We believe psychedelics create an opportunity for healing and transformation, both in individuals and the community. But are psychedelics right for my patient? We sat down with Dr. Dave Rabin to learn about prescribing ketamine, and what it may look if MDMA and psilocybin become FDA-approved treatments.
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Our growing community already includes over 1200 licensed therapy providers, and we hope you’ll join us. In our speaker series, experts from our community weigh in on current practices and issues in psychedelic medicine.
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Dr. Rabin is a board-certified psychiatrist, neuroscientist, entrepreneur, and inventor. He’s studied resilience and the impact of chronic stress on our lives for more than 15 years. Dr. Rabin works with a team at the Appollo Clinic, where they empower clients to take control of their mental and physical health. They help patients tap into their ability to heal themselves.
Dr. Rabin offers integration therapy, as well as plant and natural medicine, couples therapy, and medicine-assisted psychotherapy. He also specializes in treatment-resistant mental illnesses. He’s co-founder of Appollo Neurosciences, a wearable monitor for stress resilience. As the executive director for the Board of Medicine, Dr. Rabin works to establish clinical guidelines for alternative medicines. You can read Dr. Rabin’s talk below, or view the whole session here.
Dr. Rabin is a MAPS-trained MDMA psychotherapist, as well as a ketamine and cannabis therapist. He also practices general adult psychiatry and psychotherapy. He finds that using medicine to amplify therapy can be a powerful tool to prevent people from chronic psychiatric prescriptions.
“These medicines are just tools, which help us to navigate complex illnesses with patients.” Dr. Rabin said. He started our chat by emphasizing the importance of “using medicine softly”, regardless of the medication or substance. Dr. Rabin is excited about psychedelic-assisted psychotherapy, and encourages us to constantly ask, “How do we make people’s lives easier? How do we make them suffer less?”.
Currently, patients diagnosed with PTSD in the United States have a therapy response rate of less than 50% when treated with the gold-standard regimen. The last 20 years have only seen two new medications approved for PTSD. This is despite the National Institute of Health being formed in 1949 to explore and treat trauma-related illnesses. We’ve been dealing with poor outcomes in PTSD for a long time.
Investigating new therapies, like psychedelic medicine and wearable technology, can help us expand treatment options and improve outcomes.
Are Psychedelics Right for My Patient?
Ketamine is the only legal psychedelic medicine to date. It became legal because of its uses in pain and anesthesia, and its utility on the battlefield. Its potential anesthetic effects are helpful in surgical procedures. At lower doses, it creates “dreamlike states”, like lucid dreams, which can be guided by the therapist to help patients understand their subconscious.
Dreams are the most fundamental psychedelic experiences. They help “reveal the mind”, letting us see what is beneath the surface. Dreams allow us to access the subconscious. In sleep, our ego filter is weakened, as it is in low-dose ketamine sessions. Through ketamine’s NMDA-receptor antagonism, we can access dream-like states. Some other scholars posit that ketamine works on our endogenous opioid receptors as well.
Esketamine (a type of ketamine) is approved for treatment-resistant depression and for depression symptoms in patients with major depressive disorder with suicidal thoughts. Ketamine is in trials for addiction disorders, PTSD, and other conditions. Ketamine-assisted psychotherapy (KAP) helps people with trauma illnesses to “get to the root trauma that is blocking us from being ourselves”. Ketamine can be used across diagnoses off-label.
Oral ketamine gets broken down rapidly in the gut, so patients only absorb about 10-20% of the dose.
Dr. Rabin prefers sublingual or transbuccal administrations, which typically last two hours at about 200 mg. This route is safe but requires patients to “swish” around in their mouth and hold it for several minutes. Sublingual ketamine takes between 15-20 minutes for onset and 20-30 minutes at peak state.
Intramuscular and IV ketamine are better for in-person settings. This is the fastest route, with 3-5 minutes before onset and an hour or more of peak state. But on an IV, patients can’t move, which they sometimes want to do while on ketamine. Intramuscular is easier for this reason, and is fairly easy to administer “boosting” doses.
