EP 183: Redefining Recovery: The Psychedelic Revolution | Matthew Johnson PhD

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Hi, welcome to the Radical Responsibility podcast. This is Fleet Maul, your host and today I'm having a conversation with the renowned Matthew Johnson, Dr. Matthew Johnson at Johns Hopkins, one of the leading researchers in the emerging field of psychedelic assisted psychotherapy. Now he's long been a researcher in the field of addictions altogether and done some really interesting studies on tobacco addiction, as well as other addictions and cancer related depression and other illnesses and human conditions that can possibly benefit from psychedelic assisted psychotherapy. So this is really one of the leading researchers in this emerging field and just an incredible interview. So please listen in and I'm really.

Thrilled to be here Today with Matthew. Dr. Matthew Johnson, welcome.

Oh, thank you Fleet. Pleasure to be with you.

So your research on psychedelics and psychoactive drugs has really been pivotal, as described in your in your bio, in reshaping our understanding of these substances and really as medicines and their potential as psychedelic medicines. So I'm wondering maybe we could just start by maybe some of your latest research, especially related to addiction, on the potential therapeutic applications of psychedelic medicines.

Right. So kind of the latest is recently wrapped up a.

My second study on using psilocybin for tobacco smoking cessation. This was an 82 person study. So we recently got into our six month follow up point. This is six months after the psilocybin session which is tied to the quit attempt, the date that they plan plan to quit smoking. And so that's our primary outcome. So we're working up the manuscript now to submit it. I should be light on the results because sometimes sending to the prestigious journals, they don't want you to say anything about the results, but I'll just say that they kind of want to break that news. But I'll say it's still looking very promising. This was a study comparing it to psilocybin, a single session actually just to nicotine patch. The standard FDA.

Guidelines for using over the counter nicotine patch, both with cognitive behavioral therapy, kind of the standard talk therapy to help people quit smoking. So there's some really promising results there that hopefully folks can stay tuned for.

We are very, very nearly about to start the third study in that line of research. This was the first study funded by the US Federal government for looking at the therapeutic effects, actually administering a classic psychedelic or therapeutic effects since the the earlier era of psychedelic research about 50 years ago. So really excited about that. That's again in the same line of research using psilocybin to treat smoking cessation. This is a double blind study, so there's going to be a placebo group. It's a multi site study with the two other sites right now are New York University and University of Alabama Birmingham with some great colleagues who have already been conducting extensive psychedelic including psilocybin work, although using it to treat tobacco addiction is a new aspect for them. Also, it's a bit stalled, but have poised up an approved study to use psilocybin to treat opioid addiction. And also.

Related to the treatment of addiction is some work also using lsd. It hasn't started yet, but it's approved.

Using LSD to treat chronic pain with people that misuse opioids. These aren't people who are full fledged opioid use disorder but are sort of one of the major funnels into opioid use disorders. Those people who unfortunately develop a habit, a pattern of using.

From its medical application, the medical application of.

Opioid analgesics for chronic pain. So yeah, a few different things that are kind of either ongoing or lined up to start.

Oh, a couple of follow up questions there.

So the tobacco cessation studies, were those replicating your earlier studies or was there something new about these studies?

The first study was an open label pilot, so it didn't have a control group.

So you know, that nature of that study is one where you're necessarily constrained in the conclusions you can draw. However, one of the nice things about the area really in terms of that study to tell me whether we're even, whether there's any hope here, whether this is worthy of follow up is that we have an extensive literature in the scientific field of addictions for smoking cessation. We know a lot about what the range of successful abstinence rates are. And so we got a very high abstinence rate. That was a study with three psilocybin sessions. The first psilocybin session on the same date was that that was their target quit date for quitting smoking. Six months later we had an absence rate of 80% that held up at two and a half years at 60%. So these are just very high rates. Again, you had to be constrained about your conclusions. But, but typical success rates vary depending on your method. At six months will vary from, you know, something like, you know, 12, 15% up to lower mid-30s depending on the treatment. The best medication you've had is. Is varenicline.

Trade name Chantix Studies, some studies have suggested abstinence rates in the, in the 30% somewhere. So you know, just at the absolute level of.

In terms of those absolute percents of people. In a small sample, this is 15 people. So again, lots of reason to be constrained at the beginning, but an extremely high absolute success rate. So again, the question really is or was is this worthy of follow up? Like might we be on to something? And the. The answer was absolutely freaking lutely because it was such a high, you know, success rate. And I think it really fits like, you know, having talked to now so many people and now again having.

You know, gotten to our primary outcome in the subsequent study of 82 people, I've just, you know, gotten a lot of feedback from people. We did a formal qualitative analysis on trying to understand how it works and you know, like across the site at least the sort of the psychedelic therapy model using a so called large or heroic dose with an introspective framework.

It really seems to be because of general mechanisms, people are taking a wildly different perspective on themselves. They can have insights, they have an experience that's sort of a touch tone for them that they could draw upon in the future. It's basically a learning experience. People go through something and they learn something about themselves, about the relationship to tobacco. And it really, in many ways the heart of it is psychotherapy. And I would say that about psychedelic therapy in general. Sure, there's a medication involved, but the way it works, when it does work, it's psychotherapeutic process. Again, they learn things, they see themselves from a different perspective, they develop a new relationship with the issues that they've been dealing with.

So. Well, we'll look forward to your research coming out soon. But you kind of answered one question I had both in relation to those studies and the study with opioids.

