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Brian C. Peacock, Psy.D. Candidate
Psychology Resident, Denver Health
Psychedelic Treatment Planning:
Opportunities in Integrated Care
Ā© Brian Peacock, 2023
Overview
MY RESEARCH CONSTRAINTS OF
MANAGED CARE
INDICATIONS &
USE CASES
Ā© Peacock 2023
Whatā€™s different
about psychedelics?
(compared to other therapies)
ā€¢ Psychedelics produce striking changes across all
levels of the human systemā€”molecular, neurological,
phenomenological, affective, and cognitive.
ā€¢ Effects propagate through time, resulting in changes
to mind, brain, body, and behavior lasting anywhere
from minutes up to a lifetime.
ā€¢ Clinical decision making is complicated by the varied
properties of psychedelics and the environmental
variables that affect psychedelic experience.
ā€¢ We most choose among psychedelics, therapeutic
techniques, and therapeutic sequences to maximize
treatment efficacy while minimizing risk.
Ā© Peacock 2023
My Research
Ā© Peacock 2023
Dissertation
ā€œApplications of psychedelic-assisted psychotherapy across personalities and
psychopathologies: An integrative literature review with meta-analysis.ā€
ā€¢ Compared different psychedelic therapies and their efficacy in treating psychiatric
conditions.
ā€¢ Examined variation in response to psychedelics across different personality traits.
ā€¢ Drew insights from basic psychedelic research that can be applied clinically.
ā€¢ Completed July 2022
Psilocybin
Mescaline LSD DMT Ayahuasca MDMA Ketamine Ibogaine
DEFENDED
Ā© Peacock 2023
Method
ā€¢ Systematic Literature Search
ā€¢ Matrix of 128 topic keywords combined with 8 psychedelics for a total of 1,024 Google
Scholar searches.
ā€¢ Yielded 4,409 references
ā€¢ 1,164 references were included
ā€¢ Preliminary Meta-analysis ā€“ Normalize data across studies by calculating effect sizes
when not reported.
ā€¢ Integration & Synthesis ā€“ A method for making all this data clinically useful!
Psilocybin
Mescaline LSD DMT Ayahuasca MDMA Ketamine Ibogaine
Ā© Peacock 2023
ā€¢ Colors represent the search date
(and made it more fun)
ā€¢ Boxes include:
ā€¢ [total number of search results],
ā€¢ [number of results reviewed],
ā€¢ [number of articles yielded]
Ā© Peacock 2023
Summary Tables
ā€¢ Pharmacological Properties
ā€¢ Impacts on Neurotransmission
ā€¢ Life Stage and Psychedelic Safety
ā€¢ Medical Risk Factors and Contraindications
ā€¢ Long-Term Medical Risks
ā€¢ Psychedelic Phenomenology
ā€¢ Acute
ā€¢ Subacute
ā€¢ Psychological Change
ā€¢ Subacute
ā€¢ Long-term
ā€¢ Neuropsychological Effects
ā€¢ Acute
ā€¢ Subacute
ā€¢ Long-term
ā€¢ Psychological Risks
ā€¢ Acute and Subacute
ā€¢ Long-Term Psychopathogenesis
ā€¢ Psychological Risk Factors
ā€¢ Patient Factors Affecting Psychedelic
Experience and Outcome
ā€¢ Psychedelic Treatment Targets
(Peacock, 2022)
Ā© Peacock 2023
(Peacock, 2022)
Ā© Peacock 2023
Gertrude Smith
72-year-old, White,
cis-gender woman
72
72
Gertrude Smith Brian Peacock
/ / O / / / /
O
Ā© Peacock 2023
Gertrude Smith
72-year-old, White,
cis-gender woman
72
72
Gertrude Smith Brian Peacock
/ / O / / / /
O
None
Heart Disease
Cystitis
/ / / / / X
X
Ā© Peacock 2023
72
72
Gertrude Smith Brian Peacock
/ / O / / / /
O
None
Heart Disease
Cystitis
/ / / / / X
X
Depression
2x Suicide Atmpt.
Ket associated w/
dev./worsening cystitis
SSRI / / / X
X MDMA and MAOI risk
serotonin syndrome
Gertrude Smith
72-year-old, White,
cis-gender woman
/ / / / / /
X
/
X X /
/
/
/
/
/
Ā© Peacock 2023
72
72
Gertrude Smith Brian Peacock
/ / O / / / /
O
None
Heart Disease
Cystitis
/ / / / / X
X
Depression
2x Suicide Atmpt.
Ket associated w/
dev./worsening cystitis
SSRI / / / X
X MDMA and MAOI risk
serotonin syndrome
Gertrude Smith
72-year-old, White,
cis-gender woman
/ / / / / /
X
/
X X /
/
/
/
/
/
/ X / X X X
/ X
Ā© Peacock 2023
Jon George
21-year-old, biracial,
transgender man
Jon George
Age 21
PTSD
AUD
Dysthymia
ADHD
O O O O X / O O
+ + /
+ ++ ++ +
?
?
?
?
?
?
++ ++ ++ + + + ? ++ ++
++
++
++ ++ ++ ++
?
?
?
?
Ā© Peacock 2023
Jon George
21-year-old, biracial,
transgender man
Jon George
Age 21
PTSD
AUD
Dysthymia
ADHD
O O O O X / O O
+ + /
+ ++ ++ +
?
?
?
?
?
?
++ ++ ++ + + + ? ++ ++
++
++
++ ++ ++ ++
?
?
?
?
Ā© Peacock 2023
Influencing
Factors
ā€¢ Sex
ā€¢ Age
ā€¢ Personality Traits
ā€¢ Psychopathology
ā€¢ Family History
ā€¢ Cognitive Ability
ā€¢ BMI
ā€¢ Genetics
(Peacock, 2022)
Ā© Peacock 2023
Jon George
21-year-old, biracial,
transgender man
Jon George
Age 21
PTSD
AUD
Dysthymia
ADHD
O O O O X / O O
+ + /
+ ++ ++ +
?
?
?
?
?
?
++ ++ ++ + + + ? ++ ++
++
++
++ ++ ++ ++
?
?
?
?
Trans Man - Consider transference
- Psilocybin: More ā€˜bad tripsā€™ for female sex.
- MDMA: Reduce dose and monitor closely for subacute depressive sx more common in female sex.
Under 22 - LSD: Less insight gain
High Neuroticism - Psilocybin: More challenging experience -> increased efficacy
Low trait absorption - Classical psychedelics: Less mystical experience -> decreased efficacy
Little positively
valenced language - Psilocybin: Predictive of treatment response for depression
SUDs hx - Ketamine Inf: Greater reduction in depressive sx @ 1 & 7 days
- Ketamine Inf: Greater tx response for depression
Slowed processing speed
Ā© Peacock 2023
Jon George
21-year-old, biracial,
transgender man
Jon George
Age 21
PTSD
AUD
Dysthymia
ADHD
O O O O X / O O
+ + /
+ ++ ++ +
?
?
?
?
?
?
++ ++ ++ + + + ? ++ ++
++
++
++ ++ ++ ++
?
?
?
?
X X 1. -
- 2. - 3.
-
Trans Man - Consider transference
- Psilocybin: More ā€˜bad tripsā€™ for female sex.
