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Brian C. Peacock, Psy.D. Candidate
Psychology Resident, Denver Health
Psychedelic Treatment Planning:
Opportunities in Integrated Care
© Brian Peacock, 2023
Overview
MY RESEARCH CONSTRAINTS OF
MANAGED CARE
INDICATIONS &
USE CASES
© Peacock 2023
What’s different
about psychedelics?
(compared to other therapies)
• Psychedelics produce striking changes across all
levels of the human system—molecular, neurological,
phenomenological, affective, and cognitive.
• Effects propagate through time, resulting in changes
to mind, brain, body, and behavior lasting anywhere
from minutes up to a lifetime.
• Clinical decision making is complicated by the varied
properties of psychedelics and the environmental
variables that affect psychedelic experience.
• We most choose among psychedelics, therapeutic
techniques, and therapeutic sequences to maximize
treatment efficacy while minimizing risk.
© Peacock 2023
My Research
© Peacock 2023
Dissertation
“Applications of psychedelic-assisted psychotherapy across personalities and
psychopathologies: An integrative literature review with meta-analysis.”
• Compared different psychedelic therapies and their efficacy in treating psychiatric
conditions.
• Examined variation in response to psychedelics across different personality traits.
• Drew insights from basic psychedelic research that can be applied clinically.
• Completed July 2022
Psilocybin
Mescaline LSD DMT Ayahuasca MDMA Ketamine Ibogaine
DEFENDED
© Peacock 2023
Method
• Systematic Literature Search
• Matrix of 128 topic keywords combined with 8 psychedelics for a total of 1,024 Google
Scholar searches.
• Yielded 4,409 references
• 1,164 references were included
• Preliminary Meta-analysis – Normalize data across studies by calculating effect sizes
when not reported.
• Integration & Synthesis – A method for making all this data clinically useful!
Psilocybin
Mescaline LSD DMT Ayahuasca MDMA Ketamine Ibogaine
© Peacock 2023
• Colors represent the search date
(and made it more fun)
• Boxes include:
• [total number of search results],
• [number of results reviewed],
• [number of articles yielded]
© Peacock 2023
Summary Tables
• Pharmacological Properties
• Impacts on Neurotransmission
• Life Stage and Psychedelic Safety
• Medical Risk Factors and Contraindications
• Long-Term Medical Risks
• Psychedelic Phenomenology
• Acute
• Subacute
• Psychological Change
• Subacute
• Long-term
• Neuropsychological Effects
• Acute
• Subacute
• Long-term
• Psychological Risks
• Acute and Subacute
• Long-Term Psychopathogenesis
• Psychological Risk Factors
• Patient Factors Affecting Psychedelic
Experience and Outcome
• Psychedelic Treatment Targets
(Peacock, 2022)
© Peacock 2023
(Peacock, 2022)
© Peacock 2023
Gertrude Smith
72-year-old, White,
cis-gender woman
72
72
Gertrude Smith Brian Peacock
/ / O / / / /
O
© 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
© 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 /
/
/
/
/
/
© 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
© 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
+ + /
+ ++ ++ +
?
?
?
?
?
?
++ ++ ++ + + + ? ++ ++
++
++
++ ++ ++ ++
?
?
?
?
© 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
+ + /
+ ++ ++ +
?
?
?
?
?
?
++ ++ ++ + + + ? ++ ++
++
++
++ ++ ++ ++
?
?
?
?
© Peacock 2023
Influencing
Factors
• Sex
• Age
• Personality Traits
• Psychopathology
• Family History
• Cognitive Ability
• BMI
• Genetics
(Peacock, 2022)
© 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 ‘bad trips’ 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
© 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 ‘bad trips’ 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
© Peacock 2023
Next Steps
• Proposed Book: Psychedelic Treatment Planning: An Evidence-Based Clinical Guide
• Simplified symbols and treatment planning workflow
• Clinical case examples
• Revisions and updates
• Starting independent practice for:
• Pre-evaluation and preparation for psychedelic therapy.
• Psychedelic integration therapy for patients experiencing distress, spiritual
emergency, or emerging psychopathology following psychedelic therapy with other
providers.
• Develop assessment measure designed for assessing traits relevant to
psychedelic-assisted treatments.