I guess people are on the edge or potential of opioid disorder. Having gotten involved with opioids as an analgesic for dealing with pain that was medically prescribed. And I know this is a serious issue because I've had a couple of surgeries, full knee replacements, where I was using opioids to deal with the pain and get through the rehab. And I got no counseling from the medical providers about it at all. I discovered when I was getting off it the first time that I was having symptoms that I wasn't sure what it was. And I thought, oh man, I'm having withdrawal symptoms. And I started, you know, doing Some research online and I discovered this whole world of forums of people dealing with opioid addiction. And they were all people who had started off with back surgery or knee surgery or some kind of surgery that created severe pain and or other chronic pain situations. And then they found their way into struggling with opioids. So wow, really important research. So my question you answered, I was curious if this was the heroic dose, large dose form of therapy with psilocybin. So that was the case for the smoking cessation. I assume that was also the case with the opioid study.

Yeah, that's the plan with the opioid study. To really use those large heroic doses, so to speak, to speak plainly about.

Your thoughts about maybe the mechanisms of change. Now you described you think the actual psychotherapy is the most important part and the insights people get and their understanding of addiction and maybe reframing themselves and their identity. I know I stopped smoking, I don't know, 35, 40 years ago, thank goodness. And it really was an identity shift at some point where I was able to shift from someone who liked smoking, who identified being a smoker but wanted to quit because I knew it wasn't good for me, to being a non smoker and someone who just couldn't even relate. It was really an identity shift. And I think those kind of reframings can really happen for people through psychedelic experiences. But I'm also wondering, you know, I have some colleagues involved in ibogaine clinical research in Mexico, actually working with a lot of opioid addiction and having a lot of success. I have a colleague who spent his whole career as an addiction counselor in the US and then retired, went down there. He's been working in a clinic for quite a while. And his sense of it, I guess is an oversimplification, but that it kind of does like a reset on the brain in a sense. It's kind of like pushing the reset button which just gives an opportunity then.

For change. This is where the therapy becomes very important. But there's some kind of. It creates a window of opportunity, maybe cuts the momentum of the addiction cycle or something momentarily so that someone would have the opportunity to enter into a therapeutic process of change. I wonder how that resonates with you or what your understanding is about what you think the therapeutic mechanism or the contribution from the medicines themselves is to the change process.

Yeah, I think something like that is going on. Of course, you know, these are metaphors and you know, there's no reset button. And so, you know, it is a metaphor. But I really think it points to something that, that so far seems, it seems true. It's consistent in the sense that there are threads of evidence. For example, in the non human animals, rodents, we see multiple forms of neuroplasticity unfolding after psilocybin and other psychedelics. And while we don't know yet, it's harder to know if that's happening in people because we don't want our brains cut open after treatment. That's how you discover these things in rats.

It's a good bet that this is unfolding. I don't think that's all of this because that's really, you know, is an aspect that I think is not identical to these kind of larger scale psychological shifts. The perspective taking, the learning, however, it could complement those. You have those big picture experiences and you have something to learn from. And then if you have this neuroplasticity, that could enhance the ability, perhaps this is speculative, to take hold and become the new normal. And I should define myself. Neuroplasticity is a kind of a general term, but different ways in which the cells of the brain, the neurons.

Can change.

So growing new branches to form new connections amongst different neurons and even some evidence suggesting the growth of new neurons. So those are all different aspects of neuroplasticity. And to be clear, you know, just plasticity by itself is not, you know, by definition a good thing. I mean, you know, growing new cells isn't always a good thing. One at one form of that we call cancer. So it's, you know, and I think that from that journal perspective it's, it's good to remember there can be a dark side to psychedelics. We see extreme cases where, you know, be it cases of, you know, essentially brainwashing. You know, Charles Manson really looked like to use psychedelics to kind of, you know, shape his, his cult, you know, wasn't the only thing going on. But you know, I think that's, that's sort of consistent with this idea that if you make a system more plastic, you can make it better or worse, depending on the conditions. You kind of heat up a literal plastic, you know, in an oven and put it in the hands of a good art and they can make something beautiful. Put it in my hands, you'll probably come up with something that might be mistaken for some of these go in the garbage pile. So it depends on what happens there. But I think that, so that could be one aspect of the reset, that neuroplasticity, which again we don't know for sure is happening. In humans. But it's a very decent bet, I think might be part of the so called afterglow that's been talked about since the 1950s. People feel like this, this kind of the effects are over, the primary effects are over. This is like the next day, for example, maybe a few days, maybe a couple of weeks. But they feel, well, reset or that they are kind of able to take decisions as new ones rather than falling into the same pattern, just the habitual behavior that they've engaged in before. One other speculation is that there's these powerful effects acutely. In other words, when the drug is in the system, that the brain is communicating with itself in very different ways. These are so called brain network dynamics, the synchronization across different brain areas. A lot's been looked at there in terms of the acute effects, what's happening in the brain when you're on the psychedelic. But then there's a really lot to figure out in terms of what long term changes what, you know, perhaps there is a normalization of suboptimal patterns in those brain communication patterns long term. And so these are actually some of the things. We do have a neuroimaging component of that study that's recently wrapped up with smoking cessation. So we'll be. We weren't doing brain imaging during the therapeutic sessions, but we were doing before and after snapshots with FMRI brain imaging. And so, and this is obviously something that others in the field are looking at as well. Hopefully we'll have an answer.