- MDMA: Reduce dose and monitor closely for subacute depressive sx more common in female sex.
Under 22 - LSD: Less insight gain
High Neuroticism - Psilocybin: More challenging experience -> increased efficacy
Low trait absorption - Classical psychedelics: Less mystical experience -> decreased efficacy
Little positively
valenced language - Psilocybin: Predictive of treatment response for depression
SUDs hx - Ketamine Inf: Greater reduction in depressive sx @ 1 & 7 days
- Ketamine Inf: Greater tx response for depression
Slowed processing speed
Ā© Peacock 2023
Next Steps
ā€¢ Proposed Book: Psychedelic Treatment Planning: An Evidence-Based Clinical Guide
ā€¢ Simplified symbols and treatment planning workflow
ā€¢ Clinical case examples
ā€¢ Revisions and updates
ā€¢ Starting independent practice for:
ā€¢ Pre-evaluation and preparation for psychedelic therapy.
ā€¢ Psychedelic integration therapy for patients experiencing distress, spiritual
emergency, or emerging psychopathology following psychedelic therapy with other
providers.
ā€¢ Develop assessment measure designed for assessing traits relevant to
psychedelic-assisted treatments.
Ā© Peacock 2023
Constraints of
Managed Care
Ā© Peacock 2023
Current
Availability
ā€¢ Off-label ketamine
ā€¢ Other psychedelics
used in:
ā€¢ Clinical research
ā€¢ Underground practice
Ā© Peacock 2023
Nov 2024
Natural Medicine Health Act
ā€¢ Colorado Prop. 122
ā€¢ Psilocybin and psilocin
ā€¢ Licensed treatment
centers
ā€¢ Regulated by the
Natural Medicine
Advisory Board
(Colorado Department of Regulatory Agencies)
Ā© Peacock 2023
ā€¢ FDA Approval Pending
ā€¢ Phase 3 Clinical Trial
Complete
ā€¢ Currently in ā€œExpanded
Accessā€ phase
ā€¢ Priority roll-out to
academic medical
centers
(Steinberg, 2023)
Mid 2024
MDMA-PT for PTSD
Ā© Peacock 2023
ā€¢ DMT, ayahuasca,
ibogaine, and mescaline
(excluding peyote) may
become available in CO.
ā€¢ Only if recommended by
the Natural Medicine
Advisory Board
(Colorado Department of Regulatory Agencies)
June 2026
Natural Medicine Health Act
Ā© Peacock 2023
Bias Against LSD Remains
Who pays?
ā€¢ Right Now, Most Psychedelic Therapy is Out of Pocket
ā€¢ Most psychedelics are generic medications
ā€¢ Predominant costs are:
ā€¢ Evaluation/screening
ā€¢ Therapist time ā€“ Including preparation, drug, and integration sessions
ā€¢ Facility costs
ā€¢ March 3, 2023 ā€“ AMA approved new CPT III code for ā€œContinuous In-Person
Monitoring and Intervention during Psychedelic Medication Therapyā€ to become
effective January 1, 2024 (Benzinga, 2023).
Ā© Peacock 2023
Cost Savings
ā€¢ MDMA-AT costs $11,537 per patient using protocol from FDA Phase 3 trials
ā€¢ Per 1,000 patients, compared to standard of care:
ā€¢ MDMA-AT saves $132.9 million over 30 years in discounted net health care savings
ā€¢ Averts 61.4 premature deaths
ā€¢ Generates 4,856 quality-adjusted life-years (QALYs)
ā€¢ Break-even at 3.8 years
ā€¢ Expanding access for MDMA-AT to 25-75% of eligible patients is projected to:
ā€¢ Averts 43,618ā€“106,932 deaths
ā€¢ Gains 3.3ā€“8.2 million QALYs
ā€¢ ā€œMost of the expected cost-savings arenā€™t on the psychiatric side, theyā€™re on the physical side.ā€
ā€“ Elliot Marseille (Kary, 2022)
(Marseille et al., 2022; AvanceƱa et al., 2022)
Ā© Peacock 2023
Infrastructure ā€“ Current Research
(Sprunt/WAMU, 2019)
Johns Hopkins University ā€“ Center for
Psychedelic and Consciousness Research
ā€¢ Individual Psilocybin Therapy Room
ā€¢ Two Therapists Present
ā€¢ One Licensed Psychologist or Psychiatrist
ā€¢ One Other Provider
ā€¢ EXPENSIVE
ā€¢ Similar protocols for MDMA-AT
Ā© Peacock 2023
Infrastructure ā€“ Individual Psychedelic Therapy
ā€¢ Ketamine Infusions can be done in:
ā€¢ Inpatient units (as is being done at Denver Health)
ā€¢ Outpatient infusion clinic in group setting
ā€¢ MDMA-AT and Ketamine-AT can be done in outpatient therapy
offices modified to have:
ā€¢ Calm lighting and dĆ©cor
ā€¢ Windows to monitor sessions and prevent boundary violations while patient
is in a vulnerable, suggestable, and disinhibited state.
Ā© Peacock 2023
Infrastructure ā€“ Group Psychedelic Therapy
ā€¢ Group psychedelic therapy will reduce costs in managed care setting.
ā€¢ Indigenously, ritual administration in groups has been the norm.
ā€¢ Group psychedelic therapy is safe and feasible per recent studies.
ā€¢ Therapies not requiring intensive individual intervention during the psychedelic
experience can be done in groups:
ā€¢ High-dose psilocybin therapy (depression, cancer-related distress, AUD, etc.)
ā€¢ Ibogaine for SUDs
ā€¢ Ayahuasca, DMT, and Mescaline
ā€¢ Ketamine Infusion
ā€¢ Active group process may be feasible with low-dose psychedelic therapy.
ā€¢ This is similar to ritual practices and more research is needed.
Ā© Peacock 2023
What might a psychedelic
treatment center look like?
Ā© Peacock 2023
Group Psychedelic Therapy Room
ā€¢ Inpatient and outpatient groups for various indications.
ā€¢ Two group sessions per day.
Psychedelic Treatment Unit ā€¢ Infrastructure to treat patients needing medical support.
Main Hospital ā€¢ Quick access to emergency medical care if needed.
Individual Therapy Rooms
ā€¢ Space for individual care when respite from group needed.
ā€¢ Individual MDMA-AT and Ketamine-AT sessions.
Two Bathrooms
ā€¢ On unit so no tripping
patients interact with
others.
ā€¢ Showers for emergent
hygiene needs
*Lack of patient
diversity pictured due
to software limitation.
Ā© Peacock 2023
Windows Make it
Bright and Airy
Natural Elements to Create
Therapeutic Setting
Sound System
for Music
Guides Standing By
Windows to Monitor
Patient-Therapist Dyads
Empty Room Available in Case
Individual Attention is Needed
by Group Member
Unit Separated From
Hospital for Tranquility
Psychedelic Treatment Unit
Main Hospital
Ā© Peacock 2023
Indications &
Use Cases
Ā© Peacock 2023
Ketamine in Inpatient Psychiatry &
Eating Disorder Treatment
August 2022 ā€“ Denver Health policy approved for using intranasal racemic ketamine to treat
patients with treatment-resistant MDD or bipolar depression.
