Elias Dakwar on Treating Addiction with Ketamine

any type of drug. Hello, Psychoactive listeners. So today our guest is a Columbia professor, Elias Dakwar, who's done this fascinating research on using ketamine combined with mindfulness meditation to help people struggling with drug addiction. And he's actually one of the few people in the United States to actually

have received federal funding for research on psychedelics. I'm delighted to have you on the program and lives so just God, just start off, just tell me your name and introduce yourself and your title and where you are right now and such. Thanks for having me. My name's Liastkwar. I'm currently at the Columbia Medical Center, calling from my office

here in New York City. I'm an associate professor here of psychiatry, and I've been interested in research with ketamine, combining it with therapy for a variety of addictions and but addiction. I mean you started off in all this, even before you get into the kid amine about working on addiction and addiction treatment. Isn't that right? Correct? Yeah?

I started my foray into addiction treatment with meditation. I was very interested in how meditation might be helpful for disrupting some of the automaticity and reactivity that can happen with addiction, and developed an interest in combining meditation with other modalities. Meditation alone wasn't quite cutting it, and this grew. I mean you first got these insights from your own

personal experience with meditation and its value in your own life. Yeah, both personal experience with meditation, also with non ordinary experiences more generally, what do you mean in ordinary experiences? I guess psychedelic type experiences, fasting, mystical experiences, those sorts of things. Meditation has been the most I think durable and reliable

for me route towards those sorts of states. And you know there's a practice associated with it and a practice that enjoys a lot of social legitimacy, at least here in the United States, so it seemed something that could lend itself to treatment in Western models for addiction. Things have changed quite a bit since I started doing that research with greater interest and incorporating substances that previously had

been deemed inappropriate and medical settings like the psychedelics. But at the time it seemed like a fairly straightforward strategy think about meditation. Were you aware of that kind of earlier era, back in the sixties where Timothy Learry and Richard Albert In a whole host of other people were actually experimenting madelsty and I think mess Glinn perhaps philocybin, psilocybin and addiction. I mean, did you did you know that history when you first got interested in this stuff?

I did now. I grew up in the Bay Area and my uncle's were part of the counterculture during the sixties and would browse their bookshelves growing up reading R. D. Lange and Carlos Kostayeta and ram Das and all of those things, So it wasn't completely unusual or foreign to me. I didn't anticipate that it would gain the level of social currency that it has now. It's it's quite impressive and it's beautiful to see that it's being embraced as

it is now. There are some challenges we'll talk about later. I was well aware of the earlier attempts to understand how these substances could be helpful the unfortunate end to that research because of criminalization of these substances back in

the late sixties and such. Yeah, exactly. And in terms of your mentors and such when you started to study addiction treatment, right, I guess in your earlier years of training in psychiatry, Um, were you encouraged by them to look into these avenues of the role of the ketamine or psychedelics at that time. There's an interesting story I, Um, you know Karl Hard of course. Um, he's been a mentor to me and big source of support when I first mentioned to him that I was interested in in

doing this sort of work. I was interested in psilocybin. Actually, at the time, Roland Griffith at Johns Hopkins had come out with the repeat of the Good Friday experiment, where he showed that psilocybin given to healthy volunteers can lead to sustained improvements and well being and these very profound mystical experiences that they remember as among the most important in their lives and maybe just explain, actually, what's that initial Good Friday experiment was sure. It was an experiment

done at Harvard investigating psilocybin. The experiment took people who have an interest in spiritual matters, people from the seminary clergy, and investigated what happens when psilocybin is given, whether there's an improvement and spiritual understanding, whether it occasions experiences comparable

to mystical states. And Roland Griffiths, who himself has a longstanding interest in meditation, did an experiment that basically duplicated those effects and found that psilocybin has the propensity to cosmistical states, changes in time and space, a sense of knowing something that's beyond words, a sense of revelation of

seeing things in a profoundly new way. And these experiences went on to be remembered for um years subsequently as among the most powerful the person's life and also impactful with friends spouses, noting that there was a clear difference in the person after versus before. So that was the the experiment that Roland Griffiths had done, and that pretty much opened the door to this research being done again

on a mass scale. Actually, actually, Lass, if I recall correctly, even before Roland Griffiths had done that study, I think Rick Doblin, the founder of MAPS and Multidisiplinary Associated Cycholic Studies, had done his own twenty five year follow up on that Good Friday experiment and had tracked a lot of

these participants. I think these Boston University Divinity students down to see what they thought about this experience twenty five years later, and I think it found that many of them still regarded it as one of the most profound spiritual experiences in their lives. They wish they could talk openly to their congregants about it, uh, you know, they wish they could do it with their kids. Things like this. Some of them felt it had brought them closer to Jesus.

