It seems like psychedelics have never been more popular, buoyed by clinical trials, popular media and international psychedelic retreats. They’re sometimes marketed as a fast-acting panacea for mental health struggles, but the truth is far more complicated — and mysterious. New York Times national correspondent and author Ernesto Londoño and psychiatrist Dr. Eric Noble join us to talk about the potential uses, risks and benefits of psychedelics. This episode was made with the generous support of Ken Stevens.
It seems like psychedelics have never been more popular, buoyed by clinical trials, popular media and international psychedelic retreats. They’re sometimes marketed as a fast-acting panacea for mental health struggles, but the truth is far more complicated — and mysterious. New York Times national correspondent and author Ernesto Londoño and psychiatrist Dr. Eric Noble join us to talk about the potential risks and benefits of psychedelics.
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Dr. Denise Millstine: Welcome to the “Read. Talk. Grow.” podcast, where we explore health topics through books. In the same way that books can transport us to a different time, place or culture, “Read. Talk. Grow.” demonstrates how they can also give us a new appreciation for health experiences.
Books can provide understanding of health topics and provide a platform from which health can be discussed. At “Read. Talk. Grow.” we use books to learn about health conditions in the hopes that we can all lead happier, healthier lives. I'm your host, Dr. Denise Millstine. I'm an assistant professor of medicine at Mayo Clinic, where I practice women's health, internal medicine, and integrative medicine. I am always reading and I love discussing books with my patients, my friends, my professional colleagues, and now with you. Our book today is “Trippy: The Peril and Promise of Medicinal Psychedelics” by Ernesto Londoño. Our topic is one that promises to be interesting to many people using psychedelics for health and medically.
I'm so excited about our guests. Ernesto Londoño is a national correspondent at The New York Times, where he's worked for 10 years. He was born and raised in Colombia and has spent the past two decades covering some of the most important stories of his generation. His assignments included covering the wars in Iraq and Afghanistan, the Arab Spring, serving on the editorial board of The New York Times and running the newspaper's bureau in Brazil. Trippy is his first book. Ernesto, welcome to the show.
Ernesto Londoño: Thanks so much for having me.
Dr. Denise Millstine: Our second guest is Dr. Eric Noble. Eric is a board-certified psychiatrist who trained at UCLA. He received his bachelor's degree at Brown University and his doctorate of medicine from Mount Sinai School of Medicine in New York City. He's a staff physician at Mayo Clinic in Arizona and has participated in medical studies on psychedelic use in mental health. Eric, welcome to the show.
Dr. Eric Noble: Glad to be here. Thanks so much for having me.
Dr. Denise Millstine: “Trippy” is part memoir and also predominantly an exploration of the exploding use of psychedelic substances such as ayahuasca and others to treat depression, PTSD and other mental health conditions. It’s currently not fully legal to use psychedelics clinically. In the United States, psychedelics are accessed via a number of channels and experiences that Ernesto explored and reported on over many years. “Trippy” brings us the account through a seasoned reporter's eye and with a first-hand perspective.
Ernesto, you had the idea of writing about psychedelics on your topic list for some time before diving in. In fact, “Trippy” talks about you taking the leap to experience an ayahuasca retreat with a mental health crisis of your own. Would you tell our listeners about that?
Ernesto Londoño: Yeah. So the origin of my interest in psychedelics dates back to 2017, when I moved to Brazil to take a new assignment at The New York Times. And just a few weeks before moving, I had a conversation with a colleague of my sister who's a psychiatrist at Yale. He told me about field research he'd been doing in South America, taking a look at psychedelic retreats that were increasingly catering to foreigners, and especially American veterans who felt stuck with the healthcare they were getting in the mainstream system and had found their way to the jungles of Peru and Brazil through word of mouth for these unconventional interventions. So I tucked it away as something that was really interesting and promising. And soon after arriving in Brazil, I found myself in this downward spiral of depression. And one night, when I was at a low point and having a sleepless night, I googled “ayahuasca retreats Brazil” and stumbled across this kind of loopy YouTube video recorded by an Argentine woman who was one of the pioneers of building this field of psychedelic retreats. And what began as a journalistic interest soon turned personal, and I felt this gravitational pull toward this mysterious place and this mysterious woman. I applied for a retreat, and just a few weeks later, I was there for a series of ceremonies in the night.