ā€¢ Adult inpatients on Psychiatry Unit and ACUTE Center for Eating Disorders.
ā€¢ Low-stimulation environment for 120 minutes on the unit.
ā€¢ Re-dose every 2-4 days.
ā€¢ No guidelines for psychotherapy during session or preparation/integration therapy.
ā€¢ Has been put to use!
(Carron, 2022)
Current
Ā© Peacock 2023
The Peacock Perspectiveā„¢:
ā€¢ Ketamine should be a first-line treatment for depression and acute suicidality.
ā€¢ Ketamine robustly and rapidly reduces symptoms of depression and suicidality.
ā€¢ Ketamine effects only last a week (though emerging research may suggest that repeat dosing
may be more durable)
ā€¢ This provides a functional window for other intervention (e.g., psychotherapy or other
psychedelic treatments).
ā€¢ Frequent and ongoing ketamine treatments are concerning
ā€¢ Chronic recreational ketamine use is linked to bladder cystitis, abdominal pain, sexual
dysfunction, and fertility decline.
ā€¢ Both clinically and recreationally, long-term ketamine use is linked to neurocognitive damage.
ā€¢ There is substantial evidence for ketamineā€™s addictive potential, which is particularly relevant to
self-administered ketamine nasal sprays.
(Peacock, 2022)
Ketamine in Inpatient Psychiatry &
Eating Disorder Treatment
Current
Ā© Peacock 2023
The Peacock Perspectiveā„¢:
ā€¢ Like depression PTSD symptoms are rapidly reduced by ketamine, again providing a window
for other interventions.
ā€¢ Ketamine-assisted psychotherapies show promise in durably treating:
ā€¢ OCD
ā€¢ PTSD
ā€¢ SUDs
ā€¢ Avoidant Personality Disorder
ā€¢ Given low-risk of ketamine therapy, attempting off-label treatment when other therapies
are not working may be worthwhile.
(Peacock, 2022)
Ketamine in Inpatient Psychiatry &
Eating Disorder Treatment
Current
Ā© Peacock 2023
Ketamine for Alcohol Use Disorder
2021 Pilot Trial at Denver Health ā€“ Ketamine for high-utilization inpatients with AUD
ā€¢ Principal Investigator: Dale Terasaki, M.D.
ā€¢ Ketamine vs. Naltrexone vs. ā€œLinkage Aloneā€ (IV Ketamine 0.5 mg/kg)
ā€¢ 30-day Readmission Rate:
ā€¢ Ketamine 15.4% [n=13]
ā€¢ Naltrexone 21.4% [n=14]
ā€¢ Linkage Alone 41.2% [n=17]
ā€¢ 14-day Addiction Clinic Encounter
ā€¢ Ketamine 61.5%
ā€¢ Naltrexone 50.0%
ā€¢ Linkage Alone 41.2%
ā€¢ Ketamine may help with depression and withdrawal in addition to cravings.
The Peacock Perspectiveā„¢: This is AWESOME!
(Terasaki, 2023)
Current
Ā© Peacock 2023
Psilocybin-AT for
Cancer-Related Distress
ā€¢ FDA trials taking place at CU Anschutz led by Stacy Fischer, M.D.
ā€¢ Highly effective treatment
The Peacock Perspectiveā„¢:
ā€¢ There is NOTHING available for these patients who are suffering profound existential distress
while suffering from extreme pain.
ā€¢ Psilocybin therapy is exceptionally low risk.
ā€¢ Evidence is emerging about the potential for psilocybin to treat chronic pain, making
psilocybin treatment a double whammy.
ā€¢ We need this treatment available as soon as possible.
(Peacock, 2022)
September 2024
Ā© Peacock 2023
Psilocybin-AT for Other Indications
The Peacock Perspectiveā„¢:
ā€¢ Psilocybin-AT has shown robust efficacy to durably treat:
ā€¢ Unipolar Depression
ā€¢ Suicidality
ā€¢ Anxiety
ā€¢ OCD
ā€¢ Alcohol Use Disorder
ā€¢ Tobacco Use Disorder
ā€¢ Outcomes tend to improve with higher doses!
ā€¢ High-dose psilocybin therapy tends to be an introspective experience where patients
typically wear eye-shades. This lends itself to group administration.
(Peacock, 2022)
September 2024
Ā© Peacock 2023
MDMA-AT for PTSD
ā€¢ Phase 3 FDA trials of MDMA-AT for PTSD have been successfully completed.
ā€¢ MDMA-AT has received Breakthrough Therapy Status
ā€¢ The expanded access program for MDMA-AT is prioritizing academic medical centers.
ā€¢ MDMA-AT requires individual rooms for conversation with therapist during the session.
The Peacock Perspectiveā„¢:
ā€¢ MDMA experience tends to be gentler than other psychedelics, making it ideal for
emotionally vulnerable patients.
ā€¢ MDMAā€™s neurocognitive impact is minimized by avoiding body temperature elevation:
ā€¢ Administer MDMA in a cool environment and monitor for increased body temperature.
ā€¢ Use the R(ā€“)-MDMA instead of racemic or S(+)-MDMA.
ā€¢ Need more research on neurocognitive impacts of clinical MDMA.
(Peacock, 2022)
Mid 2024
Ā© Peacock 2023
MDMA-AT for Other Indications
ā€¢ FDA appears to be restricting off-label use of MDMA more so than other drugs through
regulating a drug/therapy combination for the first time.
The Peacock Perspectiveā„¢:
ā€¢ Strong findings for treating social anxiety in autism spectrum disorder (Danforth et al., 2018)
ā€¢ Some evidence for MDMA-AT to treat:
ā€¢ Generalized anxiety
ā€¢ Phobias
ā€¢ Avoidant personality disorder
ā€¢ Could help build therapeutic alliance with paranoid and schizoid patients who tend to be
resistant to therapy due to difficulty trusting clinicians.
ā€¢ Historically used in couples therapy, which will likely return.
(Peacock, 2022)
Timeline Unknown
Ā© Peacock 2023
Ibogaine
(Peacock, 2022)
ā€¢ Substantial promise as an addiction treatment
ā€¢ Can completely attenuate withdrawal symptoms for opioids and other drugs.
ā€¢ Low relapse rates compared to conventional treatment.
ā€¢ Fatal cardiovascular risk is exceptionally high; therapeutic doses commonly exceed pharmaceutical
safety standards.
The Peacock Perspectiveā„¢:
ā€¢ Risk of death may be deemed acceptable for those with terminal SUDs.
ā€¢ Alternatives with less toxicity but similar antiaddictive properties:
ā€¢ Noribogaine, the primary metabolite of ibogaine.
ā€¢ 18-methoxycoronaridine (18-MC), an ibogaine analog.
Possible June 2026
Ā© Peacock 2023
Ayahuasca
(Peacock, 2022)
ā€¢ Most research and current use is in ritual contexts.
The Peacock Perspectiveā„¢:
ā€¢ Hesitant about ayahuasca in a clinical setting due to established cultural lineage.
ā€¢ More inclined to refer out to ritual ayahuasca treatment centers.
ā€¢ Evidence of neurocognitive benefits from ritual ayahuasca use across all cognitive domains
except verbal memory, which according to one study may be reduced.