© Peacock 2023
Constraints of
Managed Care
© Peacock 2023
Current
Availability
• Off-label ketamine
• Other psychedelics
used in:
• Clinical research
• Underground practice
© Peacock 2023
Nov 2024
Natural Medicine Health Act
• Colorado Prop. 122
• Psilocybin and psilocin
• Licensed treatment
centers
• Regulated by the
Natural Medicine
Advisory Board
(Colorado Department of Regulatory Agencies)
© Peacock 2023
• FDA Approval Pending
• Phase 3 Clinical Trial
Complete
• Currently in “Expanded
Access” phase
• Priority roll-out to
academic medical
centers
(Steinberg, 2023)
Mid 2024
MDMA-PT for PTSD
© Peacock 2023
• DMT, ayahuasca,
ibogaine, and mescaline
(excluding peyote) may
become available in CO.
• Only if recommended by
the Natural Medicine
Advisory Board
(Colorado Department of Regulatory Agencies)
June 2026
Natural Medicine Health Act
© Peacock 2023
Bias Against LSD Remains
Who pays?
• Right Now, Most Psychedelic Therapy is Out of Pocket
• Most psychedelics are generic medications
• Predominant costs are:
• Evaluation/screening
• Therapist time – Including preparation, drug, and integration sessions
• Facility costs
• March 3, 2023 – AMA approved new CPT III code for “Continuous In-Person
Monitoring and Intervention during Psychedelic Medication Therapy” to become
effective January 1, 2024 (Benzinga, 2023).
© Peacock 2023
Cost Savings
• MDMA-AT costs $11,537 per patient using protocol from FDA Phase 3 trials
• Per 1,000 patients, compared to standard of care:
• MDMA-AT saves $132.9 million over 30 years in discounted net health care savings
• Averts 61.4 premature deaths
• Generates 4,856 quality-adjusted life-years (QALYs)
• Break-even at 3.8 years
• Expanding access for MDMA-AT to 25-75% of eligible patients is projected to:
• Averts 43,618–106,932 deaths
• Gains 3.3–8.2 million QALYs
• “Most of the expected cost-savings aren’t on the psychiatric side, they’re on the physical side.”
– Elliot Marseille (Kary, 2022)
(Marseille et al., 2022; Avanceña et al., 2022)
© Peacock 2023
Infrastructure – Current Research
(Sprunt/WAMU, 2019)
Johns Hopkins University – Center for
Psychedelic and Consciousness Research
• Individual Psilocybin Therapy Room
• Two Therapists Present
• One Licensed Psychologist or Psychiatrist
• One Other Provider
• EXPENSIVE
• Similar protocols for MDMA-AT
© Peacock 2023
Infrastructure – Individual Psychedelic Therapy
• Ketamine Infusions can be done in:
• Inpatient units (as is being done at Denver Health)
• Outpatient infusion clinic in group setting
• MDMA-AT and Ketamine-AT can be done in outpatient therapy
offices modified to have:
• Calm lighting and décor
• Windows to monitor sessions and prevent boundary violations while patient
is in a vulnerable, suggestable, and disinhibited state.
© Peacock 2023
Infrastructure – Group Psychedelic Therapy
• Group psychedelic therapy will reduce costs in managed care setting.
• Indigenously, ritual administration in groups has been the norm.
• Group psychedelic therapy is safe and feasible per recent studies.
• Therapies not requiring intensive individual intervention during the psychedelic
experience can be done in groups:
• High-dose psilocybin therapy (depression, cancer-related distress, AUD, etc.)
• Ibogaine for SUDs
• Ayahuasca, DMT, and Mescaline
• Ketamine Infusion
• Active group process may be feasible with low-dose psychedelic therapy.
• This is similar to ritual practices and more research is needed.
© Peacock 2023
What might a psychedelic
treatment center look like?
© Peacock 2023
Group Psychedelic Therapy Room
• Inpatient and outpatient groups for various indications.
• Two group sessions per day.
Psychedelic Treatment Unit • Infrastructure to treat patients needing medical support.
Main Hospital • Quick access to emergency medical care if needed.
Individual Therapy Rooms
• Space for individual care when respite from group needed.
• Individual MDMA-AT and Ketamine-AT sessions.
Two Bathrooms
• On unit so no tripping
patients interact with
others.
• Showers for emergent
hygiene needs
*Lack of patient
diversity pictured due
to software limitation.