Dr. Denise Millstine: For our listeners who haven't read the book yet, you do a great job of going into detail about what the experience was like, which I can only imagine was quite challenging. I think at one point you say it's like being on the retreat, but with one eye open, experiencing it, but also trying to record. And so thank you for giving us that direct experience with it through your eyes.
Eric, you've certainly had many patients in your psychiatric practice who are either interested in psychedelics or maybe have even used them. Do you find this approach to be something that's engaged early, as people are realizing they have a mental health condition, or do you find it's usually something that comes up later in the journey?
Dr. Eric Noble: Yeah, it's a good question. First off, I think I just want to commend you on this book. It was a great read and I thought it was just an awesome combination of both journalism and memoir and a really brave book. I think it's not easy to put yourself out there and to talk about mental health and your own experiences and wondering about the professional repercussions of it, and I just thought it was really, really well done and brave. So thank you so much for putting it out there.
I think we're living in an interesting time in terms of psychiatry treatments in this burgeoning field of psychedelics, and it's getting so much press not just in scientific literature but in the popular press. So the amount of people, both that I just meet casually in social settings and who come to my office, they're asking about psychedelics all of the time and wondering if it can be helpful for them. So yeah, it's very fascinating from a scientific standpoint. Most of the studies that are done on psychedelics are really for people who have what's called treatment resistant depression, so that they've tried and failed at least two trials of antidepressants. And so when we're thinking about psychedelic use for those patients, we have to keep in mind that that's the recommendation and that's the approval. But in reality, a lot of the patients who are coming to us might be treatment naive for depression or anxiety, who've never had a trial or done therapy, who are just coming because they've heard about these substances.
Dr. Denise Millstine: Yeah. That's tricky, isn't it? Because the science is really lagging with the experience. Particularly when you look at how these are accessed, which you talk about Ernesto in the book. So can you give our listeners more of an idea of what these retreats are like? Because they really span from remote areas, small gatherings to even luxury resorts. So can you give us a picture of what that looks like?
Ernesto Londoño: Yeah. Well, if you take a look at, I think kind of the countries in Latin America that have become something of a laboratory for these newer interventions. Typically, you sign up for a weeklong, or 14-day retreat in the jungle, in the Amazon for instance. And the first step is to do a little bit of patient screening. So this varies somewhat from retreat to retreat. But generally the people running these retreats want to have a sense of your medical history and of what drove you to consider this. So this will rule out some people, for instance, if you're taking SSRI, it's currently you're going to be turned down at most retreats because there is a concern that, the combination of both two substances could be dangerous, could induce serotonin syndrome. And then I think also retreat organizers want to have a sense of what kind of support structure you're going to have on the back end of this experience, because unlike a formal relationship with a therapist, typically when you sign up for a retreat, you know, once the retreat is completed, there's really no ongoing patient relationship between the retreat organizers and the individual. So if you happen to have a destabilizing experience, I think it's important to think about what kind of safety net it's going to be waiting for you on the other side. But for people who get in, I mean, who are accepted for at these retreats, there's usually a series of nighttime ceremonies. And in the case of ayahuasca, which is a brew from the Amazon that has roots in indigenous communities going back, centuries, typically what happens is you lay on a cot in a dark ceremony room, and there's either live music or a playlist. You imbibe this drink, which tastes foul. And generally within 40 minutes to an hour, and you start experiencing disruptive thinking. You know, your senses become more acute. You experience the music or the sounds of the jungle in a really, intense way. Oftentimes you're sort of drawn to memories from childhood or from formative or traumatic moments in your life, and you're kind of really anchored in them for a long period of time. And are sort of forced to reimagine or reframe what those experiences meant and how they shaped you. Now, in terms of how this winds up being therapeutic, there are some theories, but I think it remains sort of largely mysterious. Exactly what happens to the brain, how long these periods of disruptive thinking or disruptive brain activity last, and how exactly you sort of harness these periods of so-called neuroplasticity or periods when, you know, parts of the brain that typically don't engage with each other are more connected. How does that lead you to think more clearly and more strategically about the problems that brought you to this place in this experience, and to start making different choices? But what I've seen time and again, people walk away from these mind-bending experiences with some profound insights about their lives and their problems. They have sort of this opportunity to see things more clearly and with greater wisdom. And then oftentimes people make different choices about their relationships, about their careers, about their diets, about their relationship with alcohol and other drugs. And quite often, people feel a lot better in the immediate aftermath of these experiences, but also embark on a set of changes personally that suit them well and that make them better equipped to deal with depression or substance use in the years ahead.