Intranasal is also commonly used for maintenance and low-dose therapy. Dr. Rabin doesn’t use it much, because he finds it too convenient for abuse. As an anesthetic, ketamine numbs us, and convenient at-home administration can create dependency. “We want to discourage numbing and escapism behavior”, which can happen with intranasal ketamine.
One viewer asked if Dr. Rabin treats patients with a substance abuse problem with ketamine. Here are the substance dependencies Dr. Rabin described, and whether or not he treats them with ketamine therapy:
- Ketamine can be appropriate for patients with cannabis or nicotine dependency because there is little cross-over between the two. It can be very helpful in nicotine cessation. Patients who are dependent on cannabis need to be weaned to a lower THC dosage before ketamine therapy, because it can amplify the psychedelic effects of ketamine.
- Ketamine is not appropriate for patients addicted to other numbing and distracting agents, like benzodiazepines, alcohol, opioids, or stimulants. In these patients, ketamine dependency can create more numbing and may be a “band-aid” treatment that helps them avoid the deep therapeutic work.
- Ketamine is not appropriate for people who are dependent on psychedelics. In these patiets as well, ketamine may become its own dependency.
Dr. Rabin emphasized that medications and substances are not always the answer to substance dependency. Patients need to be effectively tapered from the misused substances described above before considering ketamine therapy. He recommends lithium microdosing and CBD-A for weaning patients, as well as new routines, and stress management.
Once patients have achieved a month of sobriety, Dr. Rabin gives them one dose of ketamine therapy. Integration therapy follows. And gradually, a ketamine treatment plan may become appropriate. It is vital that patients experience full problematic substance independence before using ketamine, to avoid replacing one substance with another.
Ketamine’s Subjective Effects
- Feelings of disembodiment
- Out-of-body experiences, or illusions
- Changes in perception, cognition, and emotion
- Vivid imagery, visual hallucinations, or distortions
- Altered auditory perception and proprioception
- Mood enhancement
- Ego dissolution
- Transcendence of space and time
- Mystical experiences
- Experiences of death and rebirth
- Muscle relaxation
- Pain relief
- Feelings of awe and wonder
200 mg of sublingual ketamine, or 70 mg of injected IM ketamine, will allow most patients to experience these effects. People who are new to ketamine can be traumatized by the ego death and memory impairment of larger doses. These lower doses allow people to hit a “sweet spot”, and patients can remember their experiences to benefit from them.
Ketamine’s Acute Adverse Reactions
- Increased vitals (blood pressure and heart rate)
Much of the anxiety around ketamine happens in the transition from waking into a dream state. People who experience nausea and vomiting are often not used to the transition back into ego after this dream state. They may move too quickly after the experience, causing nausea and vomiting. Dr. Rabin’s clinic does 3-hour sessions, plus prep and integration afterward to give patients the chance to adjust after therapy.
Dr. Rabin has music recommendations for ketamine therapy sessions – 1221 Opening and The Golden Islands (more psychedelic therapy playlists here). This music helps guide people through experiences “in a non-aggressive way”. Patients’ bodies will feel different after therapy, but many of these side effects are rare with the right patient prep.
Anxiety begins with apprehension. Patients need the right preparation and education before their session. They need to know that “the point of the ketamine experience is to let go of control”. They need to let the medicine do its work, and patient’s intentions influence therapy.
Dr. Rabin uses breathwork, as well as four pillars, to prepare patients physically and psychologically.
These four pillars are:
When prepping anxious patients, Dr. Rabin says that “gratitude is always the first place to start”.
Dr. Rabin also uses his wearable touch therapeutic, Apollo, to help anxious patients going into psychedelic experiences. Using this device, people who have apprehension and anxiety can get the benefits of breathwork without extensive training.
Learn more about ketamine therapy vs. ketamine infusion on our blog.
MDMA is more stimulating, coming from the amphetamine family. It doesn’t facilitate dream states but is more safety-enhancing. It has longer oral bioactivity, between 3-6 hours and 6-8 with a supplement dose. A typical dose is 75-125mg depending on weight.