Relatively, at least a few more clues in terms of whether some of this stuff is going on. But that could be another part of this so called reset. But just anecdotally, and this is kind of consistent with the qualitative analysis I mentioned, the kind of the formal open ended interviews we did with people in our first smoking cessation work, people do feel that they can have a.

It'S seemingly more agency.

And sometimes these can fit into what I, I call the duh moments. Because even when the person says them, they, they realize like what they're saying doesn't, you know, a response could be duh, like what do you mean? That doesn't make sense. Like one of, one of my participants, I think he just like really emphasized like I could just decide to quit smoking, like flicking off a bug, like I could decide to quit smoking. I mean, yeah, it sounds like duh, like yeah, okay, you can decide to qu smoking, why haven't you? But people feel this very deeply and I really think they're they are getting at layers of psychological process that are we just. It sounds like a duh statement because we don't have the language. It's perhaps part of the inevitable. We're getting to aspects of our functioning that we don't have a great language for. But really visiting this sense of agency that wow, I could really have this top down influence on my own behavior. I don't have to fall into these same patterns.

So that's something I'm very interested in going into the future mechanistically at the psychological level. Really aside from the philosophical very interesting question of whether free will actually exists or not, which I'm not. I'm not holding my breath that psychedelics or really any other research is going to crack that puzzle. Sort of like the hard so called hard problem of consciousness. Nonetheless, I think at least whatever we clearly we feel.

Sometimes more than others, like we have agency, we have free will, whatever that is. It seems to me like psychedelics can.

Oftentimes turn that up a notch. Again, it doesn't matter whether the philosophy of whether it's truly is futile or not. Perhaps just believing that you actually have.

This agency, that you have this ability to make these big picture decisions in your life analogous to these other disorders with the depression or how you're dealing with the cancer diagnosis. More in the spirit of the cognitive processes, wow, I could actually change the way I think about this issue. I can change these reactions I have within myself. I could change the way these labels I put on myself. I can change the kind of this story that I keep telling myself. And in fact I think that's very much like there's more in common than. Than different at those deepest levels between the so called addictions and the affective disorders. It's like these are both ways of falling to a suboptimal pattern. And it takes kind of like you know, often shaking up the system to kind of break that habitual pattern. Which is one way of saying yeah, perhaps that reset you mentioned. I really do think that's kind of a key. We have a lot to figure out how that's happening. But that's why this stuff seems to work so well, I think.

Yeah, I think so. In the whole realm of research around change processes and social psychology and so forth. I mean it's the idea of pattern interrupt of some kind of whether that's psychological or physiological or in this case possibly neurophysiological.

Creates some possibility, it seems. It's really important what you're talking about there with the sense of Agency, because it seems like a felt experience of not having agency really characterizes addiction. Right. The feeling of being out of control or under the control of something else and feeling a lack of agency. And so that does seem to be. If there is somehow that we recover some sense of self agency through these experiences. That seems really powerful and an important line of research.

And I'll just add quickly, I think also for the affective disorder, so depression, that lack of agency, there's a concept going back decades called learned helplessness. This idea that as a model of depression that you just basically learn no matter what you do, it's not going to have any influence on your life. And so you're just kind of a, you know, you've learned that to give up. You know, same thing, I think, as an addiction.

Yeah, I think from a strictly, you know, scientific method point of view, the hard problem of consciousness that you alluded to and all of that is still. The jury's still out. But it seems pretty hard to be around the world of psychedelics very much and hold onto a highly reductionist, deterministic view of things. It does seem to shake things up and at least make one wonder about the source of things.

Yeah, I think it's humbling for people in terms of not being too confident that they know that everything there is to be known. And people wildly differ. And in terms of, you know, sometimes this can go into the, you know, what, what we may call the supernatural. And I'm always. I feel it's very important that, you know, we can't speak to ground truth. People have, you know, spiritual experiences that could mean totally secular things like feeling connected to others, having meaning in your life. Something any hardcore atheist would. Most would say like, oh, those are important things, but then it can contain the supernatural. And so we really don't know ground truth. But whether it's at those levels or just sort of understanding the complexity of oneself or the complexity of human interactions or the complexity of the world.

Just to not be so sure about what's going on. I do think that sometimes that's an aspect that seems to be helpful.

With psychedelics. I mean, Huxley, Aldous Huxley said it in an interview many decades ago about psychedelics that some paraphrasing but very learned people that have.

You know, very fixed. They're very confident about the way they think things work in the world. Like, this might be an interesting experience for those people, he said.

So you, you alluded to the. There's some risk and potential dark sides with psychedelics and I know you published a set of safety guidelines that I think were quite important. So I wonder if you could talk about that, about having established safety guidelines and the approach to make research safe so that we can continue exploring the potential benefits from these psychedelic medicines.

Right.

I don't really ever like to talk about psychedelics in any form without at least mentioning the risks. And so that paper really covered.

What I kind of see now is the basics. So just very, very quickly, it appears at least for some people with the so called psychotic disorders, schizophrenia and related disorders that a psychedelic experience can destabilize them. So.