ā€¢ Small study in South America suggested that rates of ADD may be lower among ritual ayahuasca-
using adolescents (2.5%) compared to controls (17.5%) [N=80; p<.057] (Da Silveira et al., 2005).
ā€¢ Superior working memory and executive functions in ritual ayahuasca users compared to controls.
ā€¢ Further research warranted as a possible treatment for ADHD.
Possible June 2026
Ā© Peacock 2023
Ayahuasca
(Peacock, 2022)
The Peacock Perspectiveā„¢:
ā€¢ Ritual ayahuasca use associated with fewer symptoms of:
ā€¢ Anxiety
ā€¢ OCD
ā€¢ PTSD
ā€¢ Substance Abuse
ā€¢ Grief
ā€¢ Borderline Personality Disorder (observational study)
ā€¢ Ayahuasca SUDs treatment centers exist in South America.
ā€¢ Efficacy has only been demonstrated through uncontrolled trials.
ā€¢ Findings are mixed.
Possible June 2026
Ā© Peacock 2023
DMT
(Peacock, 2022)
The Peacock Perspectiveā„¢:
ā€¢ Few known clinical applications
ā€¢ Could be useful for preparing patients for successful treatment with other psychedelics (E.
Sola, personal communication):
ā€¢ Psychedelic-induced mystical experience strongly predicts symptom improvement across
treatment targets
ā€¢ A, ā€œtendency to reject information that is not easily explained through rational, logical, and
scientific processesā€ was negatively correlated to mystical experiences from psilocybin (Russ et al.,
2019, p. 4).
ā€¢ The all-encompassing intensity and ineffability of DMT experience may help gain a broader
epistemological perspective, leading to better treatment outcomes with other psychedelics.
Possible June 2026
Ā© Peacock 2023
Mescaline
ā€¢ Most research is pre-1950 and most current use is in ritual contexts.
The Peacock Perspectiveā„¢:
ā€¢ Very long duration (12ā€“18 hours) makes it impractical for clinical use.
ā€¢ No indications where mescaline would be more effective than psilocybin or LSD, though
appears to have similar effectiveness in ritual contexts.
ā€¢ Should be considered when culturally congruent for a patient.
(Peacock, 2022)
Possible June 2026
Ā© Peacock 2023
LSD
ā€¢ Long timeline for clinical availability but research is happening.
ā€¢ Abundance of historical LSD research up until mid 70s.
The Peacock Perspectiveā„¢:
ā€¢ Historically, psycholytic LSD therapy was used to treat many conditions including depression,
anxiety, phobias, OCD, conversion disorders, personality disorders, and schizophrenia.
ā€¢ Findings are yet to be validated according to modern medical standards.
ā€¢ LSD is uniquely suited for psycholytic therapy compared to psilocybin:
ā€¢ Increases outward focus and extraversion vs. psilocybin being more sedating and inward-focused.
ā€¢ LSD has dopaminergic effects and weaker agonism of the sedating 5-HT2C receptors.
ā€¢ These properties make low-dose LSD uniquely suited for active intervention during the experience,
allowing for therapeutic work using psychodynamic techniques
(Peacock, 2022)
Timeline Unknown
Ā© Peacock 2023
Call to Action
ā€¢ All Providers:
ā€¢ Seek training in psychedelic-assisted modalities.
ā€¢ Lobby for availability of psychedelic medicines and insurance reimbursement.
ā€¢ Psychiatrists:
ā€¢ Offer ketamine therapy when indicated.
ā€¢ Arrange preparation and integration therapy.
ā€¢ Psychologists and Therapists:
ā€¢ Provide preparation and integration therapy for ketamine therapy patients.
ā€¢ Suggest psychedelic therapies when indicated.
ā€¢ Provide input on how patient personality may impact psychedelic therapy.
ā€¢ Administrators and Clinical Leaders:
ā€¢ Work to develop policies for providing other psychedelic-assisted therapies, particularly with psilocybin and MDMA.
ā€¢ Apply to become a licensed facility with the Natural Medicine Advisory Board.
ā€¢ Obtain funding for a dedicated psychedelic-assisted treatment center.
Ā© Peacock 2023
Thank You!
Ā© Peacock 2023
References
AvanceƱa, A. L. V., Kahn, J. G., & Marseille, E. (2022). The Costs and Health Benefits of Expanded Access to MDMA-assisted
Therapy for Chronic and Severe PTSD in the USA: A Modeling Study. Clinical Drug Investigation, 42, 243ā€“252.
https://doi.org/10.1007/s40261-022-01122-0.
Benzinga (May 2, 2023). EXCLUSIVE: AMA Moves Toward Psychedelic Therapy Reimbursement, Filing A Gap In Regulations
[online, accessed July 13, 2023]. Business Insider. https://markets.businessinsider.com/news/stocks/exclusive-ama-
moves-toward-psychedelic-therapy-reimbursement-filing-a-gap-in-regulations-1032283416.
Carron, B. (2022). Administration of intranasal ketamine for psychiatric inpatients. Denver Health and Hospital Authority
[Internal Clinical Care Guideline]. PolicyStat ID: 12275022.
Colorado Department of Regulatory Agencies. Natural Medicine Health Act - Implementation Timeframe. [online, accessed July
7, 2023]. https://dpo.colorado.gov/dpo-home/natural-medicine-health-act-home/natural-medicine-health-act-
implementation-timeframe.
Danforth, A. L., Grob, C. S., Struble, C., Feduccia, A. A., Walker, N., Jerome, L., Yazar- Klosinski, B. B., & Emerson, A. (2018).
Reduction in social anxiety after MDMA- assisted psychotherapy with autistic adults: A randomized, double-blind,
placebo- controlled pilot study. Psychopharmacology, 235(11), 3137ā€“3148. https://doi.org/10.1007/s00213-018-5010-9.
Da Silveira, D. X., Grob, C. S., de Rios, M. D., Lopez, E., Alonso, L. K., Tacla, C., & Doering-Silveira, E. (2005). Ayahuasca in
adolescence: A preliminary psychiatric assessment. Journal of Psychoactive Drugs, 37(2), 129ā€“134.
Kary, T. (October 17, 2022). Will Medical Insurers Agree to Cover Psychedelic Trips? [online, accessed July 13, 2023]. Bloomberg
Newsletter. https://www.bloomberg.com/news/newsletters/2022-10-17/could-psychedelic-trips-end-up-being-covered-
by-health-insurance.
Ā© Peacock 2023
References
Marseille, E., Mitchell, J. M., & Kahn, J. G. (2022). Updated cost-effectiveness of MDMA-assisted therapy for
the treatment of posttraumatic stress disorder in the United States: Findings from a phase 3 trial. PLOS
ONE, 17(2). https://doi.org/10.1371/journal.pone.0263252.
Peacock, B. C. (2022). Applications of psychedelic-assisted psychotherapy across personalities and
psychopathologies: An integrative literature review with meta-analysis [Doctoral Dissertation, The
Wright Institute]. ProQuest Dissertations and Theses Global (In Press).