Dr. Denise Millstine: Wow. There is so much to unpack in what you've just said. Because I really appreciate how you gave that whole perspective. Eric, I wonder if you would explain what Ernesto was referring to about some of the psychiatric medications, like the SSRI concerns. Even though these substances tend to be natural, they could have an interaction with your prescribed medications.
Dr. Eric Noble: Yeah, there's still so much to be learned. I think this is why a lot of us are drawn into the field of psychiatry and mental health is that, you know, you're dealing with the brain, which is the most complex thing in the universe, which is very exciting, but also overwhelming and sometimes demoralizing to think about how little we know about how the brain works and how these various treatments work, even SSRIs, which are kind of the mainstay of treatment for depression and anxiety. They've been around since the 1980s. The popular names are, you know, Prozac, Zoloft, Lexapro. Those are thought to work primarily on the serotonin system. Even that is a really big simplification. And to be honest, there's still so much that needs to be illuminated about how these medications are affecting various brain networks. But yeah, in terms of specifically the psychedelics and interactions with existing treatments, psychedelic medication also has an effect on serotonin pathways.
So as I mentioned, there's a risk of kind of overloading your system with serotonin, which in extreme cases can be dangerous and cause attacks of high blood pressure and all the bad resulting things from that. But interestingly, ketamine, which is the first sort of class of medications that's got an FDA approval under the umbrella of psychedelic treatments. The initial study that approved it, it was actually in use in conjunction with an antidepressant medication. So, you know, there's still so much to be learned about the safety profiles and the interactions with other medications.
Dr. Denise Millstine: Well, and maybe this is a good point to talk about how we're referring to psychedelics as a group of substances, but they are certainly not having the same mechanism, nor are they coming from the same source. We've grouped together, perhaps artificially to some degree these substances that seem to have a fairly similar effect. You're nodding your head, so are you in agreement that it's a bit of a, kind of mishmash of characterization?
Ernesto Londoño: Yeah. I mean, I think there's a class of psychedelics that have a similar effect on the same receptors in their brain, but there is great variance in terms of the intensity of the experiences and the duration of the trip. So for instance, ayahuasca, which is what I have the most experience with, contains DMT, which is one of the so-called classic psychedelics. And these trips tend to be pretty long, anywhere from 4 to 8 hours. They tend to be really hard on the body, in the sense that oftentimes they induce purging in the form of vomiting or diarrhea or shaking. So not only are you kind of experiencing some crazy disruptions in the way our thinking mind works and our memory process works, but it's also a very intense somatic experience, just slightly different than something like magic mushrooms or even, ketamine, which is, I think, less of a classic psychedelic and more of a dissociative (unclear).