© 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
© Peacock 2023
Indications &
Use Cases
© Peacock 2023
Ketamine in Inpatient Psychiatry &
Eating Disorder Treatment
August 2022 – Denver Health policy approved for using intranasal racemic ketamine to treat
patients with treatment-resistant MDD or bipolar depression.
• Adult inpatients on Psychiatry Unit and ACUTE Center for Eating Disorders.
• Low-stimulation environment for 120 minutes on the unit.
• Re-dose every 2-4 days.
• No guidelines for psychotherapy during session or preparation/integration therapy.
• Has been put to use!
(Carron, 2022)
Current
© Peacock 2023
The Peacock Perspective™:
• Ketamine should be a first-line treatment for depression and acute suicidality.
• Ketamine robustly and rapidly reduces symptoms of depression and suicidality.
• Ketamine effects only last a week (though emerging research may suggest that repeat dosing
may be more durable)
• This provides a functional window for other intervention (e.g., psychotherapy or other
psychedelic treatments).
• Frequent and ongoing ketamine treatments are concerning
• Chronic recreational ketamine use is linked to bladder cystitis, abdominal pain, sexual
dysfunction, and fertility decline.
• Both clinically and recreationally, long-term ketamine use is linked to neurocognitive damage.
• There is substantial evidence for ketamine’s addictive potential, which is particularly relevant to
self-administered ketamine nasal sprays.
(Peacock, 2022)
Ketamine in Inpatient Psychiatry &
Eating Disorder Treatment
Current
© Peacock 2023
The Peacock Perspective™:
• Like depression PTSD symptoms are rapidly reduced by ketamine, again providing a window
for other interventions.
• Ketamine-assisted psychotherapies show promise in durably treating:
• OCD
• PTSD
• SUDs
• Avoidant Personality Disorder
• 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
© Peacock 2023
Ketamine for Alcohol Use Disorder
2021 Pilot Trial at Denver Health – Ketamine for high-utilization inpatients with AUD
• Principal Investigator: Dale Terasaki, M.D.
• Ketamine vs. Naltrexone vs. “Linkage Alone” (IV Ketamine 0.5 mg/kg)
• 30-day Readmission Rate:
• Ketamine 15.4% [n=13]
• Naltrexone 21.4% [n=14]
• Linkage Alone 41.2% [n=17]
• 14-day Addiction Clinic Encounter
• Ketamine 61.5%
• Naltrexone 50.0%
• Linkage Alone 41.2%
• Ketamine may help with depression and withdrawal in addition to cravings.
The Peacock Perspective™: This is AWESOME!
(Terasaki, 2023)
Current
© Peacock 2023
Psilocybin-AT for
Cancer-Related Distress
• FDA trials taking place at CU Anschutz led by Stacy Fischer, M.D.
• Highly effective treatment
The Peacock Perspective™:
• There is NOTHING available for these patients who are suffering profound existential distress
while suffering from extreme pain.
• Psilocybin therapy is exceptionally low risk.
• Evidence is emerging about the potential for psilocybin to treat chronic pain, making
psilocybin treatment a double whammy.
• We need this treatment available as soon as possible.
(Peacock, 2022)
September 2024
© Peacock 2023
Psilocybin-AT for Other Indications
The Peacock Perspective™:
• Psilocybin-AT has shown robust efficacy to durably treat:
• Unipolar Depression
• Suicidality
• Anxiety
• OCD
• Alcohol Use Disorder
• Tobacco Use Disorder
• Outcomes tend to improve with higher doses!
• 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
© Peacock 2023
MDMA-AT for PTSD
• Phase 3 FDA trials of MDMA-AT for PTSD have been successfully completed.
• MDMA-AT has received Breakthrough Therapy Status
• The expanded access program for MDMA-AT is prioritizing academic medical centers.
• MDMA-AT requires individual rooms for conversation with therapist during the session.
The Peacock Perspective™:
• MDMA experience tends to be gentler than other psychedelics, making it ideal for
emotionally vulnerable patients.
• MDMA’s neurocognitive impact is minimized by avoiding body temperature elevation:
• Administer MDMA in a cool environment and monitor for increased body temperature.
• Use the R(–)-MDMA instead of racemic or S(+)-MDMA.
• Need more research on neurocognitive impacts of clinical MDMA.