Sprunt, B. (October 15, 2019). Psilocybin Paves Path For Addiction Research At Johns Hopkins [online,
accessed July 13, 2023]. WAMU American University Radio.
https://wamu.org/story/19/10/15/psilocybin-therapy-at-john-hopkins-finds-success-in-addiction-
research/
Steinberg, B. (April 21, 2023). MDMA expected to be approved to treat PTSD by October: study [online,
accessed July 7, 2023]. New York Post. https://nypost.com/2023/04/21/mdma-expected-to-be-
approved-to-treat-ptsd-by-october-study/
Terasaki, D. (2023). MAF presentation: Ketamine on acute care floors [oral presentation]. Denver Health.
Ā© Peacock 2023

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Psychedelic Treatment Planning: Opportunities in Integrated Care

  • 1. Brian C. Peacock, Psy.D. Candidate Psychology Resident, Denver Health Psychedelic Treatment Planning: Opportunities in Integrated Care Ā© Brian Peacock, 2023
  • 2. Overview MY RESEARCH CONSTRAINTS OF MANAGED CARE INDICATIONS & USE CASES Ā© Peacock 2023
  • 3. Whatā€™s different about psychedelics? (compared to other therapies) ā€¢ Psychedelics produce striking changes across all levels of the human systemā€”molecular, neurological, phenomenological, affective, and cognitive. ā€¢ Effects propagate through time, resulting in changes to mind, brain, body, and behavior lasting anywhere from minutes up to a lifetime. ā€¢ Clinical decision making is complicated by the varied properties of psychedelics and the environmental variables that affect psychedelic experience. ā€¢ We most choose among psychedelics, therapeutic techniques, and therapeutic sequences to maximize treatment efficacy while minimizing risk. Ā© Peacock 2023
  • 5. Dissertation ā€œApplications of psychedelic-assisted psychotherapy across personalities and psychopathologies: An integrative literature review with meta-analysis.ā€ ā€¢ Compared different psychedelic therapies and their efficacy in treating psychiatric conditions. ā€¢ Examined variation in response to psychedelics across different personality traits. ā€¢ Drew insights from basic psychedelic research that can be applied clinically. ā€¢ Completed July 2022 Psilocybin Mescaline LSD DMT Ayahuasca MDMA Ketamine Ibogaine DEFENDED Ā© Peacock 2023
  • 6. Method ā€¢ Systematic Literature Search ā€¢ Matrix of 128 topic keywords combined with 8 psychedelics for a total of 1,024 Google Scholar searches. ā€¢ Yielded 4,409 references ā€¢ 1,164 references were included ā€¢ Preliminary Meta-analysis ā€“ Normalize data across studies by calculating effect sizes when not reported. ā€¢ Integration & Synthesis ā€“ A method for making all this data clinically useful! Psilocybin Mescaline LSD DMT Ayahuasca MDMA Ketamine Ibogaine Ā© Peacock 2023
  • 7. ā€¢ Colors represent the search date (and made it more fun) ā€¢ Boxes include: ā€¢ [total number of search results], ā€¢ [number of results reviewed], ā€¢ [number of articles yielded] Ā© Peacock 2023
  • 8. Summary Tables ā€¢ Pharmacological Properties ā€¢ Impacts on Neurotransmission ā€¢ Life Stage and Psychedelic Safety ā€¢ Medical Risk Factors and Contraindications ā€¢ Long-Term Medical Risks ā€¢ Psychedelic Phenomenology ā€¢ Acute ā€¢ Subacute ā€¢ Psychological Change ā€¢ Subacute ā€¢ Long-term ā€¢ Neuropsychological Effects ā€¢ Acute ā€¢ Subacute ā€¢ Long-term ā€¢ Psychological Risks ā€¢ Acute and Subacute ā€¢ Long-Term Psychopathogenesis ā€¢ Psychological Risk Factors ā€¢ Patient Factors Affecting Psychedelic Experience and Outcome ā€¢ Psychedelic Treatment Targets (Peacock, 2022) Ā© Peacock 2023
  • 10. Gertrude Smith 72-year-old, White, cis-gender woman 72 72 Gertrude Smith Brian Peacock / / O / / / / O Ā© Peacock 2023
  • 11. Gertrude Smith 72-year-old, White, cis-gender woman 72 72 Gertrude Smith Brian Peacock / / O / / / / O None Heart Disease Cystitis / / / / / X X Ā© Peacock 2023
  • 12. 72 72 Gertrude Smith Brian Peacock / / O / / / / O None Heart Disease Cystitis / / / / / X X Depression 2x Suicide Atmpt. Ket associated w/ dev./worsening cystitis SSRI / / / X X MDMA and MAOI risk serotonin syndrome Gertrude Smith 72-year-old, White, cis-gender woman / / / / / / X / X X / / / / / / Ā© Peacock 2023
  • 13. 72 72 Gertrude Smith Brian Peacock / / O / / / / O None Heart Disease Cystitis / / / / / X X Depression 2x Suicide Atmpt. Ket associated w/ dev./worsening cystitis SSRI / / / X X MDMA and MAOI risk serotonin syndrome Gertrude Smith 72-year-old, White, cis-gender woman / / / / / / X / X X / / / / / / / X / X X X / X Ā© Peacock 2023
  • 14. Jon George 21-year-old, biracial, transgender man Jon George Age 21 PTSD AUD Dysthymia ADHD O O O O X / O O + + / + ++ ++ + ? ? ? ? ? ? ++ ++ ++ + + + ? ++ ++ ++ ++ ++ ++ ++ ++ ? ? ? ? Ā© Peacock 2023
  • 15. Jon George 21-year-old, biracial, transgender man Jon George Age 21 PTSD AUD Dysthymia ADHD O O O O X / O O + + / + ++ ++ + ? ? ? ? ? ? ++ ++ ++ + + + ? ++ ++ ++ ++ ++ ++ ++ ++ ? ? ? ? Ā© Peacock 2023
  • 16. Influencing Factors ā€¢ Sex ā€¢ Age ā€¢ Personality Traits ā€¢ Psychopathology ā€¢ Family History ā€¢ Cognitive Ability ā€¢ BMI ā€¢ Genetics (Peacock, 2022) Ā© Peacock 2023
  • 17. Jon George 21-year-old, biracial, transgender man Jon George Age 21 PTSD AUD Dysthymia ADHD O O O O X / O O + + / + ++ ++ + ? ? ? ? ? ? ++ ++ ++ + + + ? ++ ++ ++ ++ ++ ++ ++ ++ ? ? ? ? Trans Man - Consider transference - Psilocybin: More ā€˜bad tripsā€™ for female sex. - MDMA: Reduce dose and monitor closely for subacute depressive sx more common in female sex. Under 22 - LSD: Less insight gain High Neuroticism - Psilocybin: More challenging experience -> increased efficacy Low trait absorption - Classical psychedelics: Less mystical experience -> decreased efficacy Little positively valenced language - Psilocybin: Predictive of treatment response for depression SUDs hx - Ketamine Inf: Greater reduction in depressive sx @ 1 & 7 days - Ketamine Inf: Greater tx response for depression Slowed processing speed Ā© Peacock 2023
