Comment by troydavis | Hacker News Reader

Comment by troydavis | Hacker News Reader

At least as written, the advice for problems during medication sessions is pretty simple (though note the presence of a physician "sitter" alongside the therapist):

> Responding to intense, painful affect states

> The therapists will gently encourage the subject to “lean in” or “go towards” intense or difficult affective states, rather than try to avoid or diminish them.

> Responding to agitation or restlessness

> The therapist will encourage breathing exercises and grounding techniques, as described above. If these are not helpful, the participant will be invited to sit up, take off the eyeshades and make visual contact with the therapists and the room. The therapists may offer reassurance that such states are to be expected and are likely to be short lived.

> Responding to marked agitation

> If the subject displays significant or marked agitation and previously mentioned interventions fail, the therapist will consult with the physician regarding the possible administration of benzodiazepine or antipsychotic medication. Medical intervention will be utilized only when agitation is persistent, and no other means to help relieve the agitation are effective.

Based on just what you've copied here, Maps.org's manual for MDMA-assisted therapy seems more thorough and detailed.

Arguably this is where mainstream medicine needs to catch up, and where a lack of multi-disciplinary approach still exists: Rick Doblin (the founder of Maps.org) has suggested that if someone has difficulty processing during an Ayahuasca ceremony (a potentially more intense, more potent version of Psilocybin session/ceremony) said to give a half-therapeutic dose of MDMA (100mg to 125mg is therapeutic dose; 180-200mg is generally what's used recreationally, usually not all at once) - and so I hope sooner than later this guide is updated to replace "possible administration of benzodiazepine or antipsychotic medication" with "possible administration of MDMA;" instead of numbing a person's nervous system/emotions with a benzodiazepine or changing how their brain is actually functioning, instead use MDMA to cause the brain to release more serotonin at once than it naturally can - allowing everything to feel and be easier to connect to and process; reducing the stress level enough where it's not acting as a blocking function, hence PTSD is from extremely stressful past experiences that are too overwhelming to process.

Because of the presence of MAOIs, mixing ayahuasca with other drugs that affect serotonin such as MDMA or anti-depressants such as selective serotonin reuptake inhibitors (SSRIs), may be particularly dangerous.

via https://adf.org.au/drug-facts/ayahuasca/

I imagine what Doblin meant is working with MDMA after an ayahuasca ceremony.

Good thought - but nope, and I've done it. The issue with SSRIs are them being reuptake inhibitors - they actually change how the brain functions vs. MDMA is simply causing serotonin to be released.

I also happen to be taking a dopamine agonist to treat a benign brain tumour I have (prolactinoma) - first line of treatment is adding a dopamine agonist to the system, and not using an SSRI/SNRI/etc that changes the actual function was fine as well for ceremony; a caveat to research or understand/have caution with is that I had done 30+ Ayahuasca ceremonies prior to taking a dopamine agonist - and so my mind/brain was generally already "opened" how it will be. Care/caution may be necessary if a person has never "opened" up their mind/brain yet (after X ceremonies/experiences) and if they are taking dopamine for whatever reason, as maybe once the pathways that get opened from Ayahuasca et al then the impact of the dopamine would shift as well - perhaps then overcompensating for blocks that get cleared by the Aya etc - and the person may then experience undesired levels of effects from the dopamine.

MDMA isn't directly changing the actual function, they're not causing inhibition; the action of how is important, the nuance is important to understand - though like from your comment - there isn't this general understanding that there is a difference, and I imagine most doctors/professionals will jump to the same conclusion without thinking about it - misattributing the different actions instead of critical thinking from foundational principles. It's not the neurotransmitter(s) that are a problem, at least not serotonin and dopamine, it's if the function change of how they're allowed to flow changes that's the problem.

Interview/chat between Dr. K (Healthygamer_gg) and Rick Doblin - https://www.youtube.com/watch?v=1e2h-awLC-s - where he mentions taking half-therapeutic dose; more of a casual conversation where you can also hear a bit of Rick's origin story.

I did fairly deep research on this beforehand, looking into actual pharmacological aspect of interactions with things like dopamine, etc - a few people over the last 20 years have been keeping track of all related research. I don't have the link for the most succinct, detailed writeup I read handy.

> I did fairly deep research on this beforehand, looking into actual pharmacological aspect of interactions with things like dopamine, etc

While you can read about mechanisms and in vitro this and that all day, this is not the same as quality applied clinical research, which frankly just doesn't exist in any meaningful quantity. I am a practitioner, and I am very sympathetic to the movement of alternative treatments counter to established standards of care, however at the end of the day it doesn't change the fact that the controlled research is non-existent or poor, and things like the MAPS manual are essentially woo.

