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Hey, y’all. Welcome back to The Testing Psychologist.
Full transparency, I have tried to record the introduction to this podcast probably close to 10 times now and keep managing to mess something up. So fingers crossed, this is the one that sticks. We will see. I’m excited to be [00:01:00] here with a return guest, Dr. Craig Heacock. He’s a friend, he is a fellow podcaster and runner, and he’s a local psychiatrist.
Craig was here probably six months ago to talk about substance-induced psychosis, specifically with THC. That episode was very popular. He’s back today to talk with me about psychedelic-assisted intervention.
A little about Craig.
He is an adolescent, adult, and addiction psychiatrist here in Fort Collins, Colorado, where he also hosts and co-produces a psychiatric storytelling podcast called Back from the Abyss. Fantastic podcast. It is linked in the show notes and you should definitely check it out.
Craig has a special interest in the use of ketamine and psychedelics to treat mood disorders and PTSD. He’s a graduate of the University of New Mexico School of Medicine and did his psychiatry training at Brown University.
So like I said, we’re talking about psychedelic-assisted intervention. [00:02:00] We tackle the three, what I would call main interventions right now in the psychedelic world. So we tackle ketamine, MDMA, and psilocybin or “magic mushrooms”. And for each of those, we dive into the neurochemistry involved and what’s happening in the brain when we use these substances. We talk about appropriate clinical populations for these substances, and we also talk about contraindications for each of these and folks who should probably stay away from psychedelic-assist treatment.
So this is a great episode. Not directly testing-related, but certainly intervention related. So many of us are making referrals after our evaluations for appropriate treatment. And as you’ll hear in this episode, Craig feels that we are in the middle of a very special moment in psychiatric treatment as we figure out how to [00:03:00] use these psychedelics to treat some pretty common and debilitating conditions. So stay tuned and enjoy this episode with Dr. Craig Heacock.
Craig, welcome back to The Testing Psychologist podcast.
Dr. Craig: It’s great to be here. Thanks, Jeremy.
Dr. Sharp: Yes. I’m glad to be here with you. Our last episode on substance-induced psychosis talked specifically about THC. Super popular and super important in the mental health landscape these days. But we’re going to dive into psychedelic-assisted treatment, which is also huge right now, and more on the helpful side then. So grateful to have you. I’m excited to dive in.[00:04:00] Dr. Craig: Me too. Thanks for having me.
Dr. Sharp: Absolutely. So let’s start. My standard opening question of course is why this is important to you. Interesting, I asked this question back with the psychosis episode as well, and this is another topic that is really important to you and I’m really curious how you are making space for this and why you’re making space for this in your practice.
Dr. Craig: Well, I would say on two levels, this is a deeply important, interesting topic for me. One is because as a psychiatrist, it’s been abundantly clear to me over the last two decades that there are at least three kinds of clinical presentations in psychiatry that we have had very little to offer people. One would be trauma. In fact, in my residency, we barely discussed trauma. Now, granted that was 2001 to 2005, but it was more like a side dish. PTSD was something that, [00:05:00] it wasn’t a main course. Trauma was a factor, but it’s amazing how things have changed in psychiatry ever since.
So the first would be trauma, and secondly, psychiatrists had very little to offer people who don’t have an endogenous depression but have more like a demoralization, a psychospiritual depression, a grief-based depression because depression is a final common pathway with many roads there. And a lot of those people show up and get diagnosed with treatment-resistant depression, which is really not a thing. We can talk more about the concept of that. And the third thing, which is less relevant to this talk today, is the negative symptoms of psychosis and schizophrenia that we just haven’t had much to offer.
For years in my practice, I had all these people with treatment-resistant depression/trauma, and none of them were getting better. We’ve given them medicines and therapy and it’s [00:06:00] become abundantly clear to me over the last few years and also working on my podcast, Back from the Abyss, that for so many people, trauma is the source of their psychiatric symptoms and medicines and talk therapy will not get you there. You have to go deeper. You have to go into realms that standard psychiatric medications and talk therapy don’t go.
And so, we’re finding out with psychedelic-assisted therapy that we’re actually able to go to the depths of places that were never possible before. It’s almost like if psychiatric medicines and talk therapy were like fishing in the upper levels of the ocean, the upper 20 feet, and effective like if things were swimming up there, we could capture them but psychedelic-assisted therapy has opened up the other bottom 10,000 feet of being able to go places that aren’t possible and also where a lot of the stuff lies. So that’s just thrilling.
Dr. Sharp: Yeah. I love that analogy of the [00:07:00] deep sea fishing. I think we’ve been doing our best over the past 20, 30, 40 years with these things. It’s interesting to hear, it seems like there’s a parallel in psychiatry as there is our side, the psychological side, with trauma where it’s just coming more and more to the forefront. So many of the things that we misdiagnose as depression or anxiety or personality issues, we’re seeing that trauma plays a really big role.
Dr. Craig: Yeah. Another really, it’s kind of a side topic, but really interesting. I think we’re seeing for psychedelic-assisted therapy that it’s not only a really interesting, often effective treatment, it’s also diagnostic. You can imagine that these substances can be like a deep MRI of the psyche of the unconscious, to take people down to places to understand what’s actually going on. [00:08:00] Because I think so often with trauma, a lot of what ails people is not cognitive, it’s not verbal- neglect being a perfect example. And so few patients or clients I think can really, especially early neglect, it’s so difficult to put words to that. It’s really more of a somatic and psychospiritual wound. And psychedelics potentially can take you down to these non-verbal somatic realms and help show you and guide you and help you understand why you’ve been suffering some.
Dr. Sharp: Yes. So we’re going to dive into specific substances, that doesn’t seem like the right word, but we’re going to dive into specific treatments, right? We’re going to do psilocybin, ketamine, and MDMA during the podcast, but I want to ask a broad question since you’re bringing it up here at the beginning. I immediately think, [00:09:00] okay, how do we separate the healing or the journey that happens with these interventions from either a placebo effect or some kind of memory placement that were unduly influencing clients to remember things that may or may not be there? It seems like that’s a really fine line walk with some of this treatment. Am I off on that? What would you say?
Dr. Craig: No, you’re right on. We know from the placebo research that active placebos, placebos that cause side effects are more powerful. And we know that placebos that have strong side effects are even more powerful. So surely the placebo effect plays a role in some aspects of psychedelic therapy but that’s not bad. We learned in my residency, we had a number of seminars about harnessing the placebo effect to help people because it’s a thing. [00:10:00] But that’s said, there are abundant examples of psychedelics being used, even open-label, without a placebo group, where surely the placebo effect is not evidence.
Perfect example would be obsessive-compulsive disorder. There’s essentially no placebo effect with OCD. There’s a strong placebo effect with depression and anxiety, with OCD no. Placebos do nothing, which I think is really interesting. Suggest that OCD is a very hardwired deeply ingrained illness, which makes sense because it’s so chronic. Usually starts so early. When you give people highish doses of psilocybin for treatment-resistant OCD, they often go into partial or full remission for many weeks or months. And that’s open-label. That’s not a placebo-controlled group. And again, the placebo response in OCD is essentially zero.
Dr. Sharp: Sure, [00:11:00] that’s a great example. Okay.
Dr. Craig: Yeah. But it is true that we could imagine that a more powerful or even difficult psychedelic therapy experience could be perceived as more effective. Someone coming out, wow, that was really hard. And then that could foster more healing just out of the placebo effect. But again, I don’t think we need to talk about the placebo effect in a pejorative way. It actually can be helpful and the more that we understand it and harness it, it’s just another way to help people.
Dr. Sharp: I appreciate that perspective. Yeah, it’s easy to throw it out as that didn’t work or it’s just, but you have a great point if it’ll help.