The common denominator is that all these mind-altering drugs induce a period of more malleable thinking and feeling. Oftentimes, they allow people to sit with painful memories or kind of really difficult subjects that are in our everyday conscious mind (that) may be hard to access or really kind of make room for. And that, I think, is where the therapeutic potential lies is in kind of reaching a state of vulnerability or malleability that allows you to metabolize, for lack of a better term, some of this darkness that has become depression or PTSD or that has led you to start abusing drugs in ways that are unhealthy. The term “psychedelics,” actually, interestingly enough, was coined by a psychiatrist in the ‘50s, and the words mean “mind-manifesting” or “soul-manifesting,” depending on how it's translated. So I think the thinking back then was, here are these compounds that can sort of peel back some of the layers of complexity in the mind and reveal something important and useful. But the reality is that if you look sort of deeper into the history of these substances, especially if you look at the cosmology and the worldview of indigenous people that have been using them for many, many years, they understand them primarily as sacraments and as sort of portals to a spiritual realm in which we can sort of tap into wisdom or, divine intelligence to change our lives here on this earthly plane. So I think that was what made this really interesting, the fact that there's this period right now where there's a lot of research going on, there's a lot of interest in understanding how these compounds can change our brains and can change our behavior. But there's sort of this deeper layer of history that is more spiritual than it is medical.
Dr. Denise Millstine: Yeah. Thank you for that. Eric, the view I'm seeing is that perhaps the psychedelics — and this is, I think, how Ernesto puts it in “Trippy” — really are the opening. They're not necessarily going to be the, have the treatment, participate in the retreat, and then on the back side, everything is fine and doesn't need attention. Are you seeing that same process happening that this is all about kind of cracking open, and then there's still work to be done after the experience?
Dr. Eric Noble: That's definitely my impression. But I think so much is still being illuminated about these things. So whenever I meet with a patient and I teachmedical students in psychiatric residencies in psychiatry, we really want to think from a bio-psychosocial spiritual perspective. And so when we're assessing someone or thinking about the treatment plan, we're trying to think of things from a biologic. So in terms of genetics, different brain networks receptors, molecules. That's the bio. The psycho is someone's perspective, frame of mind, their thought patterns. Socially is, their day-to-day relationships and activities and habits and their environment. And then spiritual in terms of their beliefs and their existential views and their connection to, something greater to themselves.
And all of those things have an influence on our mental wellbeing. And it's so hard to tease apart the effects of one versus the other. And for psychedelics in particular, we don't know, Ii it actually the mechanism of action? Is it just that it's affecting the biological, the receptors and the chemicals in our brain, or is it also having an impact psychologically in terms of enabling us to have a new pair of glasses, a new worldview of letting go of old unhelpful thought patterns? Or is it the spiritual? Is it the mystical aspect of the experience that's connecting us to something greater than ourselves that is crucial to the anti-depressive or anti-anxiety standpoints. Or even socially, is it going on a retreat and interacting with really great other people and feeling like you're part of the community? Is that what's making a difference?And so trying to tease apart all these different things is really hard in terms of designing a clinical trial and trying to isolate all the variables. It's nearly impossible, which is frustrating, but also super fascinating. And the nitty gritty in the gray area of psychiatry, which is so fun.
Dr. Denise Millstine: Well, I'm convinced from “Trippy” that it's touching all of those aspects. Certainly, your personal experience Ernesto is that you looked at some memories and experiences that you had pushed aside or even suppressed and found space and ways to explore those and reconsider whether your beliefs around them … were accurate or it was time for them to change. And I think that goes to your point earlier in the show where you talked about the importance of who's going to support you after this experience, do you agree?
Ernesto Londoño: Yeah, absolutely. When I think what I benefited from the most, since I look back on sort of years of experiences in this field, is it gives you the ability to show earlier versions of yourself compassion that you just weren't equipped to deal with in real time. And what's really interesting about going on a psychedelic retreat, that makes it very different than just having sort of a therapist, is you get to watch people process during the retreat. To some extent, it starts feeling like you're in a reality show where people gradually start revealing more and more of themselves and become increasingly vulnerable. And, you know, to a person, you know, I found among the dozens of people that I sort of met and shared these spaces with, that there's a pathway to people forgiving themselves for things that they have done that made them feel ashamed or created distress or harm. So there's this very, very frequent sort of realization that I need to get to forgiveness of myself and others in order to heal and move forward and sort of move through the world. That's a lighter version of myself. And also, I think this recognition that I've been really hard on myself, you know, going back to childhood, my adolescence and my 20s, like people just kind of go back, turned back to the really formative, important moments that kind of were key to the reason they became sick or distressed or depressed and are able to kind of untangle this knot of self-compassion. And it almost makes it easy to bring these painful, dark memories or moments into the light and just make them something that becomes easier to carry. But how that works and how much of it is biological, how much of it is kind of like neural activity, how much of it is almost like a spiritual awakening or a mystical phenomenon? I think we may never quite understand. I think to a large extent what exactly happened, and the way in which this changes people's psyche and outlook will forever remain somewhat mysterious.