But you were saying about Karl Hart. So then Carl, our mutual friends, says to you, so I had mentioned that I that I'm interested in potentially doing treatment study with psilocybin for addiction and said, well, you're not going to be able to get an I H funding for it. My friend Um he's spoken with Nora Valkao herself, who said that ni H NEIDA, in particular our death set against funding any of that research and just explained Nora

local is. She's the head of the National Institute on Drug Abuse NIDA, which is the premier funding agency within NIH, fueling a lot of the research being done to investigate treatments for addiction and also the harms associated with drug use. NIDA emerged in lockstep with the War on Drugs as the science arm two identify what the risks of drugs might be and how to best deal with any problems that might emerge. So he was emphatic that I would be wasting my time trying to pursue that kind of

research if I hope to get funded by NIDA. He thought there might be a better chance looking at ketamine. Ketamine has comparable effects to psilocybin, but it's not scheduled. It's Schedule three, which means that it has known medical use with some risk of abuse. It emerged in the fifties as an anesthetic that lends itself to very easy use.

It can be given to people in the battlefield, in accident settings without requiring intubation, because it doesn't depress respiration, doesn't cause people to stop breathing, doesn't have any effects on cardiac functioning, so it lends itself to easy administration. You can innesthetize people in settings that don't require the

usual supports that hospitals provide. So in the Vietnam War, for example, it would it be too exactular what you're dealing with that And it was also used for in animals, right what animal surgery, veterinarians used to, etcetera. Yes, and it continues to be used in those capacities, both in veterinary and human medicine. And you may know as well that ketamine is a descendant, let's say, of PCP, So PCP works in a very similar way to ketamine. It

binds to the PCP site of the glutamate receptor. Glutamate is one of the most abundant excitatory neurotransmitters in the brain and can lead to dissociation. With that effect, it binds to the site antagonize his glutamate, and it can lead aspects of experience that are usually coupled to become decoupled,

so the feeling and the thinking part, the conscious and unconscious. Well, it's when I remember about PCP though, was all the hysteria in Washington, d c. Where it became one of the most popular drugs of use and abuse for a while, and you'd have cops telling these stories about people crazed on PCP, you needed five cops to tie them down and all this sort of stuff. But um, I didn't

realize the connection between PCP and kennemine in that regard. Yeah, PCP definitely became one of the scare drugs of the DARE program. Growing up in the Bay Area, every year we had the same story from the cops who came with the suitcase of drugs to tell us about why to stay away from heroin, why to stay away from acid, pot, and PCP always involved a story of you know, someone craze, either ripping out his eyeballs or jumping out of a building or trying to do something of hercue lee in excess,

like trying to flip over a cop car. But PCP is basically ketamine, except it's longer acting and has greater affinity for the glutamate receptor. So with proper dosing. It can work functionally like ketamine does. The one difference is that it is longer acting. Ketamine is incredibly short acting um It has a very rapid clearance right the half life short so after a single administration of ketamine, the

person is fairly back to normal after forty minutes. But where people feel actively under the influence of the kenemine, is it only that length of time as well? Or depends on how it's administered um so intranasally, which is the way that it's most commonly administered in recreational settings. The last about twenty minutes intramuscularly, last about forty minutes intravenously. It can last as long as it's being infused, as

long as it's stripping into the person's bloodstream. You know, as I say, I think the first time I ever read about ketamine, I think it was reading some kind of autobiographical book by John Lily right. And John lily was a founder of stay teaching communications, you know, communications buying among dolphins and whales, and also the guy who

invented the isolation tank. And he talked about taking ketamine and he had suffered from migraines and he felt the migraines just kind of separating from his head, and then he got into a much more exploratory phase. I think of taking ketamine like every hour on the hour in one of his isolation tanks and almost killing himself that way or something. But it was the first time I

realized that there was this drug called kenemine. I don't even know if I was aware at the time of its role in surgery and things like that, but it does seem like this incredibly versatile drug exactly. The versatility comes from the variety of effects that can have based