Dr. Craig: It’s a side note about the placebo effect, it’s very genetic. Its people bifurcating into treatment groups or two response arms. There’re people that respond really well, very strongly placebos, and they’re people that don’t at all.[00:12:00] So actually it’s interesting. So if you think about the placebo effect, it’s an average really of those two groups. So placebo responders often have a very vigorous placebo response, which if you can identify those people, you can actually harness that, take advantage of that.
Dr. Sharp: Is there any way to identify those folks? Are we that sophisticated?
Dr. Craig: There’s at least one or two genetic alleles that have been linked to strong placebo. In fact, I can’t remember what they are right now but you can imagine that’s a really cool idea that when you’re trying to figure out treatment for people as wanting to know not just their blood or urine or a genotype, but actually specifically looking like, are you going to be a big placebo responder?
Dr. Sharp: Right. Do you have any idea, this is a naive question, but any idea of the neurology behind that? Like what’s happening in the placebo effect and how folks can be so bifurcated as said?
Dr. Craig: It seems to me it’s [00:13:00] related to a serotonin or dopamine transporter gene, at least. There’s probably multiple factors. I don’t know.
Dr. Sharp: Yeah. It’s fascinating. Well, let’s transition to some specific treatments. We’ve got, like you called it before we started recording, the big three of psychedelic treatments these days, a lot of research, but into each of these intervention. And I’d love to tackle each of them. Let’s start with ketamine. Let’s start there. That seems to be the one that is most approved. There’s probably a better term for that, but it’s in, well, wide use.
Dr. Craig: Yeah, and most abundant.
Dr. Sharp: Most abundant.
Dr. Craig: It’s been FDA approved for anesthesia for 50 years.
Dr. Sharp: Sure. Okay. Let’s start with ketamine. I would love to talk first, just about the neurochemistry involved there, like what’s happening when someone takes ketamine and we can go from there as far as how it’s helpful, [00:14:00] so forth.
Dr. Craig: Yeah. Ketamine is a really interesting molecule because unlike say, psilocybin or MDMA, which have multiple effects in the brain, but those are pretty easily characterized, ketamine has a bunch of different effects in the brain. So it works on the NMDA glutamate receptor. It seems to work on opioid receptors. It seems to have some effect on deep sleep cycles. It is involved in neurogenesis and neuroplasticity and it also is very dose dependent. So as you go up on ketamine, different chemical systems take precedent. So ketamine is a very different substance at different dose ranges.
One way to think about ketamine is the three steps of ketamine. The lowest step would be psycholytic ketamine, which is opening up the psyche. The medium [00:15:00] doses would be psychedelic ketamine. And then the top step would be anesthetic ketamine. We’ve well-characterized it because it’s been around for decades, but the effects that you’re getting therapeutically vary a lot depending on where you are dose wise and in the context.
Dr. Sharp: Yeah. Can you give just a brief history of ketamine and it’s metamorphosis. From my understanding anyway, it’s used as an anesthetic to now treatment for mental health concerns. Can you walk us through that real quick?
Dr. Craig: Like so many things in medicine, we often see a medication approved for one purpose and then used widely for something else. So for decades, it was used primarily in general anesthesia. But in the 90s, there started to be some folks, especially on the West Coast and I [00:16:00] believe in New Zealand, who were experimenting with using it for depression because doctors were hearing some of their patients come in and say, hey, I did recreational ketamine. It really helped my mood. So there were some enterprising docs that on the DL were using ketamine and often with pretty good success, but it wasn’t until the aughts, the early mid aughts that the research community really started publishing on it.
There were, I believe, the seminal study, I think it was 2006 or 2008, there was a study that really rocked the psychiatric world where they gave IV ketamine to suicidal patients in an emergency room and a very significant percentage of them reported no suicidality after 6-12 hours. So that got people’s interest, but then it was really another decade, 2017, 2018, until things really started taking off with ketamine.
And ketamine, I think, and this is often true in medicine, ketamine use has really been driven [00:17:00] by the clinicians, not by the researchers. So I think a lot of the depression research questions are still not known, but clinicians all over the country have taken over because once a medication is FDA approved for one thing, you can use it for other things. And we’re seeing uses of ketamine are outpacing what the research shows. But that said, ketamine is arguably the best depression medicine to come along, I would say, since Lamictal in 1994.
Dr. Sharp: A strong statement. So walk us through just a little bit what is actually happening maybe at each of those different doses; however you might want to characterize it. What is happening and how is ketamine working for some of these concerns?
Dr. Craig: Well maybe we’ll talk about depression first because I think it’s doing different things for trauma. [00:18:00] And again, it’s hard to talk about depression and we’re talking about depression like’s a thing, but depression is a syndrome. And again, we could be talking bipolar, depression, trauma-driven depression, existential depression. But again, let’s talk about people who show up and have vegetative symptoms of depression, are doing very poorly and haven’t responded to other treatments.
It appears that ketamine is doing a number of things: So number one, ketamine is improving sleep quality. Everyone with a mood disorder has sleep disturbance effect. I and many other people argue that you can’t have a mood disorder without sleep disturbance.
Ketamine is definitely doing something with the glutamate system; the glutamate is the main activating neurotransmitter of the brain. Very few of our depression medicines work on glutamate. Lamictal does, interestingly, lamotrigine, but Ketamine’s working in that system. Ketamine is promoting new brain cell growth. [00:19:00] Ketamine is doing something with the opioid receptors and I think what it’s doing is it’s repotentiating them.
Very interesting finding that if you’re on an opioid, whether that’s a full-strength opioid like oxycodone or whether you’re on a partial agonist opioid like buprenorphine Suboxone and you do ketamine like a significant dose of psychedelic IV or IM Ketamine, the next day when you take your opioid, you’ll get high from it in a way that you didn’t before. And I’ve seen that in my practice. And so it’s pretty clear to me that one of the short-term powerful effects of ketamine is that it’s it’s repotentiating opioid receptors.
And if you think what are the endogenous opioid receptors do, they’re involved in feeling safe and warm and protected and like everything’s okay. And that’s one of the things people often report after ketamine is they feel like things are going to be okay. The sense of overwhelm is dialed way down. Whatever is weighing people down and overwhelming them [00:20:00] is much abated. And I’m wondering if that’s actually directly related to potentiating opioid receptors.
And there was a study that came out of Stanford a few years ago where they gave people opioid blockers and then gave them IV ketamine and they didn’t get nearly as good antidepressant response, so they still got some, but not as powerful. So I’m not saying that the endogenous opioid receptors are all of it, but they’re definitely part of it. In fact, one of the contraindications for IV or IM Suboxone or depression, is probably being on an opioid or Suboxone because you can’t really repotentiate those receptors like you would if you weren’t on an opioid. And I’ve seen that in my practice that people who are on opioids or Suboxone, they just don’t get that much antidepressant benefit from ketamine.
Dr. Sharp: That’s interesting.
Dr. Craig: Yeah.
Dr. Sharp: All right. So a lot of different mechanisms. I totally agree with you on the sleep disturbance [00:21:00] being such a real part of concerns, it seems crucial. So we started with depression. Can we talk about trauma a little bit then? What do you feel like is happening on the trauma side when someone take ketamine?
Dr. Craig: Well I think we could talk about brain effects and then psychospiritual effects. So let’s talk brain effects. So I think the biggest one would come back to what I was just talking about, that people with post-traumatic stress disorder have derangements of their endorphins. And the endorphins are to help us feel safe and protected and soothed and calmed. That’s what endorphins do.
Particularly people with early childhood abuse tend to have really major derangement in the endorphin system. I think one of the things ketamine’s doing is rebooting the endorphin system and giving people a sense of calm and peace but [00:22:00] there’s something more than that, and I think this is where it’s hard to talk about this in ways that I think people are trained in allopathic Western psychiatry or even psychology can get a handle on but that ketamine, like these other substances is working in the psychospiritual realm.