Dr. Denise Millstine: I really love one of the parts of “Trippy” where you talk about an experience from high school that you had created a narrative around, with a friend who you become somewhat distanced from. And now you are back together again, and you found yourself apologizing to this friend. And essentially he was like, “What are you talking about? I didn't view it that way at all.” And I think you say in the book, “I had created, I had been damaging myself because I had decided that was traumatic for him, but in fact, that was just me making up a narrative that wasn't actually his reality.” So those are the kinds of vulnerable moments I think we see in “Trippy,” where we can start to really examine that.
There is probably a lot of baggage that it's time to just put down in and walk away from it and heal from, like you said. You mentioned the people that you meet on retreat, and there are a number of different populations, if you will, that you see. From veterans, there's a queer retreat that you go on, we see soccer moms, there's some of the facilities that seem to cater to almost celebrities.
I wonder if Eric, you might comment on sort of who the psychedelics are not being targeted to, but can the populations that we're looking at as benefiting from these substances in the future? And is there a common theme? Kind of around that, is that, that these people have had some form of trauma, in their lives, and that's what makes them maybe potentially able to benefit from this type of treatment.
Dr. Eric Noble: Yeah. I think in terms of thinking about that question, it's important to kind of separate the official market from the unofficial market and kind of the different marketing systems that that are used for both. And I think in terms of the retreats and some of the stuff that goes on more underground here in the U.S. or aboveground in South American countries and markets, sometimes it's marketed as a sort of panacea for addiction, for just not feeling good. I think that that can attract a whole range of folks, and I think that bleeds over into even the official market and people who come into my office. There's so much now in pop culture and narratives about these substances that people from all walks of life are getting a curiosity about them. The official market, where kind of psychiatry as a field would like to focus on is more just the thinking of people for more of like a DSM diagnosis standpoint, who officially meet criteria for either PTSD or depression or substance use.
But in reality, there's a lot more gray area. But I think one thing that was really, really important about Ernesto's book is that you're really attracting a lot of people who are vulnerable. And that's, I think, one really important thing about this treatment and psychedelics is that you have a vulnerable population who is struggling with shame, trauma, really difficult experiences, and then you're using a treatment and a molecule that will induce really vulnerable and suggestible states. And I think that's part of the process of its power, and that it can kind of break all thought patterns and induce a new way of viewing things. But it also holds the peril of all of the bad things that can happen when someone is in a suggestible, vulnerable state in terms of abuse of power, of having a bad trip, of having side effects and things go wrong.
There's all this news about Matthew Perry and what happened with him passing away from a ketamine overdose and folks who struggle with substance abuse and the vulnerability of that. And I think in his case, he initially went and got official treatment from a mental health clinician for anxiety and depression. And then that spiraled into getting ketamine in more unofficial and underground ways and being taken advantage of and having that intertwined with his history of substance abuse. The combination of vulnerable populations with the medicines inducing this vulnerable state that is really dangerous.
Ernesto Londoño: And I think one big take away from my reporting is that given the history of prohibition and the legal and regulatory framework, it still makes it really hard to study and access these compounds in a clinical setting. What we're left with is a world in which it's very often the most vulnerable people wind up in the care of the people, the guides or the practitioners with the people with fewest scruples. I think for people out there who may be interested in this or know somebody who may be a good candidate for this, because they've tried everything else and it's failed, I think it's important for people to be skeptical of any claims that are grandiose. There is so much hyperbolic marketing in this field. There are retreats that outright promise a miracle in a week, as long as you can shell out $7,000.
