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Join Lynn Marie Morski, a physician, attorney, and president of the Psychedelic Medicine Association. We’ll explore the historical roots of psilocybin, its emerging clinical applications, safety considerations, and the role of health care professionals in educating patients.

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

She discusses the KevinMD article, “The importance of physician education regarding psilocybin therapy.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Lynn Marie Morski. She’s a physician, attorney and president of the Psychedelic Medicine Association. We’re going to talk about the KevinMD article “The importance of physician education regarding psilocybin therapy.” Lynn Marie, welcome back to the show.

Lynn Marie Morski: Thanks so much for having me, Kevin.

Kevin Pho: So you’re president of the Psychedelic Medicine Association. How did you get interested in this area?

Lynn Marie Morski: I was working at the VA for about nine years, and a lot of the patients I would see come through there obviously had a lot of mental health issues. In that same period of time, I was learning what psychedelics could do to help a lot of those same mental health issues that I saw just weren’t being properly addressed, or sufficiently addressed. You know, I know doctors at the VA were doing everything they could with the tools they had, but still, PTSD was really predominant, and depression, and I was seeing where psychedelics were being shown to be effective against depression and PTSD. So I got really interested in that, because I saw, man, if I could get these medicines to the patients that I’m seeing who really need them. But obviously there was this chasm: These medicines still weren’t legal, and a lot of clinicians didn’t know about them.

So that’s why I first started the Psychedelic Medicine Podcast, to try to educate people as a whole, but then I founded the Psychedelic Medicine Association specifically to educate clinicians, because that’s who the majority of people go to with their medical questions. You know, I know a lot of people go straight to WebMD, but still, a lot of people go to their family doctor or their psychiatrist and say, “I’m struggling with this. What can I do?” I wanted clinicians to know that psychedelics are an option that either is available today, in the case of ketamine, or in the case of psilocybin in Oregon, or that will likely be available soon.

Kevin Pho: And let’s set the table. Specifically, we’re going to talk about psilocybin, so tell us what the current state of that is and how often it’s being used.

Lynn Marie Morski: So psilocybin in the United States is currently legal only for adult use in Oregon, and it’s in a very specific model where you have to go to a licensed center that has gotten their psilocybin from a licensed grower, and then you will see a licensed facilitator. So it’s a very regimented system, but you can come from other states; you don’t have to be, you know, an Oregon resident to take advantage of this.

And then psilocybin is decriminalized in other places in the country, which means it’s not legal, and you can’t sell it, but it is not criminalized, so you are allowed to have it, or it’s the lowest priority on the police’s docket. But for actual clinical use, if a doctor wants to recommend somebody go do psilocybin therapy, the only legal place in the U.S. right now is Oregon. Colorado has passed similar legislation, and so in the next couple of years, psilocybin, along with a few other natural psychedelics, should have the same kind of structured adult-use program.

Kevin Pho: So let’s go even further back than that. What exactly is psilocybin, and what are some of the indications you use it for?

Lynn Marie Morski: Psilocybin is the active ingredient in what most of us colloquially know as magic mushrooms. Psilocybin has been shown to be effective in things like end-of-life anxiety, which is one of the first studies. It’s extremely effective when added to CBT for tobacco cessation. They’re finding it effective in major depression and treatment-resistant depression. Studies are coming out showing that it has some efficacy in anorexia. It’s also being studied for things outside of the mental health realm, like migraines and cluster headaches. So it has a wide range of uses, and it’s likely to be the second FDA-approved psychedelic. MDMA is likely to be the first, but psilocybin is, you know, entering phase 3 trials at this time.

Kevin Pho: All right. And in your KevinMD article, you talk about the importance of physician education regarding psilocybin therapy. So go into your article. Why did you write it?

Lynn Marie Morski: So like I said, in Oregon, this system is now up and running. So imagine you’re a primary care doctor in Oregon, and your patient comes to you and says, “I hear about these psilocybin centers. I see that, you know, a lot of people are really interested. Could this be effective for me and the condition I’m concerned about? And also, is it safe for me, knowing that I’m taking XYZ medications and my mental and physical medical history is this?” Our concern is that since we were not educated on psilocybin in medical school, a lot of primary care and other physicians, across Oregon especially, are going to be caught a little bit like a deer in the headlights. So in the Psychedelic Medicine Association, it became very important for us to focus on Oregon and get doctors there up to speed, so that they’d feel more comfortable talking about the indications, talking about the contraindications and doing, you know, at this point, we can’t do an actual medical clearance for it, because we don’t have enough data.