Thankfully one can screen out people through reliable testing. Whether they, they fall into that category would say there's anecdotes of people saying it's with those disorders that they've been helped by psychedelics. I'm not saying that's not possible. I'm not saying that should never be researched. If, if as a field we research that, we just have to be, have even extra guards up and there's certain things you do say, okay, what if we are making people worse? How do we detect that really early and make sure we don't? We could stop the study, you know, so just to make that clear. But for most things you're looking at, unless you have that on, the targets and have, are really dialed in to navigate that like yeah, excluding folks with that potential is a very good idea.

People with severe heart disease, most of these at least the classic psychedelics are really robustly safe at the physiological level, meaning at gosh, even far above typical doses. They don't cause people to stop breathing, cause them to have cardiac events like strokes or heart attacks, cause their liver to fail. Those are the kind of the tip, the big ways where you take too much of a substance, even caffeine or you know, Tylenol and you, you know, you opioids certainly and you, you die if you take too much.

So with some of these like psilocybin and lsd, there's no known lethal like you know, theoretically one could take a hundred or even, you know, perhaps a thousand times what they intended to, you know, take. And there's not going to be a mechanism for death. But that's for you know, most healthy people there are it, these drugs do modestly raise blood pressure and pulse.

And so people at that more severe level of heart disease, they could have an event. So these are, you know, the people who are at risk for anything. If your doctor says oh yeah, don't shovel snow, take the elevator rather than the stairs. If you can at work if you're in that category. Yeah, it's risky to, you know, those are folks where anything. I mean, people go to the emergency department. You know, things like having sex. I mean, that's not uncommon. You know, so anything that, like, raises the, you know, gets the heart going even somewhat can have that potential to push people over the edge. But again, fortunately, that's really easy to. I mean, it's very straightforward to check out. And there's some anecdotes of. Yeah, people that, you know, have. Appear to have been hurt or even died, you know, were in that category. And the only case in the medical literature I know of with psilocybin mushrooms, someone dying is a heart transplant patient. So, yes, that's an extreme case. But, yeah, like, in that category, not a good idea to really, you know, probably doing any of the, you know, a lot of these things that could you know, really kind of push the heart response up. And then you have sort of. For anyone. So you pass all the screenings for. For any one healthy person, you could have the bad trip, the challenging experience. And that just refers to the strong anxiety, fear, the panic. And the really bad thing about that is if you do something stupid when you're, you know, when you're intoxicated or high. So, you know, I like to tell people it is relatively rare. I mean, you compare this to alcohol. You compare it to, you know, cocaine and opioids. And the emergency department visits and deaths are, you know, pale in comparison. But there's a reality here. You know, there are definitely people that, you know, they take. Take a big dose at a concert and they freak out and they're hauled off by the paramedics and the police and. Which can often exacerbate things. But paranoia is part of the territory. And, hey, you don't know everyone you're around when you're in public. And sometimes it's. Who's there? Are they out to get me, this type of thing. And I always like to remind people, yeah, you can't trust everyone. Those are settings where you. You need to, like, watch your wallet. Need to make sure for, you know, especially for women, like, yeah, you should, you know, maybe sexually assaulted. You're intoxicated in public. These are real things. So if you're in an environment where you're charged with kind of, you know, keeping your guards up, that can potentially, you know, kind of spiral. So that's why in therapeutics, it's nice to be. It's ideal to be in an environment where you completely Trust at both, you know, the medical level, most importantly, the interpersonal level, the physical safety level, that you're going to be fine. You're not going to, even at the legal level, like you're not going to be, even if it's a small chance that, especially with the paranoia, oh, what if the cops find out I'm doing something illegal? Well, this isn't illegal, you know, at all of those levels you can let go, know that you're being kept safe.

And so the bad trip is something is kind of the other aspect of other major, you know, there are other things, but those are the major ones, the risks people should be aware of. But I would say I've become more focused in recent years. Those are the basics, more focused on some of these concerns that I, the, the, the, that are more difficult and probably not recognized by most people doing psychedelic research. But kind of the, the very dramatic psychological effects. The, the, the potential for cults to be formed around this, for, for power dynamics to be amplified, sexual abuses, relationships to develop. There is this sense that psychedelics break all the rules. These are bigger experiences that don't fit the normal rules don't apply. And you see that and you know, you know, well respected researchers. There's also this sense of people like, because people not always, but often confront what I call the big questions, like what's the nature of reality? Does God exist? What is meaning? What's the meaning of life? That.

People, sort of clinicians or researchers use this as the opportunity to kind of push their own philosophy on people. And I'm very concerned about the direction that this is going to go. In fact, I've been, you know, vocally even about, it's probably minor in the scheme of things, but a very concrete example of this is, you know, why are we putting Buddhas in these clinical research session rooms? I have nothing personal against the Buddha, but I, you know, my suggestion is byob, bring your own Buddha or crucifix or flying spaghetti monster. If you're a Richard Dawkins atheist or whatever, pictures of your family, like, why are we, we're not aware of, like, you know, who is looking at this? Who says, well that's not for me, you know, a Muslim, a more fundamentalist Christian, you know, a hardcore atheist. I've seen people in all these categories profoundly affected and, and claim they've been helped by psychedelics. So this is not just for hippies, this is not just for political liberals or whatever. One's conception of what stereotype of who would be into psychedelics I've seen, you know, political conservatives, grandmas that would never touch an illicit substance, you know, you know, former military folks, all of these folks, you know, if they pass the screening, you know, don't have those kind of disorders that might be extra risky for them, you know. So I'm concerned about kind of pushing.

