Albert Garcia-Romeu, Ph.D. is an Assistant Professor of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine. His research examines the effects of psychedelics in humans, with a focus on psilocybin as an aid in the treatment of addiction. His current research interests include clinical applications of psychedelics, real-world drug use patterns, diversity in science, and the role of spirituality in mental health. He is a founding member of the Johns Hopkins Center for Psychedelic and Consciousness Research and the International Society for Research on Psychedelics.
What first sparked your interest in using psychedelics as a potential medicine and treatment for mental health issues?
Psychedelics were not a primary focus of my research until I came to Johns Hopkins in 2012. Before that I was interested broadly in altered states of consciousness for many years, referring generally to ways that people experience notable changes in their mindset and sense of self. This is not a well understood phenomenon in psychology.
People change over time as part of the natural aging and development process from birth to maturity to death, but humans may be unique in their ability to make seemingly intentional choices about how they behave and go about their lives. These choices are often reinforced by environmental factors that can shape behavior in ways that lead to stable patterns, for instance, a person who likes books and reading might pursue a career as a librarian that they find rewarding.
This type of learning process can also occur in maladaptive ways for example when a person gets caught in certain patterns of thinking or behaving that can be characteristic of mental health conditions like depression or addictions. Altered states of consciousness can be thought of as techniques that people use to change how they think or feel and sometimes disrupt these stable patterns.
Using substances is just one technique for achieving altered states — you can think of something as common as having a cup of coffee in the morning to get going or drinking a beer at a social event to loosen up. In addition, there are plenty of non-substance induced ways of altering consciousness like meditation, prayer, fasting, music, exercise, and dancing to name a few. People have used strategies like these since prehistory to change the way they think and feel. Psychedelic substances happen to be a particularly powerful means of rapidly and reliably inducing altered states, which is why I think they are so interesting.
From a mental health standpoint, much of the contemporary clinical research, as well as historical research from the mid-20th century, suggest the experiences psychedelics impart can be introspective and insightful for many people, and for some, can be used in ways that are congruent with enhanced mental health. This is also consistent with the long history of traditional psychedelic use among indigenous cultures who used and revered psychedelics as part of their spiritual lives, as well as so-called recreational use that took root in the hippie counterculture of the 1960's and more recent electronic dance music and rave scenes.
For people struggling with conditions like depression or addictions the preliminary data show that psychedelics can be helpful for 'getting unstuck' and escaping certain mental and behavioral ruts we can get caught up in — only over the past decade or so have we been able to get a better idea of how this is working in the mind and brain. What we've learned so far is that aside from traditional and recreational uses of psychedelics that have value in their own right, there is great potential for medical applications of psychedelics in mental healthcare that has largely been untapped as a result of social stigma and criminalization.
As such, it's an exciting time for the fields of psychiatry, psychology, neuroscience, and pharmacology, that are now coming back to study psychedelics as potential healing agents. This is really a long-winded way of saying I've always been interested in ways people can become the best version of themselves and fulfill their highest potential, which led me to studying psychology, spirituality, and eventually psychedelics as possible avenues to fostering that process.
You’ve been involved with the Johns Hopkins Center for Psychedelic and Consciousness Research since it was formally created in 2019. How has the center and your work changed or evolved since its creation?
Roland Griffiths, Bill Richards, and Mary Cosimano, with support from Bob Jesse, were really the ones who got the ball rolling on psilocybin research at Johns Hopkins back in 2000. At that time, I was still a freshman in college at Tulane University and was not really plugged into the work that was getting underway. However, after completing my doctorate at the Institute of Transpersonal Psychology in 2012, I came to Johns Hopkins as a postdoctoral research trainee and got the opportunity to work with some incredible mentors and scientists including Dr. Matt Johnson and the team that eventually established the Center for Psychedelic and Consciousness Research in 2019.
The trajectory of the work has definitely evolved over time, with the initial research looking mainly at the effects of psilocybin in healthy volunteers and understanding dosing parameters. Those studies were published in 2006, 2008, and 2011, showing that healthy people were having powerful experiences with lasting wellbeing benefits after a single high dose of psilocybin, and that dosing in the range of 20 to 30mg of psilocybin under psychologically supportive conditions seemed to be most conducive to this. These wellbeing benefits in healthy people suggested the possibility that psilocybin could be useful as a potential treatment in people with particular health conditions, consistent with earlier research on psychedelics in the 1950s through 1970s.