There's a common description of psychedelic sessions or retreats as being “10 years of therapy in one night,” which I think sets many people up for disappointment. Because the reality is that while these can be transformative experiences, real, lasting change and healing takes a lot of work and commitments and guardrails beyond a psychedelic session. So I do worry a lot about just how much hype has been built in kind of the post-Michael Pollan “How to Change Your Mind” era that I think kind of blasted the door wide open and we're taking some steps right now, I think, toward recalibrating expectations. But oftentimes, I think people venture into these experiences in a very vulnerable state and with unrealistic expectations and not enough of a sense of the kind of things that can go wrong.
Dr. Denise Millstine: Well, and “Trippy” certainly doesn't back away from that. Thank you for raising that. Because we often think about adverse effects from medications in terms of side effects. But in this vulnerable population, in entering into a vulnerable state, it's so important that you're trusting the person or the team to whom you are leaning on for this journey. And some really terrifying things happen to people that you interviewed in the course of “Trippy.” I wonder if you would comment for the listeners about some of those things.
Ernesto Londoño: Sure. I mean, you know, one sort of very problematic aspect of this field is that there has been a pattern in history of boundary transgressions, particularly as it pertains to inappropriate sexual relations or outright sexual abuse. So the way this normally happens is people when they're in a very vulnerable state with a lot of trust and faith and whoever is guiding these experiences, and oftentimes you find yourself in this very emotionally open state and also kind of in a very malleable state where you don't really kind of have your wherewithal when it comes to being discerning about what is right and what is wrong and what feels. Transcript slip and abusive versus normal. So there's a chapter in the book of a retreat where a handful of women, put themselves in the care of this guy who had a very good reputation in the field, and who was going to teach them these modalities of medicine from the jungle. And he sexually targets three of them on three consecutive nights and rapes one of the women. What was unique about this case is the women actually spoke up after the fact, and in doing so, kind of triggered this flood of accounts of other women who had been on this retreat but chose to remain silent. I think the takeaway from that is that among people who have found healing in psychedelics, there's kind of been a reluctance to draw attention to some of the really scary things and problematic things in the field, because they don't want to tarnish the whole sort of ecosystem of these retreats.
Also, I think there's a layer of shame of people who just feel really kind of lousy about having put themselves in such a vulnerable situation, and they just don't want to be seen or heard, and they want to just kind of make it go away and then I think the other layer of this is when you become highly suggestible in the aftermath of these experiences, it's very easy for you to become great to other schemes, not just sort of sexual abuse, but there was one retreat in Costa Rica that I describe in the book, where they're toward the end of a weeklong retreat when people are very sleep deprived and still very groggy and still very much under the influence of these substances, the retreat center starts tingling. All these things you can spend money on to turbocharge your healing training. So one of them was like stem cell injections for $17,000, which was at best a placebo. And so I think it's important for people to come into these experiences, understanding that these compounds are not inherently benign or therapeutic, they can help you get to a better place, but that is determined by the setting and the guidance and the support structure you get.
So I think it's important for people to ask a lot of questions about kind of what those elements look like for the retreat they picked and whether they have done enough due diligence to trust the people that are going to be guided by experiences.
Dr. Eric Noble: And I just wanted to add on to that. I think that was, you know, there's so important to remember. And I think one thing I'd like listeners to think about is that depression, anxiety, for better or worse, as of now, these are chronic illnesses. And that's important to remember for a variety of reasons. One is that there's no fast acting miracle, miracle, cure, panacea.
Again, these are illnesses that have a combination of biologic, psychological, social, spiritual reasons and treatments, just like diabetes. There's no, as of now, magic pill or treatment. It takes constant lifelong vigilance of diet, exercise and medication to stay on top of diabetes. That's the same thing with anxiety, depression, PTSD and other mental health conditions. So going on a retreat and expecting that to fix the issues for the rest of your life is just unrealistic.