Pushing these kind of any particular spiritual narrative on people, I really believe. Which isn't to say we should be imposing materialism or anything like that. It's just that we should let the patient drive the bus when it comes to those metaphysical meanings. I think we just have to have this humility of saying, hey, look, I can tell you what serotonin type receptors hit. I can tell you some things about how the brain responds or what the research suggests is how this should be used most safely with preparation and whatnot. In terms of these big questions, what's the nature? Are you visiting different dimensions? Is this the realm of the plant spirits? Is this, you know, is this an encounter with God? My guess is as good as anybody's guess. You know, I think we have to check ourselves.

Anybody's guess, the patient, they haven't experienced, they're the world's expert at these levels of what that might mean for them and they might not have any sort of thoughts on those dimensions at all. And that's fine too. But I'm very concerned about these risks as we are going to see. I think when this is in treatment, clinicians that are kind of having this cult like vibe and they're doing, you know, sessions at their home on a Saturday night and turns out then they're having sex with half of the people that are there, maybe all of them. And you know, this type of thing. And I just think we got to have our guards up about at these levels that as intimate and as, as powerful as this can be, as vulnerable as people can be, that's part of why this works so well. But that also poses this risk. So we have to be very mindful of that and navigate these boundaries.

Yeah, I'm very happy that you brought this kind of expanded view of the necessary guardrails and the risk involved just to highlight what you were talking about with the elevated heart rate. And if somebody does have cardiovascular risk, I think ibogaine is unique among some of the psychiatric medicines to have a higher impact in that way. So people should be aware of that. But I think what you were talking about, because I know, you know, just sometimes in a world of.

Retreat, even very secular things, there's a certain, often the host of sources are kind of make assumptions of being aligned with kind of, oh, a strong alignment with kind of Eastern spirituality or alignment with liberal politics. They make assumptions about who's there and who's coming and create environments that may feel very good to them, but it may actually feel uncomfortable to someone else. And so I think it is really important to be aware of having that neutrality and letting the patient, especially when it's individual sessions, to let that patient design their own setting and with support if they want support. But I think you're pointing things that are really important and then the other human pointed to is absolutely. I think one of the really important challenges as we train more and more clinicians, that there are ethical standards and training. And it's just really important because for all psychotherapists, this training has always been important. The dangers of transference and countertransference and understanding how those can be employed psychotherapeutically. But at the same time, one needs a lot of grounding and good boundaries. But yeah, I think psychedelic medicine just kind of is all that on steroids in some cases. Right, right.

That's a great I Glass. But that's.

It's not necessarily that it's a bad therapist somewhere. We're all at risk for this. We're human beings.

Yes.

You know, we all have the potential to think we're falling in love with someone and. Or whatever. And so we just need really good training and really good boundaries. And I think that's really important area.

That you're pointing to.

Yeah. And I remind people because I've been in over 100 of these therapeutic sessions and talked to hundreds of, you know, folks for sessions I've supervised out, even if I'm not in the room. And I tell you what, it is pretty heavy to be associated with what for many people is one of the top meaningful experiences of their life and for a decent minority, the most meaningful experience of their life. I mean, that's. I can't put into words the gravity of that and how like I think just one has to be really humble and, you know, feeling that they're. They're lucky to be involved, that someone would trust them with that and to not take advantage of that, even in unconscious ways. And. And I think that, yeah, this is. It's just. It's something that's unappreciated and there's just the potential. For example, there's a lot of talk about all the importance of potentially one's own experiences. I'm actually more concerned about.

There'S not need. It's a complex answer to that whole question about whether therapists should have their own psychedelic experiences. But one thing I remind people, part of the danger is therapists imposing their own experiences on others. Yeah. You may have had 500 experiences. You haven't had the experience of that person on that day. You don't know what it's like to be a 68 year old grandmother who's dealing with cancer or whatever, whatever the. And even regardless of what demographics they're in, just that experience they're having. So again, I think the humility is something that can be lost of, you know, like. Yeah, just because anyone's had. No one knows the entire psychedelic territory.

So one has to check themselves in terms of this.

You know, arrogance.

Some real risk of inflation. There's.

Right, right, right.

Yeah. Well, in all the work that we do, I mean, humility is such a wonderful guideline and just, you know, and plus, you know, having colleagues in clinical supervision and you know, lots of ways to, for others to notice if we are getting inflated because we may be getting asked to notice.

Right, absolutely.

Yeah. I'd like to circle back to your work. The study you did on using psilocybin assisted therapy with cancer patients suffering anxiety and depression. So I wonder if you could talk about that study now. Were these people simply dealing with cancer? Was this terminal cancer? So was part of the anxiety and depression related to being terminal or was it just related to being ill? And anyway, I'll let you talk about it if you could talk about that study a bit.

Those are great questions. It was actually both. They didn't have to be terminal, but a decent sizable minority were terminal. And of course that's a thankfully diagnosis.

Yes.

Yeah. And sometimes, thankfully, some of the things that would have been called terminal even a few years ago are not terminal now. Or at least there's more hope, you know. And so with more advanced oncology, so that can be just difficult to make that determine. But some people were frankly, you know, stage four pancreatic, like for things like. Yeah, there's, you know, by any strong.

Likelihood they were towards the end.