on dose. So it was originally intended to be used in the anesthetic range where it would put people out, but it can also be used, as you said with John Lilly's self experimentation and exploration, can be used in a sub anesthetic range where it doesn't lead to loss of consciousness, but it leads to fairly profound changes in experience and perception. And that's really been where the most recent interest has been and what it might do psychiatrically

within that sub an aesthetic range. So the resurrection of ketamine came initially through if Jenny Kropitski's work actually if Jenny Krpitski was also funded by MAPS. You mentioned Rick Doblin earlier. He did some fascinating work in St. Petersburg. St Petersburg, Rushia and not Florida. Let's I thought the

name gave it away. Um. Yeah, So he he gave an intramuscular dose of ketamine, you know, enough to occasion a psychedelic state in combination with what he called ketamine psychedelic therapy, and there were lots of iterations of this therapy. What what he ultimately landed on was a therapy framework comparable to what was used in the fifties and sixties with LSD and psilocybin, where the experience was central to

the treatment. The therapy was intended to help a person and prepare for a potentially transformative experience, and then subsequently to help the person makes sense of it, integrate it, and find a way to consolidate those benefits in pursuit of a healthier life, whatever that life might look like,

depending on the challenges the person's facing. So if Jenny investigated ketamine in a similar way for alcohol addiction and heroin addiction and found remarkable effects, I think we'd be really in a different place right now if he was allowed to continue this research. Unfortunately, ketamine is now illegal and has been so for decades in Russia, and so he to end the research, a reprisal in a way of what happened in the States in the fifties and sixties,

where some promising results were aborted because of policy. Yeah, Alias should actually tell you, Um, I actually met a Ginny back in the nineties, and it was when I was starting up the International Harm Reduction Program through Soros Foundation, and we actually did a conference in St. Petersburg on drugs and HIV and harm reduction, and there was this

kind of opening period. There was even a period in the early years of Putin of his being open to decriminalization of possession and things like this, and then this massive hard turning in the opposite direction. But I mean, it's interesting to think that some of the pioneering work in this area came out of Russia. And what I think is also unappreciated is how formative if Jenny was

to biological psychiatryes embrace of Kenemine. So if Jenny had gone to Yale as a fellow while engaged in this research and in St. Petersburg and Yale, as you may know, is where ketamine was serendipitously found to have antidepressant effects. And I didn't know that when was that? The first paper was in two thousand is John Crystal, who is the editor in chief of Biological Psychiatry, and that really set the stage for how ketamine has been received by

mainstream psychiatry. It was being approached as a purely biological intervention, as a medicine comparable to e c T electro convulsive therapy. So this is emerging at Yale at the same time that ketamine a K A special K is becoming popular in the gay dance clubs in the city. I mean as an Arnold's almost simultaneously happening about twenty years ago. And does the fact that it's emerging is such a popular party drug and in the media complicate the efforts

at Yale to look at it's role in depression. I think the foresight perhaps that the psychiatrist that Yale had, but also ultimately the great blind spot, was to not look at ketamine for what its psychoactive effects might be, to look at it purely as a biological intervention. That separated it quite dramatically from why it might be used in recreational settings, which is to elicit these usually enjoyable,

interesting effects. So, in developing the story behind how ketamine might be impactful, the hope was that it would create space for ketamine like compounds without those psychoactive effects to be developed. And what do you think I mean, I'm going to ask you about your studies shortly, But in terms of uh, this notion of separating out the psychoactive effects from the medical effects, I've seen people try to think about what that can be done with cannabis, Where

we can you know, other drugs. I mean, is the psychoactive element of ketamine essential to its sickacy in dealing with whether it's depression or addiction. Well, the short answer is it's complicated. I think it's foolish, first of all, two discount the psychoactive effects to say that they're totally irrelevant and unimpactful. It's foolish for the reason that we

don't give enough attention. If we see those effects as irrelevant, we don't give it enough attention to setting the stage for them to emerge and providing a safe space and recognizing that they can potentially be impactful, and it's foolish because there may be some very powerful ways of harnessing those effects to mobilize the efficacy of ketamine. But I think the larger question you're asking is what is the

role of subjective experience in our healing? And might there be some paradigmatic deficit in the psychiatric framework that a doesn't recognize the importance of subjective experience. It's all about symptoms and the brain and behavior. What about consciousness? What about the mystery of what it means to experience and dream and imagine? Have we been missing something as psychiatrists