This led to more clinically oriented studies at our lab investigating psilocybin in people seeking treatment for issues like tobacco dependence, cancer-related existential distress, and later, major depression. All of those trials showed promising results that have now developed into larger, more carefully controlled studies, as well as expanding the scope of the health issues we are examining to include conditions like early-stage Alzheimer's Disease, Anorexia nervosa, and co-occurring depression and alcohol use disorder.
Additionally, these positive results have opened up new questions about how psychedelics work in the brain, which colleagues like Dr. Fred Barrett are examining using modern neuroimaging methods. I would say we are still relatively early on in this research in the sense that we have not yet completed trials at the scale necessary to substantiate therapeutic efficacy of psilocybin, though the field is headed in that direction. Similarly, with neurobiological research we are still learning more about how these substances work and how they can exert lasting effects even long after they are out of a person's system.
Furthermore, the potential of other psychedelics like mescaline, lysergic acid diethylamide (LSD), ayahuasca, DMT, 5-MeO-DMT, and a long list of others have not been systematically studied in humans to date, and just shows how much more work there is to be done.
What are some of the most exciting studies you’ve worked on at Johns Hopkins?
Most of the work I've done has been with Dr. Matt Johnson studying the effects of combined talk therapy with two or three high doses of psilocybin for people seeking to quit smoking. I've worked on various iterations of that project for about 10 years now, working with dozens of people going through the process of trying to quit smoking and over 100 high dose psilocybin sessions at our laboratory in that time. We published our initial findings in 2014 that showed high success rates in a small sample of 15 smokers, but the study did not have a control condition, which limited our ability to make any firm conclusions about whether this type of treatment really works.
Since then, we've designed and are in the process of wrapping up a larger trial in about 100 smokers with half of them receiving one high dose of psilocybin and the other half using a standard, FDA approved smoking cessation treatment (nicotine patches) for 8-10 weeks, and both groups receiving the same supportive counseling to quit smoking. That study is not quite finished, but the results so far continue to indicate superiority of psilocybin-assisted treatment for smoking cessation over currently approved treatments. That's incredibly exciting and has paved the way for further research in this direction with smokers, as well as in other types of substance use disorders.
Tobacco smoking in particular is a tremendous public health scourge that is responsible for about 7 million deaths per year worldwide, more than alcohol and all other drugs combined, so finding better treatments for people to quit smoking is something I've become very passionate about. In general, the area of addiction treatment has always been of special interest to me because it is such a puzzling set of conditions where people repeatedly engage in behaviors they often acknowledge as not in their best interests, but struggle to change in the long-term.
Furthermore, our currently available treatments for substance use disorders are typically not very effective, so there is a lot of room for improvement, which I'd like to help develop further by studying psychedelic-assisted treatments as well as mindfulness-based interventions.
Other research areas that I'm really excited about include studying psychedelics in people with neurodegenerative conditions like Alzheimer's Disease (AD). We are working on a small study now and, similar to smoking, there is an enormous public health need there for new and effective AD treatments — so, if psychedelics can confer some benefit, whether it be improving quality of life, or even better, slowing disease progression, that would be a literal game changer.
I've also worked on studies of psilocybin in healthy people learning to meditate and religious professionals like priests, which continue to pique my interest in terms of ways that psychedelics might also benefit people who are not dealing with any particular health condition. We have other online studies that we have also used to gather information from larger groups of people who are using psilocybin in the real-world, which I think can be really helpful to inform us about what's going on outside the lab and give us early hints about places we might look for possible risks and benefits around psychedelic use. I also have a new study of psilocybin in people with Post-Treatment Lyme Disease starting soon and an upcoming study of psilocybin for cannabis use disorder that we are excited to get underway this year.
Finally, over the last few years I've become more interested in diversity both in science generally speaking, as well as in the psychedelics space. This has led to a whole other set of inquiries and questions that I plan to develop further as new lines of research and hopefully as a means of creating a more open and equitable field for young scientists and individuals from diverse backgrounds seeking out psychedelic-assisted treatments.
You’ve been involved in a number of studies on psychedelics and their capability as a treatment option for addiction, including being a lead author in a study on the role that psychedelics could have in alcohol cessation. How do psychedelics help individuals with substance abuse disorders?
The short answer is we don't know. There have been studies dating back to the 1950's looking at psychedelics (mainly LSD) for substance use disorders including alcohol use disorder, with some of those showing promising effects. Because psychedelics were relatively novel to Western medical scientists in the mid-20th century, there was a lot of variability in the approaches used to administer these drugs and the type of supportive care provided. I suspect that led to a fair amount of noise in the early data, but the research that did yield positive effects shed some light on important elements of set and setting for optimizing psychedelic-assisted treatments that we still use today.
