Faculty Bibliography

Research activity on the potential clinical value of classic hallucinogens and other psychedelics has increased markedly in the past two decades, and promises to continue to expand. Experimental study of hallucinogen-assisted treatment, and any future clinical use, requires the development of psychotherapeutic models that are appropriate to the disorder being treated and effectively integrated with the pharmacologic component of the treatment. To provide a framework for thinking about possible treatment models, we provide an overview of the history of psychedelic-assisted treatment, review what is known about the therapeutic mechanisms of these treatments, and consider the various purposes of psychotherapy in the context of both research and clinical use of psychedelic-assisted treatment. We then provide a description of a therapy model we have developed and are currently using in a trial of psilocybin-assisted treatment for alcoholism. Finally, we discuss advantages and disadvantages of a range of alternative models, emphasizing the need for research to determine the most effective treatment models for any indications for which efficacy becomes established.

The psychological mechanisms of action involved in psilocybin-assisted psychotherapy are not yet well understood. Despite a resurgence of quantitative research regarding psilocybin, the current study is the first qualitative study of participant experiences in psilocybin-assisted psychotherapy. Semistructured interviews were carried out with 13 adult participants aged 22 to 69 years (M = 50 years) with clinically elevated anxiety associated with a cancer diagnosis. Participants received a moderate dose of psilocybin and adjunctive psychotherapy with an emphasis on the process of meaning-making. Verbatim transcribed interviews were analyzed by a five-member research team using interpretative phenomenological analysis. General themes found in all or nearly all transcripts included relational embeddedness, emotional range, the role of music as conveyor of experience, meaningful visual phenomena, wisdom lessons, revised life priorities, and a desire to repeat the psilocybin experience. Typical themes found in the majority of transcripts included the following: exalted feelings of joy, bliss, and love; embodiment; ineffability; alterations to identity; a movement from feelings of separateness to interconnectedness; experiences of transient psychological distress; the appearance of loved ones as guiding spirits; and sharing the experience with loved ones posttreatment. Variant themes found in a minority of participant transcripts include lasting changes to sense of identity, synesthesia experiences, catharsis of powerful emotion, improved relationships after treatment, surrender or letting go, forgiveness, and a continued struggle to integrate experience. The findings support the conclusion that psilocybin-assisted psychotherapy may provide an effective treatment for psychological distress in cancer patients. Implications for theory and treatment are discussed.

The US 'War on Drugs' has had a profound role in reinforcing racial hierarchies. Although Black Americans are no more likely than Whites to use illicit drugs, they are 6-10 times more likely to be incarcerated for drug offenses. Meanwhile, a very different system for responding to the drug use of Whites has emerged. This article uses the recent history of White opioids - the synthetic opiates such as OxyContin(R) that gained notoriety starting in the 1990s in connection with epidemic prescription medication abuse among White, suburban and rural Americans and Suboxone(R) that came on the market as an addiction treatment in the 2000s - to show how American drug policy is racialized, using the lesser known lens of decriminalized White drugs. Examining four 'technologies of whiteness' (neuroscience, pharmaceutical technology, legislative innovation and marketing), we trace a separate system for categorizing and disciplining drug use among Whites. This less examined 'White drug war' has carved out a less punitive, clinical realm for Whites where their drug use is decriminalized, treated primarily as a biomedical disease, and where their whiteness is preserved, leaving intact more punitive systems that govern the drug use of people of color.

