Pharmacists Will Have a Very Important Role in Psychedelic Medicine for Patients With Cancer

Pharmacy Times® interviewed Anthony L. Back, MD, physician, colorectal services at the University of Washington (UW) Medical Center; co-director, UW Center for Excellence in Palliative Care; and professor of oncology and medicine and adjunct professor of bioethics and humanities at UW.

Pharmacy Times: As an oncologist, how did you become interested in psychedelic-assisted therapies and research?

Anthony L. Back, MD: As a medical oncologist, I have talked to many, many patients who have been facing their own mortality or facing end of life or facing some kind of big change in their lives and have a really hard time adjusting to it. You probably know that we have very limited therapies available for people.

For example, if you look at depression and cancer, or anxiety and cancer, or anxiety at the end of life, depression at the end of life, the evidence base is actually very thin. There was just a Cochrane Systematic Review a couple of years ago that said that the quality of evidence for any kind of intervention for depression for people with cancer, there's just not a lot of evidence about what works.

So, I do know that there's some interventions like meaning-centered psychotherapy that have shown promise and some small trials, but really, there's not a lot out there. So, as an oncologist, I was looking for something more, and that's what got me interested in psychedelic-assisted therapy.

Pharmacy Times: What have you worked on so far in your research into psychedelic-assisted therapies?

Back: So far, I am the [primary investigator] on a study that does not involve cancer patients which is the study of psilocybin assisted therapy for doctors and nurses with symptoms of depression and burnout related to their frontline work in the COVID-19 pandemic. It's not the same population group, but in some way, there is an overlap on issues, which is seeing a lot of death, being confronted with your own mortality, and adjusting to that during a time of great uncertainty. But that's the trial that I'm finishing up now.

Pharmacy Times: What are some examples of research under investigation in the field of psychedelic medicine that are pertinent to the needs of patients with cancer?

Back: Yeah, there are a couple of trials underway that I think are notable and will be really interesting. There is a 2 site randomized trial of psilocybin-assisted therapy for people with cancer and demoralization that is being led by Dr. Steven Ross at [New York University (NYU)], and it's happening at NYU and the University of Colorado Denver.

Then there is another study that I don't think has started to enroll patients that is a trial of psilocybin-assisted therapy for people with palliative care indications, including cancer, and that one is being led by Brian Anderson, MD, at [University of California, San Francisco], and Charles S. Grob, MD, at [University of California, Los Angeles].

Pharmacy Times: What is the role of psychedelic medicine in cancer care in your view, and is it primarily connected to palliative care, or is there potential beyond this setting?

Back: First of all, I think of palliative care as appropriate for any stage of cancer because it is about addressing symptoms and stress of living with a serious illness. So that means that looking at indications related to palliative care for cancer could be at any stage of the illness. I think a lot of the studies now that are going on are going to be focused on people who have incurable cancer or advanced cancer, but I definitely think there is a potential role for psychedelic-assisted therapy, both early on in the cancer journey, and later on in the cancer journey.

I think later on, there are these issues of facing mortality, dealing with symptoms of depression and anxiety, dealing with fears of recurrence. Upstream, I think there's a slightly different landscape of also depression and anxiety, but also fears of recurrence, fears of how my life is going to be changed, fears of how I might be changing as a person. So I think those are related, but somewhat different issues that I think are places where we don't have a lot of different treatments for people. So I think the promise of psilocybin-assisted therapy for people with cancer is really about moving adjustment to a complex life-threatening disease.

Pharmacy Times: Where are we in introducing psychedelic medicine in oncology research and vice versa?

Back: Yeah, well, so I think we're really at a point where we're building the evidence base. There are a couple of small, randomized trials that look really promising and successful, and they are small trials. They were the early days of the recent renaissance of psychedelic therapy, so published in 2016. Those studies took a long time to accrue and probably have a selection in ways that we don't really understand.

So I think these larger, more extensive trials are really important to get a larger group of patients to evaluate. I think the other thing that's important to evaluate is if there are other useful models to investigate besides just the 2 therapists on 1 patient model that has been the dominant model for most of the recent psychedelic therapy.