Yeah, yeah. But that wasn't required and most people would not be in that. Weren't in that category. But it had to all be related to their cancer. So the depression and. Or anxiety had to have been instigated or exacerbated. So there could have been something before, but it was, you know, made worse by the cancer diagnosis. And there were some other rules, like if it had been an initial diagnosis, either there had to have been a metastasis or it had to have been years since the ignition diagnosis. So that we didn't take advantage of just say a naturalistic. A lot of people are, you know, understandably very freaked out at the beginning, but then, you know, they come to resolution over it, they come to peace. And.

You know, and so we didn't want to, you know, take advantage of that naturalistic kind of resolution. So for those people, it had to have been a year since their original diagnosis and they were still suffering. And this is actually following one of the recommendations. If you read the older papers from the 1960s using LSD to treat cancer, at the end, several of them said.

Wow, this was such a dramatic and helpful thing that like, what a shame that we did it during the last weeks of their lives. Like, because it would have been like much better to have in transform people's lives that didn't only have a few weeks or a couple months something left. And so that was in part inspired by that recommendation. Yeah, that's great. To transform someone's life who hopefully lives another 30, 40 years.

How long were patients involved in the study?

So that was. The active participation was a few months. I mean the screening process take a little bit. But then there was a. There were two sessions that were about a month apart. And so there were 51 patients and. And every. There was sort of a. What's called a within subject design, meaning each person served as their own control and that they had. One of those sessions was kind of the real deal high dose psilocybin session. The other was a trivial dose really. So such a low enough dose such that not even one, everyone necessarily felt it, but you know, serving as what you could call an active placebo. So we ran and the order of which they got was randomized. That people were kept on their toes basically. And so there was, you know, those set the preparation for those which went. There was eight hours of preparation. And some people came from out of town or even out of the country. And so that could sometimes be squeezed into a couple of sessions. Often it was spread out over four different sessions of about two hours each. But then we had so called integration, which is really just discussion afterwards like the day afterwards integration sessions. And so yeah, it spanned really over a couple of months. Their participation we had long term follow ups, but that was sort of after.

A long delay and was a recent cancer diagnosis. Was there any uniformity around how, how close they, how closely this followed their cancer diagnosis?

We left that being really open and gosh, I'M forgetting on the specific ranges but we did have people that have had long, you know, it'd been a long, you know, it had been years but they were still suffering again. The key just being if they were suffering because this does happen. People just, they've been in this dark place for years because of this and then forgetting what the mean was. But.

You know, most within the last, you know, last couple of years or so with the last year or so it was. But we did have people that were. They'd been dealing with it for longer.

I'm wondering if you saw anything in the trajectory of the subjects of these patients experience anything reminiscent of Kubler Ross's five stages. And I realize those are not linear and they've never. There's similar to Maslow's hierarchy of needs. Now none of these have been scientifically validated but they have a lot of common sense validity in people's experience. And there's this idea well known within the world of terminal cancer and dealing with people dealing with shock and then some kind of denial, then often shifting into anger and then maybe bargaining and then the final stage of acceptance. Even though people have reinforced again and again these are not linear and they can show up in any way and you can go back and forward. But I wonder if you just. If this does seem to describe some of the territory that people are moving through. And then was this study the psilocybin experiences and the therapy sort of facilitating them moving. I guess acceptance is considered one of, you know, a good, a good, good outcome.

Yeah, I would say so with the caveats I think you well described of yeah, things aren't linear and but as a facilitator, as I said before, of essentially psychotherapeutic process and I should say whether there's a nominal psychotherapy or not. And we didn't have a nominal psychotherapy here. There's. It's confusing because there's preparation which is rapport building and that's very psychotherapeutic. Like in fact according to the so called common factors of psychotherapy, it's for many disorders like the most important thing. It doesn't matter whether you're a Freudian or cognitive behavioral therapist, et cetera. It matters about that connection that you have this safe framing that you're moving towards growth. There's a rapport between, you know, this strong bond between patient and therapist. So whether you call it psychotherapy or not, it's very psychotherapeutic like. But yeah, yeah, I would say that, you know, going through this psychotherapeutic process which, you know, and the right. In the best situations and which is often the case with these, with these, with psychedelic therapy, you know, it's, it's something like, you know, psychotherapy under, with, under, you know, on steroids. And people do seem to more rapidly deal with those types of stages or go through them again, not linearly necessarily, but, but that's part of, we know part of how the resolution of some of these disorders work. I think we know most about that with trauma. And for a subset of these people, trauma is a deficit. You know, they would meet criteria for trauma or even ptsd.

