VA Portland Health Care System opened the Social Neuroscience & Psychotherapy Lab, known as the SNaP Lab, focused on psychedelic therapy and clinical trials, led by Dr. Christopher Stauffer.
Nick Choy
Last week the VA Portland Health Care System opened the Social Neuroscience & Psychotherapy Lab, known as the SNaP Lab, focused on psychedelic therapy and clinical trials. Dr. Christopher Stauffer, a psychiatrist, clinical researcher and director of social neuroscience and psychotherapy at Portland VA, joins us to talk about the new lab, and the two clinical trials currently underway.
The following transcript was created by a computer and edited by a volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. Last week, the Portland VA opened the Social Neuroscience and Psychotherapy Lab, known as the SNaP Lab. It’s focused on psychedelic therapy, using drugs like psilocybin and MDMA. Christopher Stauffer, a psychiatrist and researcher at the Portland VA and OHSU, is the director of the lab. He joins us now to talk about his work, including the two clinical trials that are already underway. It’s great to have you on the show.
Christopher Stauffer: Hi, Dave. Thanks for having me.
Miller: What’s the big idea behind the SNaP Lab?
Stauffer: The main idea is to give mental health treatment with new tools. The thing about psychedelic assisted therapy with MDMA or psilocybin, they’re paradigm shifting. We keep coming up against an existing system for mental health interventions, and we’re faced with squishing these interventions into pre-existing boxes or pushing back and asking the system to change to accommodate these paradigm-shifting interventions.
Miller: Broadly, what are the limitations, in terms of the available accepted treatments that you think aren’t working? Where are you running into issues that you cannot solve with the existing tools?
Stauffer: So, let’s talk about PTSD. MDMA assisted therapy, there have been a lot of clinical trials looking at that for PTSD. When we look at the existing treatments for PTSD, there are interventions that are really effective. But the VA did a big trial randomizing people to these interventions, and over half of the veterans dropped out before the treatment was completed, either because it was too challenging - it’s almost sometimes described as doing surgery without anesthesia, or they just…
Miller: Talking about trauma, that is what is like doing surgery?
Stauffer: Right. Yeah, like exposure therapy, you’re really going to move through. And that’s an effective treatment but we’re not able to reach everyone. There are people who have treatment-resistant PTSD and these interventions, like MDMA assisted therapy, have been found to be helpful for that and make the trauma processing a little bit more tolerable.
Miller: Can you describe how it works? And this is one of the clinical trials that’s underway right now, so how does MDMA assisted therapy work? What does it look like? What do people do?
Stauffer: I like the way you emphasized assisted therapy, because I really do think it is a psychotherapy, like the treatments that are already effective. And then the MDMA is just a component that’s helping that therapeutic process along. In our trial, we’re looking at group therapy for PTSD. And then each participant in the group - there’s six veterans in each cohort - they get an individual MDMA session, so they can learn about the effects of it. These are day-long sessions, so six to eight hours under the effects of MDMA. Before that, there’s a lot of preparation in both a group and individual format, and then afterward, we call it integration therapy. The individuals come back together and start to integrate and process the things that came up in the MDMA sessions.
The second MDMA session is facilitated together as a group; the cohort of six are together, and there are four therapists present, and then more integration therapy after that.
Miller: What can MDMA sessions be like? We’ve talked a fair amount over the last year and a half about psilocybin assisted therapy because of Oregon’s first in the nation system, obviously. So how is an MDMA session different?
Stauffer: If I were to watch a video of a session, the Venn diagram overlap is so much that I don’t know if I would be able to tell if it was a psilocybin session or an MDMA session. In general, the thought is with MDMA, it’s a little bit more gentle. People are more lucid, they’re able to move into what’s coming up in a little bit more of a slow and gentle way, but as far as what a typical session looks like, there’s really no answer for that because they are all so unique. It’s really the therapist’s job to have each participant lead the session. We’re really there to support what’s coming up on its own, rather than having an agenda, so every session tends to look very different.
Miller: You were one of the authors of a recent study that found that psychedelic assisted therapy in group settings has lower costs, and partly because of that, could be easier for patients to get access to than individual setting therapy. Those are important criteria, cost and access or availability. But what about the effectiveness of therapy in a group session versus individual?
Stauffer: That’s what we’re studying. This is the first phase; we’re doing what’s called an open label, so everybody gets MDMA and they know that they’re getting MDMA, just to test out the feasibility of this model and look at the safety. Then we’re looking at preliminary effectiveness, or efficacy. Future studies will look at the group model versus individual.
