Psychedelics as medicine iCAAD 2019 New kid on the block or old - - PowerPoint PPT Presentation

Psychedelics as medicine

New kid on the block or old hat?

iCAAD 2019

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

Humphry Osmond

+ Spring Grove, Maryland 1970s + Many psychiatrists and therapists active in the field, some to this day

The Harvard Psilocybin Project

+ 1971 “the most dangerous man in America” and Schedule 1

Psychedelic science

+ 1990s Johns Hopkins and NYU: psilocybin and end of life cancer + MAPS since 1986 + UK: Bristol, Imperial and Oxford + 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

Psychic vulnerability Flight instruction

In and through difficult experience: + Ego death Suggestions: + TLO + Holding lightly Collecting experience

Trust and rapport

“to trust unconditionally with one’s mind” Ego strength Adequate: set, setting, dose Intentions Set: “a conscious decision that in this set, with these people, with the preparation I’ve had, with the proper dosage and purity of this substance, I choose to be out

• f 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 uncertainty 2. Accept themselves and others for what they are 3. Spontaneous in thought and action 4. Problem-centred (not self-centred) 5. Unusual sense of humour 6. Able to look at life objectively 7. Highly creative 8. Resistant to enculturation, but not purposely unconventional 9. Concerned for the welfare of humanity

• 10. Capable of deep appreciation of basic life-

experience

• 11. Establish deep satisfying interpersonal

relationships with a few people

• 12. Peak experiences
• 13. Need for privacy
• 14. Democratic attitudes
• 15. Strong moral/ethical standards

Maslow 1954

• 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 RElaxed Beliefs Under pSychedelics

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 Hopkins

+ Psilocybin and depression in terminal cancer + Psilocybin for smoking cessation + Psilocybin in long-term meditators

Ben Sessa, Bristol (BIMA)

+ MDMA for alcohol

Rupert McShane, Oxford

+ Ketamine for treatment- resistant depression FDA approved

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

• f 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/

• verground)

• 8. Discussions

Treatment and interface

+ Treatment centres + As medication-assisted recovery via NHS

̶ Antidepressants ̶ Naltrexone ̶ Buprenorphine

Diversion and iatrogenic dependence

+ Ketamine in depression market projected at $1 + Aggressively marketed + General psychiatrists have variable addictions experience + Need for SWAPS registry (perhaps like clozapine)

Research and understanding

+ Era of psychedelic science + “Mystical experiences are biologically normal and relate to the nature of consciousness” + May reveal knowledge that is applicable to sober recovery

Questions?

+ Maslow, A. H. (1971). Self-actualization. Big Sur Recordings. + Rogers, C. R. (1963). The concept of the fully functioning person. P sychotherapy: Theory, Research & Practice, 1(1), 17. + Bowlby, J. (2012). A secure base. Routledge. + Bowlby, J. (2008). Attachment. Basic books. + Carhart-Harris, R. L., & Friston, K. J. (2010). The default-mode, ego-functions and free-energy: a neurobiological account of Freudian

• Ideas. Brain, 133(4), 1265-1283.

+ Dambrun, M., & Ricard, M. (2011). Self-centeredness and selflessness: A theory

• f self-based psychological functioning and its consequences for happiness.

Review of General Psychology, 15(2), 138-157. + Deci, E. L., & Ryan, R. M. (2008). Self-determination theory: A macrotheory of human motivation, development, and health. Canadian psychology/Psychologie canadienne, 49(3), 182 + Fonagy, P. (2018). Affect regulation, mentalization and the development of the

• self. Routledge.

+ Gerhardt, S. (2004). Why love matters: How affection shapes a baby's brain. Routledge. + Millière, R. (2017). Looking for the Self: Phenomenology, Neurophysiology and Philosophical Significance of Drug-induced Ego Dissolution. Retrieved from https://www.frontiersin.org/articles/10.3389/fnhum.2017.00245/full + Sessa, B. (2017). The Psychedelic Renaissance: Reassessing the Role of Psychedelic Drugs in 21st Century Psychiatry and Society. Muswell Hill Press. + Pollan, M. (2018). How to Change Your Mind: The New Science of Psychedelics. Allen Lane.

Bibliography

+ Maté, G. (2011). In the realm of hungry ghosts: Close encounters with addiction. North Atlantic Books + Moss, A. C., & Dyer, K. R. (2010). Psychology of addictive behaviour. Macmillan International Higher Education. + Neff, K. (2003). Self-compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and identity, 2(2), 85-101. + Orford, J. (2001). Excessive appetites: A psychological view of addictions. John Wiley & Sons Ltd. + Siegel, A. M. (2008). Heinz Kohut and the Psychology of the Self. Routledge. + Scott, G., & Carhart-Harris, R. L. (2019). Psychedelics as a treatment for disorders of consciousness. Neuroscience of Consciousness, 2019(1), niz003. + Grof, S. (1996) . Realms of the Human Unconscious: Observations from LSD Research (Condor Books) + James, W. (1983). The Varieties of Religious Experience: A study in Human

• Nature. Penguin Classics.

+ Richards, W. (2018). Sacred Knowledge: Psychedelics and Religious Experiences. Columbia University Press. + Dyck, E. (2008). Psychedelic Psychiatry: LSD from Clinic to Campus. Johns Hopkins University Press + Strassman, R. (2000). DMT: The Spirit Molecule: A Doctor's Revolutionary Research into the Biology of Near-Death and Mystical Experiences. Park Street Press.

Contact Details Dr Sarah Flowers

Priory Healthcare: Life Works Direct Contact enquiries@lifeworkscommunity.com SarahFlowers@nhs.net

Charlotte Parkin

Priory Wellbeing Centre Fenchurch Priory Wellbeing Centre Harley Street fenchurch@priorygroup.com harleystreet@priorygroup.com