Subjective Effects of MDMA
- Enhanced feelings of empathy, such as love, connectedness, and closeness to others
- Increased feelings of well-being, euphoria, and extroversion
- Reduced fear
- Increased interpersonal trust
- Radical non-judgement, or “child’s eyes”
- Pro-social effects
- Less perceived loss of control than classic psychedelics
Common Acute Adverse Reactions
- Increased vitals (body temperature, blood pressure, heart rate)
- Jaw clenching
- Lack of appetite
MDMA is currently in Phase III trials for PTSD, and phase II trials for alcohol-use disorder and social anxiety in autistic adults. MDMA combines well with cognitive-behavioral therapy, and Dr. Rabin recommends two therapists when in use. This helps the patient and therapists “navigate transference issues more effectively”.
MDMA is getting closer to commercialization. Learn more about FDA approval for MDMA here.
Psilocybin is a hallucinogen that shows our subconscious. It changes and augments activity as 5-HT2A receptors. Its effects last between 3-6 hours. Dr. Rabin emphasized for people who are trying psychoactive mushrooms that there are hundreds of different species, and dosages vary widely. Know what kind of mushroom you are taking, and its dosages, before consuming.
Subjective Effects of Psilocybin
- Vivid imagery, visual changes, or distortions caused by ego filter disruptions
- Altered auditory perception
- Synesthesia (“feeling colors, or seeing music”)
- Mood enhancement
- Ego dissolution
- Transcendence of space and time
- Mystical experiences
- Experiences of death and rebirth
- Feelings of awe and wonder
Common Acute Adverse Reactions
- Increased or decreased blood pressure
- GI upset with whole mushroom ingestion
Psilocybin, like all psychedelics, can create paranoia because it makes us more open to what is “beneath our subconscious”. People who have a lot of distrust in their history, or in their healthcare providers, can experience acute anxiety and paranoia during their experiences. Therapists need to know how to navigate this when it arises.
Psilocybin is in Phase II clinical trials for depression, as well as other mental health disorders. It benefits from assistance psychotherapy. Patients need gentle guidance in these experiences, they need to be able to guide their own treatment with support of therapy staff.
Contraindications to Psychedelic Therapy
Certain patients will not be candidates for ketamine, MDMA, or psilocybin. This includes patients with bipolar and psychotic disorders, as well as people who use amphetamines, people who have a seizure disorder, and others.
Dr. Rabin says that psychedelics can trigger mania in people with bipolar disorder. This is very challenging to treat, and other treatment methods are effective for bipolar (lithium and CBD-A). Especially in bipolar I, patients are at extreme risk of suicide when in manic or depressive states. Administering psychedelics can put people into one of these poles, and this isn’t worth the risk. Re-screening is necessary for patients presenting with bipolar disorder; misdiagnosis is common in this disorder.
He also doesn’t use psychedelics for patients who have a history of a psychotic disorder or have a recent family history of psychotic disorders. “Dissociation can dramatically worsen outcomes in this group,” he said.
People who use amphetamines should not take them while on psychedelics. They can be “dislodging” for people who take a dissociative, leaving people feeling ungrounded and paranoid. This can “rocket” patients into psychosis.
People with epilepsy or seizure disorders should proceed with caution when it comes to psychedelics. Dr. Rabin does not recommend any medications that decrease seizure threshold, such as magnesium. Some patients who have only had one seizure may still be appropriate for psychedelic therapy, but only when there’s been a long period of “seizure freedom”.
With respect to other medicines, there are few contraindications to ketamine. People with bladder problems, as well as anyone with arrhythmias, should not be prescribed ketamine. Other than that, ketamine is well-tolerated, and can be taken with most medications without the need for tapering.
MDMA and psilocybin should not be administered with SSRIs, SNRIs, MAOIs, or any medications that influence the serotonin system. This can blunt the effects of the psychedelic substances. administration with MAOIs can result in serotonin syndrome, which can be severe and even deadly. This is a medical emergency.