Let me just give an example of that. I had a really scary thing happen last year where my dog turned on me and attacked me. It was horrifying. I wasn’t physically wounded, but I was definitely traumatized and psychospiritually wounded. I did an IV ketamine treatment that was a total game changer and part of this treatment, my dog was attacking me through the treatment, but I could tell it was weird. I didn’t have awareness to realize, oh yeah, this needs to happen. Like I need to have my dog attack me in this weird bloody, ketamine way. And it wasn’t scary. Essentially [00:23:00] it was just calm and devoid of emotion. I was watching my dog’s face just lunge out at me and bite me but I thought, oh, this is the processing; this is me going through this dog attack trauma. It’s haunting me because that’s the way I think of trauma. Traumas are haunting. And with that one treatment it was done. I felt at peace again because before that I was just in 24/7 fight-flight.
And I think you talk to other people who the ketamine or some of the other psychedelics, and they’ll describe positive effects, consistent with brain effects, like less overwhelm or energy, less suicidal ideation, for example, or improved mood but then again, if there’s trauma involved, you often will hear people describe like they feel less haunt or like this [00:24:00] sense of doom and dread has just been dialed way down for a while.
Dr. Sharp: Sure. See, when I hear you describe that experience, it makes me think I’m such […] person much to my wife’s chagrin. Sometimes she dwells in this psychospiritual realm a lot more than I do, I think. But I think about the engagement of the executive system and the frontal lobe and I’m like, what is happening there that brings the processing part of our brain online and the meaning, the rational part of the brain online a little bit more in detaching from the emotional component, right? And so again, I just come back to the neurochemistry involved there and what is happening that we’re talking about is a psychospiritual experience, something happening.
Dr. Craig: There’s something happening. I think I’ve experienced this in my therapy and also hear this a lot from patients is [00:25:00] Andy, I saw this in my work on the MAPS MDMA study, is that….
These kinds of psychedelic sessions, don’t go the way you think they’re going to go. Patients are like, well, this is my intention. This is what I want to do or the therapists are thinking, maybe we should go here. No, I think what you’re really doing is you’re trying to set up a container and a safe place for the unfolding and the unfolding. It’s often the kind of thing that you look in hindsight and you say, oh yeah, that makes total sense that it unfolded that way, but it’s not necessarily something you would’ve ever predicted or planned. And I think psychedelics have a way of doing that, of going down into your unconscious and makes me possibly a broader psychospiritual realm or collective unconscious, or however you want to imagine that, and taking you to places that you never could have mapped out before with your conscious rational mind.
Dr. Sharp: Certainly the way [00:26:00] that I hear people describe it. I’ve experienced these things. I think that’s a nice segue actually to work backward a little bit. I would love to have you talk about the setting for ketamine treatment. I know just from talking to you and others that there’s several different ways to administer ketamine. You do a lot of IV or intramuscular where you’re injecting it. And there are also just oral administration methods. So can you walk us through what it actually looks like for someone to do ketamine treatment?
Dr. Craig: Yeah. So, again, going back to this idea of three levels of ketamine, again, the bottom realm would be lower dose, often oral psycholytic ketamine opening up the psyche. The middle dose would be psychedelic ketamine. In the upper step, the highest dose would be anesthetic dose.
In psychiatry, people are doing the lower and medium dose. [00:27:00] Usually it looks like this: either a lower dose psycholytic ketamine oral typically oral lozenges. And that’s typically done with a therapist in the room. So for example, the patient or client might do a 100 or 200 milligrams of oral ketamine and then would do a 2-hour talk therapy session or somatic trauma therapy session with a therapist in the room.
Now more and more people are doing these by telehealth, and there’s been a lot written about that and New York Times had a big expose of that last week where people are taking lozenges at home and then logging on and doing “therapy” on their laptop while they’re on ketamine.
Dr. Sharp: What do you think about that?
Dr. Craig: I could see if you live in the Yukon, you live in rural Alabama, you live someplace where there’s just not any mental health care. Sure. [00:28:00] I think that’s a fine option. But if you live in Denver or Des Moines or San Diego, I think if you’re doing that, you’re getting a very sad, distant, not even a second, a distant fifth to what you could get from in-person therapy because so many people that are doing psychedelic therapy have interpersonal wounding.
There’s a lot of kinds of trauma, but arguably the worst trauma is when people hurt people. That’s the most damaging. And that’s the kind of trauma that having a therapist with you in the room working with you, I think is the most healing. Not that it can’t be some healing off the screen, but that’s not the way we’re wired. We’re wired to read each other’s energy and microexpressions. I think you just lose a lot. I think it’s just not nearly as good a therapy.
Dr. Sharp: And my wife has said too, my wife’s a ketamine-assisted therapist. I think [00:29:00] probably has said that even bearing witness to someone’s experience even without as much structured treatment per se or intervention has been really powerful just to have, she says that her clients get a lot of benefit even from just being with someone through this experience and then doing some processing of course, but just having someone be there with you as you go on this journey.
Dr. Craig: Yeah, I’ve had patients tell me they could never “do therapy”. They could never open up, they could never trust their therapist, they could never feel comfortable, and then they did the low dose oral ketamine psycholytic therapy, oftentimes with therapists just as witness, just as partner, container holder, and they were able to feel a sense of safety and then move into psychotherapy and somatic therapy in a way they never did before. So I totally agree. Sometimes what you just needed is someone there with you.
So [00:30:00] the lower dose, often oral psycholytic ketamine, that has a lot of uses that can be helpful. One, just to help people enter therapy because sometimes it takes people weeks or many months to feel comfortable with their therapist. You can imagine that psycholytic oral ketamine could help people feel closer to their therapist and speed up the therapeutic relationship. It can help people access, that’s the psycholytic opening the psyche, open things in their unconscious that they have had only partial or no access to. It can help a lot with cracking open dissociation because a lot of people live in parasympathetic numbing after trauma and ketamine can help open that up. And even low doses of ketamine are helpful for different subtypes of depression. So someone who’s depressed in therapy but not able to engage as much emotionally or cognitively because of depression, the Lourdes laws in therapy can help people with that.
Dr. Sharp: Yeah. And what’s this [00:31:00] experience like at this dose? So my experiences of ketamine come from college where I experimented with a lot of substances, not ketamine, but I had friends that were in the k-hole a lot, so to speak. And so I have those reports and now fast forward 20 years or whatever, and my wife is telling me and other therapists are telling me about these ketamine-assisted therapy experiences where folks are having some opening and revelation and so forth. But I’m curious, like subjectively, how would you describe the patient experience at this low dose?
Dr. Craig: Yeah, I would say low dose non psychedelic ketamine, so k-hole by definition, that’s psychedelic ketamine. That’s the mid-level or higher, could be anesthesia. Low dose ketamine, actually the experience of it is similar to alcohol, but maybe with more warmth, more somatic [00:32:00] involvement, more connectedness. I think alcohol is disconnecting and I think ketamine is more, I think say it has a warmer connected quality to it in the psycholytic lower doses, which changes drastically once you get to the next level, the psychedelic level.
Dr. Sharp: Okay. Yeah. Let’s transition and talk about that.
Dr. Craig: Yeah. When people come in my office and are interested in ketamine therapy, when I’m thinking about what type of ketamine therapy, I’m first thinking, are you like a KAP, ketamine-assisted psychotherapy, psychedelic low dose kind of person, and or, it could be both, you are a higher dose k-hole psychedelic IV or IM person. Actually, one way to think about this is like so many things in psychiatry, if someone’s having mild and moderate symptoms of whatever, ADD, depression, anxiety, there’s a lot of different things you can do. If someone’s having [00:33:00] moderate to severe symptoms, that narrows the treatment option.
So when I have someone in my office with moderately severe to severe depressive symptoms, I’m not going to recommend low dose ketamine. I’m going to say, we need to go deep, we need to go IV, IM. We need to get you feeling better. And then you maybe do ketamine-assisted psychotherapy after that. But again, I’m equating KAP with low dose oral Ketamine because can you do ketamine-assisted psychotherapy with high dose or the medium dose psychedelic ketamine? Yes, kind of. But it tends to be such a discombobulating experience that a lot of people come out of it and are fairly speechless.
