Abstract
Despite growing availability of several evidence-based approaches in the treatment of substance use disorders, existing pharmacotherapy and psychosocial interventions continue to have significant limitations, such as low treatment retention rates and high rates of relapse. There is a need to develop new strategies and models to address these limitations and target underlying psychosocial drivers of addiction, such as motivation to change – a crucial factor in achieving positive addiction treatment outcomes. Re-emerging clinical evidence and literature signal the promise of psychedelic-assisted psychotherapies as being novel, adjunctive treatments for a range of mental health and substance use disorders, encouraging further research. However, there remains a lack of formally validated metrics to evaluate recovery capital and motivation, limiting interpretation of the growing psychedelic literature. This commentary describes the current state of this line of investigation and potential impact of psychedelic-assisted psychotherapy on enhancing motivation to change in addiction treatment, and the need for validated metrics to evaluate recovery motivation and capital to assess the potential for psychedelic-assisted psychotherapies to elicit positive, lasting changes in substance use behaviors among those seeking treatment.
Substance use disorders (SUDs) continue to be a source of major morbidity and mortality, accounting for an estimated greater than 20% of all deaths globally (Gakidou et al., 2017). Despite the heavy burden of illness, little is known about how individuals can best overcome and resolve SUDs (Kelly, Bergman, Hoeppner, Vilsaint, & White, 2017). Several evidence-based psychosocial and pharmacological treatments exist; however, they face a range of limitations such as low retention rates, limited availability, and high rates of relapse (BCCSU, 2019). Furthermore, individual differences in neurochemical interactions, psychosocial factors related to substance use (e.g. housing, social security and supports), and understanding of harms associated with ongoing drug use creates a multi-dimensional challenge (Bardo, Neisewander, & Kelly, 2013). Recent data highlight the limited success of currently available addiction treatments in various substance use disorders (Wood, 2018). In addition to this, patient lack of motivation or ambivalence about addiction treatment can serve to inhibit positive treatment outcomes (Palmer, Murphy, Piselli, & Ball, 2009). Consequently, novel evidence-based strategies are urgently needed to enhance support of an individual's internal and external personal, cultural, social, and environmental resources, alongside the development of validated metrics to evaluate recovery motivation in this context.
One important concept that has emerged in the addiction treatment space is that of recovery capital. This refers to quality and quantity of internal and external factors that, if enhanced, may enable an individual with a SUD to remain motivated throughout treatment and sustain abstinence (Laudet & White, 2008; White & Cloud, 2008). Treatments that support an individual's recovery capital have the potential to translate into better treatment outcomes (Köpetz, Lejuez, Wiers, & Kruglanski, 2013; Laudet & White, 2008). Motivation is a significant aspect of recovery capital that can be influenced by psychosocial interventions, such as Motivational Enhancement Therapy and Motivational Interviewing (MI) (Miller & Rollnick, 2012; Sellman, Sullivan, Dore, Adamson, & MacEwan, 2001), and is widely acknowledged as a crucial factor in addiction treatment (Miller, 2016). While patients present to treatment settings with a range of internal and external motivations, spanning from relative ambivalence to high motivation for change, approaches that nurture an individual's recovery capital can lead to sustained positive outcomes, including abstinence (Köpetz et al., 2013; Laudet & White, 2008; Palmer et al., 2009). One such re-emerging approach is psychedelic-assisted psychotherapy, which may hold promise in bolstering aspects of recovery capital when used in conjunction with existing treatment modalities (Tupper, Wood, Yensen, & Johnson, 2015).
