Frustration.

If you’ve treated patients with PTSD, I’m guessing that both you and your patients have experienced frustration at numerous points along the treatment course. And it’s understandable – up until this point, the efficacy of PTSD treatments has been notoriously poor. The best options aimed to diminish the severity of symptoms with a combination of therapy and daily medications.

However, the U.S. is on the brink of having a new FDA-approved therapy for PTSD. In Phase 3 trials of this therapy, 67 percent of study participants no longer qualified as having PTSD.

You read that right: it wasn’t that 67 percent had decreased symptoms – 67 percent no longer fulfilled the criteria to carry a diagnosis of PTSD.

The treatment? MDMA-assisted psychotherapy. Yes, MDMA – the active ingredient in the club drug often referred to as ecstasy, E, or molly.

And right behind MDMA in the line for FDA approval is psilocybin, as a therapy for treatment-resistant depression. Psilocybin is the active ingredient in what is commonly referred to as magic mushrooms.

Currently already legal for use in depression and other conditions is ketamine (the anesthetic). Used in the correct amounts and in the proper set and setting, ketamine may decrease suicidal ideation.

What these substances have in common is that they are widely considered to fall into the category of psychedelics. What else they have in common is that the vast majority of us physicians learned nothing about them in medical school or residency, as most psychedelics are classified as Schedule 1 substances, which suggests they have no currently accepted medical use and pose a high potential for abuse.

With these psychedelic-based therapies, clinicians are now presented with options to help patients who haven’t benefited from traditional treatments. These therapies are vastly different from current medical models in that there is generally no pill to take every day, and some treatments need to be done only one or two times to have a lasting effect.

As some psychedelic therapies are already available, and more are coming soon, now is the time for us to get up to speed on what these psychedelic medicines are, how they work, what conditions they may be able to treat, how they interact with other medications, possible dangers, and what our role may be in facilitating patient access to these medicines.

A (very brief) history of psychedelic medicines

The current wave of research on the therapeutic potential of psychedelics is not the first time this has been explored. Prior to the DEA classifying most psychedelics as Schedule 1, some therapists had been using them to assist therapy sessions for conditions including mood disorders and alcohol dependence.

Getting to the root, not chasing symptoms

Why are psychedelic-assisted therapies so effective? Much of the reason is that psychedelic journeys, when done with qualified therapists in a proper setting, can often reveal the root causes of conditions like PTSD or depression. 

Often in psychedelic journeys, patients can identify what lies at the heart of their struggles, and they can work with a qualified therapist to re-evaluate the event. For example, MDMA effectively takes the amygdala (the brain’s fear center) offline – and in this state, a patient may be able to view a traumatic event with less fear and be able to neurologically process it in a more adaptive manner.

Crucial components of a therapeutic psychedelic session

As suggested above, there are certain elements that tend to produce the most therapeutically-beneficial psychedelic journeys. The first is proper preparation prior to the journey so that the patient knows more or less what to expect, and so that they can set an intention for what they’d like to explore during the journey. Secondly, it is imperative to have a qualified therapist guiding the journey, both to maximize therapeutic benefit, but also for harm reduction purposes, as journeys can get quite intense. 

The next crucial elements are referred to as set and setting. “Set” refers to the mindset one has when undergoing the journey. Entering sessions with as calm a mindset as possible is likely to lead to better outcomes. ‘Setting’ refers to the physical setting in which the journey takes place – preferably a safe, comfortable room with calming decor. 

The final piece is called integration, which happens in the weeks and months following the journey with the psychedelic itself. In integration, the patient works with a therapist to make sense of what they experienced during their psychedelic sessions. The two work together to help the patient integrate the lessons learned or insights gained into their daily lives.

What role will physicians play in this new field?

As ketamine is currently the only legally-available psychedelic medicine, it has yet to be seen exactly what physicians’ role will be in the realm of psychedelic therapies. Likely, psychedelic medicine will be viewed as any other specialty, meaning that primary care physicians would refer patients to psychedelic therapists like they would refer them to a surgeon or dermatologist, though referring physicians may be responsible for clearing patients for these therapies.

Addressing physicians’ concerns

When discussing psychedelic medicine with physicians, two questions most commonly arise: are these substances addictive, and is it legal to discuss them with patients? 

First, regarding the addictive potential, it’s important to know that most psychedelics are not only not addictive (meaning they lack the pharmacological mechanisms that lead to addiction), but that they’re often anti-addictive, meaning that they can help patients overcome addiction. 

Psilocybin mushrooms, along with cognitive behavioral therapy, have been shown to be an effective method for combating tobacco addiction. Also, a psychedelic called ibogaine has shown evidence to help patients heal from opioid addiction, often without withdrawal symptoms.

And as far as what physicians are allowed to discuss with patients, there is legal precedent allowing physicians to discuss illegal substances with their patients, as long as the discussion is of an informative nature and does not delve into aiding the patients to obtain the substances illegally. 

It is also worth noting that as with any medical treatment, there are potential risks with psychedelic-assisted therapies, including drug-drug interactions, elevation of heart rate or blood pressure, and increased risk of arrhythmias, to name a few. And therapies that require high-dose psychedelics can put patients in an altered state of consciousness, which can unmask certain psychiatric conditions or lead to psychological trauma, especially without a trained guide present.

A reason for hope

As clinicians, many of us have felt very impotent when faced with difficult to treat medical conditions, and it’s some of those conditions where psychedelic therapies seem to be most effective. So these new developments are a reason for optimism – for our patients, who have been struggling for too long, and for us clinicians who care for them, as we will finally be able to offer hope to those patients.

Lynn Marie Morski is a physician, attorney, and president, Psychedelic Medicine Association.

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