I think actually the therapy that’s most useful after these, medium dose psychedelic experiences, is more two or three days after because a lot of times people are much more resourced, they’re much calmer, their overwhelm is dialed down, and then they can really go deeper into EMDR or [00:34:00] somatic work or psychotherapy whereas the KAP work, the lower dose, they’re actually doing that while people are under the influence lower dose ketamine. But that’s a real distinction I think, that the therapy if you will, the timing of it is very different with the low dose versus the medium psychedelic dose.
Dr. Sharp: That makes sense. Yes. When you describe a psychedelic experience with ketamine, I think for a lot of folks out there, if you’re not steeped in this research and in this world that can sound crazy, right? Like what are we doing putting people into psychedelic states and how is that even helpful for mental health concerns? So I’m curious from your perspective in psychiatry, you do a lot of this IV, IM higher dose ketamine. What’s the benefit? What’s the client experience like that is so helpful in [00:35:00] those cases?
Dr. Craig: Yeah. I would say with psychedelic ketamine, the experience may or may not be part of what’s helpful, talk about that in a minute. It’s I think with the lower KAP oral sessions, the experience is huge. You’re trying to catalyze an experience. I think with the psychedelic doses, sometimes people come out and have pull up something really powerful and other times people just come up and just like, what was that?
And I should clarify too, and I’ve talked about this a lot on my podcast, that IV and IM is not synonymous with psychedelic ketamine. So much of the ketamine in America has done IV, what I would consider low dose, like 0.5, 0.65 mg/kg, which is not a psychedelic dose. It’s a weird and warm and interesting dose, but you’re not going to reach what we call full [00:36:00] dissociation until you get significantly higher than that 0.5, 0.9mg/kg. And that’s where people, in those kind of psychedelic treatments, people, as we say lose the room, they lose their body, they lose the knowledge that they’re in a room getting ketamine.
We don’t yet have good dose-response studies on ketamine but many of us who do this work are pretty convinced that the higher fully dissociative deeper doses of ketamine are more effective. I’ll speak to those, those sessions are very powerful. They’re unbelievably bizarre. They are often at least, have parts of them that are scary. And again, sometimes […] comes up during those sessions that provides people insights or comfort or something to work on in therapy. And other times it’s just like people got a shot to the center of [00:37:00] the earth and spun around on a centrifusion, squashed between magma chambers and then extruded back up to the surface and that’s their treatment but then the next day they’re texting me saying, man, I don’t want to die anymore. I feel good or gosh, I felt like there was a 10,000-foot weight on my shoulders and it’s gone.
Dr. Sharp: Yeah. And so from your perspective as a psychiatrist in that situation, are the patients talking to you? Are you intervening, so to speak, or I’m just curious what this actually looks like if there was a fly on the wall.
Dr. Craig: So again, I think we have to bifurcate this, that with IV, IM ketamine, it really matters the dose. So a lot of places in the United State are using sub-dissociative. In a sub-dissociative treatment you could potentially talk or take instructions from the therapist or ask question. With what I’m doing, no, there’s no talking. Maybe the first few minutes people might say a little bit, but no, they’re [00:38:00] going, as I tell people like, we’re going to do a full baptism in the river K, like you’re going under, and I’ll say to people, you’re going down the river K and you’re going to go through the Class 4 rapids. We’re going to catch you at the other end. You’re going to be safe. It’s going to be a wild ride. Tuck that in your mind that you’re safe. We got you. But just get ready, put your seatbelt on, put your feet downstream because it’s going to be a wild ride.
Dr. Sharp: Here we go. Yeah. How long does it last?
Dr. Craig: Well, we’re still trying to figure out what the ideal ketamine psychedelic dose experience is, but typically, most places drip in an IV over 35, 45 minutes. And I would say, you’re deeply in the experience for 45 minutes or so.
Dr. Sharp: So speaking of the, going through the rapids, that’s going to be safe, et cetera, I imagine there are some folks for whom this may not be appropriate. [00:39:00] Is that accurate or no?
Dr. Craig: Yeah. I think we have a number of U/L cautions or contraindications with ketamine. Ketamine really has two main side effects at a U/L psychedelic dose. One is that it can make you very motion sick. So anybody with significant motion sickness is going to need a scopolamine patch and motion sickness patch. And also ketamine can really raise your blood pressure, especially if you’re a male over 50 or if you have preexisting hypertension. We’ll have people double up on their blood pressure medicines or we’ll predose people with blood pressure medicine and we monitor blood pressure during it.
So those aren’t contraindications. Those are just cautions. If you have motion sickness or hypertension, if you’re male over 50, if you have a history of psychosis, that’s not necessarily a contraindication. It depends where your psychosis came from. If you have psychosis from schizophrenia, yes, contraindication. [00:40:00] But if you had psychosis from, say, schizoaffective bipolar 1, which again, schizoaffective bipolar or schizoaffective disorder bipolar type is probably a bipolar 1 variant. That’s more and more what people think and ketamine’s a great bipolar treatment. So if people have had psychosis out of a bipolar type illness or schizoaffective illness, that’s not a contraindication.
If people really struggle with depersonalization, derealization, ketamine is a relative contraindication because ketamine definitely depersonalizes you and put you into a state of derealization. I think more often than not, when we see people in chronic depersonalization, those are people that are using a lot of THC. Again, I would argue if you’re using a lot of THC, you’re just not likely to get a lot of antidepressant or anti-trauma benefit from ketamine because a THC is so activating and destabilizing for those illness.
An interesting contraindication, I’ve seen this go very badly, [00:41:00] borderline personality disorder and ketamine is not a good mix. It actually can make suicidality and self-harm urges way worse. And when I first observed this a few years ago, I thought that doesn’t make sense, but I’ve seen this now a number of times and talked to other people. So that is a contraindication.
Dr. Sharp: Okay. That’s surprising given the link between trauma and borderline and the effect of ketamine to work with trauma, do you have any idea why that’s happening?
Dr. Craig: I’m guessing that might be because one of the core features of borderline personality disorder is a lack of an integrated self, and so people with borderline personality don’t know who they are. They have these porous poorly differentiated selves. Ketamine, especially at psychedelic doses, totally dissolve you. You become part of the cosmic slop [00:42:00] and so I’m imagining that, and I’ve had two patients describe this to me as they reconstitute and their body and psyche comes back together as they’re coming out of ketamine and that. I think most people just feel a deep sense of relief. Like, oh, I made it. I’m a person again with toes and fingers. And I think some folks with borderline personality disorder, when they’re reconstituted, they’re back feeling how awful they feel in their, it’s not selfless, but confused, undifferentiated selves and it feels awful. And it’s almost like a reminder how unhealthy their psyche is when it’s dissolved and put back together. So I think it can actually make people feel much worse.
Dr. Sharp: This has been really helpful. I think a lot [00:43:00] of what we’ve talked about with ketamine is going to transfer over to the next two interventions we’re going to talk about. But yeah, let’s jump to MDMA. I feel like that’s maybe the next one on the rung as far as approval and widespread use. So let’s go through the same process. Let’s start with the neurochemistry behind it. What’s happening with MDMA?
Dr. Craig: Yeah, so MDMA is methylenedioxymethamphetamine, so it’s crystal meth with another little ring on it. So it is an amphetamine which is important because amphetamines can be hard on the brain and we can talk about that a little later. Ketamine in reasonable doses at reasonable frequency seems actually very good for the brain. Psilocybin seems good for the brain. MDMA in high doses or two frequent doses is definitely not good for the brain, and that’s probably at least due in part. It’s an amphetamine. [00:44:00]
I think MDMA is such a powerful example of the vast gulf between mind and brain because we can say, okay, it works on serotonin receptors, it works on oxytocin. It turns up dopamine. And so we can look at how it affects different receptor subtypes in the brain and how it affects different hormone systems. And that’s all interesting. That is such a profoundly vast gulf from when you get to mind, like the actual experience of being on MDMA, the experience of working with someone who’s working through trauma, working with a couple on MDMA because what MDMA is doing in the psyche, in the mind, if you will, is it’s dialing down fear.
