Oregon Psilocybin Services and Access to Care – Keith Kurlander & Will Van Derveer – HPP120

SPEAKERS

Keith Kurlander, Dr. Will Van Derveer

 

Dr. Will Van Derveer  00:06

Thank you for joining us for the Higher Practice Podcast. I’m Dr. Will Van derveer with Keith Kurlander, and this is the Podcast where we explore what it takes to achieve optimal mental health. Well, hi, Keith.

 

Keith Kurlander  00:25

Hey there.

 

Dr. Will Van Derveer  00:26

So today, we’re going to get into some new and exciting developments that are happening in regards to access to treatments that we believe can be real game changers for people who’ve been struggling for, you know, in some cases, decades with difficult to treat conditions, depression, treatment resistant trauma. We’re going to talk about the initiatives happening, primarily and what got passed in Oregon and what’s happening there, but also the new initiative in Colorado that’s on the ballot for November. So why don’t you kick us off and tell us a little bit in broad strokes of what is happening in Oregon and what makes the Oregon initiative interesting and controversial?

 

Keith Kurlander  01:14

Yeah, so Oregon passed a psilocybin services ballot which now will be we’ll start seeing psilocybin facilitators probably right at the beginning of January, mid January of 2023. So this was a cool and interesting law for Oregon, just to note that this is a state law, not a federal law that got passed. So in Oregon, they outlined what they’re calling psilocybin services, and this is a non medical model, which is really a non mental health model, you could say. So what happens is that starting in January, there are licensed facilitators, in order to become a licensed facilitator, you have to be a resident in Oregon for two years and you will need to go through an approved training. So as you know, Will, our training was accepted a few weeks ago, to be an approved training and their training requirements, I’ll just go through all the nuances here. And then we’ll kind of talk about what this means. So their training requirement is 120 hour training that was approved by the state, they have 12 core competency areas, 30 hours has to be in person for that training. And on top of the 120 hours, you need a 40 hour practicum that’s also in person. And that practicum can have psilocybin services in Oregon as part of the practicum. If it’s an approved practicum site, but it doesn’t have one, you don’t have to be working with psilocybin in a practicum that can also be through like watching recordings and things. So, a facilitator can be age 21, or over with a high school degree. That’s the qualifications from the state level, but you still have to get into a program and each program has different requirements. As you know, our program obviously is geared toward licensed professionals, mental health professionals. A little more nuance here is that in Oregon, I can’t remember the name of their department of health services or something. They are not the licensing boards for physicians or psychotherapists, so this is not run through there. They have told me that the board hasn’t necessarily taken a position one way or the other, if a therapist chooses to go offer this, so we’ll see what happens there. Okay, so that’s that, and then there’s going to be licensed service centers. And those applications will be starting towards the end of this year. My understanding so far is you have to be both a licensed facilitator and a licensed service center to offer this, and then there’ll be licensed manufacturers of psilocybin. The similarity of, you know, one thing that people might be interested in, obviously, psilocybin is a schedule one substance in federally in the United States, so it’s federally illegal to consume psilocybin or I should say to carry psilocybin, right, but that at state level now in Oregon, it’s essentially it’s sort of like a de Krim effort around giving people these experiences under the therapeutic model, right? In Oregon. So that’s really interesting. So similar to cannabis, it’s not legal federally, it’s now the Got the state level for this particular service? I think that covers the details, they missed anything there you think?

 

Dr. Will Van Derveer  05:07

No, I think I just want to highlight a couple of things that you said that I think are really interesting about the initiative there that are, I guess you could say it’s a law there, because now it’s not, it’s past. And it’s happening. One thing is keeping psilocybin services outside of the medical model, keeping it outside of the medical and psychotherapy context entirely, is a really interesting DRM strategy. Because, of course, inside of the medical model, we have doctors and therapists who are licensed on the state level, as you alluded to, particularly physicians who not only have a state license, but also have a DEA license. And so one of the sticky things for, I think, for physicians in Oregon, who are going to get involved in psilocybin services, is this issue of being regulated by a federal agency and DEA, but then operating under applicable local and state law in Oregon. So there is this kind of difficulty there for not just doctors, but also for therapists who are working with their licensure in Oregon as a therapist.

