Psilocybin and Ketamine: An Option for Palliative Care

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Psychedelics have gained mainstream attention because of media’s reporting on promising research and Michael Pollan’s recent documentary on Netflix, How to Change Your Mind. The promise to reduce symptoms related to mental illness, and an ever-growing list of other conditions, such as neurodegenerative diseases, anorexia, cluster headaches, autism, substance use disorders, and more, is too good for people to ignore.

Many of the studies show promising results, with none more compelling than those using psilocybin with adjunct psychotherapy to reduce psychological and existential distress in those with life-threatening illnesses. For two decades, prestigious universities such as Johns Hopkins, NYU and UCLA have consistently shown that the use of psilocybin-assisted therapy reduces anxiety and depression in participants with advanced-stage cancer. Not only that, but participants also confronted their fear of dying, found meaning in their lives and felt at peace with their death and dying.

The JHU researchers found that six months after two psilocybin dosing sessions with associated psychotherapy, 79% and 83% of participants significantly reduced depression and anxiety, respectively, and >80% reported increased feelings of well-being. Similarly, in a study conducted at the New York University Langone Medical Center, research showed that eight months following a single psilocybin dose, 83% and 58% of the participants were in remission for depression and anxiety, respectively.  

From these studies and others, participants commonly report a feeling of oneness and a reduction in the fear of dying, the latter considered a correlate for increased anxiety and depression in palliative care patients. JHU published a study August 24, 2022, to compare people who have used psychedelics to people who have experienced near death or similar experiences (NDEs). They surveyed 3,192 participants, 933 of them were non-psychedelics users but had NDEs, the remaining participants had used a variety of psychedelics, including psilocybin and LSD. One similarity between the groups found that 88% of the non-psychedelic users and 89% of the psychedelic users, experienced a reduction in their fear of dying. In general, they also found that the scores on the mystical and near-death experience questionnaires, were significantly higher in the Psychedelic Group than those in the Non-Psychedelic Group.

This leaves those of us wanting to ease the suffering for those at end-of-life in a tremendous quandary. Currently, the only legal recourse to the use of psilocybin is to travel out of country to places such as, the Netherlands, Jamaica or Costa Rica. One psilocybin retreat in Jamaica is the first to offer a specially curated psilocybin exploration with facilitated discussions on the topics of death and dying, as well as experiential training for hospice and palliative care professionals (full disclosure, I am on contract with them). The retreat, developed by an end-of-life doula and led by a psychedelic-trained psychotherapist with 30 years’ experience as a hospice social worker, helps attendees and their families explore what a good death means to them.

Psychedelics have gained mainstream attention because of media’s reporting on promising research and Michael Pollan’s recent documentary on Netflix, How to Change Your Mind. The promise to reduce symptoms related to mental illness, and an ever-growing list of other conditions, such as neurodegenerative diseases, anorexia, cluster headaches, autism, substance use disorders, and more, is too good for people to ignore.

Many of the studies show promising results, with none more compelling than those using psilocybin with adjunct psychotherapy to reduce psychological and existential distress in those with life-threatening illnesses. For two decades, prestigious universities such as Johns Hopkins, NYU and UCLA have consistently shown that the use of psilocybin-assisted therapy reduces anxiety and depression in participants with advanced-stage cancer. Not only that, but participants also confronted their fear of dying, found meaning in their lives and felt at peace with their death and dying.

The JHU researchers found that six months after two psilocybin dosing sessions alongside psychotherapy, 79% and 83% of participants significantly reduced depression and anxiety, respectively, and >80% reported increased feelings of well-being. Similarly, in a study conducted at the New York University Langone Medical Center, research showed that eight months following a single psilocybin dose, 83% and 58% of the participants were in remission for depression and anxiety, respectively. Even more compelling are the results from a follow-up study to measure reductions in depression 18 months after a single dose of psilocybin. Fully 67% of the participants reported significant reductions and 57% were in remission. The field of study has exploded as researchers seek to prove the benefits of psilocybin therapy to this vulnerable population. There are no less than 10 studies being planned or underway. You can find them by going to clinicaltrials.gov and using keywords such as psilocybin, cancer, anxiety, or depressions.

From these studies and others, participants commonly report a feeling of oneness and a reduction in the fear of dying, the latter considered one of the major reasons for increased anxiety and depression in palliative care patients. JHU published a study August 24, 2022, to compare people who have used psychedelics to people who have experienced near death or similar experiences (NDEs). They surveyed 3,192 participants, 933 of them were non-psychedelics users but had NDEs, the remaining participants had used a variety of psychedelics, including psilocybin and LSD. One similarity between the groups found that 88% of the non-psychedelic users and 89% of the psychedelic users, experienced a reduction in their fear of dying. In general, they also found that the scores on the mystical and near-death experience questionnaires, were significantly higher in the Psychedelic Group than those in the Non-Psychedelic Group. Given these results, the field of study has exploded as researchers continue to seek to prove the benefits of psilocybin therapy in this vulnerable population. There are no less than 10 studies being planned or underway as of early 2024. You can find them by going to clinicaltrials.gov and using keywords such as psilocybin, cancer, anxiety, or depressions.