It’s so many people that come to therapy, but specifically people with trauma, with a lot of psychiatric illness or even just with a lot of activation in their marriage, are filled with fear and anxiety and MDMA probably through [00:45:00] effects on the amygdala, it dials down fear and through possibly oxytocin or other mechanisms, it dials up trust. So imagine a therapy where you can dial down fear and dial up trust, like two of the most important factors in working with somebody. We have patients come in our office and if they don’t trust us and or they’re fearful, we’ve got a hard road ahead. And MDMA is something that you can do months or years even of attachments, trust therapy, work with your patient or client with the substance.
So I think we can think of psychedelics as non-specific amplifiers or modifiers but MDMA is a huge amplifier of trust and a minimizer of fear.
Dr. Sharp: Sure. Yeah. It’s so crucial. So being in this community, I think we have a lot of psychologists, [00:46:00] therapists, friends, right, who are married and have taken MDMA and down the path of marriage counseling, like DIY marriage counseling. And without fail. I think every single one of our couple friends come back and said, this was like a year of couples therapy in four hours for us.
Dr. Craig: Yeah. Well before MDMA was made illegal in 1985, it was used fairly extensively in underground couples work. And I say underground, it wasn’t illegal at that point, but it was unkown. And so again, now I think a lot of people hear about MDMA think of it as a trauma treatment, which it is a good trauma treatment, but it was originally used more in couples work, again because it can build connection, dial down fear, bring back trust, and I think help people see in their partner what they originally saw. So many marriages and years and microtraumas and big [00:47:00] traumas can just put this ease and cloud between you and your partner and you can’t see clearly who they were, why you chose them and I think MDMA just like blows all that smoke and cobwebs away so you can actually reconnect with the person that you chose years or decades ago.
Dr. Sharp: Well said. So you mentioned trauma, that’s in my understanding again, the majority of the research around MDMA as an intervention, as a psychotherapeutic intervention or psychiatric intervention. Is that accurate?
Dr. Craig: Yeah. I think most people suspect that, Rick Doblin’s a smart guy. I think when he was thinking, and he’s the head of MAPS, about how to get MDMA to the people, he realized that trying to get an indication for couples therapy not going to happen but again, as I mentioned at the beginning of this podcast, arguably the biggest unspoken need in mental health is PTSD [00:48:00] attachment. Complex PTSD. And so to have a treatment that actually could move the needle on trauma would be a total game changer. And so that’s why Rick and MAPS set their sights on PTSD years ago and knowing that not just the brain, but more particularly the mind qualities, the psyche qualities of MDMA would make it potentially groundbreaking treatment for trauma.
Dr. Sharp: Sure. And you participated in some of those MAPS trials, the studies, right? You were a practitioner. Can you tell us a little bit about that and what that looked like? When you say PTSD, what populations you’re working with? What it’s maybe most effective for?
Dr. Craig: Yeah. There’s so many interesting aspects of that question. One thing I might just comment on this, on the diagnosis of PTSD, one thing that became clear to me and to our study site here in Fort Collins is that [00:49:00] there’s two very different types of PTSD, so there’s PTSD that is from early childhood wounds, if you will, complex PTSD, parent-child, PTSD that started before age five, six, and then there’s everything else. And it’s seeming in the study that people who have terrible rape trauma in adolescents or war trauma in their 20’s, and assuming they didn’t have significant early life trauma, those people were often getting home run cure with MDMA because in the MAPS study, there were three MDMA treatments or placebo plus a bunch of integration and preparation sessions.
And then there’s another group of people who are probably much more represented in that study population or in our clinical populations. These are people with zero to five trauma, and this is a whole different [00:50:00] thing. And I think it would be interesting to see when the data’s fully out, but at least at our site, it looked like people with more complex PTSD, zero to five trauma, definitely got benefit from MDMA, but MDMA if when it’s made legal, medicalized hopefully the next 18,24months but that would probably be more of intermittent ongoing treatment, maybe over years, like maybe somebody with zero to five significant complex PTSD is doing an MDMA-assisted therapy session once or twice a year over 10 years or something because those wounds are so deep. It really is a completely different beast than later life PTSD. And I think, again, such an example of how the DSM misses a lot just by putting symptom clusters or zero to five trauma, it’s a whole different piece.
Dr. Sharp: Sure. Yeah, I know we could go down that path of is how do we even [00:51:00] define PTSD, I have some issues with that. Well do a job of, yeahthat this is fascinating to me. It’s top of minds. I’ve been doing here recently, these evaluations with incarcerated individuals to try to hook them up community resources and they all, to a person have complex PTSD and of all forms that start very early. And it’s very striking how little anyone really knows what to do for them to hear that there maybe option, really helpful.
Dr. Craig: Yeah, super helpful.
Dr. Sharp: Yeah. So let’s talk about the other indications. Are there other issues that we might address with MDMA, aside from [00:52:00] trauma and couples work?
Dr. Craig: Yeah, but maybe we could say a little bit more about trauma because there’s a lot of different types of trauma, but I think MDMA’s sweet spot is early attachment trauma and sexual trauma.
Dr. Sharp: Okay.
Dr. Craig: Clearly many people have addressed those two issues with ayahuasca or ketamine or psilocybin or other psychedelics. Not to suggest that MDMA is the only thing, but I think MDMA’s ability to open the heart to allow people to feel love, that people on my podcast describe that. I’ve heard that with the patients say they never experienced what love felt like until they had an MDMA experience with a caring, compassionate therapist. So I think that is a special sweet spot for people with these really deep attachment wounds. And sexual trauma is arguably all kinds of trauma rolled together. And [00:53:00] I think we’re going to see a lot of those people who’ve been so hard to treat get a lot of benefit and progress with MDMA.
Dr. Sharp: Yeah. That’s very helpful. Let’s see, are there other aspects of trauma that we may need to touch on or application you see is relevant?
Dr. Craig: Well, I think of trauma, especially if you are “PTSD”. I think if you are haunted by your trauma, you have PTSD. I like the word haunted but there’s another part of haunting, and that’s shame. And I think so often, not with earthquake trauma or hurricane trauma or something, but with interpersonal trauma, there’s so often shame that’s all tied up with that fear and lack of trust. And again, I think all these psychedelic treatments have potential to address shame.
I think MDMA [00:54:00] might be uniquely qualified to help people go into shame and if you will work through it. You can’t talk your way through shame. I’ve tried in my office. I’m sure you’ve tried. It has to be experiential as [..] has said in my podcast that all effective trauma therapies share, that they’re experiential. And so I think, and I saw that in the MAPS study, that people would go back to the scene of the crime if you will, and rework it, redo it, and go through it in a non shame-based way.
Dr. Sharp: That’s so powerful and I think what we know is an antidote to shame is bringing it out to the open. And again, having somebody witness it and be there with you through it and provide some kind of reassurance, whatever that look like broken, that’s not you. [00:55:00] Yeah. That’s super powerful. And like you said, the opening and the trusting and the bringing down fear.
Dr. Craig: Yeah.
Dr. Sharp: Yeah. So again, questions about other things that we might use it for outside of couple’s work.
Dr. Craig: I think that’s a pretty good list of, besides couples work, I think it’s going to be hugely helpful for that. Even more than ketamine, I think we should talk about cautions and contraindications, because in general, ketamine is pretty darn safe. There are few people I think that Ketamine couldn’t potentially be beneficial for. I think that’s a much bigger group with MDMA. So medically, we have to look at anybody with cardiovascular issues because this is methylenedioxymethamphetamine. It’s very [00:56:00] stimulating. So it can put stress on the heart, on the vasculature. So anybody with significant cardiovascular risk, stroke risk, untreated hypertension, history of seizures, there’s a bunch of medical issues which are potentially problematic with MDMA.
