‘Don’t be an ostrich: we want to talk about it.’
The role of the C-L psychiatrist in treating patients with serious illness who request access to ketamine and psychedelic-assisted therapies (PAT) was comprehensively discussed in a workshop at CLP 2023.
Speakers described a growing interest in novel therapeutics for psychospiritual distress in patients with serious illness.
While not a classical psychedelic, ketamine has demonstrated safety and potential efficacy for treating depression and anxiety in patients with serious illness, and is increasingly accessible in community settings.
Classical psychedelics, primarily psilocybin, a Schedule I substance, are still being actively studied and show promising results attenuating psychospiritual and existential distress in patients with cancer.
Neither ketamine nor psilocybin is currently readily available for clinical use in seriously ill patients, which presents a unique challenge when medically and psychiatrically complex patients seek these treatments.
Based on their experience working at Dana Farber Cancer Institute, Harvard Medical School, Boston—a major cancer center with an active PAT research program—speakers reviewed the challenges and ethical considerations raised in responding to requests for consultation and advice on the consumption of ketamine and PATs, and discussed the potential risks and benefits of offering guidance on its use in therapeutic settings outside the institution.
They also reviewed the challenges and ethical considerations encountered in liaising with both licensed and non-licensed community providers, and considered the appropriation of psychedelic medicines from indigenous peoples, including limitations in participation in research, and access to ketamine and PAT for patients of color.
“We failed with cannabis,” said Ilana Braun, MD, in her presentation, as she considered what lessons could be applied to ketamine and PAT from medical cannabis use and the ways it had not been successfully integrated into serious illness care.
Dr. Braun described the gap that exists between medical providers’ knowledge and confidence in discussing cannabis use with their patients; the level at which patients are accessing and using cannabis for a variety of symptoms; and the perceived lack of clinical oversight among some adults who medicate with it.
She quoted from a Dana-Farber Cancer Institute patient survey which disclosed that only 12 per cent of patients received cannabis information from their cancer doctor or nurse, while 74 per cent wished they had.
As PAT becomes more widely accessible, Dr. Braun urged C-L psychiatrists to:
“We don’t want to be an ostrich,” she said. “We want to talk about it.”
Among further presenters, Roxanne Sholevar, MD, said there was strong evidence that the use of PAT with cancer patients at the end of life had a positive effect on anxiety and depression.
People with serious illness experience distress over and above the physical symptoms of their specific condition, she said. Sixty-two per cent feel anxious, confused, or helpless; 48 per cent have emotional or psychological problems caused by their condition; 32 per cent feel left out, lacking in companionship, or isolated from others. Distress extends beyond traditional psychiatric diagnoses and includes spiritual well-being and desire for hastened death.
PAT, she said, is not a standalone intervention. Psychedelic medication administered to induce a non-ordinary state of consciousness is embedded in a framework of support of pre and post treatment, as well as support during administration. “Research has shown how powerful the psychedelic experience can be, and how support is critical to both reduce harm and optimize effect,” said Dr. Sholevar.
John Peteet, MD, and Angela Landerholm, MD, described cases illustrating typical patient questions about PAT; Carrie Wu, MD, presented ethical issues in recommending PAT at this time; and a general discussion ensued.
The workshop, All the Buzz: Practical Considerations for Practicing Psychosocial Oncology in the World of Cannabis, Ketamine, and Psychedelic-assisted Therapies (below), is one of many CLP 2023 sessions recorded and available on the CLP 2023 website.