Miller: Do you have a hypothesis about the relative effectiveness of these therapies done in community versus being alone? I mean, alone with a qualified therapist. What is your gut [sense] about the benefits or drawbacks of those two versions of therapy?
Stauffer: I’m really drawn to group therapy, family therapy, couples therapy. I think there are unique qualities to doing therapy in a group that don’t exist in one on one therapy. I’m really hoping, because MDMA is such a relational drug, that combining MDMA with group therapy will have unique healing potential that that individual therapy doesn’t have, and that’s really why I’m drawn to it. Then, if it is effective, I think the cost effectiveness and time effectiveness of it would be a bonus.
Miller: What does it mean to call MDMA, which on the street people often call Ecstasy, a relational drug?
Stauffer: It’s known to increase empathy, increase feelings of connection to others and to yourself. That’s primarily what I mean. Then, we see that manifesting in different ways in psychotherapy as well.
Miller: Let’s turn to the other clinical trial that’s underway right now: psilocybin therapy. What exactly are you hoping to study in this trial?
Stauffer: There’s been a tradition of looking at psilocybin, which is a classic psychedelic. It’s a different drug category than MDMA, but there’s a history of looking at classic psychedelics and the treatment of substance use disorders, starting with alcoholism with LSD in the forties and fifties. Then, with Psilocybin assisted therapy in particular, there have been some alcohol studies, alcohol use disorder, with good outcomes. There’s been studies showing it can help people quit smoking. There’s a study finishing up with psilocybin assisted therapy for crack cocaine use disorder. Ours is a study of psilocybin assisted therapy for veterans with methamphetamine use disorders, so they’re using meth. They’re staying on campus in a residential treatment facility while they’re participating in the trial.
Miller: What are the challenges of meth addiction in particular?
Stauffer: It’s one of the substances that we don’t have an FDA approved treatment for at this time. There are FDA approved medications to help with alcohol use disorder, to help with opioid use, but there’s not for methamphetamine. In this residential treatment environment, we see people coming in, struggling with alcohol use or struggling with opioid use. And there’s a good path forward for them after they leave the residential treatment facility. For people who use methamphetamine, there’s just a higher rate of leaving treatment early, a higher rate of going back to meth when they leave treatment, and ending up back in the facility. It’s one of the addictive disorders that we just have the fewest solutions for.
Miller: For the existing studies that have shown promise, going back a number of decades now for, say, alcohol use disorder or other addiction, when it comes to psilocybin treatment, are we talking about a couple sessions of psilocybin and maybe some kind of reintegration session, or more intensive and ongoing therapy?
Stauffer: It’s a really good question. The existing studies for things like alcohol, smoking cessation, those were just, I think, one, two, or three psilocybin dosing sessions with the framework of psychotherapy. For things like methamphetamine use disorder, we don’t yet know what the right dosing would be and the amount of time that we would need to spend with people.
Miller: How much have researchers been able to learn about how or why it is that psilocybin works? When I’ve talked to Michael Pollan about this in the past, who himself had spoken to a number of some of the sort of OG (original) researchers in the mid-20th century about how this work, it’s always seemed like a little bit of a magic trick, a kind of resetting of the brain. Not everybody is totally fine, but a lot of researchers would say that this has been more effective than anything else they’ve seen. It’s always been a little bit of a mystery to me as to why. How much do we know about that why?
Stauffer: I think we have a lot of hypotheses. As far as the mystery, the mystery is there for sure. I think we speak a lot in metaphor. I know that Michael Pollan likes the metaphor that psilocybin is like a fresh coat of powder on a ski hill that can allow us to lay down new tracks.
Miller: As opposed to being stuck in a rut, or in very skied tracks where your brain just follows this line, whether you wanted to or not. That was his metaphor. Do you like that one as a researcher?
Stauffer: I do, yeah, I do. I know there are things that get a little bit more reductionistic, like increase in neuroplasticity. During the psilocybin session, there are lots of parts of the brain talking to each other that don’t usually talk to each other. We see cognitive flexibility, and these open windows that last even after the session for things to restructure.
Miller: That was the next part of my question: how durable are these findings? It’s one thing to get a fresh coating of powder on an already skied track, to sort of belabor this metaphor, but what happens six months later, or six years later?