 

Keith Kurlander  06:23

Yeah, it’s very tricky. Right now, we have a model for this, which is a field trip in Amsterdam. So one place is attempting to work within a system like this, because it’s a very similar situation. Except this is a little different in Oregon, because this is actually the decrease effort here is around psilocybin services, as therapeutic encounter with psilocybin in Amsterdam, you have truffles that are legal. So field trip does have a model there, that, you know, I one saw on there doing this sign of a hybrid, we’re not practicing medicine. We’re a wellness center, but they still incorporate aspects of making sure people are appropriately fit and having nurses on site. So Oregon’s different in that there’s really, there’s nothing about, you know, nurses on site and medical staff on site. So. So this is, I think, an interesting topic for us to kind of explore, you know, what does that mean? How’s that gonna go?

 

Dr. Will Van Derveer  07:22

Yeah, yeah. And just zooming out for a moment. I think, you know, there’s this bigger context that I think is really fascinating around. Why are these efforts happening at state level, and what’s going on? Because, obviously, psilocybin since we’re talking about psilocybin might as well stay inside of the psilocybin conversation that psilocybin is progressing through FDA trials. And there is an expectation that there will be a phase three clinical trial that will occur at some point, we’ve been anticipating that now for a couple years, it’s seems to be slower than anybody hoped it would be. But there are different players involved, not only on the nonprofit side, but also on the for profit side, with Compass pathways in the UK. And so there’s this mechanism for scheduling one drug to become legal at the federal level. But at the same time, you have this very long history of psilocybin, in particular, being used in indigenous contexts for healing, which arguably, validates Western medicine completely and totally right. We’re talking about millennia of use in Central America, and so in other places. And so I think it’s a really interesting philosophical question about whether a natural medicine that’s been used for millennia, should live inside of the regulatory structure or not, of Western medicine.

 

Keith Kurlander  09:01

So that’s a whole philosophical question. Right? So for people who aren’t very familiar, let’s sort of just paint a picture of before we get more into Oregon, the different ways sort of psilocybin is being used. Historically, we have indigenous ceremonies and indigenous healing practices. We have psilocybin being used in the underground healing world, not just in the US and other places, one on one with healers, and therapists and ceremonies with groups, shamans who have trained through different lineages, but maybe didn’t grow up in those lineages. With psilocybin obviously being used recreationally at concerts and you know, hanging out with friends and And now we have psilocybin. This new piece here is psilocybin in Oregon, which is a non medical model. But it’s a therapeutic model. And someone can be a facilitator, they had, you know, this 100 120 hours worth of training, right. So again, this is another sort of granular approach to how it could be used, and now it’s within a regulatory body in the US. Yeah, and you know, there are people with very well respected, very thoughtful, highly intelligent people who have really strong opinions on both sides of this kind of, if you will debate or controversy about where psychedelics belong, in American, you know, 21st century American culture.

 

Dr. Will Van Derveer  10:49

And, you know, I read these opinions from people, whether it’s Michael Pollan, or David Bronner, or you know, any of these very thoughtful, and highly intelligent folks thinking about, where’s the best place for these tools that clearly come with a lot of promise for potential healing for a lot of people. And with psilocybin, the range of challenges is pretty wide. Actually, it’s more than just depression with psilocybin, showing promise for cluster headaches and OCD and end of life anxiety. And it’s particularly helpful for a fear of death and cancer and eating disorders. There’s all kinds of research going on. I can see benefits and drawbacks to both sides of this argument about that it should be regulated, and then it should be taken outside of the medical context, like what’s happening in Oregon are completely different. Right?

 

Keith Kurlander  11:50

It’s right. It’s a whole nother movement, which is, you know, de-crime at the state level.