BACKGROUND: Increasing reports of synthetic cannabinoid (SC)-related adverse events have largely comprised case reports and analyses of calls to poison control centers. Existing studies have also mostly involved white male populations. OBJECTIVES: The purpose of this study is to systematically describe clinical characteristics of SC use in a relatively large, diverse, urban sample presenting to a psychiatric emergency setting. METHODS: SC users (n = 110) were identified by reviewing charts (n = 948) from the psychiatric emergency service of a large, urban public hospital in the United States for November 2014, which was randomly selected from the 12 months of that year. Sociodemographic data were collected from administrative databases and clinical data were collected from the electronic medical record. RESULTS: SC users were mostly non-white (90.0%) males (95.5%), who were likely to be police-involved (34.5%) and homeless (84.5%). SC users also had significant and often pre-existing psychiatric and substance use comorbidity, including acute psychotic symptoms (70.0%), more than one comorbid psychiatric diagnosis (31.8%) and primary psychotic disorder diagnosis (40.0%), past psychiatric visits to the hospital (70.9%), comorbid substance use (62.7%), agitation requiring intervention (22.7%), and the need for extended psychiatric observation (15.5%) and inpatient admission (34.5%). Relatively limited medical complications were identified. Conclusions/Importance: In this sample, SC use affected a sociodemographically disadvantaged and mentally ill population, likely exacerbating existing psychiatric problems. This is one of the only studies to systematically examine the clinical effects of SC use in a significant clinical sample, and the first study in an urban, racial/ethnic minority, and vulnerable sample.

BACKGROUND: Alcohol and drug use is a leading cause of morbidity and mortality that frequently goes unidentified in medical settings. As part of a multi-phase study to implement the NIDA Common Data Elements for collecting substance use screening information in electronic health records (EHRs), we interviewed key clinical stakeholders with a goal of identifying barriers and facilitators affecting the implementation of substance use screening in primary care clinics. METHODS: Focus groups and individual qualitative interviews were conducted with 67 stakeholders, including primary care patients, medical providers (faculty and resident physicians, nurses), and medical assistants, in two urban academic health systems. Themes were identified, discussed, and revised through an iterative process, and mapped to the Knowledge to Action (KTA) framework (Graham, 2006), which guides the selection and implementation of new clinical practices. RESULTS: Factors affecting implementation based on KTA elements were identified from participant narratives. Identifying the problem: Participants unanimously agreed that having knowledge of a patient's substance use is important because of its impacts on health andmedical care, that substance use is not properly identified in medical settings, and that universal screening is the best approach. Adapting knowledge: The majority of patients and providers stated that the primary care provider should play a key role in substance use screening and interventions. There was discrepancy of opinion regarding the optimal approach to delivering screening. Some felt that patients should self-administer questionnaires, while others thought that patients would be more comfortable having face-to-face discussions with their primary care provider - though not with other members of the care team. Many providers reported that being able to take effective action once unhealthy substance use is identified is crucial. Assessing barriers: Patients expressed concerns about confidentiality, 'denial', and providers' lack of empathy. Barriers identified by providers included individual-level factors such as lack of knowledge and training, and systems-level factors including lack of time, resources, and space, disjointed communication between members of the medical team, and difficulty accessing addiction treatment. CONCLUSIONS: Based on these findings, we designed and are testing an implementation strategy utilizing universal screening, patient self-administered questionnaires, and EHR-integrated clinical decision support to assist providers in conducting brief motivational counseling and linking patients to behavioral health services, to address unhealthy substance use in primary care clinics

The number of network members and the roles they play can influence risk behaviors and consequently intervention strategies to reduce HIV transmission. We recruited 652 people who use drugs (PWUD) from socially disadvantaged neighborhoods in New York City (07/2006-06/2009). Interviewer-administered surveys ascertained demographic, behavioral, and network data. We used logistic regression, stratified by exchange sex, to assess the relationship between HIV status and the number of network members with different roles, treated as independent and multiplex (i.e., drug + sex). Those with more multiplex risk ties were significantly more likely to be HIV positive, but only among those not reporting exchange sex (AOR = 3.2). Among those reporting exchange sex, men reporting recent male sex partners were more likely to report HIV positive status (AOR = 12.6). These data suggest that sex and drug relationships among PWUD are interrelated. Interventions that target multiplex rather than single-role relationships may be more effective in influencing behavior change.