  • 18. Jon George 21-year-old, biracial, transgender man Jon George Age 21 PTSD AUD Dysthymia ADHD O O O O X / O O + + / + ++ ++ + ? ? ? ? ? ? ++ ++ ++ + + + ? ++ ++ ++ ++ ++ ++ ++ ++ ? ? ? ? X X 1. - - 2. - 3. - Trans Man - Consider transference - Psilocybin: More ā€˜bad tripsā€™ for female sex. - MDMA: Reduce dose and monitor closely for subacute depressive sx more common in female sex. Under 22 - LSD: Less insight gain High Neuroticism - Psilocybin: More challenging experience -> increased efficacy Low trait absorption - Classical psychedelics: Less mystical experience -> decreased efficacy Little positively valenced language - Psilocybin: Predictive of treatment response for depression SUDs hx - Ketamine Inf: Greater reduction in depressive sx @ 1 & 7 days - Ketamine Inf: Greater tx response for depression Slowed processing speed Ā© Peacock 2023
  • 19. Next Steps ā€¢ Proposed Book: Psychedelic Treatment Planning: An Evidence-Based Clinical Guide ā€¢ Simplified symbols and treatment planning workflow ā€¢ Clinical case examples ā€¢ Revisions and updates ā€¢ Starting independent practice for: ā€¢ Pre-evaluation and preparation for psychedelic therapy. ā€¢ Psychedelic integration therapy for patients experiencing distress, spiritual emergency, or emerging psychopathology following psychedelic therapy with other providers. ā€¢ Develop assessment measure designed for assessing traits relevant to psychedelic-assisted treatments. Ā© Peacock 2023
  • 21. Current Availability ā€¢ Off-label ketamine ā€¢ Other psychedelics used in: ā€¢ Clinical research ā€¢ Underground practice Ā© Peacock 2023
  • 22. Nov 2024 Natural Medicine Health Act ā€¢ Colorado Prop. 122 ā€¢ Psilocybin and psilocin ā€¢ Licensed treatment centers ā€¢ Regulated by the Natural Medicine Advisory Board (Colorado Department of Regulatory Agencies) Ā© Peacock 2023
  • 23. ā€¢ FDA Approval Pending ā€¢ Phase 3 Clinical Trial Complete ā€¢ Currently in ā€œExpanded Accessā€ phase ā€¢ Priority roll-out to academic medical centers (Steinberg, 2023) Mid 2024 MDMA-PT for PTSD Ā© Peacock 2023
  • 24. ā€¢ DMT, ayahuasca, ibogaine, and mescaline (excluding peyote) may become available in CO. ā€¢ Only if recommended by the Natural Medicine Advisory Board (Colorado Department of Regulatory Agencies) June 2026 Natural Medicine Health Act Ā© Peacock 2023
  • 25. Bias Against LSD Remains
  • 26. Who pays? ā€¢ Right Now, Most Psychedelic Therapy is Out of Pocket ā€¢ Most psychedelics are generic medications ā€¢ Predominant costs are: ā€¢ Evaluation/screening ā€¢ Therapist time ā€“ Including preparation, drug, and integration sessions ā€¢ Facility costs ā€¢ March 3, 2023 ā€“ AMA approved new CPT III code for ā€œContinuous In-Person Monitoring and Intervention during Psychedelic Medication Therapyā€ to become effective January 1, 2024 (Benzinga, 2023). Ā© Peacock 2023
  • 27. Cost Savings ā€¢ MDMA-AT costs $11,537 per patient using protocol from FDA Phase 3 trials ā€¢ Per 1,000 patients, compared to standard of care: ā€¢ MDMA-AT saves $132.9 million over 30 years in discounted net health care savings ā€¢ Averts 61.4 premature deaths ā€¢ Generates 4,856 quality-adjusted life-years (QALYs) ā€¢ Break-even at 3.8 years ā€¢ Expanding access for MDMA-AT to 25-75% of eligible patients is projected to: ā€¢ Averts 43,618ā€“106,932 deaths ā€¢ Gains 3.3ā€“8.2 million QALYs ā€¢ ā€œMost of the expected cost-savings arenā€™t on the psychiatric side, theyā€™re on the physical side.ā€ ā€“ Elliot Marseille (Kary, 2022) (Marseille et al., 2022; AvanceƱa et al., 2022) Ā© Peacock 2023
  • 28. Infrastructure ā€“ Current Research (Sprunt/WAMU, 2019) Johns Hopkins University ā€“ Center for Psychedelic and Consciousness Research ā€¢ Individual Psilocybin Therapy Room ā€¢ Two Therapists Present ā€¢ One Licensed Psychologist or Psychiatrist ā€¢ One Other Provider ā€¢ EXPENSIVE ā€¢ Similar protocols for MDMA-AT Ā© Peacock 2023
  • 29. Infrastructure ā€“ Individual Psychedelic Therapy ā€¢ Ketamine Infusions can be done in: ā€¢ Inpatient units (as is being done at Denver Health) ā€¢ Outpatient infusion clinic in group setting ā€¢ MDMA-AT and Ketamine-AT can be done in outpatient therapy offices modified to have: ā€¢ Calm lighting and dĆ©cor ā€¢ Windows to monitor sessions and prevent boundary violations while patient is in a vulnerable, suggestable, and disinhibited state. Ā© Peacock 2023
  • 30. Infrastructure ā€“ Group Psychedelic Therapy ā€¢ Group psychedelic therapy will reduce costs in managed care setting. ā€¢ Indigenously, ritual administration in groups has been the norm. ā€¢ Group psychedelic therapy is safe and feasible per recent studies. ā€¢ Therapies not requiring intensive individual intervention during the psychedelic experience can be done in groups: ā€¢ High-dose psilocybin therapy (depression, cancer-related distress, AUD, etc.) ā€¢ Ibogaine for SUDs ā€¢ Ayahuasca, DMT, and Mescaline ā€¢ Ketamine Infusion ā€¢ Active group process may be feasible with low-dose psychedelic therapy. ā€¢ This is similar to ritual practices and more research is needed. Ā© Peacock 2023
  • 31. What might a psychedelic treatment center look like? Ā© Peacock 2023
  • 32. Group Psychedelic Therapy Room ā€¢ Inpatient and outpatient groups for various indications. ā€¢ Two group sessions per day. Psychedelic Treatment Unit ā€¢ Infrastructure to treat patients needing medical support. Main Hospital ā€¢ Quick access to emergency medical care if needed. Individual Therapy Rooms ā€¢ Space for individual care when respite from group needed. ā€¢ Individual MDMA-AT and Ketamine-AT sessions. Two Bathrooms ā€¢ On unit so no tripping patients interact with others. ā€¢ Showers for emergent hygiene needs *Lack of patient diversity pictured due to software limitation. Ā© Peacock 2023
  • 33. Windows Make it Bright and Airy Natural Elements to Create Therapeutic Setting Sound System for Music Guides Standing By Windows to Monitor Patient-Therapist Dyads Empty Room Available in Case Individual Attention is Needed by Group Member Unit Separated From Hospital for Tranquility Psychedelic Treatment Unit Main Hospital Ā© Peacock 2023
  • 35. Ketamine in Inpatient Psychiatry & Eating Disorder Treatment August 2022 ā€“ Denver Health policy approved for using intranasal racemic ketamine to treat patients with treatment-resistant MDD or bipolar depression. ā€¢ Adult inpatients on Psychiatry Unit and ACUTE Center for Eating Disorders. ā€¢ Low-stimulation environment for 120 minutes on the unit. ā€¢ Re-dose every 2-4 days. ā€¢ No guidelines for psychotherapy during session or preparation/integration therapy. ā€¢ Has been put to use! (Carron, 2022) Current Ā© Peacock 2023
