Novel Treatment Approaches for Substance Use Disorders : Therapeutic Use of Psychedelics and the Role of Psychotherapy

Michael Koslowski, Matthew W. Johnson, Gerhard Gründer, Felix Betzler

Current Addiction Reports, 2021, 1-11.

doi : 10.1007/s40429-021-00401-8

 

Abstract

Purpose of Review : The use of psychedelics in a therapeutical setting has been reported for the treatment of various diagnoses in recent years. However, as psychedelic substances are still commonly known for their (illicit) recreational use, it may seem counterintuitive to use psychedelic therapy to treat substance use disorders. This review aims to discuss how psychedelics can promote and intensify psychotherapeutic key processes, in different approaches like psychodynamic and cognitive behavioral therapy, with a spotlight on the treatment of substance use disorders (SUD).

Recent Findings : There is promising evidence of feasibility, safety, and efficacy of psychedelic therapy in SUD. In the whole process of former and current psychedelic therapy regimes that have shown to be safe and efficacious, various psychotherapeutic elements, both psychodynamic and behavioral as well as other approaches, can be identified, while a substantial part of the assumed mechanism of action, the individual psychedelic experience, cannot be distinctly classified to just one approach.

Summary : Psychedelic therapy consists of a complex interaction of pharmacological and psychological processes. When administered in well-defined conditions, psychedelics can serve as augmentation of different psychotherapy interventions in the treatment of SUD and other mental disorders, regardless of their theoretical origin.

Keywords : Psychedelics · LSD · Psilocybin · Psychotherapy · Psychodynamic · CBT · Addiction

 

Introduction

Psychedelics, also known as serotonergic hallucinogens, exert their main effects via stimulation of the serotonin 5-HT2A receptor [1]. Not included in the use of the term psychedelics in this article are dissociative anesthetics (e.g., ketamine), empathogen-entactogen stimulants (e.g., MDMA; 3,4-methylenedioxy-meth-amphetamine), ibogaine, or new psychoactive substances (NPS, “legal highs”). The best known psychedelics are LSD (5R,8R-lysergic acid diethylamide), psilocybin, DMT (N,N-dimethyltryptamine), and mescaline (3,4,5-trimethoxyphenethylamine). These substances cause an altered state of consciousness, usually lasting several hours, with profound changes in perception,
including hallucinations, synesthesia, altered experience of time and space, and strong activation of emotions and emotionally formative memories [1]. In Europe, psychedelics are best known to be used in recreational settings, while overall lifetime-prevalence levels among young adults have been
generally low and stable for a number of years between 1 and 2% [2]. While their individual and societal harm ranks the lowest among many illegal legal substances, and their addiction/dependence potential seems negligible, [3, 4], most psychedelics are controlled under the Convention on Psychotropic Substances of 1971. It might therefore seem counterintuitive to use these substances to treat addiction.

However, in this article, the authors present psychotherapeutic frameworks and possible mechanisms of action, in order to show why and how addiction treatment with psychedelics may be beneficial, which has been suggested in a number of epidemiological and observational trials [5–11], clinical trials [12–15], metanalyses [16], and conceptual articles [17–21]. There is growing evidence that psychedelics can be used to intensify psychotherapy processes in certain conditions, and thus serve as a non-specific augmentation of certain psychotherapeutic processes, which play a role in different forms of psychotherapy. We put a focus on psychodynamic therapy and CBT in this article for the high
availability of empirical data in reported trials, as well as for their well-known historical and conceptional differences, which makes the similarities concerning the combination with psychedelic even more striking. High quality empirical data about other psychotherapies (e.g., hypnotherapy, group
therapy) in psychedelic therapy is sparse though, and would be worth being further investigated.

Psychedelic Use, Research, and Therapy

Psychedelics have been used for several millennia in the context of traditional practices and shamanic rituals, for healing physical and mental disorders, for religious reasons and divination [22]. Since the beginning of the twentieth century, psychedelics have aroused the interest of botanists, psychologists, and psychiatrists. This interest was reinforced by the discovery of the psychedelic effects of LSD in 1943 [23]. Along with the associated counterculture in the 1960s, psychedelics became increasingly popular for recreational use. It is estimated that more than 30 million people living in the USA have used LSD, psilocybin, or mescaline in their lifetime [24].

In a clinical and research context, these substances were initially used as an experimental disease model for research on psychotic disorders (“psychotomimetics”), and rarely for self-exploration among psychiatrists. Further aspects of their therapeutic potential in the treatment of mental disorders
were recognized later [25]. In fact, investigators who first tried LSD as an alcoholism treatment hypothesized that a psychotic-like experience would mimic a safer version of delirium tremens, because delirium tremens often preceded sobriety, but were also frequently fatal. However, these investigators found that under interpersonally supportive conditions, instead of psychotic-type experiences, patients
often had positively-valenced experiences, for example insightful, peak, or mystical-type effects (e.g., feeling at one with the universe) that led to sobriety [26–28]. It was psychiatrist Humphry Osmond who coined the term psychedelic in 1957 to describe the mind-manifesting, revealing properties of these substances, after having observed that high doses of LSD in patients with alcohol dependence
lead to profound experiences and strong effects on alcohol relapse prevention [26]. Between the late 1950s and early 1970s, approximately 40,000 patients worldwide with different mental disorders (substance use disorders, affective disorders, neurosis etc.) were treated with psychedelics— primarily LSD, mescaline, and psilocybin—sometimes with reports of remarkable therapeutic success described in
over 1000 publications [29]. Following the largely socially and politically motivated international ban on psychedelics in 1971, almost all research activity in this field came to a halt. It was not until the 1990s that interest in psychedelic research has resurged. Since about the year 2000, there has been an increasing number of basic science and clinical studies [23, 25].

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