by over emphasizing neurobiology, symptoms, behavior? I mean, is that a general failing of psychiatry and psychiatrists even we compare to other forms of psychotherapy. That that's the focus on the pharmacological and the focus on the medical element of this just as kind of become. Whether we call it a crutch or a barrier to thinking of in the ways that you're describing right now, I think it is

a general challenge with psychiatry. The missing link here, I think is that ketamine was also for a period and continues to be so to some extent, a pharmacological model of psychosis, mean ing that ketamine was being approached as a medicine that can simulate what it means to be psychotic, schizophrenic hearing voices, having unusual thoughts, and this was an

effort to better understand the neural underpinnings of psychosis. So John Crystal's work with ketamine originally using sub anesthetic doses of ketamine to investigate what psychosis might be and what

the role of glutamate might be in psychosis. And the serendipitous finding came from doing that research, according to John Crystal, that he was providing it to healthy volunteers and finding that people were reporting that they were feeling better afterwards, that there was an improvement in mood, even if they weren't necessarily depressed beforehand, and that led to investigating ketamine again in a in a biological frame, meaning there's no therapy.

The psychoactive effects are there, but they're not prepared for

or integrated or anything like that. It's given to depressed people one occasion and then they were followed for a few weeks to see how the depression was affected, and that spurred a variety of studies looking at ketamine in a similar way for depressions through ideality PTSD obsessive compulsive disorder, giving a single dose in the absence of any kind of psychotherapeutic framework, without much regard for the psychoactive effects,

to see how symptoms might change. Now, that's not really different than how ketamine in a psychedelic framework might work. What's different is the lens that was brought to ketamine. The lens in this case was very biological, looking at it as something that's entirely pharmacological in the sense that it's entirely brain based without the psychoactive effects or effects that might lend themselves to therapy being a part of the process and investigating from there are other compounds that

might work like ketamine, but with reduced psychoactive effects. We'll be talking more after we hear this add I'm curious to hear. I mean, now that you've been doing these studies right with people struggling, you know, with alcohol problems, of cocaine problems, and cannabis problems. Um, could you just describe a couple of your patients and what that was like. Yeah. Sure.

As I mentioned before, I've been interested in how the meditative state might be helpful at disrupting addiction, and how it might lend itself to a practice whereby the usual automaticity and reactivity of addiction have my automaticity, you mean people sort of just reflexively doing something on consciously, not necessarily unconsciously, but there's such a pronounced reactivity. If there's a particular feeling, the compulsion to respond to that feeling

by using something or craving becomes so impactful. People aren't able, who are in the throes of severe addiction that are not able to allow the craving to simply pass. There's a feeling of needing to act on it at the same time that we can surmise that a meditative practice might help with those things. Of course, a meditative practice

requires some suspension of those things as well. Otherwise you're not gonna be able to meditate if you're feeling agitated, and if if your thoughts are causing you to move in this way and that. So the hope was that by providing an experience that is easier to come by comes through a medicine, that the meditative state that happens would serve as a stepping stone for understanding how to

continue meditating. And what to aim at. And also the hope was that the medicine might provide an enduring opening with improved craving sensitivity, improved mood, improved anxiety, so that

the usual vulnerabilities aren't so compromising. It noticed, it's using ketamine as a way to get people to move into meditation, integrating meditation and life right, and that's somehow that would be helpful in that regard correct yet by approximating the meditative experience, by making it easier to practice, and also

by motivating people to do it. You know that there's been a lot of research suggesting that one of the critical vulnerabilities to engaging fruitfully with any treatment is tenuous motivation is just not feeling inspired or capable of doing something, and that demoralization is I think a big part of addiction, that sense of having resigned oneself to the addiction, having tried again and again to stop it, and feeling like,

what's the why It's it's no good. So I also hope that the medicine would disrupt that, that it would provide a sense of refresh possibility. Well, let me just back up for one second, so just to get a picture of this so when these people are in your studies, First of all, these people are generally more middle class or people are more living on the street kind of living rough. It cuts through different cuts across and and they're coming into a facility at Columbia UM. They're in

a room. Are they wearing blindfold? Is their music in the background? Are you sitting by them while they're going through it? Are they hooked up to an ivy? What does it look like? Yeah, so it happens at Columbia Medical Center. But we created a space for administering the medicine that is as warm and comfortable as possible. The old you know catchphrase of set and setting remains very

important to respect. You know, these medicines, because of how profoundly they can change experience, require an environment where people can continue feeling safe. Environment conducive to allowing different experiences to emerge safely and in a manner that allows the person to feel heard and respected. So having a sterile medical environment did not seem appropriate given what we were trying to do. So we took a room that was ordinarily used for laboratory experiments and made it look like

a living room. They are guided through a meditation exercise prior to the ketamine being delivered. It's delivered through an ivy.

