Nicotine patches, chewing gum, cold turkey. Giving up cigarettes can be tough, but there are many strategies smokers can try. Matthew Johnson wants to add another: he says he can help smokers quit by giving them another drug – psilocybin – that has been illegal for years in much of Europe and North America. And yes, he realises that sounds unconventional.
“The idea that this research sounds counterintuitive, it makes sense to me,” he tells me as we sit in his office at Johns Hopkins’ Behavioural Pharmacology Research Unit in Baltimore.
It's been off limits for all the wrong reasons – Matthew Johnson, pharmacologist
Johnson is a behavioural pharmacologist who has been researching the relationship between drugs, the brain, and human behaviour for more than 20 years. The last 10 of those have been spent here at Johns Hopkins, where he and his team have focused on psilocybin, a naturally occurring psychedelic and the active ingredient in ‘magic mushrooms’. Illegal it might be, but if psilocybin is given to smokers a few times in a carefully controlled way, it can be a remarkably effective aid to help them kick the habit, he says.
“Most people will naturally assume that we're looking at substitution therapy in the spirit of methadone for heroin addiction or nicotine patch or nicotine gum to replace smoking. [But] we're not talking about putting someone on psilocybin or mushrooms every day. It's not trading one addiction for the other.”
This new research has been inspired by work done in the 1950s and 60s that looked at using psilocybin and LSD as treatments for addiction. Although results back then were hugely promising, the research hit a dead end as use of these substances spread from labs and into the emerging drug counter-culture. The drugs were criminalised, and clinical research became impossible to conduct.
“It's been off limits for all the wrong reasons,” Johnson explains. “We know [these substances] continue to be used, and because of not wanting to encourage uncontrolled recreational use, we've been so restrictive that we haven't allowed research. We're really playing a catch-up game. This stuff should've been done in the mid 70s…the whole research agenda was just put in deep freeze for multiple decades.”
In 2008 Johnson co-authored a paper entitled 'Human hallucinogen research: guidelines for safety’, which outlined how to responsibly conduct medical trials with psilocybin and other hallucinogens. It included recommendations on how to screen potential volunteers, prepare them for the experience, and how to conduct the drug-taking sessions safely. The paper signalled a change in attitude towards researching these compounds, reflected by the fact that more than 460 psilocybin sessions have now been conducted at Johns Hopkins alone, ranging from investigating its use by cancer patients through to its effects on meditation. But it’s the Smoking Cessation programme, which has just finished its pilot stage, that has attracted the most recent attention.
It begins with a mantra...
The programme seems deceptively simple at first. Fifteen volunteers, all long time smokers from the Baltimore area who have tried and failed to quit smoking multiple times, start with a course of cognitive behavioural therapy. CBT is the standard psychological approach to quitting smoking, encouraging subjects to reflect on their established thinking patterns.
A vital part of the Hopkins programme’s CBT approach is the writing and reciting of a personal mantra; a simple phrase that each volunteer creates that encapsulates why they want to quit. “This is really our mission statement. If you had one sentence that you could remind yourself down the road why you quit. We’ve had some people for whom it’s about family: ‘I want to be there for my granddaughter.’ For other people, it's more philosophical, ‘The air that I breathe. I want it to be free.’”
This mantra becomes even more central on the day they take their first psilocybin. After four sessions of CBT, the volunteers smoke what is meant to be their last cigarette. For some this is the night before, for others it’s literally just before the session. “We've had people smoke in the parking lot right before they come in here,” Johnson tells me.
Then, it’s time for the drug. Albert Garcia-Romeu, a post-doctoral fellow at Johns Hopkins, who ‘guides’ the volunteers through the CBT and the psilocybin sessions, describes how it works: “We have them self-administer the capsule. We take their cell phone. We take their shoes. We give them some slippers. We want them to relax into the day and feel almost like they're in a spa. They don't have to go to work. They don't have to do their normal day-to-day thing.”
“We practice before. Give them our hand so that they have the support if they need it,” explains Mary Cosimano, another of the guides who has been working in the field for more than 15 years. “We tell them, ‘We're here for you as much as you like’.”
“Once the drug effect starts to kick in, we encourage them just to lie down,” continues Garcia-Romeu. “They put on headphones. They cover their eyes. We have them just lay back and watch and wait.”
We usually discourage them from getting too chatty
From this point, the researchers step back. “What we do here is psychedelic therapy,” explains Garcia-Romeu. “That's high-dose. That's generally not a talking therapy. We usually discourage them from getting too chatty because it can be really easy to get absorbed in the interesting sensory things that are going on. We try to encourage them to go inward and that's really where a lot of the important work happens. I'm mostly just there as a safety-monitor.”