You know, if you’re going for surgery, you go to anesthesia, and they do your medical clearance. Well, first off, we don’t have quite that setup yet, where we’re going to send somebody to anesthesia. But, you know, if you’re the PCP, you’re going to have to do kind of a basic risk assessment: Look at their medicines, look and see if there are any drug-drug interactions with psilocybin, and look at particularly their psych history and heart history and see if those might make it more or less risky. We can’t really say what the absolute contraindications are at this point, because there haven’t been enough studies done, but we wanted to get doctors starting to feel comfortable having those conversations, especially in Oregon.

Kevin Pho: So let’s say I’m a primary care clinician in Oregon. Take me into an exam room. What would a typical patient request, or what would a typical case, look like where psilocybin would be appropriate?

Lynn Marie Morski: So like I said, for somebody who might have major depression or treatment-resistant depression, those are great starting points for psilocybin. Another thing I will just kind of pop in here is that to use Oregon’s system, you don’t have to have an indication. A lot of people undergo psilocybin and other psychedelic journeys just for general well-being or some introspection. But there are some indications, like I said, end-of-life anxiety being one of the first studied, and tobacco cessation. Any of those things that the patient may be concerned about or wishing to address are great starting points. There’s a lot of research on those.

But that patient might come in and say, “You know, I’m taking this antidepressant. Will that affect my psilocybin journey?” And so then, you know, there’s a list, and you can kind of cross-reference. They might also say, “Well, I have a first-degree relative that has a history of psychosis,” or “I myself have been diagnosed with bipolar disorder.” Unfortunately, for example, those are two areas where research is not fleshed out enough yet to make a decision. There’s ongoing research in those areas, but at this point, you know, the doctor may urge caution: We don’t know enough to say it’s safe in those areas. Same with pregnancy; we don’t have any research on that yet. But the doctor can at least give the patient the knowledge that, yes, those are concerns. We’re not saying it’s an absolute contraindication, but so far it hasn’t been studied.

Or if the patient comes in and doesn’t have any of those mental or physical conditions in their history, the doctor may just look at the drug-drug interactions, make sure everything’s OK and say, “OK, your heart seems to be OK enough,” because most of the psychedelics can transiently raise, you know, heart rate and blood pressure. And they may say, “Look, yeah, go ahead. This seems to be safe.”

Kevin Pho: What kind of forms does psilocybin typically come in?

Lynn Marie Morski: So in Oregon, you know, there are generally two forms. One is the natural mushroom form, and the other is synthetic. The way that I believe they’re doing it in Oregon is they are growing one certain specific type of mushroom, and then they process it to come in a capsule, so that we have exact milligram or gram amounts, because when you just eat the raw mushroom, it’s harder to get the exact amount. So that’s part of what Oregon has done to standardize it. So if you’re taking it in Oregon, it will probably come from a natural source, but in a capsule form.

Kevin Pho: Now, if I’m a clinician considering psilocybin for, say, depression, what kind of questions should I ask myself to make sure that this is right for the patient versus, say, an SSRI?

Lynn Marie Morski: Well, again, this is where it’s not an either-or. It may be an issue of, they’ve tried an SSRI and it wasn’t working, or it may be what you want to try as first line, you know. It’s just kind of individualized. The SSRIs have side effects. They might work for some people, and maybe they’re working for somebody, but they say, “The side effects are really, you know, bumming me out more than the depression was.” And so that may be an indication where it’s, “Hey, let’s try psilocybin.”

Because something that I should have pointed out at the beginning is that with some of the psychedelics, psilocybin being a great example, you don’t take this every day. You generally do one to two higher-dose sessions, with therapy, with preparation and with what we call integration afterward, so that you can integrate what you saw or felt or learned on your specific medicine day. So it’s not like, “OK, versus taking an SSRI daily, now I’ll be taking psilocybin daily.” It’s either take an SSRI daily, or maybe do one or two sessions with psilocybin, and then the goal is to not have to be taking something daily.