They're wearing an eyemask, laying down on a bed. I'm sitting next to them or another physician is sitting next to them, as well as the therapist, And throughout the experience they're being guided through what's called a body scan in mindfulness, that means paying attention to one sensations, one's breathing, if thoughts come up, noticing the thought, but maintaining a mindful stance, which means being open, being non judgmental, accepting, attentive,

and no music in the background. No music, and we we keep it very silent. So and another hypothesis of tacit hypothesis I was operating under here is that a lot of the suffering that comes with addiction comes from losing sight of the primordial mystery of experience. You know, what can't be known, what can't be reduced to words, concepts that the experience of someone in addiction is very overdetermined and over interpreted to organize too knowing in a

way for its own good. And I wanted the experience to allow for accessing what is beyond knowledge basically what can't be put into words, And for that reason I wanted the experience to remain as unanchored in things that are ordinarily intelligible, like music, going deep into ineff ability. Basically,

it sounds like what you're describing. When I read about some of the psychedelics therapy, sometimes it seems like something that's almost more explosives the wrong word, but I mean kind of more profound transformational that causes people to rethink their lives, to rethink their experience. And it sounds like what you're describing is a more modest form of that. Is that right? Well, listen, if an explosive transformation is coming, I welcome it. What and they do happen? They do happen.

Even having one's systems of knowledge dissolve in you know, the primordial silence, it's not an easy thing to go through. Um. At the same time, I think you're picking up on something. I am skeptical of these kind of fantastical narratives of communing with the divine or having some kind of pivot point. They may be helpful, I'm sure, but in my mind, what's most helpful is to find one's footing and have some kind of regular, enduring practice that helps one navigate

the trials and tribulations of life. Yeah, well, you know what you make me think of. You know, one of the historical pieces that many people don't know is that one of the founders of Alcoholics anonymous Bill Wilson, right, and this was all about, you know, dealing with very serious alcoholics and uh, you know, and the the whole

twelve step model. And then at some point he began taking I can't remember this LSD or mescal in LSD, and he came to believe that basically this could play an important role in very serious inebrious alcoholics coming to a kind of come to Jesus moment um in terms of their own self awareness, you know, that kind of moments that they're seeking for. And then I guess in his case what followed from that was less the meditative practice and more the fellowship of the whole twelve step approach.

But I wonder how you see what you were doing comparison to what he experienced and talked about, or was actually discouraged from talking about once he started talking about it. I I, as I said, I'm supportive of anything that could be hopeful and a transformative experience clearly can be impactful. I mean, many scholars have written about this, starting with

William James. Bill Miller, the founder of Motivational Dansmo Therapy, also wrote about the role of transformative experiences in recovery. So I'm very supportive of them. I just wanted to ensure that I maintained as comprehensive a model as possible, so that while the experience can lend itself to that if it were to occur, that if it doesn't occur and someone merely, if merely is the right word, enters into an eff ability, then that's fine too. We'll make

do what we can. Let's take a break here and go to an ad Among your patients or the subjects in the study, is there one that one or two they just sort of stand out that you could describe their experience? Yeah? What one, very powerful story, which I think also indicates just how severe some of the addictions we were dealing with our It was a laboratory study

investigating how ketamine might disrupt cocaine self administration. So woman who had worked as a sex worker at a cocaine addiction, very significant history of trauma, had multiple um scars all over her body that came from having been abducted by several men and mutilated and what sounds like some kind of bizarre ritual um. She was able to get away with severe wounds all over her body, but it was

able to escape. She worried that if she hadn't she might have died, and it's haunted her as continued to be an important part of her pathology, unfortunately. But she came in with a fairly significant crack cocaine addiction, and the experience that she had with ketamine is one of the most remarkable I've seen speaking of transformative So this was a study that wasn't really intended to help people

stop using. It was, as I mentioned, a lab study to investigate a very specific question whether it reduces cocaine self administration. Beyond the mindfulness training to help the person prepare for the infusion, et cetera, there wasn't much support and she had an experience where she began with moaning