And specifically the problems I have is that ironically, these alternative treatments which are supposedly trying to overcome boundaries of established care are extremely proscriptive themselves.. they're limited, just differently, and the justifications have very little evidence based backing.

Woo? Are you familiar with their clinical research/results and still saying it's woo?

"very little evidence based backing"

Many studies have been done, not just in vitro but in real people with just about the most severe mental issues there are: severe depression and PTSD, and the results have been positive, and these studies have been published in peer reviewed journals and been well received by the scientific and medical community.

So can you describe what evidence you're looking for and what would satisfy you?

Also, you say you're a practitioner. I wonder what you are a practitioner of exactly. If it's some sort of traditional therapy you should be aware that for PTSD and severe depression the evidence is that traditional therapy is very ineffective. So what would you suggest for those suffering from these conditions if not psychedelic-assisted therapy, which from my reading is actually far more effective for these conditions than traditional therapy?

Oh, interesting!

I’ve also sat a comparable amount of ceremony — and so of course there’s strictness about SSRIs...but I have never thought about the mechanisms like this. It just wouldn’t have occurred to me to explore in this way.

If you do find the succinct, detailed write up I’d love to see. Thank you for finding the YouTube link, I want to check it out!

Interesting. For me, MDMA comeup is 45 minutes of restlessness and agitation. I'm not sure how I would be able to tolerate that if I'm already at a point where a medical intervention is needed to calm me down. Though the actual effects of MDMA would be wonderful for processing the difficult emotions, I agree.

What's the environment/setting? Who were you with? What dose? Most people hit peak from a dose between 70-90 minutes. How were you onboarded, what was told to you about how to deal with "restlessness and agitation"/anxiety or if anything came up for it that felt hard/difficult for you? Also are you 100% sure it was just MDMA and not something that may have been mixed with something like meth/speed, etc - e.g. was it tested?

The restlessness and agitation you're speaking of is often why people go dancing as when taking it primarily for recreational purposes, as it can have therapeutic effect as well; it can release energy that you need to do something with.

My experiences have been either alone or with good friends at home settings, in a small intimate club with pleasurable company, and at a rave with lots of unknown people. Always with proper spacing between experiences (usually a year).

Doses between 60 and 100 mg of crystal that I have tested with Marquis reagent to be MDMA, as accurate as that test can be (there's no substance testing available for public in my country).

I had read beforehand that the comeup can feel uncomfortable especially right before the full effect hits. During my first experience I was kind of surprised how restless and annoyed I became at everything and I attributed it to not being able to be alone (I'm an introvert). On subsequent experiences alone I have come to realize that it's just part of the comeup for me and now I know to just ride it out. I read somewhere that MDMA triggers the release of norepinephrine which would make sense. One of my friends also commented that during comeup he too gets quite annoyed, to the point of ready to fight someone.

Basing on my experiences, the long comeup and the additional agitation is why I find it surprising to recommend MDMA for psychedelic crises. A benzodiazepine like Xanax has a quick onset of action and calms people down which makes more sense to me for these kinds of situations.

as far as my recreational common knowledge goes: mixing MDMA with any other triptamines is risky. Read up on risks of "candyflipping"

I haven't seen any therapeutic guidelines recommending this, nor research supporting it, but anecdotally and from personal experience, doing something expressive with the body like dancing, chanting, singing, or playing an acoustic instrument during difficult experiences can help.

This is, of course, something that's been done for millennia by traditional cultures in altered states of consciousness and during ritual, so there's plenty of precedent for it and it's far from a new idea.

I hope some research is done on this sort of intervention, and expect the results will be positive.

Another tip, along the same lines as dancing, is to do some physical exercise. Excess physical energy and restlessness is a common side effect of psychedelics, and that can easily translate into mental anxiety. Expending some of that energy through jumping jacks, push ups, running, hiking or whatever can help calm the jitters and make it easier to relax into the experience. Just don't do anything that involves too much coordination or dealing with traffic :)

A safety tip about that:

Before taking whatever it is you're taking be sure to thoroughly investigate its physical effects and learn about the precautions you should be taking, and what to or not to do.

For example, MDMA, which is sometimes sold on the street as Ecstacy or Molly (and sometimes other drugs are sold under those names, which is yet another danger) can interfere with the body's temperature regulation ability, so when you take it and start dancing and get hot you might not be able to cool off as effectively... which is one reason why people can die from it, especially if they're dancing a lot in already hot environments (like at an outdoor festival on a sunny day or in a hot club with poor ventilation), or when they don't drink enough water, or drink too much water.. any of these can kill you, and people have died from just this.