And so it may be that, you know, somebody is maybe, let’s say, slightly fearful of a psychedelic journey, or maybe it’s not medically indicated for them, so, you know, start with the SSRI. But if somebody is healthy and willing to try the psychedelic, it may be, you know, generally these go in and address the root cause of the depression, as opposed to SSRIs, which are generally trying to address the symptoms. And so that’s another thing to decide, like, you know, if this patient is ready to maybe delve into the root cause.

Kevin Pho: So from a patient standpoint, when they take these psilocybin capsules in Oregon, what would be a successful example? What would it feel like when you take these?

Lynn Marie Morski: Well, just to be clear, we don’t want to set any expectations, because people’s journeys can look very, very different. But what we would hope is that two things happen. Psychedelics not only work by having some kind of hallucinatory journey, which is generally there, but they also work on a physiologic level. They work on the serotonin receptor, and they lead to a lot of neuroplasticity, and they reopen critical learning periods and all these things. So, you know, some of those periods you had when you were younger and able to re-form neural pathways, those are reopened. So regardless of whether you have a crazy hallucinatory journey that shows you anything or gives you any insights, you probably will still have those physiologic factors. So if you don’t have a crazy journey, don’t think, “Oh, I’ve failed psilocybin.” The psilocybin still worked on you in some way.

But secondarily, during, you know, the hallucinations that can often come with these psychedelics, very often it elucidates some negative pattern of thinking or some limiting belief. It may highlight some old trauma that’s causing the PTSD or causing the depression, and it may help you reframe it, or it may take the fear center away a little bit for a minute, so that you can take a good look at it and readdress it. And then generally, after that, hopefully that event has less effect on you overall, meaning that it should be causing less depression or less post-traumatic stress.

Kevin Pho: Any concerns about psilocybin being habit-forming?

Lynn Marie Morski: No, psilocybin is not shown to be addictive, and in fact, many of the psychedelics are shown to have anti-addictive properties. So they can be used, like I said, in the case of tobacco cessation, to help somebody address addiction and become part of their, you know, their withdrawal or their sobriety.

Kevin Pho: Now, what about the cost? What’s the cost of a typical regimen of psilocybin?

Lynn Marie Morski: So in Oregon, that is kind of the biggest issue, because it is fairly costly at this point, and the price is per amount. So if you’re taking a larger amount, then you have to pay more, because the journey will probably be longer, and, you know, they’re having to buy more psilocybin. But it can get into the thousands of dollars. I think, you know, $3,500 is something we’ve seen, and if you’re looking at that as a one-time cost, that might be a lot up front, especially because it’s not covered by insurance.

But again, I just want to reframe that. Yes, that is costly. There are places outside of the U.S., again much less regulated, that have different prices. But with a lot of these psychedelics, while they have kind of, you know, maybe a sticker-shock upfront cost, what you have to look at is the fact that you’re not having to pay for an SSRI every month. If this happens to be, let’s say, successful at addressing something like depression or PTSD, you may not have to pay for nearly as much therapy. Let’s always hope somebody still goes to therapy, but it may not have to be so intensive or so frequent. You may not need to pay for a number of medications.

And then on the other end, you know, they did an MDMA cost-effectiveness study, for example, and with the amount of disability that people were having to be paid out by the government for, you know, loss of the ability to work from PTSD, once you looked at all of those costs, the upfront cost of the psychedelic was significantly less. And so yes, it’s a little pricey on the upfront side, and it’s not yet covered by insurance, but that is also being worked on.

Kevin Pho: If I decided that psilocybin would be right for my patient, how would one go about writing this? Is this something they’ll take a prescription for to a dispensary? What dose would you prescribe? So how would you start someone on this?

Lynn Marie Morski: So luckily for physicians in Oregon, they don’t have to do any of that, because that would require a lot more knowledge: “OK, now I have to know the doses and the forms and all of these things.” The patient doesn’t need any of that to go to a psilocybin facility. They can go there and work with the facilitator to decide on that dosage, and the facilitators are all trained by programs specifically licensed for Oregon facilitation. So, like I said, every aspect of this has been really regulated by the state.

And so the physician really just has to talk to the patient and say, “OK, hey, to me it looks like this might be effective for you. You might want to look into trying it.” They don’t have to say, “Please go there.” It doesn’t have to be a referral or any of those things. It’s mostly, at this point, just a discussion you’d have with the patient about whether psilocybin might address the conditions they have. What we like to focus on, especially in the Psychedelic Medicine Association, because we made an entire course about this, is how primary care doctors can help their patients by doing a risk assessment, by looking, like I said, at the medications they’re on and their mental and physical health history, and seeing whether or not it is likely that psilocybin will be safe for them to try.