You have to think about these as chronic illnesses that require ongoing vigilance and treatment. And I think that's also important to know from a provider standpoint that a lot of people who get attracted to this field in terms of providing the treatment, both psychiatrists, therapists and unofficial people, they have their own history of mental health difficulty. That's one of the reasons they go into this, because they've found some solve and some treatment for themself that works. And there's both a genuine desire to share that treatment with others. But we're also human, and we want money and power and other things. but I think a lot of people from a provider standpoint, they have to realize that their own issues are chronic, and just because they've been helped by one thing doesn't mean that they're cured lifelong. And people who have their own history of difficulty with mental health. I mean, I've had my own struggles with depression and anxiety. I think that makes me really valuable in a lot of ways, working with other patients, because I have a certain level of personal experience that I can draw on and empathy, but I also have to be careful about that and use that in a way that's still keeping the patient's interests in mind. And from the perspective that these are chronic illnesses.
Dr. Denise Millstine: One of the things I really appreciate about “Trippy,” is that I agree with you that Michael Pollan's book “How to Change Your Mind” definitely cracked open the topic for me. I didn't know I was even interested in this topic, but I'll read anything Michael Pollan writes. And so that's what my exposure was. And I don't think I was alone in that. But I agree that we are in this era where much of the rhetoric around psychedelics is positive, as these miracle cures as, you know, the next thing in psychiatry. And while that might be true, we have to approach that in a balanced way, with a level of skepticism and an understanding that all interventions have the potential for side effects and adverse events, no matter how benign. Well, maybe not breathing exercises. I don't I don't think anybody was ever harmed by breathing exercises, but all medications, procedures, you know, ingestions have the potential, for harm as well.
I like the end of “Trippy,” where you go to the meeting. It's a psychedelic conference called Wonderland. And you say it's full of quacks, show boats and acclaimed scientists, I think Ernesto. Oh, you went to that meeting hoping to meet people like Eric, who had been studying in the field and were trying to bring a level of understanding. It did seem like the beginning of your journey started with an academic physician, I believe, from Yale. And then ended with some further researchers as well. I'm curious from both of you, what you see will be the future of the science and the use of psychedelics, particularly in medical settings. I know neither of you has a crystal ball, but standing at this point in the middle of 2024, where do you see the near future for psychedelics?
Ernesto Londoño: I can go first. I think there's been two main tracks over the past few years in which, you know, this has been advancing. On the one hand, this sort of the clinical science path where there's been a goal of rescheduling some of these compounds, meaning, changing the way they're classified under the government system of assessing how dangerous and medically useful certain drugs are.
So psychedelics right now are in the strictest category, schedule one, and there's been clinical trials that have been conducted with an aim toward rescheduling, meaning getting the government to acknowledge that there is therapeutic value in these compounds and that they can't be used safely in clinical settings. So but that effort has run into some serious turbulence. I think the critical test was whether we could get MDMA to be approved by the FDA as a treatment for post-traumatic stress disorder, and the FDA in recent days decided that the studies that have been conducted in the pursuit of that don't quite persuade them enough that these experiences and these drugs can be administered safely if they feel that they're still important questions that need to be wrestled with. So right now, we find ourselves kind of stuck in the sense that there's really promising medical literature that points to the therapeutic potential of these compounds. But regulators are not persuaded that you can really open that door safely and responsibly now. So there's a lot of interest that has been forming, among patients that are frustrated with what the mainstream system has to offer and where that's leading them is to be underground or sort of this pseudo spiritual spaces, that are becoming the path of least resistance for people who might want these interventions and the problem with that is that there are far fewer safeguards and guardrails in those settings. So you have sort of the scientific community has given legitimacy to the idea that these compounds can be really effective and can be really transformative for people. But there is a real barrier to access. Very, very few people can get these experiences in a clinical setting, usually only in kind of the context of clinical trials.
So that pushes the demand into the wild west of so-called psychedelic churches, which are sort of blending spirituality and medicine in a way that's really intriguing, but also, I think, fraught with peril.