The study you mentioned on psychedelics for alcohol cessation that we published in 2019 was one of our online studies where rather than bringing people in and testing a treatment, we solicited anonymous survey responses from people who used psychedelics like psilocybin or LSD outside a laboratory and who noted subsequent changes in their alcohol use. While we can only make limited inferences from this type of data — and there are drawbacks to the anonymous, online study design — it does provide another piece of corroborating evidence that, for people struggling with problematic substance use, psychedelics may offer some outlet for making positive behavioral changes.
Other observations surrounding traditional psychedelic use also suggest that it can be associated with recovery from alcohol or other substance use issues, for instance, among members of the Native American Church who use peyote as part of their spiritual practice.
This points to some of the preliminary hypotheses about how psychedelics could help people overcome substance use problems, namely, by eliciting powerfully transcendent, insightful, or otherwise mind-altering experiences that can facilitate behavior change and enhance motivation to do so. Other models of recovery such as 12-step programs place a major emphasis on relationship to a higher power or experiences that could be considered spiritual as valuable resources for helping people manage addictions, so this could be one way that psychedelics are helping as suggested by my colleague Dr. David Yaden and others (including Bill Wilson, the founder of AA).
We've also learned more recently about certain biological effects of psychedelics for example in enhancing neuroplasticity in animals, and even reducing alcohol consumption in animals, that really just begins to scratch the surface of explaining some of the positive long-term effects we've been seeing in human trials.
You authored a review paper focused on how psychedelics could offer novel treatments for people suffering from Alzheimer’s. Is the use of psychedelics as a treatment option for Alzheimer’s promising? If so, which psychedelics have the most potential?
That paper was meant to collect the available data on psychedelics and Alzheimer's Disease (AD) and present a rationale for additional research in this area. At the moment, there are not any rigorous human studies to my knowledge that have specifically administered psychedelics to people with Alzheimer's Disease that would allow us to say this approach has any benefit in AD or that one compound is better than another.
We are currently conducting a small pilot study in people with depressed mood and early-stage Alzheimer's Disease, where we administer two doses of psilocybin under psychologically supportive conditions to examine whether there is any notable impact on mood and quality of life in these individuals.
As far as I know this is the first study to administer moderate and high dose psilocybin in this population, so we are looking forward to seeing the results, which will give us some better answers about potential benefits of psilocybin in AD. Other psychedelics should also be studied, though there are many hurdles to conducting this type of research, including regulatory restrictions due to their legal status, but I predict we will see more work in this area relatively soon because there is such a great need for novel treatments.
What role does neurogenesis and neuroplasticity play in addressing brain disorders like Alzheimer’s?
This is a complicated question, and I am not a brain scientist or medical doctor, so take my response with a grain of salt here. However, we know that neurodegenerative conditions like Alzheimer's involve a number of biological markers including neuronal and synaptic loss. In AD this can follow particular patterns of regional and symptomatic progression over time. So far, there have not been many effective treatments discovered for Alzheimer's Disease, in part because the biology and pathophysiology have proven so complex.
A lot of recent AD drug development has focused on toxic beta amyloid proteins that accumulate in the brain, and though there's been some progress on that front, that has not necessarily led to major breakthroughs yet. Other approved medications for AD work by slowing the breakdown of acetylcholine which is a neurotransmitter involved in thinking and memory and those can be moderately helpful for some. To my knowledge, there are currently no approved AD medications that specifically work via neuroplasticity or neurogenesis-related mechanisms, so this is not a tried and true therapeutic target right now.
However, recent data suggest even a single dose of psilocybin can lead to persistent increases in projections like dendrites from brain cells and new connections between neurons in key regions like the frontal cortex in animals, while other studies have shown enhancements in animal learning and memory related to psychedelic administration.
This at least hints at the feasibility of psychedelic-induced neuroplasticity as a potential therapeutic mechanism in conditions like AD that are characterized by loss of neuronal connections. Additionally, given the high degree of neuropsychiatric comorbidities faced by people with AD, and compelling data suggesting antidepressant and quality of life enhancing effects of psychedelics in people with serious illness, these further support research in this direction to assess whether such effects generalize to people with AD.