in a in a kind of aroused way. Then it went into sobbing to um trying to escape something, writhing on the bed, and that's where the support of physician therapist can be crucial when you know, it's not simply a meditative state, but this kind of intense ab reaction or or a reliving means to occur. And she ultimately, by the end of the infusion, had calmed down and was just repeating over and over again how the knife had been removed, that it had been half out without

her realizing, but finally been removed. And she said something very powerful, which I think of quite regularly. You know, when you have a knife in you, she said, you get used to it, and it's not until it's coming out that it really hurts. And it was really the the space that the ketamine provided her that allowed her the safety, the the relaxing of defenses to finally allow

the knife out. And what was remarkable is that, as again because this was not intended to necessarily provide treatment, it was to ask a very specific question, she nonetheless stopped using cocaine for the duration of the follow up period after this this laboratory study. We continued seeing them for four weeks after. And that's an example I think of how there are things going on here which remain very untapped, you know, the capacity for these single experiences

to shift things so dramatically. Again, I'm not hanging my hat on that for every patient, and I'm trying to find a very durable, resilient framework by which we might tap into those benefits. I think using meditation and having a psychotherapeutic framework important for that. But it can happen. It's not simply anecdote. And well, I tell me, have you done the follow up with her or others? You know, not just four weeks later, but six months later, a

year later, and to see how they're doing. Yeah. So we we've had two clinical trials that UM involved fairly long follow up, one with cocaine addicted people and one with alcohol dependent individuals. They were both several week trials that involved several months of follow up after they completed the trial, and we continued to ask how they were

doing and what their youth patterns were. And in both UM studies, the rates of abstinence with the people who received ketamine were significantly higher than with the control group. So these are durable effects and all based upon the one session. Was it just one session or two sessions you did with them? Yea, for these studies it was one session. I see. But when I think about like a friend of mine who was suffering very seriously from

depression and trauma. Man having some pain, and he did, I think what many people do, and man, you know more and more where he did six ketamine sessions in the space of a month, followed by one a month for a year and did get some lasting many years thereafter benefit. But have you considered doing that model as well, or is there a reason to keep it to the more a model which involves giving fewer administrations. It's a very important question, and I think this gets at some

of the strictures that come with doing controversial research. So I should mention that all of the research I've done has been NIH funded either um NEIDA, which we talked about before, and I Triple A, which is the wing

of ni H that's focused on alcohol treatment. And in getting funding from both agencies, I needed to do a lot of politicking because even though the grants that I had submitted had received great scores from the Science Committee, the more bureaucratic wing of both agencies was not interested in investigating a mind altering substance for addiction because they were worried about the political fallout, or because of their own ideologies or ignorance, or there's a notion which is

erroneous that people who are prone to addiction whatever that means, are also prone to getting addicted to other substances if they were exposed to them. So if you're providing something like ketamine to someone with cocaine problems, it's like you're introducing potentially problematic, addiction prone substance to someone. Is there any rational, evidence based approach for people within the NIDA bureaucracy to take that view. No, No, it's a prejudice.

I have to tell you. It's just infuriated me. No end. I mean it's a tragedy because NIDA provides I think of all the funding for drug abuse research, not just in the US but globally, and to be in this incredibly rigid, ideological, you know, perspective on this stuff. I mean, are they even funding any psychedelics research now apart from ketamine? No? Nothing. I mean, well that's I should say, they're not funding any therapeutic um, only looking at the harms of these

things exactly. Uh. Yeah, And to your point, a lot of the substances that have been helpful for addiction, methadone, puper nor pine if they were, for whatever reason, illegal, we would be missing out on a tremendous opportunity. Those substances are psychoactive, They activate receptors that other so called drugs of abuse do. So, you know, the the argument is definitely specious, but that was the argument I was contending with. And as you seem aware, the challenge here

is that we're not really dealing with only science. We're dealing with politics. We're dealing with ideology. We're dealing with a particular perspective on drugs and addiction that comes less from evidence and careful experiment and more from you know, the drug war. I mean, I'm curious if you imagine in the future, let's assume that at some point the the other psychedelics actually become as legally available and permissive to work with um for you know, drug treatment, ptsd, O,

c D, depression, whatever it might be. When more of these are available, well ken amine play a lesser role. I mean, is ketamine having some of its time in the sun because the other ones are so hard to get funding for except from private sources. That's a great question. Yeah, I would not dismiss the power of ketamine. I don't think it's simply that it has it's fifteen minutes due to the other drugs being inaccessible. It has its own power. And I should tell you a story a colleague of mine,