  • 36. The Peacock Perspectiveā„¢: ā€¢ Ketamine should be a first-line treatment for depression and acute suicidality. ā€¢ Ketamine robustly and rapidly reduces symptoms of depression and suicidality. ā€¢ Ketamine effects only last a week (though emerging research may suggest that repeat dosing may be more durable) ā€¢ This provides a functional window for other intervention (e.g., psychotherapy or other psychedelic treatments). ā€¢ Frequent and ongoing ketamine treatments are concerning ā€¢ Chronic recreational ketamine use is linked to bladder cystitis, abdominal pain, sexual dysfunction, and fertility decline. ā€¢ Both clinically and recreationally, long-term ketamine use is linked to neurocognitive damage. ā€¢ There is substantial evidence for ketamineā€™s addictive potential, which is particularly relevant to self-administered ketamine nasal sprays. (Peacock, 2022) Ketamine in Inpatient Psychiatry & Eating Disorder Treatment Current Ā© Peacock 2023
  • 37. The Peacock Perspectiveā„¢: ā€¢ Like depression PTSD symptoms are rapidly reduced by ketamine, again providing a window for other interventions. ā€¢ Ketamine-assisted psychotherapies show promise in durably treating: ā€¢ OCD ā€¢ PTSD ā€¢ SUDs ā€¢ Avoidant Personality Disorder ā€¢ Given low-risk of ketamine therapy, attempting off-label treatment when other therapies are not working may be worthwhile. (Peacock, 2022) Ketamine in Inpatient Psychiatry & Eating Disorder Treatment Current Ā© Peacock 2023
  • 38. Ketamine for Alcohol Use Disorder 2021 Pilot Trial at Denver Health ā€“ Ketamine for high-utilization inpatients with AUD ā€¢ Principal Investigator: Dale Terasaki, M.D. ā€¢ Ketamine vs. Naltrexone vs. ā€œLinkage Aloneā€ (IV Ketamine 0.5 mg/kg) ā€¢ 30-day Readmission Rate: ā€¢ Ketamine 15.4% [n=13] ā€¢ Naltrexone 21.4% [n=14] ā€¢ Linkage Alone 41.2% [n=17] ā€¢ 14-day Addiction Clinic Encounter ā€¢ Ketamine 61.5% ā€¢ Naltrexone 50.0% ā€¢ Linkage Alone 41.2% ā€¢ Ketamine may help with depression and withdrawal in addition to cravings. The Peacock Perspectiveā„¢: This is AWESOME! (Terasaki, 2023) Current Ā© Peacock 2023
  • 39. Psilocybin-AT for Cancer-Related Distress ā€¢ FDA trials taking place at CU Anschutz led by Stacy Fischer, M.D. ā€¢ Highly effective treatment The Peacock Perspectiveā„¢: ā€¢ There is NOTHING available for these patients who are suffering profound existential distress while suffering from extreme pain. ā€¢ Psilocybin therapy is exceptionally low risk. ā€¢ Evidence is emerging about the potential for psilocybin to treat chronic pain, making psilocybin treatment a double whammy. ā€¢ We need this treatment available as soon as possible. (Peacock, 2022) September 2024 Ā© Peacock 2023
  • 40. Psilocybin-AT for Other Indications The Peacock Perspectiveā„¢: ā€¢ Psilocybin-AT has shown robust efficacy to durably treat: ā€¢ Unipolar Depression ā€¢ Suicidality ā€¢ Anxiety ā€¢ OCD ā€¢ Alcohol Use Disorder ā€¢ Tobacco Use Disorder ā€¢ Outcomes tend to improve with higher doses! ā€¢ High-dose psilocybin therapy tends to be an introspective experience where patients typically wear eye-shades. This lends itself to group administration. (Peacock, 2022) September 2024 Ā© Peacock 2023
  • 41. MDMA-AT for PTSD ā€¢ Phase 3 FDA trials of MDMA-AT for PTSD have been successfully completed. ā€¢ MDMA-AT has received Breakthrough Therapy Status ā€¢ The expanded access program for MDMA-AT is prioritizing academic medical centers. ā€¢ MDMA-AT requires individual rooms for conversation with therapist during the session. The Peacock Perspectiveā„¢: ā€¢ MDMA experience tends to be gentler than other psychedelics, making it ideal for emotionally vulnerable patients. ā€¢ MDMAā€™s neurocognitive impact is minimized by avoiding body temperature elevation: ā€¢ Administer MDMA in a cool environment and monitor for increased body temperature. ā€¢ Use the R(ā€“)-MDMA instead of racemic or S(+)-MDMA. ā€¢ Need more research on neurocognitive impacts of clinical MDMA. (Peacock, 2022) Mid 2024 Ā© Peacock 2023
  • 42. MDMA-AT for Other Indications ā€¢ FDA appears to be restricting off-label use of MDMA more so than other drugs through regulating a drug/therapy combination for the first time. The Peacock Perspectiveā„¢: ā€¢ Strong findings for treating social anxiety in autism spectrum disorder (Danforth et al., 2018) ā€¢ Some evidence for MDMA-AT to treat: ā€¢ Generalized anxiety ā€¢ Phobias ā€¢ Avoidant personality disorder ā€¢ Could help build therapeutic alliance with paranoid and schizoid patients who tend to be resistant to therapy due to difficulty trusting clinicians. ā€¢ Historically used in couples therapy, which will likely return. (Peacock, 2022) Timeline Unknown Ā© Peacock 2023
  • 43. Ibogaine (Peacock, 2022) ā€¢ Substantial promise as an addiction treatment ā€¢ Can completely attenuate withdrawal symptoms for opioids and other drugs. ā€¢ Low relapse rates compared to conventional treatment. ā€¢ Fatal cardiovascular risk is exceptionally high; therapeutic doses commonly exceed pharmaceutical safety standards. The Peacock Perspectiveā„¢: ā€¢ Risk of death may be deemed acceptable for those with terminal SUDs. ā€¢ Alternatives with less toxicity but similar antiaddictive properties: ā€¢ Noribogaine, the primary metabolite of ibogaine. ā€¢ 18-methoxycoronaridine (18-MC), an ibogaine analog. Possible June 2026 Ā© Peacock 2023
  • 44. Ayahuasca (Peacock, 2022) ā€¢ Most research and current use is in ritual contexts. The Peacock Perspectiveā„¢: ā€¢ Hesitant about ayahuasca in a clinical setting due to established cultural lineage. ā€¢ More inclined to refer out to ritual ayahuasca treatment centers. ā€¢ Evidence of neurocognitive benefits from ritual ayahuasca use across all cognitive domains except verbal memory, which according to one study may be reduced. ā€¢ Small study in South America suggested that rates of ADD may be lower among ritual ayahuasca- using adolescents (2.5%) compared to controls (17.5%) [N=80; p<.057] (Da Silveira et al., 2005). ā€¢ Superior working memory and executive functions in ritual ayahuasca users compared to controls. ā€¢ Further research warranted as a possible treatment for ADHD. Possible June 2026 Ā© Peacock 2023