(Peacock, 2022)
Mid 2024
© Peacock 2023
MDMA-AT for Other Indications
• 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 Perspective™:
• Strong findings for treating social anxiety in autism spectrum disorder (Danforth et al., 2018)
• Some evidence for MDMA-AT to treat:
• Generalized anxiety
• Phobias
• Avoidant personality disorder
• Could help build therapeutic alliance with paranoid and schizoid patients who tend to be
resistant to therapy due to difficulty trusting clinicians.
• Historically used in couples therapy, which will likely return.
(Peacock, 2022)
Timeline Unknown
© Peacock 2023
Ibogaine
(Peacock, 2022)
• Substantial promise as an addiction treatment
• Can completely attenuate withdrawal symptoms for opioids and other drugs.
• Low relapse rates compared to conventional treatment.
• Fatal cardiovascular risk is exceptionally high; therapeutic doses commonly exceed pharmaceutical
safety standards.
The Peacock Perspective™:
• Risk of death may be deemed acceptable for those with terminal SUDs.
• Alternatives with less toxicity but similar antiaddictive properties:
• Noribogaine, the primary metabolite of ibogaine.
• 18-methoxycoronaridine (18-MC), an ibogaine analog.
Possible June 2026
© Peacock 2023
Ayahuasca
(Peacock, 2022)
• Most research and current use is in ritual contexts.
The Peacock Perspective™:
• Hesitant about ayahuasca in a clinical setting due to established cultural lineage.
• More inclined to refer out to ritual ayahuasca treatment centers.
• Evidence of neurocognitive benefits from ritual ayahuasca use across all cognitive domains
except verbal memory, which according to one study may be reduced.
• 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).
• Superior working memory and executive functions in ritual ayahuasca users compared to controls.
• Further research warranted as a possible treatment for ADHD.
Possible June 2026
© Peacock 2023
Ayahuasca
(Peacock, 2022)
The Peacock Perspective™:
• Ritual ayahuasca use associated with fewer symptoms of:
• Anxiety
• OCD
• PTSD
• Substance Abuse
• Grief
• Borderline Personality Disorder (observational study)
• Ayahuasca SUDs treatment centers exist in South America.
• Efficacy has only been demonstrated through uncontrolled trials.
• Findings are mixed.
Possible June 2026
© Peacock 2023
DMT
(Peacock, 2022)
The Peacock Perspective™:
• Few known clinical applications
• Could be useful for preparing patients for successful treatment with other psychedelics (E.
Sola, personal communication):
• Psychedelic-induced mystical experience strongly predicts symptom improvement across
treatment targets
• A, “tendency to reject information that is not easily explained through rational, logical, and
scientific processes” was negatively correlated to mystical experiences from psilocybin (Russ et al.,
2019, p. 4).
• 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
© Peacock 2023
Mescaline
• Most research is pre-1950 and most current use is in ritual contexts.
The Peacock Perspective™:
• Very long duration (12–18 hours) makes it impractical for clinical use.
• No indications where mescaline would be more effective than psilocybin or LSD, though
appears to have similar effectiveness in ritual contexts.
• Should be considered when culturally congruent for a patient.
(Peacock, 2022)
Possible June 2026
© Peacock 2023
LSD
• Long timeline for clinical availability but research is happening.
• Abundance of historical LSD research up until mid 70s.
The Peacock Perspective™:
• Historically, psycholytic LSD therapy was used to treat many conditions including depression,
anxiety, phobias, OCD, conversion disorders, personality disorders, and schizophrenia.
• Findings are yet to be validated according to modern medical standards.
• LSD is uniquely suited for psycholytic therapy compared to psilocybin:
• Increases outward focus and extraversion vs. psilocybin being more sedating and inward-focused.
• LSD has dopaminergic effects and weaker agonism of the sedating 5-HT2C receptors.
• 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
© Peacock 2023
Call to Action
• All Providers:
• Seek training in psychedelic-assisted modalities.
• Lobby for availability of psychedelic medicines and insurance reimbursement.
• Psychiatrists:
• Offer ketamine therapy when indicated.
• Arrange preparation and integration therapy.
• Psychologists and Therapists:
• Provide preparation and integration therapy for ketamine therapy patients.
• Suggest psychedelic therapies when indicated.
• Provide input on how patient personality may impact psychedelic therapy.