Psychedelics research has historically faced a consistent issue with underrepresentation of minorities despite promising research into the benefits of psychedelics as a treatment option for addressing racial trauma. How do you think the space, as a whole, can begin to address this racial inequity?
This is definitely an area where we need to do better. It's important to point out though that this has been a problem broadly in clinical trials for decades, with only 4-5% of clinical trial participants in studies of FDA approved medications between 1997-2014 coming from under-represented racial and ethnic backgrounds.
That trend has carried over to studies with psychedelics like psilocybin and MDMA, and there are likely a lot of complex social factors at play here including: mistrust of biomedical research institutions due to a history of abuse and unethical practices, concern about use of stigmatized Schedule I substances in the context of the 'War on Drugs', and lack of diversity among researchers themselves. Despite these challenges, preliminary survey data have indicated psychedelics may hold potential for ameliorating symptoms related to racial trauma in people of color, such as anxiety. This suggests there could be an important role for psychedelic-assisted treatments in healing intergenerational trauma suffered by marginalized populations who already struggle with substantial health disparities.
In terms of how to deal with these racial inequities, I wish I had a well-formed answer, but there are a lot of issues here that scientists and other stakeholders should be paying close attention to, including increased diversity and cultural competency among researchers and their clinical staff, community outreach to better understand the needs and concerns of under-represented populations, and concerted efforts to address those issues in creative ways when conducting clinical trials. Furthermore, should psychedelic treatments become approved it will be crucial to find ways to make these widely accessible to individuals in need and who could benefit from them, not just those who can afford a hefty price tag — though I see this as a problem that is endemic to capitalist, for-profit healthcare systems in general and not unique to psychedelics.
Additionally, I think it's critical that Western scientists consider the role of reciprocity and humility in our approach to studying psychedelics that have often been used in indigenous cultures long before we brought them into the laboratory. Historically, use of these substances has been criminalized and oppressed for decades (or longer if we go back to European colonialism in the 15th Century). So, now that there is growing scientific (and financial) interest in psychedelics, it should be acknowledged that ritualized use of many of these substances like psilocybin and ayahuasca emerged within marginalized cultures that possess valid knowledge, and that whatever we discover and develop by way of research with psychedelics should also be leveraged to give back to those communities in ways that provide appreciable value like healthcare and material resources.
What is your role with NeonMind Biosciences and how have you been involved with the work they are doing?
I'm a paid scientific advisor to NeonMind Biosciences and have been working with them since early 2021. They initially approached me with the idea of developing a psilocybin-assisted treatment to help people who were struggling with obesity. I was intrigued by the proposition, and based on what we know about psychedelics' general ability to facilitate psychological flexibility, insight, and behavior change, thought this could be a worthwhile direction to develop a novel line of clinical research.
This work is still under development, but NeonMind has already carried out promising preclinical (animal) research looking at the potential of psychedelics in altering appetite and eating behavior, and I am currently aiding in the development of clinical studies in humans to examine psilocybin administration as part of a possible weight-loss treatment program.
Because I've been conducting clinical trials with psilocybin for about 10 years now at Johns Hopkins, I have a good understanding of the regulatory landscape and ways to optimize psilocybin's therapeutic effects, which I am providing to help in the design and conduct of new studies NeonMind plans to undertake.
What do you believe is the most common misconception about psychedelics?
To me, one of the most common and problematic misconceptions about psychedelics is that they are some sort of silver bullet that will solve people's problems outright. A lot of the narratives I've seen proliferated through media and pop culture make it seem as though people come in for a drug session one day and simply walk out healed, transformed, freed from a lifetime of ego entanglements and interpersonal dynamics, and unfortunately this is not the case.
I think it really speaks to a natural human desire to have our troubles whisked away without anything required on our part, like finding a winning lottery ticket, or perhaps in more religious terms to 'be saved'. While this can be nice in theory, it sidesteps the reality of the situation which is that change can be difficult, and even if we ourselves put in the work to change that does not mean the circumstances or people around us will follow suit. As a result, people may have truly profound, eye-opening psychedelic experiences that in the end don't amount to much in terms of real-world changes. They can leave with a vision of a better life, an image of a more actualized self, but if they don't put that into practice it goes nowhere, just like if I spent lots of time reading about how to get in great shape but never bothered working out.