I keep her anonymous. I've been struggling with fairly severe psychiatric issues for most of her life and did not receive benefit from the conventional approaches. Met a healer who worked with various types of psychedelics m d m A, psilocybin, d MT LSD, and went through all of those, tried every single one, but it wasn't until ketamine. It wasn't

until high dose intramuscular ketemine that she found relief. So you know, these are ultimately different compounds, and there will always be a place, I think for the very unique effects that ketamine has. I should also say that ketamine lends itself to easy administration much more than psilocybin. For example, does it shorter acting, it doesn't last for hours and hours, it doesn't require the same level of psychological preparation, hand holding, integration.

It lends itself to all of those things. So they mentioned with the case of the sex worker who definitely needed support and guidance, but in in a lot of cases, people have a fairly calm experience and they're able to

move forward. I mean, unless I should tell you. You know, I had my own experience with kenemine a guided session last summer, and I hadn't really done it that way before, and I was struck that compared to mushrooms, it was comparably powerful and as you say, much shorter acting, but it came on in my body in a much gentler way, you know, And maybe this's is part of it as I get older, mushrooms kind of you kind of a little bit raggedy effect coming in. But the kennemy was

very calm and easy. And then after it's over, um, you know, barely an hour later and one could re engage in normal activities that one wanted to. Well, let me ask you this whole thing with the commercialization. You know, you can't pat into stuff is basically a generic substance now, but pharmacitic companies find their way to do it right.

You see, with the locks, you know, the thing that's so crucially important for reversing overdose, but manufacturers find ways of selling them in a form this administer that costed dramatically more money than the few bucks and knocks on the cost, and you started talking about something that's happening in this area as well, where kenemine is now this thing called esketamine or something like that. Just can you

explain what's going on there, what your concerns are about it? Well, Ketamine is a receimate, meaning that it has two molecules in equal proportion. One is the right handed ketamine molecule, the others the left handed kenemine molecule. There basically mirror images of one another, and each molecule may have its own role to play in the benefits. Kenemine provides. What Jansen has done which has s ketamine or spravado on the market currently is It's taken the left handed molecule

s ketamine and patented it for depression. Also packaged it in a way that it could be administered in a clinic without necessarily I V S or needles involved. It's done intranasally, and took it through the usual pipeline to get FDA approval and just barely skated by. Didn't do nearly as well as they think broadcast um and the FDA in fact made an exception. Usually you need a few trials that are positive to grant that a drug might be used in a certain way. There was only

one that worked. There was only one trial that showed efficacy in the case of stemine. In any case, it has its challenges. Um from a clinical perspective, may not be as effective as ketamine. But I think the most problematic aspect of it, in my mind is how mercenary it is. So ketamine costs a dollar or two to administer, I mean, in terms of the medication costs, s ketamine is about a thousand dollars. It does, so it's it's half the compound, but you know thousand times as much.

And why did if why did f D a fast track it? Because it's dealing with a severe issue, depression, treatment resistant depression especially very problematic. I was hearing that if you look at which of the clinics and clinicians are doing a better job, typically the ones making the effort to use ketamine are having better results and being more responsible towards their patients. Then are the ones that are trying to profiteer off of using this asketamine approach. Well,

the profiteering is only on the industry side. Yeah, the doctors who are involved are more often kind of more conventional types who told the line, let's say they're given this medicine drug, reps come provide information on how to provide it. They may not be operating from a more holistic framework where therapy is integrated into the process. With ketamine clinics, therapy is invariably a big part of it.

There's an understanding that a proper framework is important, that the psychoactive effects need to be attended to with provado

not so much. Again, it's just a procedure. Yeah, somebody described to me, you know, and entsiologists just trying to make some additional money on the side basically and having some experience with kennemine by virtually being an a thesiologists and saying, here's another opportunity for them to make money without basically investing the time or the energy to understanding all the dimensions that you and I have been talking about. Because can be abused, right, people do get in trouble

with it. I'm just wondering if that whole more commercialized approach might lend itself to giving in trouble as well. Absolutely, you know, I think one of the big challenges we're going to be facing in these sorts of compounds entering into therapeutic settings, is the eagerness with which they might be pushed. You know, this transformative potential story can also have its dangerous Oh we need just need to keep

trying until we get that transformative experience. And you know that could be a road to nowhere or a road to real problems as you're suggesting. So yeah, there there's a definite danger with ideological interests or maybe a pecuniary interest and phasizing continuing to try the medicine, continuing to try the medicine even as it doesn't seem to be doing much. So, Elias, I want I want to finish up by asking you two questions, one backward one forward.