 

Dr. Will Van Derveer  11:58

Right? Yeah, there is a concern that what’s happening with this context that you described, that’s already in place in Oregon, that that is the first step toward, you know, seeing psilocybin solid with marijuana and, you know, kind of a fully deep REM state level context.

 

Keith Kurlander  12:19

Well, so let’s talk about the different aspects of this. So the services in Oregon will obviously increase accessibility to a lot of people, of course, you’d have to go to Oregon, if you’re not living in Oregon to access this service. I mean, I think overall, my sense is, this is a really good first step in this country, of, you know, a state taking a stand that these medicines have healing properties that we need to take advantage of. And we can’t wait forever to take advantage of these things in a way that’s going to help people. So on one level, I think this stand that Oregon took is really amazing, because we’re really moving the needle forward. Here, it’s time to make psilocybin in a therapeutic context available to people. And we don’t know if psilocybin will get through phase three, and when, if and how. And if it does, it’s interesting, right? Because that’s strictly going to be in a medical model. When we go through a medical model, like we’re doing with MDMA, the benefits of a medical model is you can put a ton of controls in place, to how people have to the set and setting and safety. And the level of training is going to be the highest in the medical model, because people have a ton of training once they’re in the medical model already. So there’s a lot behind that movement, right, that I think has a lot of merit. Clearly, right?

 

Dr. Will Van Derveer  13:56

Absolutely. Yeah. But it does restrict access, as you’re pointing out significantly, and access, you know, not just from a regulatory point of view, but also from a cost perspective as well.

 

Keith Kurlander  14:10

Yeah, obviously, the cost of doing anything in the medical model is very expensive, right? Education is expensive for people who practice in the medical model. Some medical staff are expensive, clinic staff is expensive. It’s an expensive model, more expensive model. Right. Right. And with that said, we’ll likely see the insurance companies coming online as things get through phase three trials. And you know, that’s a different world when things go through a phase three trial and if they could pass and we’ll start to see insurance having some involvement over time probably with these medicines if they get through phase three trials. So we don’t know we’re not there yet. But the medical model has a lot of benefits to it, and it has drawbacks around accessibility and other things in the medical model. at all. And then with Oregon’s model, obviously accessibility, that was one of the largest benefits of the Oregon model. And that’s a huge benefit. Because there are a lot of people that need this help. And they need it soon. So to me, the question then becomes, there’s two factors I think about with Oregon that I’m curious about. One is screening and safety. So I wonder what we should talk about. And then the other is just the training of the facilitator. So let’s talk about screening and safety. What’s your What are your feelings on? That essentially, clients are being informed to self screen? Because they’re not being medically assessed? Right. So they’re basically having to be informed about what the different contraindications and risks are? And then they have to essentially rule themselves out as a client. So what do you think about that system?

 

Dr. Will Van Derveer  16:08

Well, you know, I think that there’s a substantial risk of harm from taking psilocybin without being well informed about what the risks are, and who is a good candidate and who isn’t for psilocybin use. And then obviously, there’s, there’s a risk of, of harm in the wrong context and the wrong setting setting, which I think also I include inside of that comment of setting setting the qualities of the facilitator. But when I just for a moment to, to flush that out just for a second about facilitation, I think that we obviously run a really in depth training for licensed people who want to go deeper and weave in what they’ve already been trained in into the best practices, let’s say, for psychedelic therapy for sitting with people and psychedelics. But my own journey as a MDMA therapist, and then later a ketamine therapist, I would say that you could think about your, your training, facilitating psychedelic sessions, the same way you would think about your training in graduate school or your, for me training in residency, it gives you a basic kit that would hopefully prevent you from harming people and teach you how to screen people properly. But it’s not going to make you a, you know, a black belt in psychedelic therapy that takes many, many, many, many hours of sitting with people and learning and making mistakes and addressing the mistakes. So my point is that, to come back to your question, specifically, what are the risks? I mean, I think the concern about DRM, which I think is valid, is that people making decisions, whether there are people with mental health challenges, or extremely inexperienced facilitators, that there’s just a higher risk of missing something important. And having someone go into a psilocybin experience, who might be at a higher risk of breaking up and an underlying tendency towards psychosis and having a difficult integration experience from that. Or someone who maybe is prone to bipolar disorder, who is now taking something that hits the serotonin system pretty hard and could trigger mania. These are things that tend to get rolled out in clinical trials. And so we don’t screened out my point, people with such vulnerabilities are usually not included in psilocybin trials. And so the safety profile for psilocybin is excellent in clinical trials, but it’s really important for people to understand that the participants in those trials are carefully selected to minimize harm to participants.