Stauffer: I think it depends on what we’re using it for and which medicine we’re using. It’s a little bit less clear for things like psilocybin. The interesting thing about MDMA, using MDMA assisted therapy for PTSD [is] the long-term follow up studies. At 12 months or more, people’s PTSD continues to get better, even after the intervention has already ended, which I think is pretty remarkable.
Miller: At this point, when we could talk about other drugs that only in relatively recent years - the last decade and a half or so - do we have more information about, as you said at the very beginning, the new tools to deal with various behavioral or mental health problems. Whether we’re talking about MDMA or ketamine or psilocybin or other drugs, how good are you all, right now, at matching the new tool to the problem?
Stauffer: I think there’s a lot of work to still be done and a lot of questions still unanswered as far as that goes.
Miller: You help train psychiatry residents and PhD candidates now. There’s a long list of people on the bio page of your new lab. How much has changed, in terms of the acceptance of psychedelic research and practice since you started your residency 14 years ago?
Stauffer: A lot has changed. I think there was a tipping point when Michael Pollan started writing about this. But prior to that, if I were to even bring this up, usually in an academic setting, it would quickly be kind of waved to the side. Then I noticed after Michael Pollan’s New Yorker article, and his book came out, there was a lot more curiosity. Then, just within the last few years, there’s more than curiosity. There’s a lot of movement and a lot of evolving conversation about it in the academic and medical space.
Miller: You arrived in Portland from San Francisco in March of 2020, a globally challenging time to create anything. But if we set aside pandemic related challenges, what were the other bureaucratic challenges that you ran into in setting up a lab that was going to be focused on these substances?
Stauffer: You know, interestingly, I think there has been so many decades of other people setting up this work that when it came to all the regulatory approval processes we had to go through, like with the FDA, the DEA, the Institutional Review Board, those actually went pretty smoothly. I know they haven’t gone smoothly in the past, when these were kind of new, but this is no longer new to the FDA, so that was actually pretty smooth.
I think just setting this up within an existing system that doesn’t have anything like this in it yet is a challenge. Then, the companies now that are developing MDMA and psilocybin for pharmaceutical use, they’ve gone from being nonprofit medical research organizations to now being pharmaceutical companies. We were in the middle of that transition as we were getting our clinical trials up and running as well.
Miller: Meaning that you can now legally buy your MDMA from a for-profit company the way you would, I don’t know, buy penicillin?
Stauffer: If you have a Schedule I DEA license to work with Schedule I substances, because right now, MDMA and psilocybin are not yet approved by the FDA. The FDA is right now reviewing MDMA assisted therapy for the treatment of PTSD and they’re expected to have a decision on approval by August of this year.
Miller: That ties to this question: what do you see as the next frontier in psychedelic therapy?
Stauffer: Oh man, I think it’ll be a lot of work, just figuring out how to get more people access. I think insurance coverage, things that are a little less exciting, but I think will be important in bringing these interventions to scale.
Miller: I’m glad you mentioned insurance coverage because, I mean, the way healthcare works in this country, the only way that that large numbers of people will have any access to any given therapy is if private insurance reimburses for it, or if the federal government pays for it through Medicare or Medicaid or the VA, an enormous single payer healthcare system. How far away do you think we are from those days, when it comes to psychedelic therapy?
Stauffer: I think everybody is waiting for the decision from the FDA, but I’ve been really impressed with and pleased with the things that the VA is doing to ready the system for that tipping point.
Miller: Like what? What are they doing?
Stauffer: In September, we had a group of experts, not just experts in psychedelic therapy, but experts in the VA system. We met in Colorado and talked about how this might work. And there’s lots going on behind the scenes so that there hopefully won’t be too much of a delay once FDA approval happens, if it happens, before we start to see implementation within the VA system.
Miller: Will it be the kind of thing where once some MDMA therapy is accepted for either a particular disease or in one setting, that’ll open the door for all kinds of other off-label uses?
Stauffer: That’s an open question. What people are expecting the FDA to do is implement what they call a REMS, a Risk Evaluation Mitigation System, for new newly approved drugs where there are guidelines around it. The anticipation is that for MDMA assisted therapy, one of the REMS criteria will be that you can only administer it under supervision, you can only administer it for PTSD, but nobody at this point knows how strict the REMS criteria will be. Then it’s a little bit more of a slow roll out before we start to get to being able to use it off-label.
Miller: Christopher Stauffer, thanks very much.
Stauffer: Thank you.
Miller: Christopher Stauffer is an associate professor of psychiatry at OHSU and a physician scientist at the Portland VA.
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