And then again, because MDMA is an amphetamine-based molecule like Adderall or Vyvanse, amphetamine-based molecules can make mood and psychotic disorders worse. So even though MDMA is often a really powerful treatment for trauma, and even though trauma often causes or feels depression, if you have an endogenous kind of depression like bipolar depression, MDMA could make that worse. You have psychotic or schizoaffective disorder, theoretically, MDMA could make that worse. So there are definitely a [00:57:00] number of psychiatric diagnoses, if you will, that you want to get a good evaluation before you do that.
But probably the biggest issue again, with MDMA versus ketamine, ketamine has almost no medication interactions. I mentioned the opioids, that’s a problem. It also interacts with lamotrigine but MDMA has many medication interactions and one of the tricky things that we saw in the MDMA study is that we had to get people off, essentially all their psych medicines to be in the study. And getting people off psych medicines is brutal, especially their sleep medicines because if you have trauma, if you have complex PTSD, you probably have sleep problems. And yet a lot of, not all but a number of sleep medicines have interactions with MDMA. And so this is a big problem but one which I think actually we [00:58:00] might find ketamine helpful for. So I wouldn’t be surprised in the near future when MDMA gets medicalized, that when people are coming in to do MDMA sessions, they’re tapering off some or many of their psych medicines. And we’re using ketamine like IV or IM two times before the MDMA to help them come off their medicines to make sure that they don’t plunge into depression, to help with their sleep quality, to basically buffer people and get them neurochemically ready for MDMA.
Dr. Sharp: That makes sense. Am I remembering back,[…] this research stuff, but is there some interaction between MDMA and tricyclic antidepressants as well or am I remembering something?
Dr. Craig: No, that’s true. Yeah, because MDMA works on serotonin very aggressively. And so yeah, all the medicines that work on serotonin and a bunch of others stimulants are contraindicated. [00:59:00] MAO inhibitors, some migraine medicines are not good with MDMA, so they’re a lot more medication and medical a few cautions and contraindications with MDMA, which is important to note, it’s good to know that there are other options, ketamine, and psilocybin being prototypical, very different but also potentially helpful option.
Dr. Sharp: Sure. Let me go back and double-click on the cardiovascular concerns. Selfish question but…
Dr. Craig: You can do that.
Dr. Sharp: Yeah. My wife and I, of course, have considered this, but I have exercise-induced atrial fibrillation. It’s been diagnosed. And so when you mentioned cardiovascular issues, what kind of things are we talking about there?
Dr. Craig: Well, first of all, the difference between a medicine and a poison is the dose.
Dr. Sharp: Of course.
Dr. Craig: So the difference between 100 milligrams of MDMA and 300 [01:00:00] is vastly different. For example, the cardiovascular risk, in general, the cardiovascular risk of MDMA 100 milligrams, I think is pretty darn low. 300 milligrams quite high. So can imagine that as we’re trying to stratify people for MDMA treatment, it’s not that cardiovascular problems or disease as a contraindication, it might be, hey, let’s start you lower, we’ll definitely monitor blood pressure and heart rate, and just see how you do. And again, this is one of the problems that prohibition and black market MDMA is a problem because you don’t know how many milligrams you’re getting. You don’t know how pure it is. You’re just taking a guess. When it’s medicalized we’ll be able to actually know how much we’re giving people and adjust that based on the medical comorbidities.
Dr. Sharp: Which raises an important point, I think we should probably clarify and please correct if I’m off base on this, that MDMA is not widely approved for [01:01:00] intervention. Like you’re not administering MDMA in your office, Monday through Friday these days. It’s still housed in these clinical trials or is that…?
Dr. Craig: Yeah, so it’s being studied in clinical trials throughout the US and it’s also like being used fairly extensively in the underground therapy community which is illegal. MDMA is a Schedule I drug along with heroin and LSD and interestingly marijuana, but it’s looking more and more likely that MDMA will get medical approval for PTSD treatments sometime in the next two years, cross our fingers.
Dr. Sharp: Sure. Let’s see. Anything else before we transition to psilocybin?
Dr. Craig: Maybe one other thing, I mentioned with ketamine how one of the benefits of ketamine is it can help promote connection and opening with therapists, which can be really valuable. I and I think many others would [01:02:00] argue that MDMA does that times 50. So MDMA allows people to often deeply and powerfully connect with their therapist, but that’s led to some real problems with boundary crossings and boundary violations, especially sexual ones, which again, could happen with ketamine therapy, could happen with psilocybin therapy, I think are much more likely to happen with MDMA therapy.
So I think it’s going to be interesting to see with the medicalization of MDMA, what will be common protocols? So will MDMA-assisted therapy sessions always be videotaped? Well, we always insist on two therapists because the kinds of things that are catalyzed in that power of that trusting, intimate crucible of MDMA with a therapist and a vulnerable patient, it’s potentially really devastating for both people. You can imagine either the [01:03:00] patient client could be harmed or there could be untoward or even inaccurate accusations made against the therapist that could be devastating to a career. So we’re going to need to come up with, psychedelic therapies in general but specifically I think with MDMA, protocol to make sure those sessions stay safe for therapists and client patients.
Dr. Sharp: I appreciate you saying that. Yeah. That is a major concern on my side as well, that as we take people into these clearly altered states compared to a typical therapy session, that’s got to be top of mind and how we’re going to keep everyone protected.
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Alright, let’s get back to the podcast.
All right. So I would love to transition to our last intervention. So start at the top. What’s happening in our brains with psilocybin? [01:05:00]
Dr. Craig: Wow, that’s such a big question.
Dr. Sharp: It’s a great response.
Dr. Craig: I think in much like my answer to MDMA, but I think even more vast. The gulf between mind and brain with psilocybin is so vast, like you really have to talk about it in two different ways. So on a brain level, we know that psilocybin works on the serotonin 2A receptor and then intracellularly inside of those serotonin cells, it’s causing changes which lead to new brain cell connections leading to improved learning and different ways of thinking and resilience mechanisms in the brain seem to be dialed up with psilocybin.
So there’s some very interesting circuitry changes, if you will, brain changes with psilocybin. So there’s that, but then there is what’s happening in the mind, in the [01:06:00] psychospiritual realm, and I think maybe we could even divide it two different ways. Let’s talk about eyes open psilocybin and eyes closed. And I’m going to call eyes open psilocybin, because most people who are using psilocybin, many people are using it mindfully and “recreationally” but also psychospiritually are using it often in nature and with their eyes open. And what psilocybin does is it reignites this sense of awe and wonder, I think it reconnects us with the natural world. It reminds us not just cognitively but somatically, psychospiritually we are animals, we are alive, we’re part of the great buzzing, churning life on this planet. That we are not boundary like we would think with our skin and scalp, but we are [01:07:00] actually more expansive than that, that we are connected, energetic creatures part of a greater enema, if you will.
And that is a very, for many people who’ve taken mushrooms, I think that’s something that they can relate to. And that’s something I think people seek, who take if you will, eyes open mushrooms in nature is to be reminded of the awe and wonder and beauty and just the connection because so often I think especially now, Modern American life, we’re so atomized and siloed and individualized that it can just feel like we’re each these little molecules doing our own thing and just trying to advance our molecular life and psilocybin can remind us like, oh no, we, we are part of something much bigger than that.
I think people talk about classic psychedelics as being a religious or spiritual experience, that’s what they’re talking about partially.
Dr. Sharp: [01:08:00] That makes sense. It’s very validating too. I mentioned, in college, I’ve experimented with a lot of things. Silocybin was one of them. I had many experiences back then. And that description of going back to that childlike sense of wonder, like everything is new and one of the best parts of the experience, just getting that reset.
Dr. Craig: And then if we go totally the other way, let’s go the eyes closed or eye mask, you’re going inward.