An increasing body of evidence suggests the adjunctive use of psychedelics (broadly inclusive of psilocybin, lysergic-acid diethylamide [LSD], ketamine, and 3,4-Methylenedioxymethamphetamine [MDMA]) with psychotherapy could enhance intrinsic aspects related to recovery capital such as motivation, connectedness, self-efficacy and meaningfulness, subsequently moderating positive SUD outcomes (Argento, Tupper, & Socias, 2019; Bogenschutz et al., 2015; Feduccia et al., 2019; Fuentes, Fonseca, Elices, Farré, & Torrens, 2019; Johnson, Garcia-Romeu, Cosimano, & Griffiths, 2014; Krebs & Johansen, 2012; Krupitsky et al., 2002). A meta-analysis of randomized clinical trials investigating LSD-assisted psychotherapy for AUD showed a pooled benefit difference of 16% in LSD-treated participants that improved their alcohol misuse and 15% that maintained abstinence compared to controls at 6 months follow-up (Krebs & Johansen, 2012), and a growing body of literature now highlights the significant therapeutic utility of LSD in AUD (Fuentes et al., 2019). Likewise, psilocybin-assisted psychotherapy has demonstrated positive changes in abstinence self-efficacy post-treatment and enhancement of motivation for change in AUD (Bogenschutz et al., 2015), yet validated measures of recovery capital remain elusive in the context of this therapeutic approach. Conventional smoking cessation therapies have had limited success, where the three most widely available first-line treatments have observed less than 35% of participants remaining smoke-free after 6 months (Cahill, Stevens, & Lancaster, 2014). Notably, a pilot study investigating psilocybin-assisted psychotherapy for smoking cessation found that 80% of participants, who smoked on average 19 cigarettes a day for an average of 31 years, remained abstinent at 6-months follow-up (Johnson et al., 2014). It is clear that novel, evidence-based approaches are urgently needed for opioid use disorder to address the ongoing overdose crisis. Clients discharged from residential treatment centres have relapse rates of 59% in the first week and 80% within one month (Smyth, Barry, Keenan, & Ducray, 2010), and retention rates for opioid agonist therapy, considered an evidence-based first-line treatment, are as low as 41% at 12-month follow-up (Nosyk, Marsh, Sun, Schechter, & Anis, 2010). While direct parallels cannot be drawn, historical evidence alongside emergent clinical trials suggest psychedelic-assisted psychotherapy may be beneficial within a multitargeted response to the opioid crisis (Argento et al., 2019). Higher rates of abstinence have been observed among participants with opioid use disorder receiving high dose LSD and ketamine-assisted psychotherapies compared to controls at long term follow ups (Krupitsky et al., 2002; Savage & McCabe, 1973). Although these studies show therapeutic promise of an adjunctive psychedelic approach, they continue to lack validated metrics of quantifying recovery capital, leading to inconsistency and insufficiency of this data in the literature. Given consistent findings from published preliminary studies, larger clinical trials are needed and are now underway in the field to further assess the therapeutic potential of psychedelic-assisted psychotherapy. However, the gap remains for improved metrics to evaluate psychedelic effects (Hendricks, 2018).
Evidence-based psychosocial interventions are increasingly being used to improve treatment outcomes as a monotherapy and in conjunction with other modalities to enhance recovery capital (BCCSU, 2019). For example, Motivational Enhancement Therapy, a structured counselling methodology that employs principles of MI, is designed to explore client attitudes towards change and enhance intrinsic motivation across the spectrum of substance use (Galloway, Polcin, Kielstein, Brown, & Mendelson, 2007; Miller & Rollnick, 2012; Sellman et al., 2001). While MI alone has been shown to have moderate effect sizes for SUDs compared to placebo groups (Burke, Arkowitz, & Menchola, 2003), preliminary research has demonstrated that MI in conjunction with psychedelics may strengthen recovery capital and motivation by generating “mystical-type” experiences that appear to increase self-efficacy post-intervention (Bogenschutz et al., 2015). Psychedelic-occasioned mystical experiences have been shown to enhance ratings of personal meaningfulness, spiritual significance, and connectedness, facilitating deeper personal insight that may lead to lasting behavioral change and positive outlook on life (Carhart-Harris, Erritzoe, Haijen, Kaelen, & Watts, 2018; Griffiths, Richards, McCann, & Jesse, 2006). Indeed, it has been argued that psychedelics might assist in promoting broad positive lifestyle changes, such improved diet, exercise, nature relatedness, and mindfulness practices (Teixeira et al., 2021). This may be partially explained by the meaning enhancing properties of psychedelics (such as mystical experiences and awe) that are thought to have lasting impacts on mood, cognition and substance use behaviors (Garcia-Romeu, Griffiths, & Johnson, 2014; Hendricks, 2018; Johnson, Garcia-Romeu, & Griffiths, 2017). For instance, participants in trials of psychedelic-assisted psychotherapy for SUDs expressed their experiences to be among the five most spiritually significant and personally meaningful ones in their lives (Johnson et al., 2017). Participants articulated meaningful commitment to change post-intervention and had personalized realizations with increased self-efficacy, highlighting the profound impact psychedelic-assisted psychotherapy may have on recovery capital metrics (Johnson et al., 2017; Nielson, May, Forcehimes, & Bogenschutz, 2018; Noorani, Garcia-Romeu, Swift, Griffiths, & Johnson, 2018). The connection between spiritual experiences and eliciting change also raises the possibility for psychedelics to have synergistic effects should they be integrated in broader addiction treatment programs (Yaden et al., 2021). While the literature suggests qualitative changes on recovery capital and motivation are possible, the development of validated quantitative metrics would enhance the ability to formally assess recovery capital.