Laura just started a new career and is struggling with depression. After a decade of trying talk therapy, SSRIs, and SNRIs, she wonders if she’ll ever find something that works.
Dr. Rabin said that Laura is his most common patient. She’s tried everything that’s been offered, but these treatments haven’t addressed her symptoms long-term. This is disempowering and disheartening for the patient.
He would start Laura with talk therapy to establish trust, safety, and history. He recommends a dietary and supplement consultation with all new patients. Many people over-supplement themselves. He noted vitamin D toxicity, which can manifest in the same mood issues as vitamin D deficiency. Other patients may take the right supplements at the wrong time. Dr. Rabin said that providers need to know what people are putting in their bodies.
He’d do a deep dive into who Laura is, where her stress is coming from, and potentially offer her supplement modifications. Laura may be a good candidate for ketamine therapy and can stay on her antidepressants during therapy.
How would you decide if someone should take psilocybin or MDMA?
Assuming all become FDA-approved medications, Dr. Rabin emphasized that the process is similar for all three substances. The main distinctions are the patient experiences, how long they last, and their risk profiles. He would educate the patient on their options, as well as the risk for each substance.
Patients who are on SSRIs and aren’t wanting to taper may be appropriate for ketamine therapy. At lower doses, this gentle psychedelic experience is highly controlled, and can even be done in the comfort of the patient’s home. It’s great for people who have never had a psychedelic experience. Because of safety and legal prescriptions, ketamine is a preferred option for many patients.
If a patient doesn’t have contraindications, MDMA or psilocybin may be an option. At this point, the question becomes more about logistics. With two therapists in the room during sessions for these substances, therapy becomes more expensive. There’s more integration involved in the study protocols. These factors may be cost-prohibitive for many people.
Dr. Rabin’s emphasis would first be ketamine, MDMA after that, and lastly psilocybin. This allows a slow increase in sensorium alteration over time.
Can microdosing mushrooms be helpful for tapering SSRIs?
We don’t yet have enough data to make recommendations for this. He recommended reading this nature article, one of the first crowdsourcing studies to show that microdosing can improve mood, cognitive function, and anxiety.
The challenge with microdosing is the dosing. People think that a microdose is .5 g, when a true microdose is much lower. A true microdose creates an effect that doesn’t alter function in any way. Proper microdosing requires careful dosing and happens every three days to prevent tolerance.
With the wrong dose, people can potentially become altered. From the data, it does look like microdosing can help wean people from antidepressants. But prescriber monitoring is necessary, and close dosage management is as well.
Patients who tapered off SSRIs prior to MDMA therapy have shown to experience less symptom reduction than their peers. Likely, serotonin receptors need time to recover from SSRI therapy to receive the full effects of MDMA.
Substances interplay, and combining them affects mood. THC augments ketamine and psilocybin. CBD attenuates MDMA, ketamine, and psilocybin. As we learn more about how these substances combine, we’ll understand how to combine substances to help patients achieve the best outcomes.
Dr. Erica Zelfand presented on this topic a few weeks ago on psilocybin and SSRIs, you can view her chat and read the summary here.
Are psychedelic medicines good for functional neurologic disorders?
Some trials are going on right now looking at Parkinson’s, as well as anxiety related to Alzheimer’s. This research is in the early non-human stages, but we’re hoping to see more in the coming years.
Psychedelic substances may be able to stimulate new neural pathways and neuroplasticity. But this learning acceleration can be guided in a constructive or destructive direction. It’s important for people to have a groundwork of safety.
Even microdosing can possibly rewrite our brain’s plasticity and needs to be done with safeguards. Engaging in maladaptive or destructive behaviors while microdosing might wire associative networks around maladaptive behaviors. But we need more research on microdosing to understand these effects.
Thanks so much to Dr. Rabin for offering his time and expertise to Psychedelic Support. You can find his website here, along with information about his wearable devices and booking an appointment. Reach out to Dr. Rabin on Instagram and Twitter, and grow your community in psychedelic medicine.