Dr. Sharp: Just to clarify, just for anyone who might be wondering, we’re literally talking about eyes open versus eyes closed or wearing a mask. This is not a metaphor for anything, though it could be but yeah.
Dr. Craig: Yeah, really or a different way of thinking this is outward psilocybin meaning having a psilocybin experience where you’re engaging with, hopefully not just your room or a building, but engaging with nature versus an inner experience. [01:09:00]
Dr. Sharp: Yes.
Dr. Craig: And they are completely different. Like it’s just shockingly different to experience eyes open and eyes closed psilocybin. When we’re talking about psilocybin therapy, we’re typically talking about eyes closed but not necessarily because, we saw this with the MDMA study too, that there’s something very valuable about going inside with the eyes shader or eyes closed and working through stuff and material and then coming back out with eyes open or not, and then interacting with a therapist. It’s not that you would have a psilocybin experience, it would just be one or the other, but psilocybin eyes closed/eye shade is going into the wonder and darkness and churning of your unconscious. And it takes you spiraling into the 20,000 [01:10:00] leagues under depths of you and really like your IOS or your internal operating system. I think psilocybin takes you to the building blocks of view which is fascinating and can be scary. It can unssettling but ultimately, I think, in the right context, with the right preparation, integration, right therapist, it can be life-changing.
Dr. Sharp: Yeah. That makes sense. Now, the research with psilocybin this far has happened with a few different populations, right? There’s been some research on end of life and I forget the other two all of a sudden, or the other one.
Dr. Craig: Yeah, there’s been treatment-resistant depression, which I’m always interested, like when you have a study for treatment-resistant depression, like how do you define that because that’s such amorphous term. If we could talk about yes, psilocybin for end of life, I think what’s going on there is, people feel so alone when they’re dying. [01:11:00] It feels like this annihilation and what psilocybin can do is not just remind you in your mind but remind you in your spirit and your body, like you are part of something bigger. Like there is this churning life cycle of punji and people and lemurs and cats and trees. And there’s something about psilocybin and I think that can take you deep into that. You see it’s okay. Like death is part of this cycle. It’s okay. It’s not bad. It is.
And so I think with these end of life psilocybin studies, I think that’s going to be a really interesting use of it in the coming years, is to help people get out of this conception that they are just a solo boundary animal that’s dying. It’s going to be alone, but they are part of something much bigger. It’s timeless and amazing. [01:12:00] It’s like giving someone a dose of wow versus like, oh shit, I’m going to die soon because like you can hold but I think that’s the dialectic that you’re trying to work with in end of life therapy is you are going to die soon and oh my gosh, you’re part of this amazing thing that is this self-propagating life zone that’s wrapped around this fragile planet. And it’s amazing.
Dr. Sharp: Yeah. Well, I think too, a lot of folks say this, that a lot of death anxiety is ego-driven and to break that down, perhaps some psilocybin goes a long way and let’s expand how important digital are and how meaningful it that we individually die can be really poweful. Now, [01:13:00] and there’s also been some research, just remembered with addiction, like nicotine dependence and things like that. That’s fascinating too, these different applications.
Dr. Craig: But again, like you think of the addiction work, it seems like psilocybin might have brain effects, like be well neurotransmitter second messenger effects in the brain that help people not use substances compulsively but there’s also brain, oh sorry, mind psyche effects, like one of the episodes of my podcast, a woman talked about having a really powerful mushroom experience where that mushroom entities came to her and basically showed her what her life was going to look like as her alcoholism progressed, and she was going to die of it, and she came out of that and never drank again. She had this psychospiritual experience of the, she called it the mushroom entities, showing her like; this is where you’re going which again, is completely fascinating to me. What is that?
Dr. Sharp: That’s a great question.
Dr. Craig: Yeah. I think it’s [01:14:00] something bigger than us. I do think that psilocybin taps us into something that’s, I think philosophically consciousness-wise, I’m a panpsychist, you know what that is?
Dr. Sharp: Tell me.
Dr. Craig: Panpsychism is the idea that consciousness is fundamental. It’s like matter, like it can’t be reduced to something else like we think, the dualist physical view is that consciousness comes from the brain. It’s like a epiphenomenon or emergent property whereas the panpsychist would say, no, you can’t reduce consciousness anymore. Like it’s ubiquitous and it’s essential. And I really think that psilocybin dials us into that, into this universal nature that consciousness is fundamental and it’s not just limited in our skulls.
Dr. Sharp: Right. Well, I think that taps into the idea [01:15:00] even that mushrooms or like fungi, right? There’s so much around how interconnected they are and like this “consciousness”, it’s not a plant, but you know what I mean and how it’s connected. Yeah, I could see that. And that also makes sense with the bigger universal feeling that you get, you take mushroom, connected everything.
We could spin out into any number of directions for that. I’m going to keep us on the rail with the intervention component. So this is the one, I think out of the three that’s probably the least regulated or delivered with the most endorsement from the government maybe is a good way to put it.
Would you agree with that? Like we don’t really have as much support?
Dr. Craig: Yeah. Well now in [01:16:00] Colorado Proposition 122, psilocybin is now decriminalized. So you can grow it, possess it, trade it, gift it. And then here in the coming months, state of Colorado is going to come up with regulations and rules where therapists and non-licensed therapists, presumably in Colorado, will be able to get certifications to work with psilocybin. So I think Colorado’s going to become a laboratory for what works with psilocybin, what doesn’t work. It’s exciting. It’s a little scary, but I’m really glad that we’re going to be part of this.
Dr. Sharp: Sure.
Dr. Craig: One way to think about psilocybin is to compare it with these other two kinds of prototypes, MDMA and Ketamine. And I think there are going to be significant number of people here in the coming years who might be more interested in MDMA or we might think might be better MDMA candidates, but because of psych medications [01:17:00] or medical issues that we’ll find that psilocybin is actually a better choice because psilocybin can definitely take people into doing really deep, meaningful trauma work undoubtedly.
I would say it’s a little harder and wilder than it is with MDMA because MDMA has such like a warm blanket of safety, love and protection as you go into trauma states that psilocybin doesn’t have that as much but again, there’s something I think, and this sounds very woo woo, but I believe this, a lot of other people do too, that there’s something very organic and you are like of the earth with psilocybin. It’s like the mycelium, if you’ll, psychospiritual mycelia of psilocybin get into us and reconnect us with our most essential nature [01:18:00] in a way that amphetamine based MDMA or even ketamine doesn’t do that.
Some people would say that’s because psilocybin’s of the earth and the plant spirits or the fungal spirits. Who knows if that’s what’s going on, but there is something profoundly different about psilocybin. It’s of the earth. It’s calling us back to the earth.
Dr. Sharp: Yeah. I appreciate the energy to try to articulate something that’s indelible like, it’s very hard to describe and I get it. There are many reports out there, folks who make a distinction between psilocybin as a more organic natural experience versus in a, or like LSD, for example, which feels a little more mechanical or, yeah. So I’m with you.
Dr. Craig: It’s like the AI version of psilocybin.
Dr. Sharp: There we go. Okay. Yeah, that’s fair. So how are you seeing this? We’ve got [01:19:00] end of life, anxiety, maybe some addiction, treatment-resistant depression. Are you seeing other clinical applications of psilocybin?
Dr. Craig: Well, I think there’s this whole group of people who have “trauma”, they have attachment stuff, they have parent-child stuff, they have psychospiritual wounding, and they’re not getting better with standard mediciness or talk therapy and you these people could potentially do well with MDMA therapy or psilocybin-assisted therapy or ketamine. And I think we’ll be doing a lot of guidance of people in the coming years that come in like, I want to do psychedelic work but I’m not sure. And for people who have interpersonal trauma, early childhood trauma, attachment trauma, I think we have all three of these to choose from.
I think what we don’t know with psilocybin yet is we don’t know with psilocybin how good it’s going to be for, let’s say, bipolar depression. So ketamine [01:20:00] is an incredible treatment. Arguably maybe the best treatment there is for bipolar depression but what about psilocybin? We know that psilocybin can help with existential depression and trauma, depression, and demoralization but what about if you will, endogenous genetic bipolar depression?