• Administrators and Clinical Leaders:
• Work to develop policies for providing other psychedelic-assisted therapies, particularly with psilocybin and MDMA.
• Apply to become a licensed facility with the Natural Medicine Advisory Board.
• Obtain funding for a dedicated psychedelic-assisted treatment center.
© Peacock 2023
Thank You!
© Peacock 2023
References
Avanceña, 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, 243–252.
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), 3137–3148. 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), 129–134.
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.
© 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.
© 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 © Brian Peacock, 2023
  • 2. Overview MY RESEARCH CONSTRAINTS OF MANAGED CARE INDICATIONS & USE CASES © Peacock 2023
  • 3. What’s different about psychedelics? (compared to other therapies) • Psychedelics produce striking changes across all levels of the human system—molecular, neurological, phenomenological, affective, and cognitive. • Effects propagate through time, resulting in changes to mind, brain, body, and behavior lasting anywhere from minutes up to a lifetime. • Clinical decision making is complicated by the varied properties of psychedelics and the environmental variables that affect psychedelic experience. • We most choose among psychedelics, therapeutic techniques, and therapeutic sequences to maximize treatment efficacy while minimizing risk. © Peacock 2023
  • 5. Dissertation “Applications of psychedelic-assisted psychotherapy across personalities and psychopathologies: An integrative literature review with meta-analysis.” • Compared different psychedelic therapies and their efficacy in treating psychiatric conditions. • Examined variation in response to psychedelics across different personality traits. • Drew insights from basic psychedelic research that can be applied clinically. • Completed July 2022 Psilocybin Mescaline LSD DMT Ayahuasca MDMA Ketamine Ibogaine DEFENDED © Peacock 2023
  • 6. Method • Systematic Literature Search • Matrix of 128 topic keywords combined with 8 psychedelics for a total of 1,024 Google Scholar searches. • Yielded 4,409 references • 1,164 references were included • Preliminary Meta-analysis – Normalize data across studies by calculating effect sizes when not reported. • Integration & Synthesis – A method for making all this data clinically useful! Psilocybin Mescaline LSD DMT Ayahuasca MDMA Ketamine Ibogaine © Peacock 2023
  • 7. • Colors represent the search date (and made it more fun) • Boxes include: • [total number of search results], • [number of results reviewed], • [number of articles yielded] © Peacock 2023
  • 8. Summary Tables • Pharmacological Properties • Impacts on Neurotransmission • Life Stage and Psychedelic Safety • Medical Risk Factors and Contraindications • Long-Term Medical Risks • Psychedelic Phenomenology • Acute • Subacute • Psychological Change • Subacute • Long-term • Neuropsychological Effects • Acute • Subacute • Long-term • Psychological Risks • Acute and Subacute • Long-Term Psychopathogenesis • Psychological Risk Factors • Patient Factors Affecting Psychedelic Experience and Outcome • Psychedelic Treatment Targets (Peacock, 2022) © Peacock 2023
  • 10. Gertrude Smith 72-year-old, White, cis-gender woman 72 72 Gertrude Smith Brian Peacock / / O / / / / O © 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 © 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 / / / / / / © 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 © 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 + + / + ++ ++ + ? ? ? ? ? ? ++ ++ ++ + + + ? ++ ++ ++ ++ ++ ++ ++ ++ ? ? ? ? © 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 + + / + ++ ++ + ? ? ? ? ? ? ++ ++ ++ + + + ? ++ ++ ++ ++ ++ ++ ++ ++ ? ? ? ? © Peacock 2023
  • 16. Influencing Factors • Sex • Age • Personality Traits • Psychopathology • Family History • Cognitive Ability • BMI • Genetics (Peacock, 2022) © 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 ‘bad trips’ 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 © 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 ‘bad trips’ 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 © Peacock 2023
  • 19. Next Steps • Proposed Book: Psychedelic Treatment Planning: An Evidence-Based Clinical Guide • Simplified symbols and treatment planning workflow • Clinical case examples • Revisions and updates • Starting independent practice for: • Pre-evaluation and preparation for psychedelic therapy. • Psychedelic integration therapy for patients experiencing distress, spiritual emergency, or emerging psychopathology following psychedelic therapy with other providers. • Develop assessment measure designed for assessing traits relevant to psychedelic-assisted treatments. © Peacock 2023