We know probably more than for other disorders that yeah, if it's successful, it's going to be worse before it gets better. Because facing the difficult thing is the path through very much like the instructions. It's very meta because that's how you instruct people how to go through the psychedelics experience itself. Like when it gets scary, it's like in and through. Don't deny, don't fight it. You know. But people often come out of this saying, hey, that's a metaphor for life. You know, that's easier said than done. But you know, but so it sometimes does get rougher. And so that, that, you know, makes sense with your description of going through these stages of like, yeah, you may go through even. You might go back to, let's say den and as part of this like really this cathartic like process of saying, you know, damn it, like why did the universe, whatever, you know, or use the language of God, whatever, you know, do this to me and just like get really upset about it. Like you could prompt that again and really kind of fully go through that and that might be necessary and then to go to the other stages and, and I think, yeah, acceptance is a good description of, of how like when it works well that people do get in there. And I'm also mindful any of these descriptions aren't. It's sort of like the concept of enlightenment. It's like I've never met anyone who's, you know, you know, there are people that, you know, like, I think all of us have had moments of enlightenment and the more of those moments we have, the better, the more, the more portion of our time that we can have our head in that right space, the better. So it's not like you achieve this level and you're locked in. I mean entropy is a fundamental aspect of the universe, I think, including our own psychological process. I've never known anyone that kind of is completely locked into this sort of like at a certain psychological level. And so, you know, whether it's the hierarchy, Maslow's hierarchy of needs or anything else, like yeah, you can be bouncing up and down, but to spend more moments in that acceptance, especially when it comes down to it, like in terms of making decisions like, yep, if you're enough in that acceptance, enough of time to say, yep, I'm going to plan for that vacation. You know what, maybe I won't be around, that's fine. Like I'm not going to. I know I'm going to be suffering when I don't plan for that vacation at all. Because even planning for it is part of life. Even if I never get there, it's part of this process of it's something to look forward to, it's fun, it's, you know, it's, and, and, and then hey, maybe I will get there and that'll be great too. And, and if I make it past that, I'll have memories. But like so many people, there's this pattern of where they recognize like they, they, the suffering is self inflicted. They could choose to engage with life, but they're not because of the cancer. And, and this is one of those duh things because they've told themselves that it's not like they didn't know it up here, but somehow now they feel it in their heart and in their bones. They kind of like really get it. You know, they told themselves, I don't know why, like I could be engaging with, I could be out in like the sun shining, why the hell am I out enjoying the sunshine, not spending enough time with my grandkids, this type of thing. But again, they now kind of feel it emotionally and it's kind of this deeper lesson for them. And so, you know, I would say, you know, the more you're in acceptance, the more you're able to make those decisions to engage with life. And yep, you're gonna, you're gonna be back in the denial a little bit. You're gonna be back in these other states, bouncing around. But just to have enough of that time in the acceptance is enough to make life worth living again.

Absolutely. And circling back to Elizabeth Kublerov, she talked about the importance of living until we die. Right. And so I think what you're talking about there is helping, helping people find some way into continuing to live and engage their life until, till the end. Right. So really wonderful outcomes if that therapeutic process can help that along.

I know you've been involved in while Your research is part of the effort that's leading to the possible FDA approval and rescheduling of these psychedelic medicines. And it looks like MDMA is well on its way until it happens. We don't know for sure, but it looks like it's well on its way. And some people feel psilocybin may follow soon thereafter. I wonder what you understand about that process and what you feel about the importance of psilocybin being rescheduled. And at what point will we be ready, have the proper guardrails in place to really scale some of these therapeutic applications for the benefit of people who are, whether dealing with addictions or they're dealing with anxiety and depression from a cancer diagnosis or other? Are there similar situations?

Yeah, I think, you know, your description is right, Fleet. It does appear that MDMA is poised to be the closest. Of course, depending on how you define things. You know, ketamine's already approved. Spravato and off label use of, you know, racemic ketamine is used. But, you know, definitions is always an interesting area with the psychedelics. But MDMA amongst the stuff that's left, MDMA is potentially within the year, according to the great folks at Maps who have done so much work in sponsoring, moving in the treatment of ptsd. MDMA for ptsd, they've completed two phase three trials with promising data that it's going through those final layers of the approval process.

Psilocybin for depression may be the next because there are several sponsors that have at least engaged in phase two work that looks promising and potentially approvable if scaled up to the larger numbers in phase three. And then I would say for addiction, both alcohol use disorder, the great work that Michael Bogenschutz now at nyu, has done and that the work that we've done with tobacco smoking cessation, hopefully, you know, all this depends on the data. Obviously I'm a scientist. Hey, we could find something, the results could change. Maybe this doesn't work so well as we thought, or maybe there's some danger we didn't appreciate or hadn't popped up yet. But depending on the data, I'd say it does look very promising. So hopefully within a few years.

You know, I would hope there would be more interested in moving, you know, like for smoking cessation. I remind folks, it hasn't been at the top of the list of what folks are looking at, but what some of the industry sponsors are looking at. But gosh, this is a big market, folks. There's a lot of people looking for Help a lot of like human suffering that can be alleviated and just a lot of, yeah, a lot of people out there. So I'm hopeful that there'll be, you know, alcohol use disorder and tobacco smoking cessation will also, along with depression will be within the next few years for, for psilocybin. In terms of scaling up, I mean we, and just to admit, you know, you know, we're getting to levels where it's not my square expertise for sure, you know, in terms of like, you know, the scaling of the healthcare system and the, the infrastructure of the availability of therapists, I could say for sure, you know, the way Rick Doblin has been describing with the MDMA PTSD work, he's certainly correct and that there's an unmet need. We need a lot of folks that are going to be able to provide this service. It is professionally intensive.

You know, most therapies don't require someone to sit there for you know, six hours and you know, you're paying professionals. That's a lot. That's an expensive treatment. I think, you know, when it works it pays for itself over long term or at least there's that potential. We need more of the, and I hope to do this when I have some of these smoking cessation results come through. Do these kind of larger scale cost benefit analyses showing hopefully insurance payers or government payers like Medicare, the VA or you know, the government payers in other countries that yeah, this is pricey, but when it works, you're not paying as much down the road and people keep showing up to the ER and you're dealing with chronic illnesses and so it pays for itself over time. Hopefully that's the case.