I think the jury’s still out on that. It would be really cool if it did because ketamine, well, some people can build up a tolerance to ketamine. I’ve seen that in a few of my ketamine maintenance patients, but higher doses of ketamine can be pretty overwhelming in a way that I think psilocybin doesn’t have to be. I think psilocybin is friendlier. I think it’s more “organic”. I think it’s more connecting. I think psychedelic doses of ketamine are a powerful treatment, but they’re disconnecting and discombobulating and [01:21:00] they kind of puts us through the cosmic cheese grater versus like connecting us to spirit.
Dr. Sharp: Yeah, that’s fair. What do the clinical interventions, I’m sorry, I’ll back up. What does intervention setting actually look like? Psilocybin, so we talked about so forth, but for those who are doing legit clinical intervention with psilocybin, what’s the setup look like?
Dr. Craig: Yeah, there’s usually two ways to think of doing psilocybin work. And this is like an ayahuasca models that a lot of people are doing psilocybin work in a group. So maybe doing preparatory work individually with the facilitator or therapist, but then coming together to do a psilocybin group and then having some processing post group and then maybe some integration, either group or individual afterwards.
And the advantage of that is that you, well, not only is it cheaper potentially, but [01:22:00] it allows, and psilocybin is so connecting and it’s so ritualistic and it’s so tied in with music and drumming and earth and spirit, and so there are ways that the facilitator, therapist, sham, if you will, can use the group experience, I think to really magnify the power of the whole experience.
Alternatively would be to do, for example, one-on-one work psilocybin, where the therapist is doing preparatory work with the client-patient and then doing one-on-one with them and then the integration. That is probably better for people, let’s say people who have really profound sexual trauma, profound early childhood neglect or lack of safety and might be destabilized in a group but really need that kind of womb of one-on-one work. So a lot of ways think it like [01:23:00] is individual psychotherapy better or group psychotherapy better? I think the answer is depends. And I think when we look at psilocybin work, I think some people are really going to get a lot of benefit out of the group dynamic and then other people will need to start one-on-one to establish a safe container.
Dr. Sharp: Yeah. Speaking of it depends, dosage depend as well. I know there’s a lot out there around microdosing psilocybin, LSD. What do you know about the microdosing literature and there’s an article about two years ago about could microdosing psilocybin replace buspirone that sort of thing. Where are you at with that?
Dr. Craig: Well, microdosing is a very hard thing to study because talk about a placebo effect. So the placebo effect [01:24:00] with depression anxiety is very high, especially if you’re genetically susceptible. And a lot of times people who are microdosing are, basically there are people with some mild to moderate symptoms, usually not moderate to severe. And so you can imagine that expectation bias, other confounding factors and or placebo affect can make it very difficult to tease out a benefit from microdosing.
So my understanding of the microdosing literature so far, which is not much literature, but that it hasn’t been shown to beat placebo. But that also could be because it’s a small effect size, right? But the more cynical me says, like when does micro work? Like micro exercise or micro love or micro work or, something, it’s like dose matters.
Dr. Sharp: That’s fair.
Dr. Craig: It matters how much you run. It matters how much you give compliments or do pushups or how much aspirin you take. So [01:25:00] it just seems to me why would it be that psilocybin, for example, would have some cool unique quality when you microdose it versus macrodose it? It seems like it’s probably like most other substances. It very well may have benefits in the microdosing range, but probably nothing like the benefits in the macrodosing range.
Dr. Sharp: Yeah, that’s reasonable. What about contraindications for psilocybin right now?
Dr. Craig: Yeah. There aren’t so many contraindications. Psychiatrically, I would say schizophrenia would be a contraindication. There are a few psychiatric medicines that strong psilocybin blocking effect. So anything that blocks the serotonin 2A receptor, and that’s all the atypical antipsychotics, like a […], those all blocks psilocybin effect.[01:26:00] So that’s a little problematic because those atypical antipsychotics are commonly used for treatment-resistant depression. I think we’re going to see a lot of people wanting to do psilocybin for treatment-resistant depression. They’re going to have to get off their atypicals. SSRIs seem to necessitate higher doses of psilocybin, so if you’re on Prozac, Paxil, Zoloft, Lexapro, you’re probably going to need to take 30 to 50% more psilocybin to get the same effect.
One of the big controversies right now with psilocybin work and MDMA work is what to do with people on SSRIs because SSRIs, it’s a process to get off those and you don’t want to destabilize people right before their MDMA or their psilocybin session. So more and more, I think the protocol that we’re often recommending is people are going to do that. That they either stay on their SSRI or maybe they [01:27:00] get on a lower dose for a week or two before, but not get off because it can just be so destabilizing to tape even to do a slow taper for some people to try to get ready for their psychedelic therapy session.
Dr. Sharp: Sure, yeah. You hear horror stories of getting off assessor.
Dr. Craig: Yeah.
Dr. Sharp: And for the most part, the stuff that I’ve seen is that psilocybin is otherwise physiologically safe. It’s pretty safe; it’s not going to have…
Dr. Craig: Non-toxic.
Dr. Sharp: Right. It’s non-toxic. Yeah. The LD50 is huge, like they dont know what that is.
Dr. Craig: Yeah. Like a dump truck of mushrooms. Wouldn’t kill you.
Dr. Sharp: Yeah. And the cardiovascular effects and so forth. Like you don’t have that the same or you…
Dr. Craig: Right. It doesn’t, it definitely can have some unpleasant physiological effects if you’re taking a bigger dose or it comes on quickly, but no, it does [01:28:00] seem impressively safe. And even when I talked about this on an episode a few months ago on the psychosis episode that psilocybin can theoretically trigger psychosis, but not anything like THC. And what we’re finding is that when people get psychotic on psilocybin, almost invariably, because they’re also using THC because THC can crank up the power of psilocybin, so even for people with a psychosis risk or history of psychosis, psilocybin seems way safer than THC.
And I see this in my clinical practice. I have people say with bipolar 1 or schizophrenia bipolar type, and they don’t want to give up substances and they want to smoke weed. And I’ll tell them like, look, please don’t do substances, but if you’re going to do anything, do psilocybin, don’t smoke weed because THC is just so much more likely to trigger or [01:29:00] re-trigger really scary psychiatric symptoms.
Dr. Sharp: Well, and like you said, we did an entire episode on THC-induced psychosis. If anybody’s interested in that, go check it out. So was episode 320, if I’m remembering.
Dr. Craig: That’s a lot of episodes. Oh God.
Dr. Sharp: Yeah. I’m still amazed when I look at this numbers.
Dr. Craig: Wow.
Dr. Sharp: Yeah, they just keep adding up.
Dr. Craig: That’s amazing.
Dr. Sharp: There’s a lot of testing stuff to talk about and psychedelic stuff.
Dr. Craig: Yeah.
Dr. Sharp: No, I really appreciate you sitting down with me and diving into each of these three. I think we’re just going to see the popularity and the application skyrocket over the next five years, two years, three years even as these interventions get approved, distributed, right? There’s a lot of promise with a lot with each of these.
Dr. Craig: Yeah, exciting times.
Dr. Sharp: It’s exciting to live and through it. Yeah. [01:30:00] I think I, maybe it was remembering, I don’t know who knows if I’m remembering this right or not, but we were talking two years ago, and I think you said something back then of this kind of wave of treatments is the biggest thing that’s happened in psychiatry since Prozac.
Dr. Craig: Yeah, there’s been a bunch of medicines come out over the last 20 years but this has never been a more exciting time to be in psychiatry, right now, is it?
Dr. Sharp: That’s fun. Yeah. Well, always a pleasure, Craig.
Dr. Craig: Yeah. So good to sit here with you. Thank you.
Dr. Sharp: Yeah.
All right, y’all, thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes, so make sure to check those out.
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