  • 21. Current Availability • Off-label ketamine • Other psychedelics used in: • Clinical research • Underground practice © Peacock 2023
  • 22. Nov 2024 Natural Medicine Health Act • Colorado Prop. 122 • Psilocybin and psilocin • Licensed treatment centers • Regulated by the Natural Medicine Advisory Board (Colorado Department of Regulatory Agencies) © Peacock 2023
  • 23. • FDA Approval Pending • Phase 3 Clinical Trial Complete • Currently in “Expanded Access” phase • Priority roll-out to academic medical centers (Steinberg, 2023) Mid 2024 MDMA-PT for PTSD © Peacock 2023
  • 24. • DMT, ayahuasca, ibogaine, and mescaline (excluding peyote) may become available in CO. • Only if recommended by the Natural Medicine Advisory Board (Colorado Department of Regulatory Agencies) June 2026 Natural Medicine Health Act © Peacock 2023
  • 25. Bias Against LSD Remains
  • 26. Who pays? • Right Now, Most Psychedelic Therapy is Out of Pocket • Most psychedelics are generic medications • Predominant costs are: • Evaluation/screening • Therapist time – Including preparation, drug, and integration sessions • Facility costs • March 3, 2023 – AMA approved new CPT III code for “Continuous In-Person Monitoring and Intervention during Psychedelic Medication Therapy” to become effective January 1, 2024 (Benzinga, 2023). © Peacock 2023
  • 27. Cost Savings • MDMA-AT costs $11,537 per patient using protocol from FDA Phase 3 trials • Per 1,000 patients, compared to standard of care: • MDMA-AT saves $132.9 million over 30 years in discounted net health care savings • Averts 61.4 premature deaths • Generates 4,856 quality-adjusted life-years (QALYs) • Break-even at 3.8 years • Expanding access for MDMA-AT to 25-75% of eligible patients is projected to: • Averts 43,618–106,932 deaths • Gains 3.3–8.2 million QALYs • “Most of the expected cost-savings aren’t on the psychiatric side, they’re on the physical side.” – Elliot Marseille (Kary, 2022) (Marseille et al., 2022; Avanceña et al., 2022) © Peacock 2023
  • 28. Infrastructure – Current Research (Sprunt/WAMU, 2019) Johns Hopkins University – Center for Psychedelic and Consciousness Research • Individual Psilocybin Therapy Room • Two Therapists Present • One Licensed Psychologist or Psychiatrist • One Other Provider • EXPENSIVE • Similar protocols for MDMA-AT © Peacock 2023
  • 29. Infrastructure – Individual Psychedelic Therapy • Ketamine Infusions can be done in: • Inpatient units (as is being done at Denver Health) • Outpatient infusion clinic in group setting • MDMA-AT and Ketamine-AT can be done in outpatient therapy offices modified to have: • Calm lighting and décor • Windows to monitor sessions and prevent boundary violations while patient is in a vulnerable, suggestable, and disinhibited state. © Peacock 2023
  • 30. Infrastructure – Group Psychedelic Therapy • Group psychedelic therapy will reduce costs in managed care setting. • Indigenously, ritual administration in groups has been the norm. • Group psychedelic therapy is safe and feasible per recent studies. • Therapies not requiring intensive individual intervention during the psychedelic experience can be done in groups: • High-dose psilocybin therapy (depression, cancer-related distress, AUD, etc.) • Ibogaine for SUDs • Ayahuasca, DMT, and Mescaline • Ketamine Infusion • Active group process may be feasible with low-dose psychedelic therapy. • This is similar to ritual practices and more research is needed. © Peacock 2023
  • 31. What might a psychedelic treatment center look like? © Peacock 2023
  • 32. Group Psychedelic Therapy Room • Inpatient and outpatient groups for various indications. • Two group sessions per day. Psychedelic Treatment Unit • Infrastructure to treat patients needing medical support. Main Hospital • Quick access to emergency medical care if needed. Individual Therapy Rooms • Space for individual care when respite from group needed. • Individual MDMA-AT and Ketamine-AT sessions. Two Bathrooms • On unit so no tripping patients interact with others. • Showers for emergent hygiene needs *Lack of patient diversity pictured due to software limitation. © 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 © Peacock 2023