 

Keith Kurlander  19:10

Yeah, you know, a lot of people are obviously taking psychedelics at this point, right? Yeah. Yeah, there’s a lot of psychedelic use going on. Oh, yeah. So that’s really what’s happening. And as you and I know, we saw a lot of people in our practices that did psychedelics without any container, other than the random one they found themselves in and had a lot of work to do around that integration. And so that’s really well, and, you know, the setting isn’t held in a way that meets the person where they really need to be met. So I think Oregon’s definitely a step in the right direction and I think there’s some real caution around Can you get a facilitator up to speed in 120 hours of training, most of which is online, most of which is synchronous from these laws with someone who has no background whatsoever? Not everyone does. But some people will have no background whatsoever in any healing modality. I don’t think so. I don’t think he can get someone up to speed enough in that short amount of time. But, you know, I think that sometimes we have to look at what’s the purpose of something, you know, the purpose is not they’re not calling this psychedelic assisted therapy, or psilocybin assisted therapy for a reason. Because that comes with other connotations of psychotherapy, and the person’s background and training. And so it’s not a mental health treatment. Right? Right. So and that’s okay. Right, that it’s not a mental health treatment. And the thing is, it will become a mental health treatment, whether we don’t call it that or not, for many people that are coming in with either known or unknown mental health issues. And I think that’s going to be challenging for a lot of people that have, you know, not a lot of mental health training. And so there’s going to be some challenges that arise around that, that are real. And hopefully, there’s enough awareness in the space in Oregon to make sure people get what they need, if things arise.

 

Dr. Will Van Derveer  21:29

Yeah, I mean, I think you’re making a great point, when you bring up that a lot of people are using a lot of psychedelics. And there’s an argument for looking at the big picture of how many people are actually getting into really serious trouble with psychedelics, with their mental health, on the one hand, you know, in an unregulated environment, and then on the other hand, how many people stand to gain by dropping these barriers to access? And I think that the pharmacologist David Nutt in the UK, was famously highlighted in the how to change your mind book and Michael Pollan talking about the risk of different drugs. And he got in trouble by being quoted in a newspaper in London, saying that riding horses is more dangerous than taking MDMA. But he was actually quoting the facts, he was quoting the actual statistics of what can harm you more, you know, what, what are the what are the like, what’s the likelihood? So it’s important, I think, for people like me, who’s, you know, used to taking a more conservative, and kind of even more paternalistic perspective about things that people are out there using psychedelics a lot. And sure, some people do end up in the emergency room, or some people do end up in, like people I’ve treated who needed a year to integrate an experience that they had, or people who got PTSD, taking a psilocybin dose, and then interacting with police at a concert or something like that, if I’ve seen those people. But when you think about, like, how big the problem of depression and anxiety and suicide is, and the barriers to access to treatment, it becomes a lot more palatable to consider the risk profile that way of like, you know, the number needed to do good in the world and what the actual risks are.

 