Sometimes people can go to great lengths to make personal changes but then go back to an environment or relationships that over time wear them back down into the status quo. I think of people checking into inpatient detox and rehabilitation clinics for drug use. They leave where they come from, the relationships where they developed these addictive or other unhealthy tendencies, and with some work they can make wonderful strides toward healing and recovery. But send them back to where they came from and oftentimes they settle right back into old patterns and that work can be undone. I’ve seen similar things even after powerful psychedelic experiences. Conversely, I've seen some people have puzzling, quizzical experiences that don't seem particularly insightful or meaningful, that don't fit our nice, neat rubrics of mystical experience or emotional breakthrough, and yet over time get a lot of mileage and positive impact from those experiences even though they walk out thinking, "that wasn't at all spectacular."
So, I suppose this comes back to the idea that we don't really know how people change and what role psychedelics can play in that process, but of course, the data are very promising and we will continue to study and try to learn more. On a larger scale, in terms of social issues, I would also say that we need to move away from this type of magical thinking that something like science or psychedelics will come along and save us, which is exemplified in popular media articles with titles like, ‘Can Psychedelics Save the World?’. If anything or anyone is going to save the world in these dire times, it will have to be us, regular people who come together to work towards a sustainable future. Psychedelics can be tools to move us in that direction, but we’ll be the ones who will actually have to roll up our sleeves, get our hands dirty, and start making large-scale changes with regards to geopolitics, economics, environmentalism, and so forth. Mushrooms and DMT and the like are not going to do these things for us.
There's an old Zen saying, "Before enlightenment; chop wood, carry water. After enlightenment; chop wood, carry water." I think this points to the paradox that even after the most transcendent, earth-shattering experience imaginable, we still come back to ourselves and our lives and all the various tasks that entails. Everything has changed, but nothing has changed, and so we must go on with the work of doing our best, being our best selves, and sometimes these psychedelic experiences can be a little lighthouse to help keep us going on the right path.
Do you feel that psychedelic medicine is maturing in how it approaches treatment options, dosing methodology, and clinical use?
Somewhat, but it’s very slow going. Even the idea of ‘psychedelic medicine’ is a bit of a red herring because substances like psilocybin and MDMA aren’t really out there in clinical practice yet. They are largely confined to research settings which are very different from real world medical treatment if / when these reach formal medical approval. I think we’re moving in that direction, but we are hampered by a lot of old ideas and old thinking that will take some time to move beyond.
I like Kuhn’s framework of scientific revolutions, but these take generations sometimes, think of the shift from geocentric to heliocentric models or from Newtonian to quantum physics. To paraphrase the great physicist Max Planck (who helped establish quantum mechanics), science advances funeral by funeral, so it may be a while before we see a truly mature psychedelic medicine, though I hope we see something like that in my lifetime. It certainly feels like we are at the beginning of such a revolution now, or maybe I’m being too optimistic.
For instance, with ‘gold-standard’ models of clinical research that require double-blind placebo-controlled trials, these have their place, but psychedelics are difficult or impossible to study using those models and point to the challenges and limitations there. Similarly, drug scheduling laws that only consider drugs to be either medically approved or basically outlawed also have glaring limitations (and strange inconsistencies like tobacco and alcohol that are not medically approved but legally available).
It seems to me like we are in the very early processes of building better scientific, epistemic, and metaphysical frameworks to deeply study and understand the nature of internal processes like mind and consciousness, and psychedelics are an important part of expanding that. Purely materialist scientific paradigms are by their nature limited to what we can measure and observe out in the world. However, this leaves untouched all that we experience in the first person — aka, the hard problem of consciousness. I think we’ll make a lot of headway building bridges between those realms that will lead us toward a more holistic understanding of ourselves and our place in the universe. I also hope we’ll see some more progressive thinking around drug use and legal classification generally as time goes on.
What do you see as the future of psychedelic medicine and what could their impact be on healthcare as a whole?
It’s hard to say at this point, but I think this could lead us back to a more holistic type of healthcare system that takes into account the whole person, including their physical, mental and spiritual health, as well as their social backgrounds that are often wrapped up in health issues. I hope that might also be the case in larger scale systems like economies and ecologies that are still beholden to strange and oftentimes destructive conventions, like for-profit healthcare that only allows some people to access certain potentially lifesaving treatments based on whether they can afford it financially — basically leaving other people destitute.
This reminds me of old systems of government, thinking that royal families have some special God-given right to rule over others, which we’ve largely outgrown. I hope psychedelics, along with the increasingly urgent mental health and ecological crises we are facing on a global level, will help spur us on towards building healthier, more sensible systems that work equitably for everyone. This may be a little too pie in the sky and overly optimistic, but we will see where the future takes us.
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