the preparation + TLO I’ve had, with the proper + Holding lightly dosage and purity of this substance, I choose to be out Collecting experience of control”
̶ ̶ ̶ ̶ ̶ B. Psychedelic session + 8 hours + Two trained therapists Empathic, respectful, genuine Focused, non-anxious, competent + Constant presence + Room + Eye masks and music + Download + Medically administered Dose (purity and strength) Monitored Supported
Psychedelic phenomenology + Perceptual changes + Panic, paranoia, confusion rare + Psychodynamic content + Visionary/archetypal experiences + Unitive-mystical experiences 1. Ineffable and paradoxical 2. Transcendence of time and space 3. Intuitive 4. Sacred 5. Deeply-felt positive mood 6. Unity
Self-actualisation 1. They perceive reality efficiently and can tolerate 11. Establish deep satisfying interpersonal uncertainty relationships with a few people 2. Accept themselves and others for what they are 12. Peak experiences 3. Spontaneous in thought and action 13. Need for privacy 4. Problem-centred (not self-centred) 14. Democratic attitudes 5. Unusual sense of humour 15. Strong moral/ethical standards 6. Able to look at life objectively 7. Highly creative Maslow 1954 8. Resistant to enculturation, but not purposely unconventional 9. Concerned for the welfare of humanity 10. Capable of deep appreciation of basic life- experience
C. Integration + Stage 1: Reporting - no integration + Stage 2: Making meaning and skills + Stage 3: Distilling actions
̶ ̶ ̶ ̶ 5. Relevance to addiction + Presentations due to psychedelics + Understanding of recovery: how do these drugs work? + Treatment of addiction Greater mystical experience associated with greater abstinence • LSD for alcohol: Osmond 1950/60s • Ketamine for alcohol and opiates: Krupitsky 1990s • Smoking and psilocybin: Johnson contemporary • Psilocybin for nicotine: Bogenshutz contemporary 3 contemporary examples: • Roland Griffiths: Phase-three clinical trials for MDMA and psilocybin • Ben Sessa: MDMA for alcoholism in Bristol (BIMA) • Rupert McShane: Ketamine for treatment-resistant depression + Treatment of dual diagnosis Ketamine to be licensed for treatment-resistant depression later this year. Psilocybin next? Trauma: MDMA, likely available for trauma therapy 2021
Drug harms Nutt et al, Drug harms in the UK: a multicriteria decision analysis, Lancet 2010: 376: 1558-65
Mechanisms of action: psilocybin and the dorsal node network REBUS RE laxed B eliefs U nder p S ychedelics Robin Carhart-Harris, 2018
Mechanisms of action: homological scaffolds Homological Scaffolds in Brain Functional Networks - Petri et al. 2014
Mechanisms of action: psilocybin and plasticity Calvin Ly et al. Cell Reports, 2018
Mechanisms of action: trauma and MDMA + Attachment basis + MDMA as an antibiotic for trauma “perfect tool for trauma therapy” + Empathy and stimulation also key
Commonalities and reservations
6. Three clinical/academic psychedelic doctors Roland Griffiths, John Ben Sessa, Bristol Rupert McShane, Oxford Hopkins (BIMA) + Ketamine for treatment- resistant depression + Psilocybin and depression in + MDMA for alcohol terminal cancer FDA approved + Psilocybin for smoking cessation + Psilocybin in long-term meditators
Roland Griffiths: psilocybin 254 participants in >600 sessions + Tobacco + Cancer + Meditators “As a scientist, if you can create conditions in which 70% of people have had one of the most meaningful experiences of their lives then that is incredible”
Ben Sessa, Bristol: MDMA for alcoholism + Bristol MDMA Alcohol Study (BIMA)= open label safety and tolerability study + 2 MDMA sessions (125mg, and 62.5mg) with 8 weeks of psychotherapy + Physical observation throughout www.youtube.com/watch?v=I96cnUacLg0
̶ ̶ ̶ Rupert McShane, Oxford: ketamine for depression + New class of rapid-acting antidepressant + SWAP (Substances with Abuse Potential) + Approved and licensed clinics + Psychiatric Intervention Clinic + Intravenous then oral + Reliance vs. dependence + Esketamine, Spravato + No psychotherapy + Regulation: Controlled drug (no TTO) Registry (Jannsen) Risk of dependence with off-label use
So if this is a legitimate paradigm, how do I integrate it?
Who might this work for?
7. Interface
My takeaway + Not a replacement for therapy + Not ego vs. spirituality + Not a modality conflict + Not an abstinence debate + Always comes back to be ‘needing to be seen’/attachment
Legality and stimga + Therapists’ psychedelic experience + Societal attitudes – ‘hippy’ + Competition: ̶ Expert role ̶ Financial
The future + We may be at the cusp of a new era of psychedelic medicine: the reset button + Psychedelic medicine may be restricted: ̶ High cost ̶ Not suitable for everyone ̶ May not be great enthusiasm amongst psychiatrists or therapists ̶ Unlikely to be accepted in the wider recovery community ̶ Peer support/community and ongoing psychedelic use (underground/ overground)
̶ ̶ ̶ 8. Discussions Treatment and interface Diversion and iatrogenic Research and understanding dependence + Treatment centres + Era of psychedelic science + Ketamine in depression + As medication-assisted + “Mystical experiences are market projected at $1 recovery via NHS biologically normal and relate to the nature of consciousness” + Aggressively marketed Antidepressants Naltrexone + May reveal knowledge that is + General psychiatrists have Buprenorphine applicable to sober recovery variable addictions experience + Need for SWAPS registry (perhaps like clozapine)
Questions?
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