The aim, the team explains to me, is to give the volunteers a ‘profound’ or ‘mystical’ experience that causes them to reassess their relationship with smoking. That might sound like exactly the kind of New Age drug talk that made people take this kind of research less than seriously in the past, but Garcia-Romeu explains it to me in a way that sounds much more grounded.
“[Research shows there’s a] 71% success rate for people who quit smoking just after they had a heart attack,” he explains. A heart attack would certainly qualify as a profound experience, but it’s not something you can go around triggering in people in order to stop them from smoking. Instead the aim is to use a powerful psychedelic trip to trigger a similar effect… an intense, abstract experience that changes the patient’s perspective. It’s this that the team refer to as a ‘mystical experience’.”
This experience might range from images of God, to powerful personal memories about their own life or childhood, he explains.
The person is made to feel as safe as possible
The secret to triggering this kind of experience is setting and context, Johnson explains. “Our clinical impression is that those experiences are most likely to happen under conditions where the person is made to feel as safe as possible, that they've developed a very strong rapport with the people that they're with.” Also, the team has found that making the act of taking the drug a ritual seems to help.
“We ask them to bring pictures of themselves over the years, family, people, places, and things. We've had people who have filled the room with pictures,” explains Cosimano. “Things that could be important to them, objects. People have set up altars. People bring stuffed animals or a blanket. Things that can make them feel comfortable, safe, cosy, meaningful.”
To enhance the feeling of ritual, the researchers also put the capsule in a wooden goblet with incense, and ask participants to repeat the mantra they developed during the cognitive behaviour therapy.
Garcia-Romeu and Cosimano show me the session room, the place where these rituals take place. It’s pretty much exactly as they’d described it to me – a small, cosy room, softly lit with a comfortable couch. They let me sit on it, and hand me the wooden goblet used by their volunteers. Books on Michelangelo and Van Gogh are scattered around. There’s an undeniable feeling of safety and comfort in the almost womb-like room, where volunteers spend up to six hours until the drug’s effects have worn off, after which they are taken home by a member of their family.
Talking to the team is fascinating – they’re all incredibly friendly, resolutely professional, and clearly passionate about their work – but it’s still hard for me not to shrug off the feeling that the work seems counterintuitive. Perhaps it’s my own prejudices about these drugs, but I remain sceptical.
Still, the trial program – small though it is – has produced tantalising results. Out of the 15 people, 12 were still smoke-free six months following the trials, according to the researchers. “We think and hope that there is something new going on here,” says Johnson.
“We've had people in this study, a couple of which claimed extraordinary things, like that they don't feel nicotine withdrawal and they've been smoking for pack a day for 40 years. Just seeing that in one person is pretty profound.”
I push him a little more on why he thinks psilocybin in particular might work in this way: is it purely just a psychological effect, or does he think the drug itself is affecting the brain’s chemistry? “We can best understand it at this point from a psychological perspective,” he replies. “This isn't a drug that, in a simple way, affects the brain’s nicotine receptors. Does this drug under the right conditions eventually change the way that the brain itself is interacting with its own nicotine receptors? That's something that very well could be happening. We don't know.”
Johnson is not the only person looking at psychedelic therapies. Anthony Bossis is part of a team at New York University conducting similar trials into using psilocybin to combat anxiety in cancer patients. He’s impressed by Johnson’s preliminary results. “These therapeutic approaches certainly warrant additional and careful scientific study.”
And that’s what Johnson and his team are focused on now, the next round of studies. The study sample has been expanded to 80, and volunteers will undergo MRI brain scans before and after the sessions so the team can get a better idea of what neurological effect the psilocybin is having on smoking, if any. There are clearly still years of work to be done, but Johnson is positive, and believes it could be used to treat a variety of psychological and behavioural conditions, not just addictions.
There are many hurdles to overcome before treatments become widespread
There are, of course, other hurdles that would need to be passed before these treatments become widespread. The main issue is working out who would develop these compounds commercially, says Thomas Insel, director of the US government’s National Institute of Mental Health. The pharmaceutical industry usually takes the lead in that sort of work, he says, but they generally have less interest in developing drugs for brain disorders. “That said, a version of ketamine — which also was a drug of abuse – is being developed by Johnson and Johnson as an antidepressant.”
And then there are legal questions too. “These drugs are being used in the context of psychotherapy, and we don’t have a clear regulatory framework for [that yet],” says Insel. These drugs are clearly a long way from becoming widely available in medicine. “But that’s not a reason to avoid [developing the therapies],” he says.
Ultimately, the early success of these small trials might not be repeated on larger scales. Yet after decades where psychedelic therapy was never investigated at all, scientists like Johnson and his team are now at least trying to dig deeper into the unexpected effects of this notorious drug.
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