Structured psychotherapeutic modalities for treating SUD such as MI and Cognitive Behavioural Therapy (CBT), which explore thought patterns and focus on relapse prevention through goal-directed psychotherapy (McHugh, Hearon, & Otto, 2010), have shown modest immediate post-treatment benefits, yet these effects tend to diminish with time (Magill & Ray, 2009). Meanwhile, preliminary studies of psychedelics as adjuncts to psychotherapy have demonstrated positive effects that appear to be effective and sustained (Johnson et al., 2014; Krebs & Johansen, 2012). Recent clinical trials of psychedelic-assisted psychotherapy for treating mental health conditions such as depression, anxiety and posttraumatic stress disorder, which share common neural circuitry and have high comorbidity with addiction (Ly et al., 2018), have demonstrated particularly promising outcomes with lasting effects up to 4.5 years post-intervention (Agin-Liebes et al., 2020; Davis et al., 2020; Mithoefer et al., 2019). As a result, the US Food and Drug Administration has granted psilocybin- and MDMA-assisted psychotherapy “breakthrough therapy designation” for treatment-resistant depression and posttraumatic stress disorder, respectively (Feduccia et al., 2019; Reiff et al., 2020). Thus, the expansion and integration of psychedelic research with innovative psychosocial treatments for SUDs offers a promising modality that may generate longer lasting, internally motivated change and more efficacious treatment outcomes. The validation of metrics to encompass these changes in internal and external motivation would further support the growing body of evidence and provide consistency across future literature.
Capturing and quantifying psychedelic experiences and metrics of recovery capital in the setting of psychedelic-assisted psychotherapy has proven challenging. The notable personal accounts of enhanced sense of connectedness, spirituality, and meaningfulness that individuals experience during psychedelic-assisted psychotherapy play an important role in improving and sustaining treatment outcomes (Johnson et al., 2017; Nielson et al., 2018; Noorani et al., 2018), and yet remain difficult to measure (Maclean, Leoutsakos, Johnson, & Griffiths, 2012). Furthermore, the emotion awe has been hypothesized to be a key mechanism of action underlying mystical experiences in psychedelic-assisted psychotherapy, fostering a sense of connectedness and oneness with others and acting as a principal catalyst for change within the psychedelic-assisted psychotherapy paradigm (Hendricks, 2018). These factors continue to be difficult to quantify, and although some validated scales for measuring recovery capital exist, such as the Brief Assessment of Recovery Capital (Vilsaint et al., 2017) and Recovery Capital Index (Whitesock, Zhao, Goettsch, & Hanson, 2018), corroborated measures for capturing the unique, intrinsic metrics of recovery capital that appear to be highly influenced by psychedelic-assisted psychotherapy (e.g. motivation, awe, connectedness, mystical experience and spirituality) are lacking. Development and validation of improved measures that have sufficient capacity and sensitivity to evaluate recovery capital metrics in this field will help to bolster the research and evidence emerging from the literature (Carhart-Harris et al., 2018). While psychedelic-assisted psychotherapy may continue to show promise with better validated measures, it is of notable importance that many highly motivated individuals may not be able to achieve their goals due to external structural factors such as housing or employment instability, and stigma (Hennessy, 2017; Laudet & White, 2008). As such, while supporting recovery capital and motivation in addiction settings can help to alleviate stress that comes with treatment and facilitate positive outcomes (Laudet & White, 2008), psychedelic-assisted psychotherapy should be considered alongside broader structural interventions to support individuals in achieving their substance use-related goals.
Though further research is required to substantiate evidence, a growing number of studies, including clinical trials, indicate psychedelic-assisted psychotherapy holds promise when offered concurrently with standard of care interventions. However, there remains an ongoing need in this context to develop and validate new assessment tools that better capture and measure recovery capital and motivation and related factors influenced by psychedelic-assisted psychotherapy that have the potential to sustain long-term benefits including abstinence and remission from SUDs. The global crisis of addiction calls for expanding treatment options beyond the existing therapies for SUDs that are offered today, which are characterized by significant limitations. As the field evolves, formally validated measures for psychedelic effects and impacts on recovery capital and motivation will enhance our understanding of the psychosocial aspects of an individuals' journey to remission, and the potential for psychedelics to enhance existing treatments. Continuing research and growing evidence of psychedelic-assisted psychotherapy offers a novel and promising approach to initiate and sustain internally motivated change, optimize addiction treatment outcomes and ultimately advance the way we care for those struggling with SUDs.
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