Kevin Pho: So you mentioned some of the risk factors to taking psilocybin. What types of medical drug interactions should one be aware of?

Lynn Marie Morski: So mostly, the number one drug interaction that has been shown with psilocybin is lithium, and so that’s the one to look out for, mostly. Otherwise, with SSRIs, there’s still a lot of debate on whether it affects them. There doesn’t seem to be a huge risk that something bad is going to happen if they’re on an SSRI, but it may be that the psilocybin is less effective, because, you know, they’re both somehow interacting with the serotonin receptor. And so I would say, you know, it’s your lithium, it’s your antidepressants, antipsychotics.

And, you know, if they’re on any of those, then at the Psychedelic Medicine Association, we have a kind of chart that shows what type of interaction it is, you know, if it’s a no-go, and lithium is more falling into that category, it just happens to be the one that’s shown to have some risks, or maybe it’s, “We don’t have enough data. It may affect the journey, but it may not.”

And then, you know, another thing where primary care doctors, and psychiatrists as well, may want to work with their patients in Oregon is that the patient may want to taper off their antidepressant to try this. So that’s another thing that, you know, it’s a good thing for physicians to be aware of: Patients may come in asking, “Let’s work on a taper-off schedule,” so that they can try this. And so it’s good to have doctors know that that may be a thing that’s coming.

Kevin Pho: Now, how about patient selection? Has it been studied in pregnant patients? Any other types of patients that you would not prescribe psilocybin to?

Lynn Marie Morski: Currently, like I said, patients with a personal history of psychosis, and even with a first-degree relative with psychosis, have not been studied. With patients with schizophrenia, the first studies, I think, are just happening, so there’s not enough data there, for patients either with, or, let’s say, with a first-degree relative with, most of these conditions. Schizophrenia studies are ongoing currently, as are studies with patients who have bipolar disorder. And also, we know that there are two types of bipolar disorder, so we may find that those two are different. It may not just be that all bipolar disorder patients may or may not be able to undergo it. But those are some of the main conditions on the mental health side.

On the physical health side, it’s mostly like, how well controlled is your blood pressure? Do you have any risk of heart rate issues? Psilocybin is overall very safe, but, you know, with kind of the more medically fragile patients on the cardiovascular side, that may be more of a concern as well.

Kevin Pho: How about states outside of Oregon? Are they expecting psilocybin to be legalized in other states?

Lynn Marie Morski: So like I said, in probably a year or two, Colorado will follow with their own version of Oregon’s, and then other states, like California and Washington, have had legislation that has been proposed. A lot of states, even on the East Coast, and Texas, are starting to have legislation passed to at least support research. So even if perhaps there isn’t a legalized model, you may have a patient, as a PCP, who ends up undergoing one of these trials. There are a lot of trials going on, so it’s great to just at least start educating yourself on what your patients may be going through if they happen to be going into one of these trials. But, you know, like I said, MDMA is likely to be approved for PTSD within the next year or so, and psilocybin is likely to be maybe a couple of years afterward, so hopefully this will be nationwide within the next five years.

Kevin Pho: We’re talking with Lynn Marie Morski. She’s a physician, attorney and president of the Psychedelic Medicine Association. We’re talking about the KevinMD article “The importance of physician education regarding psilocybin therapy.” Lynn Marie, tell us some of your take-home messages that you want to leave with the KevinMD audience.

Lynn Marie Morski: I would love physicians across your audience to know that psilocybin and other psychedelic medicines are here, and they’re going to continue to be FDA-approved or more readily available. And so I’d love to have everybody just pay attention and increase their knowledge, because it’s not just mental health professionals that will need to know this. They’re finding a lot of physical health conditions, and chronic pain, cluster headaches, stroke, that are being addressed by psychedelic medicines as well. And so I would love everybody to start familiarizing themselves with those, because these are coming, and patients are going to start asking pretty soon.

Kevin Pho: Lynn Marie, thank you so much for sharing your time and insight, and thanks for coming back on the show.

Lynn Marie Morski: Thanks for having me, Kevin.