DanceSafe's recommendations for MDMA are to drink one pint of water an hour.

Below are some fantastic videos from Emanuel Sferios, the founder of DanceSafe, that he gave at UC Berkeley about MDMA (and general recreational drug) safety, which I highly recommend everyone watch. You could save your life or that of a friend by learning what's in these videos.

So, everyone, please EDUCATE YOURSELF and stay safe!

[1] - Part 1 - The History of MDMA https://www.youtube.com/watch?v=8ZY-ZFJnWbg

[2] - Part 2 - Tips for Safer Use https://www.youtube.com/watch?v=HgUPKYrpBvY

[3] - Part 3 - Pharmacology and Medical Use https://www.youtube.com/watch?v=UHduGGB5kJU

[4] - Part 4 - The Need for Drug Policy Reform https://www.youtube.com/watch?v=nTSiyQHm2s4

[5] - Part 5 - Heather Brooks https://www.youtube.com/watch?v=O8s-nhlaACw

[6] - Part 6 - Joseph Pred https://www.youtube.com/watch?v=0wolzUE3lPk

[7] - Part 7 - Question & Answer https://www.youtube.com/watch?v=rovaoVjLnOk

[8] - Prohibition Fatalities and MDMA Complexities: Interview With Emanuel Sferios, the founder of DanceSafe https://www.youtube.com/watch?v=yHKYogJ8Yxs

Yes, good points!

To add to that, it's probably sensible to not engage in particularly strenuous activities like weightlifting or very intense aerobic training on MDMA. It is still an amphetamine-class stimulant on top of its other effects, with the hypertension and increased heart rate.

> doing something expressive with the body like dancing, chanting, singing, or playing an acoustic instrument during difficult experiences

A VR motion game like Beat Saber might work better in a clinical setting, because it'd be weird for a patient to dance or chant with a therapist, and the other options require considerable skill.

Is it weird that I would want a therapist who had also taken psilocybin? Preferably many times. It feels like it would be demeaning to have someone who approached it in a clinical and proscribed manner.

Not weird at all. I did a therapeutic mdma session with an incredibly well trained therapist who was also very experienced with medicine work. It’s the same for ayahuasca, which I also experienced. You wouldn’t want a shaman who hadn’t waked the walk.

If I'm not mistaken, in order to get certified to do MDMA-assisted therapy in the US you have to have had the therapy yourself (and I'd be surprised if most therapists interested in doing this kind of therapy hadn't already had multiple psychedelic experiences before and during training).

I'm not sure what the criteria for getting certified to do psilocybin-assisted therapy are or will be, but my guess is they'll probably be pretty similar.

In general, at least for now, it's pretty safe to say that most therapists interested in doing psychedelic therapy are already interested in psychedelics and probably are already "experienced" or will be during training.

For me, much more important than if they've had a psychedelic experience is if they're highly recommended by well-informed people who've gone through therapy with them and who I trust. If they green-light them, I'd feel much more secure.

That makes sense, as it’s true of many different varieties of therapy. During certification, the aspiring therapists are also required to undergo their own therapy.

Interesting the leaning into distressing states seems really scary if there is no way to correct the underlying problem. One of my disabled friends had a bad trip around the fact that he lost a leg and there was no way to correct that problem so he remained severely depressed for at least a year after the trip. He used to be a pretty bubbly guy before then.

That sounds like a very difficult experience, I’m sorry for your friend.

At risk of overstepping, I wonder if the underlying issue might be better viewed as needing to rectify and update previous ways of being, self-models, and goals with the new circumstances. As well as fully grieving this loss, coming to terms with how things are, and learning to imagine all of the new possibilities that can still be realized.

Sure, but isn't that exactly what we would be trying to treat? I would like to believe in hallucinogenic therapy, but if it can cause an underlying problem to expand to the point where it causes a negative change in behavior, that's not good. It would certainly depend on the risk, but having a risk of triggering a mental illness the person was previously coping with is not a good thing.

Finding a way to deal with your problems is the best solution. In lieu of that, I would argue coping with them without handling them is the second best, with neither handling them not coping them being a distant last place.

I would argue that in very specific cases being in ignorance/denial is better than wholly accepting your circumstances.

You could just give them a hydrocodone or other opioid to kill the trip in about 10 to 15 minutes.

~5mg of Trazadone works as well. Applies to LSD and other psyches

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