  • 35. Ketamine in Inpatient Psychiatry & Eating Disorder Treatment August 2022 – Denver Health policy approved for using intranasal racemic ketamine to treat patients with treatment-resistant MDD or bipolar depression. • Adult inpatients on Psychiatry Unit and ACUTE Center for Eating Disorders. • Low-stimulation environment for 120 minutes on the unit. • Re-dose every 2-4 days. • No guidelines for psychotherapy during session or preparation/integration therapy. • Has been put to use! (Carron, 2022) Current © Peacock 2023
  • 36. The Peacock Perspective™: • Ketamine should be a first-line treatment for depression and acute suicidality. • Ketamine robustly and rapidly reduces symptoms of depression and suicidality. • Ketamine effects only last a week (though emerging research may suggest that repeat dosing may be more durable) • This provides a functional window for other intervention (e.g., psychotherapy or other psychedelic treatments). • Frequent and ongoing ketamine treatments are concerning • Chronic recreational ketamine use is linked to bladder cystitis, abdominal pain, sexual dysfunction, and fertility decline. • Both clinically and recreationally, long-term ketamine use is linked to neurocognitive damage. • There is substantial evidence for ketamine’s addictive potential, which is particularly relevant to self-administered ketamine nasal sprays. (Peacock, 2022) Ketamine in Inpatient Psychiatry & Eating Disorder Treatment Current © Peacock 2023
  • 37. The Peacock Perspective™: • Like depression PTSD symptoms are rapidly reduced by ketamine, again providing a window for other interventions. • Ketamine-assisted psychotherapies show promise in durably treating: • OCD • PTSD • SUDs • Avoidant Personality Disorder • 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 © Peacock 2023
  • 38. Ketamine for Alcohol Use Disorder 2021 Pilot Trial at Denver Health – Ketamine for high-utilization inpatients with AUD • Principal Investigator: Dale Terasaki, M.D. • Ketamine vs. Naltrexone vs. “Linkage Alone” (IV Ketamine 0.5 mg/kg) • 30-day Readmission Rate: • Ketamine 15.4% [n=13] • Naltrexone 21.4% [n=14] • Linkage Alone 41.2% [n=17] • 14-day Addiction Clinic Encounter • Ketamine 61.5% • Naltrexone 50.0% • Linkage Alone 41.2% • Ketamine may help with depression and withdrawal in addition to cravings. The Peacock Perspective™: This is AWESOME! (Terasaki, 2023) Current © Peacock 2023
  • 39. Psilocybin-AT for Cancer-Related Distress • FDA trials taking place at CU Anschutz led by Stacy Fischer, M.D. • Highly effective treatment The Peacock Perspective™: • There is NOTHING available for these patients who are suffering profound existential distress while suffering from extreme pain. • Psilocybin therapy is exceptionally low risk. • Evidence is emerging about the potential for psilocybin to treat chronic pain, making psilocybin treatment a double whammy. • We need this treatment available as soon as possible. (Peacock, 2022) September 2024 © Peacock 2023
  • 40. Psilocybin-AT for Other Indications The Peacock Perspective™: • Psilocybin-AT has shown robust efficacy to durably treat: • Unipolar Depression • Suicidality • Anxiety • OCD • Alcohol Use Disorder • Tobacco Use Disorder • Outcomes tend to improve with higher doses! • 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 © Peacock 2023
  • 41. MDMA-AT for PTSD • Phase 3 FDA trials of MDMA-AT for PTSD have been successfully completed. • MDMA-AT has received Breakthrough Therapy Status • The expanded access program for MDMA-AT is prioritizing academic medical centers. • MDMA-AT requires individual rooms for conversation with therapist during the session. The Peacock Perspective™: • MDMA experience tends to be gentler than other psychedelics, making it ideal for emotionally vulnerable patients. • MDMA’s neurocognitive impact is minimized by avoiding body temperature elevation: • Administer MDMA in a cool environment and monitor for increased body temperature. • Use the R(–)-MDMA instead of racemic or S(+)-MDMA. • Need more research on neurocognitive impacts of clinical MDMA. (Peacock, 2022) Mid 2024 © Peacock 2023
  • 42. MDMA-AT for Other Indications • 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 Perspective™: • Strong findings for treating social anxiety in autism spectrum disorder (Danforth et al., 2018) • Some evidence for MDMA-AT to treat: • Generalized anxiety • Phobias • Avoidant personality disorder • Could help build therapeutic alliance with paranoid and schizoid patients who tend to be resistant to therapy due to difficulty trusting clinicians. • Historically used in couples therapy, which will likely return. (Peacock, 2022) Timeline Unknown © Peacock 2023