Which was I noticed in looking at your CV that you were born in Haifa, Israel, right, And I remember you're describing some of your your origins, and I wonder if you could just say something about that. Can you discern any impact of your early years growing up in your identity on the work that you're doing now? Well, I I'm not quite a refugee, but in many ways

that the story is comparable to that. I am able to go back to Israel and all of those things, but it was an environment that my parents felt wasn't as conducive to raising us, my brother and sister and I, So we went to the States to find greater, greater opportunity, greater tolerance because you're growing up in Israel, not Jewish, but growing up is a Palestinian, Arab Christian ISRAELI exactly, yeah, um, you know, and I'm speaking as someone who's parents were

like my mom spoke Hebrew better than any other language, and my dad went to UM a lot of the good universities there, so they were definitely acculturated. But there was this this element of distance, nonetheless that has stayed with me. So when you ask how that might have informed the work I'm doing, I've I've definitely felt like an outsider and always investigating the systems that are foisted

on us for their absurdity, their violence, their unreality. That that's been a big part of my um my perspective and has definitely allowed me to recognize where things might be done differently. As with ketamine, it's a look at just the last question thinking forward. I mean, you're still you know, you're early in your career, You're young. You've

been doing some fascinating research about kenemine. What's your hopes and ambitions for yourself over these coming decades in terms of do you see yourself committed to doing this research even more so on kedemine and towards psychedelics. UM. Do you think it will continue to be connected to your research and drug treatment? Is there some grand hopes that

you have for all of this? Well? I I went into this research personally with a sense of injustice at how this model, which had shown such promise in the fifties and sixties and Jenny's work, was so dismissed or even demonized, And in that regard, I feel like I've done what I need to do in an academic setting, you know, my own small role in helping rehabilitate this model and and apply it to a drug that had,

you know, just narrowly escaped being a purely a biological intervention. UM, so that art, you know, I'm not so sure what else I can do in academic settings that would be interesting to me. I think now it's about helping people more generally, and I'm under no illusion that that feeding the academic industry helps people. So I'm you know. I think the question now is what I might do to um,

you know, bring healing, understanding, social change beyond academia. Yeah, well, as we should talk, because there's somebody who my first seven years in this area worlds in academia and then I moved outward from there, um you know, and hopes that doing so we get it outside of the of the university and into the broader world. So I look forward to future discussions with you, not just on air,

but also over coffee as the pandemic recedes. But I did really really want to thank you very very much for joining me on this and it's really been a pleasure and edification. So thanks so much, and best of luck with all your research and other plans ahead. Thank you so much. Psychoactive is the production of I Heart Radio and Protozoa Pictures. It's hosted by me Ethan Naedelman.

It's produced by Katcha Kumkova and Ben Cabrick. The executive producers are Dylan Golden, Ari Handel, Elizabeth Geesus and Darren Aronovski for Protozoa Pictures, Alice Williams and Matt Frederick for I Heart Radio and me Ethan Nadelman. Our music is by Ari Blusian and a special thanks to a Vivit Brio, Sef Bianca Grimshaw and Robert Beatty. If you'd like to share your own stories, comments, or ideas, please leave us a message at eight three three seven seven nine sixty.

That's one eight three three psycho zero. You can also email us as psychoactive at protozoa dot com or find me on Twitter at Ethan Nadelman. And if you couldn't keep track of all this, find the information in the show notes. Tune in next time and hear me talk with Carl Hart, a dear friend of mine who's a neuroscientist at Columbia University, best known for his recent book

Drug Used for Growing Ups. No matter how many drugs this particular person was selling or led to him, So you shouldn't be able to kick someone's door down and then murder them on top of that, And so I think people were starting to put together Philanderer still uh, he had marijuana and that cop of shot him to death. We think about Lakwan MacDonald, the seventeen year old kid in Chicago where they said that he had PCP in

a system. And he was shot sixteen time. And people are starting to see that drugs are always used as this convenient scapegoat to justify this awful behavior. Subscribe to Cycleactive now see you don't miss it.