Keith Kurlander  23:33

Yeah. And we need help. I mean, yeah, we’re in a mental health, an unprecedented mental health crisis almost. Exactly. The rates are not stopping, they’re increasing. Every few years, they bump up, and they bump up and in ways not small ways. And so yeah, we need help with psychedelics, Shore looks like it can be one solution of many that will help and the container matters about how they’re used. And so this is an interesting experiment in new Oregon. It’s an experiment that, you know, I’m curious to see how it unfolds. And so I think that mostly it’s, it was a pretty great stand that residents of Oregon took to bring this to pass. And I do think that it’s going to be hard to discern. What do we call the user, the participant who’s going to Oregon to get this experience? It’s going to be a little hard to discern what is this service for in their mind? Because you know, people will go there because they have mental health conditions, people will go there because they don’t have medical conditions and they want to go for personal development and like, it will be a little hard to understand. What is my facilitator actually know and not know Oh, you know, you kind of assume sometimes wrongfully when you go and get treated in medicine, you’re, or in the mental health system, your therapist or your doctor is going to know a lot of again, sometime wrongfully, they don’t know much. But often there is a base of knowledge in that field that you can expect, there’s a base. So this is different, because you can’t expect the base of knowledge. And 120 hour training is fine and a good start. But that’s a very small knowledge base, when you think about the amount of hours behind any type of long term education. So it’s going to be a little confusing, I think, for the person going out there or in Oregon to use these services of what they can really expect from the service.

 

Dr. Will Van Derveer  25:47

Well, I think I think it’s like, you know, if someone came to see me, in 2003, when I had just graduated from residency, like, I could do bed management, and, you know, maybe do some cognitive therapy, but outside of that, there wasn’t much I was thinking about in terms of like, actually addressing the root causes of suffering, but you come to see somebody like who I became, you know, 20 years later, you know, 20 to 30,000 hours later, of actually studying and getting involved. It’s a different experience. And I think people need to approach any service that they go and seek out from that perspective of like, it’s going to take these facilitators in Oregon time to get really good at what they’re doing. You know, it’s just like any craft. So there’s a discernment there, that the consumer, I think that’s what they’re calling them, right? It’s consumers of services. Okay. You know, you got to be cognizant of the variety of different levels of competence that happen for people, right? If I’m going to Oregon, personally, if I’m going to go there and look for a psilocybin facilitator, I’m going to be looking for someone who’s got, you know, 10 years at least of experience, before I’m going to be willing to sit with them?

 

Keith Kurlander  27:15

Well, there’s an interesting nuance here, which is, we don’t even know how many of these facilitators will end up being therapists, or non therapists, many of these facilitators may end up being therapists who choose to do this service. Right? We don’t really know yet who’s going to choose to get licensed and whatnot. And so that’s interesting. I mean, I think I would say that for people who have mental health challenges, it’s probably better to sit with a therapist. And for people who are going for personal development and feel quite stable in themselves, it might be completely fine to sit with a facilitator who doesn’t have that background. Yeah, you could say that for, you know, indigenous experiences that you could go to right now, where, if you’re very stable, you’ll probably be fine. And they’ll probably be an amazing spiritual experience.

 

Dr. Will Van Derveer  28:06

Yeah, except for folks who have hidden childhood injuries that, you know, have escaped the attention of themselves, and many therapists they may have seen everyone else.

 

Keith Kurlander  28:18

That’s everyone. Yes. So maybe you won’t be fine. But there is that risk? Eventually, you’ll discover that too, no matter why. Right? I’m wearing you. And yeah, that’s true, too. So I don’t know either way, I think it’s it’s pretty cool thing happening in Oregon. And then we have a ballot in November coming up in Colorado, right? The next round, so to speak, among states bringing in a ballot like this, right. And again, like, and I want to also say, these are all our interpretations of what’s going on in Oregon. Everything is an interpretation of a law. And that’s really important to say, Yeah, because first of all, some of this stuff for the facilitator and the service centers, they’re not even in law, yet. They’re still in draft mode. Right training is the only thing that has actually got it moved into, like a rule. So I just want to say that like this is you and I are basically interpreting the law after a lot of conversations I’ve had with Oregon, and it’s important to know that because how these things end up on the street and get in practice is an interpretation, so to speak. Right. So that’s important to note. So now we have Colorado.

 

Dr. Will Van Derveer  29:37

I think the prop change we just saw to 122. Right? Yeah, we should just probably just call it the natural medicines act, because that’s why we call it the natural medicines act. Yeah.

 

Keith Kurlander  29:49

What do you know about the natural medicines act?