So I think we need more research to look at a wider patient population and new models that are less clinician intensive that might create the possibility of more access for more patients.

Pharmacy Times: Mental health challenges during cancer care are often considered outside the scope of oncology professionals. What is your perspective on this?

Back: Yeah, so my perspective as an oncologist is that, of course, oncologists have been super focused on anti-cancer therapy, and that's all really important. I also think that oncologists have been less focused on the issues that aren't anti-cancer treatments, because, until recently, the evidence-based treatments have been kind of limited. It wasn't until Jennifer Temel’s study [NCT01038271] showing that early palliative care really improved outcomes for patients with metastatic lung cancer. When that happened, it led a lot of oncologists to say, ‘Wow, I need to be more involved in getting palliative care to my patients early.’ I think the same will be true of psychedelic medicine for mental health issues related to cancer. I think once oncologists feel like they have something to offer that is really valuable, I think they will be a lot more interested in figuring out when to refer people.

I, of course, think oncologists have been taking care of mental health issues for a long time for people with cancer, and I think they're not that crazy about the options. I've treated lots of patients with SSRIs in this situation of advanced cancer and symptoms of depression. Honestly, the results are not that great, and there's not much evidence.

Similarly, for anxiety for patients with cancer—severe anxiety, not just mild anxiety—there's not a lot of evidence-based treatment. We end up giving people benzodiazepines, but those are kind of a temporary fix at best, and a lot of high benzodiazepine use often leads to other complications in the future that I think many oncologists are quite aware of. So these are not treatments that oncologists are super excited about. I think that's one of the reasons that oncologists have, in the past, spent less time and energy on mental health issues.

Pharmacy Times: What are some challenges you see ahead as oncology professionals look to consider psychedelic medicine for patients with cancer?

Back: So, I think the first challenge is going to be there’s not going to be a lot of research trials for all the patients who are interested. So I think there's going to be limited access there. Then I think the first indication—the first FDA-approved indication—for psilocybin is likely to be major depressive disorder, not cancer. So I think that's going to create another challenge.

Then finally, I think the last challenge is the availability of qualified therapists who actually have training and experience with psychedelic therapy. I think that's going to be the third challenge.

Pharmacy Times: The FDA has been inquisitive about whether patients with cancer and with depression can be treated with the same therapies as patients with depression and without cancer. What are your thoughts on this dilemma?

Back: Well, I mean, the ultimate thing, and this is what I'm hoping, is that there will be research and an evidence base developed for people with cancer and symptoms of depression that will establish the value of this treatment for that particular patient group.

In the short term, I think I am not sure what will happen when psilocybin is approved for major depressive disorder, and how that will be interpreted by payers and other networks in terms of availability for people with cancer. I think that's an open question that I don't think I have a prediction about. So that's why I think the evidence base developing is really important.

Credit: Adobe Stock - cendeced

Pharmacy Times: What is the role of the pharmacist on the patient care team related to psychedelic medicine in cancer care?

Back: Well, so I think, as psychedelic medicine comes into cancer care, pharmacists are going to have a really important role in helping screen patients and evaluate them for suitability for psychedelic medicine, as there are a number of important medication potential interactions. For example, the use of antipsychotics might point to a prior personal or first-degree family history of a psychosis disorder that might be an exclusion. I think there's a lot of concern that high benzodiazepine use may affect the efficacy of psychedelic therapy. So I think that is going to be something else that pharmacists will be very in touch with.

So I think pharmacists will be an important part of the interdisciplinary team, both in evaluating people for psychedelic medicine and as part of the psychedelic team itself, for patients with cancer who are receiving psychedelic therapy.

Pharmacy Times: For pharmacists interested in educating themselves further, are there any sources of information that you would recommend for the purposes of being able to better answer patient questions on the subject?

Back: Yeah, there are just some emerging sources. There are definitely programs about specialized training in psychedelics that have enrolled pharmacists in the past, including the program at the California Institute for Integral Studies. There's also a pharmacist named Benjamin Malcolm, PharmD, MPH, BCPP, who runs a site called Spirit Pharmacist that tries to collect all the evidence there is about interactions between psychedelics and other medications. He is very thoughtful guy who's trying to pull together a very fragmentary evidence base.