This leaves those of us wanting to ease the suffering for those at end-of-life in a tremendous quandary. One option is to travel out of country to places such as the Netherlands, Jamaica, Spain or Portugal where psilocybin is permitted by law. The reality, though, is that people with life-threatening illnesses are reluctant to travel overseas and leave the safety net of their medical team behind.

In the US, one option is emerging in states like Oregon and Colorado. Oregon allows for psilocybin care under state law through Licensed Psilocybin Service Centers. Although there is no program designed specifically to address the needs of someone with an advanced illness, palliative care patients have participated in sessions at the Licensed Service Centers. Colorado anticipates launching similar services in 2025 and, unlike Oregon, psilocybin care will be able to be administered within a palliative care setting or even in one’s home. In Canada, those with a life-threatening illness may be able to apply and be accepted into Canada Health’s Special Access Program which allows them access to psilocybin therapy with a trained facilitator or in group programs like Roots to Thrive. Based in Vancouver, British Columbia, RTT developed what they call a “practice in community” therapy program, offering 8 weeks of preparation and integration around a psilocybin experience. Building community is an important part of the program. Participants traverse the program in cohorts and forge deep bonds as they prepare, journey and discuss experiences together. As Dr. Pamela Kryskow, Head of Psychedelic Medicine likes to say, the participants “come for the psychedelics but stay for the community.”

There is a less glamorous “psychedelic” that is gaining traction for palliative care. Ketamine is technically not even a psychedelic, it’s a dissociative anesthetic. It can be prescribed off-label in many countries including the US, Canada and the UK and shown great promise reducing severe chronic pain and symptoms of anxiety and depression. Although many health care professionals have administered it to patients in the context of emergency care or surgical procedures, it is not yet standard protocol in most palliative care centers where it arguably would be extraordinarily efficacious.

Ketamine has its pros and cons: although rapid acting, reducing severe chronic pain, anxiety and depression, as well as suicidal ideation, it is, relative to other psychedelics, shorter lasting. Pain Management Specialist, Dr. Michelle Weiner, DO, MPH, and frequent speaker on the topics of ketamine and psychedelics for palliative care administers a series of Ketamine Intramuscular Injections (IM) over a period of 3 – 6 weeks, then offers boosters on an as needed basis to maintain the therapeutic benefit. For some patients, she also prescribes lower dose ketamine sublingual lozenges (also called troches) for at-home use. This can help to maintain a therapeutic benefit, reducing the number of in-clinic injections needed. For many cancer patients, she will also prescribe 50- 100mg ketamine lozenges for daily or every other day use for the management of pain, depression or anxiety. With the proper preparation, setting and assistance at home some cancer patients may use a 200mg lozenge to also help treat end-of-life distress.

There is an excellent guide published March 2022 by Brain Futures on Psychedelic Medicine detailing the research on multiple psychedelics, including Ketamine. They report on several studies involving palliative care since “studies suggest that those suffering from chronic pain are four times more likely to have depression or anxiety than those who are pain-free.” By reducing chronic pain, the general consensus is that ketamine can greatly mediate anxiety and depression without the potential for opioid abuse. One of the studies Brain Futures reported on showed ketamine’s ability to reduce severe pain experienced by complex regional pain syndrome (CRPS) sufferers. The researchers showed that 76% of patients reported complete pain relief with 54% remaining pain free for more than 3 months.

And, supportive of Ketamine’s ability to reduce chronic pain effectively, one 2021 study found “use of a standardized Ketamine Step Protocol showed a statistically significant reduction in pain and Morphine Equivalent Daily Dose (MEDD) in patients with predominantly neuropathic cancer pain. It also demonstrated a safe and effective method for opioid reduction after commencement of parenteral ketamine.”

Ketamine’s future may even get brighter for palliative care. Yale University received a grant to study ketamine to relieve depression in patients with Parkinson’s and PharmaTher has FDA approval for a Phase II Clinical Trial to study the effects of Ketamine to reduce Levodopa-induced dyskinesia8. Stay tuned to both psilocybin and ketamine as clinical trials and real-world studies continue to be compiled.

Christine Caldwell is the Founder and Executive Director for the nonprofit, End of Life Psychedelic Care and a member, Dying Well Initiative/Global Wellness Institute. She holds a certificate from the Psychedelics Today Vital Therapies and Integration Program. and is the former owner of a $2.2 million home health care agency. She also is a self-proclaimed neuroscience and quantum mechanics geek.

REFERENCES
1https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367557/
2https://journals.sagepub.com/doi/10.1177/0269881116675512
3https://journals.plos.org/plosone/article/file?type=printable&id=10.1371/journal.pone.0271926 
4https://www.brainfutures.org/mental-health-treatment/patevidence/
5https://pubmed.ncbi.nlm.nih.gov/15367304/
6https://www.tandfonline.com/doi/abs/10.1080/09699260.2021.1922146
7https://medicine.yale.edu/news-article/michael-j-fox-foundation-grant-will-fund-first-clinical-trial-of-ketamine-to-treat-depression-in-people-with-parkinsons-disease/
8https://clinicaltrials.gov/ct2/show/NCT04912115?term=ketamine&cond=Parkinson+Disease&draw=2&rank=2

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