 

Dr. Will Van Derveer  29:51

Well, so the understanding I have is that this is a very different model from Oregon. Actually. because it spans, controlled, regulated use, that would be overseen by the Division of regulatory agencies in Colorado, which is called Dora here, which includes the Medical Board and the psychotherapy board. And also includes so-called Healing centers, which I’m not sure what that means exactly if that’s a non medical context or, or what, but it seems like Colorado is trying to do something a little different from Oregon, and in regards to what the location and context is, for the services being provided. But they’re also focusing on psilocybin as the first step as the first medicine. Yeah. And then they’re late in 2026, to review other medicines, I believe. That’s right. Yeah. And they’re also kind of deliberately out of respect for the indigenous tradition of peyote, excluding peyote from what would be considered here for legal use. So pod is a protected sacrament in the Native American church, and so that medicine is not a part of this conversation. Lots of exciting ballot, let’s

 

Keith Kurlander  31:19

see what happens there. Yeah. And, you know, it’s interesting, as you said, we’ve got this sort of state level initiative starting to happen. And there’s also a federal, you could almost call it an initiative in terms of going through FDA trials. Right, so this initiative at a federal regulatory level that’s happening for psilocybin. So we’ll see what happens between those two separately. It’ll be interesting to see psilocybin eventually makes it through phase three, which that’s probably years away at least five to seven, if it happens. And it’ll just be interesting to see what the state initiatives what’s gonna happen if that happens.

 

Dr. Will Van Derveer  32:02

Yeah, I mean, I think, as you said, we’re in a really serious mental health crisis. And there’s a lot of people who feel like the federal pathway through FDA is not only burdensome and too lengthy. But there’s also this other philosophical argument against the FDA pathway for these medicines that FDA is really not used to evaluating a psychotherapy that is supported by a medicine. You know, the FDA is very familiar with the double blind, placebo controlled, isolated molecule model of research. And so I think there’s a really interesting argument that, well, first of all, the argument that studying psychotherapy is difficult to do in a double blind, placebo controlled format to begin with. And, you know, that’s probably a whole nother conversation for another podcast. But I guess it’s maybe just best for this context to say that the evaluation of psychedelic assisted therapy in a phase three trial is a difficult thing to do. And I think that’s one of the reasons why the pathway for psilocybin through Phase three is taking a while to get going. The other reasons are probably funding and it’s probably other reasons as well. But anyway, the point being that, once again, coming back to the conversation that people have been using these sacraments are really these natural medicines for millennia. And, you know, like any medicine there, there is risk to certain people. But there’s potentially a great benefit. And so, one way to look at the state level initiatives is that people, smaller groups, like the citizens of Oregon, or, you know, potentially, Colorado, Colorado citizens are impatient to get in a crisis to get things moved forward more quickly.

 

Keith Kurlander  34:05

Yeah, and I think that’s why we’re even having the opportunity even at the federal, you know, FDA level to see medications. Now coming into phase two and phase three, because a lot of people are recognizing, in the serious situation, that we have to do something about PTSD. And that’s just a lot of different areas where we know we need to take care of people better than we are. So hopefully people keep suspending, you know, biases or biases that might not apply any longer. And we can keep moving forward here and doing things safely and effectively. As we’re kind of ushering in a new era of healing. With psychedelics. We’ve had areas of healing with psychedelics, this is a new one. So it’ll be a great time. It’s exciting then da Yeah. Anything else to say? Before we wrap up?

 

Dr. Will Van Derveer  35:04

We can put links in the show notes to resources for people to read more about these initiatives, you know, for listeners who want to go deeper.

 

Keith Kurlander  35:13

Yeah, we can also put links about the current rules established in Oregon. It’s best to read rules this versus take our word for it, because it has a lot of details in their rules. Yeah, there’s still a lot of details in the draft in Oregon. So we’ll put some of that in the show notes too. Great. All right.

 

Dr. Will Van Derveer  35:31

Thanks. We look forward to connecting with you again on the next episode of the higher practice podcast, where we explore what it takes to achieve optimal mental health.