OBJECTIVES: This report identifies the institutional barriers to, and benefits of, buprenorphine maintenance treatment (BMT) integration in an established hospital-based opioid treatment program (OTP). METHODS: This case study presents the authors' experiences at the clinic, hospital, and corporation levels during efforts to integrate BMT into a hospital-based OTP in New York City and a descriptive quantitative analysis of the characteristics of hospital outpatients treated with buprenorphine from 2006 to 2013 (N=735). RESULTS: Integration of BMT into an OTP offered patients the flexibility to transition between intensive structured care and primary care or outpatient psychiatry according to need. Main barriers encountered were regulations, clinical logistics of dispensing medications, internal cost and reimbursement issues, and professional and cultural resistance. CONCLUSIONS: Buprenorphine integration offers a model for other OTPs to facilitate partnerships among primary care and mental health clinics to better serve diverse patients with varying clinical needs and with varying levels of social support.

Food restriction (FR) and obesogenic (OB) diets are known to alter brain dopamine transmission and exert opposite modulatory effects on behavioral responsiveness to psychostimulant drugs of abuse. Mechanisms underlying these diet effects are not fully understood. In the present study we examined diet effects on expression and function of the dopamine transporter (DAT) in caudate-putamen (CPu), nucleus accumbens (NAc), and midbrain regions. DA uptake by CPu, NAc or midbrain synapto(neuro)somes was measured in vitro with rotating disk electrode voltammetry or with [3 H]DA uptake and was found to correlate with DA transporter (DAT) surface expression, assessed by maximal [3 H]CFT binding and surface biotinylation assays. FR and OB diets were both found to decrease DAT activity in CPu with a corresponding decrease in surface expression but had no effects in the NAc and midbrain. Diet treatments also affected sensitivity to insulin-induced enhancement of DA uptake, with FR producing an increase in CPu and NAc, likely mediated by an observed increase in insulin receptor (InsR) expression, and OB producing a decrease in NAc. The increased expression of InsR in NAc of FR rats was accompanied by increased DA D2 receptor (D2 R) expression, and the decreased DAT expression and function in CPu of OB rats was accompanied by decreased D2 R expression. These results are discussed as partial mechanistic underpinnings of diet-induced adaptations that contribute to altered behavioral sensitivity to psychostimulants that target the DAT

Chronic food restriction potentiates behavioral and cellular responses to drugs of abuse and D-1 dopamine receptor agonists administered systemically or locally in the nucleus accumbens (NAc). However, the alterations in NAc synaptic transmission underlying these effects are incompletely understood. AMPA receptor trafficking is a major mechanism for regulating synaptic strength, and previous studies have shown that both sucrose and d-amphetamine rapidly alter the abundance of AMPA receptor subunits in the NAc postsynaptic density (PSD) in a manner that differs between food-restricted and ad libitum fed rats. The present study examined whether food restriction, in the absence of reward stimulus challenge, alters AMPAR subunit abundance in the NAc PSD. Food restriction was found to increase surface expression and, specifically, PSD abundance, of GluA1 but not GluA2, suggesting synaptic incorporation of GluA2-lacking Ca2+-permeable AMPARs (CP-AMPARs). Naspm, an antagonist of CP-AMPARs, decreased the amplitude of evoked EPSCs in Nac shell, and blocked the enhanced locomotor response to local microinjection of the D-1 receptor agonist, SKF-82958, in food-restricted, but not ad libitum fed, subjects. Although microinjection of the D-2 receptor agonist, quinpirole, also induced greater locomotor activation in food-restricted than ad libitum fed rats, this effect was not decreased by Naspm. Taken together, the present findings are consistent with synaptic incorporation of CP-AMPARs in D-1 receptor expressing medium spiny neurons in NAc as a mechanistic underpinning of the enhanced responsiveness of food-restricted rats to natural rewards and drugs of abuse