Psychedelic therapy for smoking cessation : Qualitative analysis of participant accounts
Tehseen Noorani, Albert Garcia-Romeu, Thomas C. Swift, Roland R. Griffiths and Matthew W. Johnson
Journal of Psychopharmacology, 2018, 1 –14
Background : Recent pilot trials suggest feasibility and potential efficacy of psychedelic-facilitated addiction treatment interventions. Fifteen participants completed a psilocybin-facilitated smoking cessation pilot study between 2009 and 2015.
Aims : The aims of this study were as follows: (1) to identify perceived mechanisms of change leading to smoking cessation in the pilot study; (2) to identify key themes in participant experiences and long-term outcomes to better understand the therapeutic process.
Methods : Participants were invited to a retrospective follow-up interview an average of 30 months after initial psilocybin sessions. Semi-structured interviews were conducted with 12 of the 15 participants. Data were analysed using thematic analysis.
Results : Participants reported gaining vivid insights into self-identity and reasons for smoking from their psilocybin sessions. Experiences of interconnectedness, awe, and curiosity persisted beyond the duration of acute drug effects. Participants emphasised that the content of psilocybin experiences overshadowed any short-term withdrawal symptoms. Preparatory counselling, strong rapport with the study team, and a sense of momentum once engaged in the study treatment were perceived as vital additional factors in achieving abstinence. In addition, participants reported a range of persisting positive changes beyond smoking cessation, including increased aesthetic appreciation, altruism, and pro-social behaviour.
Conclusions : The findings highlight the value of qualitative research in the psychopharmacological investigation of psychedelics. They describe perceived connections between drug- and non-drug factors, and provide suggestions for future research trial design and clinical applications.
Keywords : Qualitative research, smoking cessation, addiction, psilocybin, psychedelic
Recent research with classic serotonin 2A receptor agonist hallucinogens (i.e. psychedelics) has generated renewed interest in these drugs as a potential avenue for developing novel addiction treatments (Bogenschutz and Johnson, 2016; Garcia- Romeu et al., 2016; Krebs and Johansen, 2012; Sessa and Johnson, 2015). Pilot studies have shown safety and feasibility of psilocybin, a naturally occurring psychedelic found in socalled ‘magic mushrooms,’ as a therapeutic tool in the treatment of tobacco (Johnson et al., 2014) and alcohol use disorders (Bogenschutz et al., 2015). These findings add to a body of converging evidence suggesting psychedelics may have therapeutic potential.
Laboratory studies administering psychedelics to carefully screened and prepared individuals suggest these substances can occasion lasting changes in mood, behaviours, and attitudes (Doblin, 1991; Griffiths et al., 2006, 2008, 2011; MacLean et al., 2011). Epidemiological data show significant associations between psychedelic use and reduced recidivism in formerly incarcerated, substance-involved individuals (Hendricks et al., 2014), and reduced psychological distress and suicidality in a national United States sample (Hendricks et al., 2015). A meta-analysis investigating the psychedelic lysergic acid diethylamide (LSD) in the treatment of alcoholism found significantly greater reductions in alcohol misuse at initial follow-up in patients treated with LSD compared with control conditions (Krebs and Johansen, 2012). Observational studies have found decreased rates of alcohol and other drug misuse among religious users of ayahuasca, which contains the psychedelic dimethyltryptamine (Doering Silveira et al., 2005; Fábregas et al., 2010; Halpern et al., 2008).
In a recent open-label pilot study, 15 treatment-seeking smokers completed a smoking cessation intervention combining two to three administrations of psilocybin with cognitive behavioural therapy (CBT) (Johnson et al., 2014). Of the 15 participants, 80% (n = 12) were biologically verified as smoking abstinent 6 months post-treatment (Johnson et al., 2014), 67% (n = 10) were abstinent at 12 months post-treatment, and 60% (n = 9) were abstinent at a long-term follow-up an average of 30 months post-treatment (Johnson et al., 2016). Although results from an open-label study cannot demonstrate efficacy, the most effective current pharmacotherapies for smoking cessation typically show success rates ⩽35% at 6 months and beyond (Cahill et al., 2014; Hays et al., 2008; Mottillo et al., 2009; Tønnesen et al., 2003).
The psychological mechanisms of action of psychedelicfacilitated treatments remain poorly understood. Preliminary quantitative analyses suggest that acute mystical-type drug effects are significantly associated with therapeutic outcomes in psilocybin-facilitated addiction treatment (Bogenschutz et al., 2015; Garcia-Romeu, et al., 2014). Recent double-blind, controlled studies of psilocybin in patients with life-threatening cancer diagnoses also found lasting antidepressant and anti-anxiety effects that were mediated by psilocybin-occasioned mysticaltype experiences (Griffiths et al., 2016; Ross et al., 2016). Such findings are consistent with earlier researchers’ assertions that the subjective effects of psychedelics play a pivotal role in generating lasting therapeutic benefits (e.g. Osmond, 1957; Pahnke and Richards, 1966; Savage and McCabe, 1973).
Psychological insight, increased personality openness, changes in beliefs and values, increased motivation and enhanced self-efficacy have been hypothesised as possible psychological mechanisms of psychedelic-facilitated addiction treatment (Bogenschutz and Pommy, 2012). Recent novel qualitative research has offered additional insights into potential psychological mechanisms of psilocybin-facilitated treatment. One such study found that cancer patients with symptoms of depression and anxiety reported a range of positive effects from psilocybin-assisted psychotherapy, including greater relational embeddedness, emotional range and wisdom, as well as revised life priorities, alterations to identity, and movements from feelings of separateness to interconnectedness (Belser et al., 2017). A second recent study on patients’ accounts of psilocybin- assisted therapy for treatment-resistant depression reported shifts from disconnection (to self, others and the world) to connection, and from avoidance of difficult memories and emotions to acceptance (Watts et al., 2017).
The primary aim of this qualitative study was to characterise the perceived mechanisms of change attributed to a structured psilocybin-facilitated smoking cessation treatment. A secondary aim was to identify themes emerging from participant accounts of their experience undergoing psychedelic facilitated addiction treatment, including perceptions of the separate facets of treatment and the overall intervention, and any additional long-term outcomes. As clinical research with psychedelics is still in its early stages, such experiences can offer insights for improving best practice in the emerging field of psychedelic research and psychotherapy for substance use disorders.