I would think the evidence suggests that's a very, very strong potential, that it is a good bet. But it's an expensive treatment. So companies are exploring shorter acting compounds for these various disorders. So, you know, I'm, you know, I think that's a worthy exploration. I'm a fan of seeing the data for that. But you know, there's probably a complex landscape. It may be that some people really need the, you know, the extended experience offered by psilocybin or MDMA or even I mentioned some work with lsd. I have poised.

It may be that some people really need an even further extended session. There could be differences across individuals and maybe some differences across disorders. We just need a lot of exploration, a lot more studies to explore it. But you know, and I would also say in terms of kind of, you know, scaling up and disseminating I do think we have been understandably and for the right reasons at the most conservative level of risk safeguarding in terms of, you know, having two people in the room with the person. But I'll tell you what, actually in part in the smoking cessation research prompted by the pandemic, when we were initially shut down and allowed to start back, but only if we had some extra precautions in place. So one of the things we did was have just one person in the room and the other guide watching from a video feed elsewhere so they could jump in if needed. And even that model requires someone to still be on task the whole time. But I think reasonable. I don't want to have a treatment model that's so expensive that no one has ever helped. Right. You know, we need to get this in the marketplace and so that payers pay for it. And yeah, people are actually helped. So, you know, I'm fine for reasonable exploration, always with a mind on safety. But hey, to have someone else on call, they don't necessarily, necessarily need to be watching a video feed the whole time. But if you have a, you know, have a, you know, if they're by cell phone or like a, you know, whatever, a button in the room that, you know, contacts them and they're on call, their page or whatever, and they can respond to me, you know, that you have that, you know, so that, you know, you simply need to go use the restroom as a, as the primary therapist that you can let someone know and they're in there in a few minutes, they're there to relieve you and then you can, you know, take your break, what have you. Or if you simply, you know, those times where you might need multiple sets of hands, if the person's having a real panic reaction, you can call them when needed. So I think there's reasonable explorations of, of things like that. Oh, and I should also. Final things, group therapy. I know folks are, I've been curious for, gosh, going back 15 plus years on, like, obviously that's kind of the biggest thing we need to explore in terms of scaling this up because, you know, it's all over indigenous cultures and you know, just informal trip circles. You know, group therapy or group sessions are more of the norm than the exception. So I remind people that when going that direction that, you know, there's an art and science of doing group psychotherapy. And so, you know, like, so many areas, you know, we can't just wing it as psychedelic researchers. We really need to incorporate that, that real expertise from people that have been trained to do group psychotherapy outside of psychedelics and bring that wisdom and experience, that knowledge into what we're doing. Because it's one thing to have, like, two professionals guiding someone and they're the center of attention, as it should be. And. But it is quite a different dynamic when everyone around that circle has had a profound or interesting experience. And then humans are humans, Someone's going to want to kind of hog the show. You need to balance people out to get along with each other and let everyone else talk, that type of thing.

Yeah, I'm so glad you pointed to that. I know some of the experimentation with group therapy is being doing in some ways in an effort to find some way to scale this, doing individual sessions, but then bringing people together into a group for the processing and things like that. But I really hope that as this research continues, that people will respect and really look into the really compelling body of research.

On group psychotherapy, Yalom's work. And we know so much about group dynamics that you put six, eight, ten people in a circle, there's all this stuff is going to come up sooner or later. We know this. It's just the psychology of groups. Right. And it can be used therapeutically and could be married, in a sense, with psychedelic medicines in some really powerful, beautiful ways. But I think only if we go back and respect this long lineage of group therapy and bring that wisdom into the process.

Yeah, right, right. And one, you know, I just think of one example I learned early in my, you know, in graduate school with terms of group process with adolescents who have, you know, antisocial.

Issues, seems pretty convincing. Like, they tend to get worse when you put them together, which kind of makes sense because, like, you know, you know, they become the hookup for the other ones, you know, for drugs or whatever. They get in trouble together. And like, you know, and that might sound like, well, that's not going to be related. But, you know, the FDA is a. They want adolescent research, for example, maps as plans. You know, hey, once, you know, this is approved for adults, that we need the research on, you know, the, you know, the older teenagers. And then we need. If that looks good, we need younger because there's lots of these issues, trauma, etcetera, in younger folks. So, yeah, we just, like you were saying, Fleet, we need that. We need to recognize we're stepping into. This is highly interdisciplinary. We're stepping into realms that there is existing expertise and we really need to just not wing it. We need to draw on that clinical expertise and wisdom, that knowledge base Well.

I think we're toward the end of our time here. Has been incredibly rich. Thank you so much for everything you've shared with us today. Dr. Johnson, is where can people find out more about your work? In particular, they would like to follow these studies and follow your work.

Yeah. Yeah. So probably the best, most frequent places is my Twitter feed, or I guess it's xnow. Drugresearcher is my handle. Drugresearcher. And actually going into the future, I should say I'm going to be within the next several months moving onto Sheppard Pratt Hospital in terms of doing my research and moving away from Johns Hopkins and really hoping to accelerate my research program and being kind of in a more dynamic environment where I can get stuff done more expeditiously. So stay tuned for as my career evolves and I make some moves in that way.

Well, thank you so much for all your contributions and the work that pioneers in this research and leaders in this research like yourself have just made this research possible again and is really opening up so many possibilities. There's so much we don't know, but there's a lot of promise and possibility for healing for so many. So thank you very much for your work.

My pleasure.

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