  • 45. Ayahuasca (Peacock, 2022) The Peacock Perspectiveā„¢: ā€¢ Ritual ayahuasca use associated with fewer symptoms of: ā€¢ Anxiety ā€¢ OCD ā€¢ PTSD ā€¢ Substance Abuse ā€¢ Grief ā€¢ Borderline Personality Disorder (observational study) ā€¢ Ayahuasca SUDs treatment centers exist in South America. ā€¢ Efficacy has only been demonstrated through uncontrolled trials. ā€¢ Findings are mixed. Possible June 2026 Ā© Peacock 2023
  • 46. DMT (Peacock, 2022) The Peacock Perspectiveā„¢: ā€¢ Few known clinical applications ā€¢ Could be useful for preparing patients for successful treatment with other psychedelics (E. Sola, personal communication): ā€¢ Psychedelic-induced mystical experience strongly predicts symptom improvement across treatment targets ā€¢ A, ā€œtendency to reject information that is not easily explained through rational, logical, and scientific processesā€ was negatively correlated to mystical experiences from psilocybin (Russ et al., 2019, p. 4). ā€¢ The all-encompassing intensity and ineffability of DMT experience may help gain a broader epistemological perspective, leading to better treatment outcomes with other psychedelics. Possible June 2026 Ā© Peacock 2023
  • 47. Mescaline ā€¢ Most research is pre-1950 and most current use is in ritual contexts. The Peacock Perspectiveā„¢: ā€¢ Very long duration (12ā€“18 hours) makes it impractical for clinical use. ā€¢ No indications where mescaline would be more effective than psilocybin or LSD, though appears to have similar effectiveness in ritual contexts. ā€¢ Should be considered when culturally congruent for a patient. (Peacock, 2022) Possible June 2026 Ā© Peacock 2023
  • 48. LSD ā€¢ Long timeline for clinical availability but research is happening. ā€¢ Abundance of historical LSD research up until mid 70s. The Peacock Perspectiveā„¢: ā€¢ Historically, psycholytic LSD therapy was used to treat many conditions including depression, anxiety, phobias, OCD, conversion disorders, personality disorders, and schizophrenia. ā€¢ Findings are yet to be validated according to modern medical standards. ā€¢ LSD is uniquely suited for psycholytic therapy compared to psilocybin: ā€¢ Increases outward focus and extraversion vs. psilocybin being more sedating and inward-focused. ā€¢ LSD has dopaminergic effects and weaker agonism of the sedating 5-HT2C receptors. ā€¢ These properties make low-dose LSD uniquely suited for active intervention during the experience, allowing for therapeutic work using psychodynamic techniques (Peacock, 2022) Timeline Unknown Ā© Peacock 2023
  • 49. Call to Action ā€¢ All Providers: ā€¢ Seek training in psychedelic-assisted modalities. ā€¢ Lobby for availability of psychedelic medicines and insurance reimbursement. ā€¢ Psychiatrists: ā€¢ Offer ketamine therapy when indicated. ā€¢ Arrange preparation and integration therapy. ā€¢ Psychologists and Therapists: ā€¢ Provide preparation and integration therapy for ketamine therapy patients. ā€¢ Suggest psychedelic therapies when indicated. ā€¢ Provide input on how patient personality may impact psychedelic therapy. ā€¢ Administrators and Clinical Leaders: ā€¢ Work to develop policies for providing other psychedelic-assisted therapies, particularly with psilocybin and MDMA. ā€¢ Apply to become a licensed facility with the Natural Medicine Advisory Board. ā€¢ Obtain funding for a dedicated psychedelic-assisted treatment center. Ā© Peacock 2023
  • 51. References AvanceƱa, A. L. V., Kahn, J. G., & Marseille, E. (2022). The Costs and Health Benefits of Expanded Access to MDMA-assisted Therapy for Chronic and Severe PTSD in the USA: A Modeling Study. Clinical Drug Investigation, 42, 243ā€“252. https://doi.org/10.1007/s40261-022-01122-0. Benzinga (May 2, 2023). EXCLUSIVE: AMA Moves Toward Psychedelic Therapy Reimbursement, Filing A Gap In Regulations [online, accessed July 13, 2023]. Business Insider. https://markets.businessinsider.com/news/stocks/exclusive-ama- moves-toward-psychedelic-therapy-reimbursement-filing-a-gap-in-regulations-1032283416. Carron, B. (2022). Administration of intranasal ketamine for psychiatric inpatients. Denver Health and Hospital Authority [Internal Clinical Care Guideline]. PolicyStat ID: 12275022. Colorado Department of Regulatory Agencies. Natural Medicine Health Act - Implementation Timeframe. [online, accessed July 7, 2023]. https://dpo.colorado.gov/dpo-home/natural-medicine-health-act-home/natural-medicine-health-act- implementation-timeframe. Danforth, A. L., Grob, C. S., Struble, C., Feduccia, A. A., Walker, N., Jerome, L., Yazar- Klosinski, B. B., & Emerson, A. (2018). Reduction in social anxiety after MDMA- assisted psychotherapy with autistic adults: A randomized, double-blind, placebo- controlled pilot study. Psychopharmacology, 235(11), 3137ā€“3148. https://doi.org/10.1007/s00213-018-5010-9. Da Silveira, D. X., Grob, C. S., de Rios, M. D., Lopez, E., Alonso, L. K., Tacla, C., & Doering-Silveira, E. (2005). Ayahuasca in adolescence: A preliminary psychiatric assessment. Journal of Psychoactive Drugs, 37(2), 129ā€“134. Kary, T. (October 17, 2022). Will Medical Insurers Agree to Cover Psychedelic Trips? [online, accessed July 13, 2023]. Bloomberg Newsletter. https://www.bloomberg.com/news/newsletters/2022-10-17/could-psychedelic-trips-end-up-being-covered- by-health-insurance. Ā© Peacock 2023
  • 52. References Marseille, E., Mitchell, J. M., & Kahn, J. G. (2022). Updated cost-effectiveness of MDMA-assisted therapy for the treatment of posttraumatic stress disorder in the United States: Findings from a phase 3 trial. PLOS ONE, 17(2). https://doi.org/10.1371/journal.pone.0263252. Peacock, B. C. (2022). Applications of psychedelic-assisted psychotherapy across personalities and psychopathologies: An integrative literature review with meta-analysis [Doctoral Dissertation, The Wright Institute]. ProQuest Dissertations and Theses Global (In Press). Sprunt, B. (October 15, 2019). Psilocybin Paves Path For Addiction Research At Johns Hopkins [online, accessed July 13, 2023]. WAMU American University Radio. https://wamu.org/story/19/10/15/psilocybin-therapy-at-john-hopkins-finds-success-in-addiction- research/ Steinberg, B. (April 21, 2023). MDMA expected to be approved to treat PTSD by October: study [online, accessed July 7, 2023]. New York Post. https://nypost.com/2023/04/21/mdma-expected-to-be- approved-to-treat-ptsd-by-october-study/ Terasaki, D. (2023). MAF presentation: Ketamine on acute care floors [oral presentation]. Denver Health. Ā© Peacock 2023