  • 43. Ibogaine (Peacock, 2022) • Substantial promise as an addiction treatment • Can completely attenuate withdrawal symptoms for opioids and other drugs. • Low relapse rates compared to conventional treatment. • Fatal cardiovascular risk is exceptionally high; therapeutic doses commonly exceed pharmaceutical safety standards. The Peacock Perspective™: • Risk of death may be deemed acceptable for those with terminal SUDs. • Alternatives with less toxicity but similar antiaddictive properties: • Noribogaine, the primary metabolite of ibogaine. • 18-methoxycoronaridine (18-MC), an ibogaine analog. Possible June 2026 © Peacock 2023
  • 44. Ayahuasca (Peacock, 2022) • Most research and current use is in ritual contexts. The Peacock Perspective™: • Hesitant about ayahuasca in a clinical setting due to established cultural lineage. • More inclined to refer out to ritual ayahuasca treatment centers. • Evidence of neurocognitive benefits from ritual ayahuasca use across all cognitive domains except verbal memory, which according to one study may be reduced. • 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). • Superior working memory and executive functions in ritual ayahuasca users compared to controls. • Further research warranted as a possible treatment for ADHD. Possible June 2026 © Peacock 2023
  • 45. Ayahuasca (Peacock, 2022) The Peacock Perspective™: • Ritual ayahuasca use associated with fewer symptoms of: • Anxiety • OCD • PTSD • Substance Abuse • Grief • Borderline Personality Disorder (observational study) • Ayahuasca SUDs treatment centers exist in South America. • Efficacy has only been demonstrated through uncontrolled trials. • Findings are mixed. Possible June 2026 © Peacock 2023
  • 46. DMT (Peacock, 2022) The Peacock Perspective™: • Few known clinical applications • Could be useful for preparing patients for successful treatment with other psychedelics (E. Sola, personal communication): • Psychedelic-induced mystical experience strongly predicts symptom improvement across treatment targets • A, “tendency to reject information that is not easily explained through rational, logical, and scientific processes” was negatively correlated to mystical experiences from psilocybin (Russ et al., 2019, p. 4). • 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 © Peacock 2023
  • 47. Mescaline • Most research is pre-1950 and most current use is in ritual contexts. The Peacock Perspective™: • Very long duration (12–18 hours) makes it impractical for clinical use. • No indications where mescaline would be more effective than psilocybin or LSD, though appears to have similar effectiveness in ritual contexts. • Should be considered when culturally congruent for a patient. (Peacock, 2022) Possible June 2026 © Peacock 2023
  • 48. LSD • Long timeline for clinical availability but research is happening. • Abundance of historical LSD research up until mid 70s. The Peacock Perspective™: • Historically, psycholytic LSD therapy was used to treat many conditions including depression, anxiety, phobias, OCD, conversion disorders, personality disorders, and schizophrenia. • Findings are yet to be validated according to modern medical standards. • LSD is uniquely suited for psycholytic therapy compared to psilocybin: • Increases outward focus and extraversion vs. psilocybin being more sedating and inward-focused. • LSD has dopaminergic effects and weaker agonism of the sedating 5-HT2C receptors. • 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 © Peacock 2023
  • 49. Call to Action • All Providers: • Seek training in psychedelic-assisted modalities. • Lobby for availability of psychedelic medicines and insurance reimbursement. • Psychiatrists: • Offer ketamine therapy when indicated. • Arrange preparation and integration therapy. • Psychologists and Therapists: • Provide preparation and integration therapy for ketamine therapy patients. • Suggest psychedelic therapies when indicated. • Provide input on how patient personality may impact psychedelic therapy. • Administrators and Clinical Leaders: • Work to develop policies for providing other psychedelic-assisted therapies, particularly with psilocybin and MDMA. • Apply to become a licensed facility with the Natural Medicine Advisory Board. • Obtain funding for a dedicated psychedelic-assisted treatment center. © Peacock 2023
  • 51. References Avanceña, 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, 243–252. 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), 3137–3148. 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), 129–134. 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. © 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. © Peacock 2023