Dr. Eric Noble: Yeah, I think you hit the nail on the head. There's the separation of kind of the scientific community with sort of the underground access. I'll just speak from, from a psychiatrist perspective and working with training psychiatrists and medical students, I mean, there's such a huge growing interest in popularity in these compounds and a ton of research going into them. I think psychiatrists are really hungry for new treatments. We haven't add new treatments for depression and anxiety for a very long time, and these open up the possibilities of treatments that have a whole new way of working and providing an exciting line of research into how the brain might work. So that's really exciting. I also think there's a level of like coolness to psychedelic treatment and this space, and there's like a certain cool cachet to them that I think as a, as a group of nerdy medical students, psychiatry sometimes yearn for a level of like, cool factor.
So I think that's why a lot of people are getting into the field. But I think, as Ionesco mentioned, the FDA kind of splashed a bunch of cold water on the field. And this was just about a week ago when they rejected MDMA as a therapy for PTSD to get FDA approval, typically you need phase three trials to demonstrate that a treatment is safe and effective, and to have a phase three trial requires a lot of money, a lot of time, and a lot of participants. Right now, there are a couple of phase three trials going on for psilocybin. they haven't been completed yet, but those are for treatment resistant depression. So I think a lot of people are anxiously awaiting the results of those. But the smaller phase two trials were very encouraging. I think there's several issues with scientific studies in general, and one of the main things that the FDA had trouble with with the MDMA studies was placebo blinding.
And basically 90% of the people in the trial could correctly guess whether they got placebo or MDMA. And obviously that's going to skew the data. And that's an inherent difficulty with psychedelic research, is how do you properly blind and control these studies to make sure that, patients expectations aren't incorrectly skewing the data. So I think in general, the cat's out of the bag. And I think that's a really good thing in terms of there's going to be more research on this. I think somewhat slowing down. And, looking at these things in a more deliberate, scientific way is important. But at the same time, the more we slow down from a scientific and regulatory standpoint, the more it allows for this opportunity for the underground to capture these really high need patients. It's juggling a lot of ethical, scientific questions and risks and benefits. I don't have the answers to those, and I don't think anyone's come up with a really good answer to those.
Dr. Eric Noble: I think the question that I'm most interested in, if I could fast forward ten years down the line, is, you know, if in fact, kind of the medical lane is really, really slow to open, how will psychedelics change our collective spiritual life? And could there be sort of mental health dividends if in fact many, if not most people end up experiencing these journeys for work, these modalities in a ritualistic or ceremonial setting?
We're in a moment where a lot of people have drifted away from organized religion, and pews are emptying out. So I think people feel kind of a deficit of sort of, a meaningful spiritual life, which I think can be really grounding and valuable for people to just navigate it or city and feel connected to something larger. And psychedelics do become kind of an anchor for revitalizing spirituality at the personal level.
Could that lead us to healthier communities and society leads in a way that somewhat bypasses the clinical model. And there's all sorts of things that could go wrong, like some of these communities could devolve into cults that may be a lot more harmful than them healing for people. But that, to me, is seeing kind of the seeds of this ecosystem which are really taking root primarily in ceremonial settings.
And being led by people who see themselves first and foremost as spiritual practitioners. You know, could that ultimately be the way in which this makes the greatest impact on people's mental health and just their general sense of well-being? I'd love to know the answer to that. I'd love to know how that evolves and whether at some point, if this really grows by leaps and bounds, the clinical side of it catches up and offers something distinct and unique.
Dr. Denise Millstine: And the balance goes on. The future will be interesting no doubt. I want to thank you both for being here to talk to me about psychedelics, their medicinal use, the peril and promise. as the book indicates. It's been a pleasure to talk with you.
“Read. Talk. Grow.” is a product of the Women's Health Center at Mayo Clinic. This episode was made possible by the generous support of Ken Stevens. Our producer is Lisa Speckhard-Pasque and our recording engineer is Rick Andresen.
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