A Better Way to Live & Thrive: Multimodal Approaches to Psychedelic Therapy


Episode 193

Reid Robison, M.D.

Dr. Reid Robison, Chief Clinical Officer at Numinus, joins Paul F. Austin to discuss psychedelic research, legislation, & complementary modalities.

Dr. Robison shares the challenges and innovations in psychedelic therapy, drawing from his own clinical research and current projects at Numinus, a mental health company that brings safe, evidence-based psychedelic-assisted therapies to people in need.
Explore topics such as the efficacy of psychedelic-assisted therapies, the pros and cons of psychedelic patents, and the need for multimodal approaches to mental health care.

Dr. Reid Robison is a board-certified psychiatrist and Chief Clinical Officer at Numinus, where he oversees clinical services, including teaching and training in ketamine-assisted psychotherapy, for the company's clinics across the US and Canada. He has led over 200 clinical trials in neuropsychiatry and previously served as coordinating investigator for the MAPS-sponsored MDMA-assisted psychotherapy study of eating disorders.

Dr. Robison is currently principal investigator for a number of psychedelic medicine studies with psilocybin, LSD, and DMT. As a researcher and early adopter of ketamine in psychiatry, Dr. Robison got his first grant to study that medicine in 2011, around which time he also led a pivotal IV ketamine study for treatment-resistant depression.

To date, Dr. Robison has guided thousands of ketamine therapy journeys and Spravato dosing sessions, and has also worked in ayahuasca retreat settings abroad. Dr. Robison is an adjunct professor at both the University of Utah and Brigham Young University, and board chair of the Psychedelic Institute, focused on education and research.

Podcast Highlights

  • Dr. Robison's journey into the world of psychedelics, from ketamine research to psilocybin advocacy on Capitol Hill.
  • How patents can expand access to psychedelic therapy through health insurance.
  • Dr. Robison’s innovative studies and projects at Numinus.
  • The need for a new standard of mental health care and the role of complementary modalities in achieving it.
  • Exploring modalities complementary to psychedelic therapy.
  • The promise of personalized mental health care.
  • The pioneering efforts of Numinus in offering employee psychedelic mental health care via ketamine.
  • The future of insurance and the potential for greater coverage of ketamine-assisted psychotherapy.
  • What’s on the horizon at Numinus.

This episode is brought to you by Numinus, a mental health company bringing safe, evidence-based psychedelic-assisted therapies to people in need. They have clinics in the US and Canada, providing mental health treatments such as: ketamine-assisted therapy, talk therapy and virtual mindfulness programs and practitioner training. Numinus is a leader in psychedelic-assisted therapy, both through research and in practice where approved by governing bodies. Learn more at www.numinus.com.

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Podcast Transcript

0:00:00.1 Paul Austin: Welcome back to The Psychedelic Podcast by Third Wave. Today, I'm speaking with Dr. Reid Robison, the Chief Clinical Officer at Numinus.

0:00:11.5 Reid Robison: In a world of ketamine clinics and ketamine organizations showing up, I really believe in the importance of surrounding the ketamine with not only psychotherapy, but with really good mental health support. These medicines aren't for everyone, whether it's ketamine or psilocybin, and they're extremely important tools we wanna use in the course of someone's journey of healing and growth when needed as catalysts, but support them on the whole journey.


0:00:45.8 Paul Austin: Welcome to The Psychedelic Podcast by Third Wave, audio mycelium connecting you to the luminaries and thought leaders of the psychedelic renaissance. We bring you illuminating conversations with scientists, therapists, entrepreneurs, coaches, doctors and shamanic practitioners, exploring how we can best use psychedelic medicine to accelerate personal healing, peak performance and collective transformation.


0:01:22.4 Paul Austin: Third Wave is grateful to Numinus, a mental health company bringing safe evidence-based psychedelic-assisted therapies to people in need. Numinus has joined us as a partner. They have clinics in the US and Canada where they provide mental health treatments such as ketamine-assisted therapy, talk therapy, as well as virtual mindfulness programs and practitioner training. Numinus is a leader in psychedelic-assisted therapy, both through research and in practice where approved by governing bodies. They've also created a Music as Medicine program, where they partner with leading ambient musicians to foster a community of individuals seeking mindfulness and alignment. Numinus has been advocating for greater access to psychedelic therapy for years, and we're proud to partner with them as they continue to push the envelope. You can learn more at numinus.com.

0:02:13.4 Paul Austin: Hey, listeners, I'm so excited to have Dr. Reid Robison on the podcast today. Reid is a pioneering psychiatrist who first got involved in the psychedelic space in 2010, almost a lifetime ago, and was one of the first psychiatrists to legally work with ketamine in the State of Utah, helping people to address issues like depression and suicidality with not just Spravato, also generic ketamine. And so in today's episode, we go deep into the efficacy of psychedelics from a clinical perspective, we talk about the trajectory and path of Numinus, we talk about why Reid is so interested in this space. One of the interesting topics that we dive into is the importance of patents and how the patenting of Esketamine, also called Spravato, enables health insurance, whereas generic ketamine is not covered by health insurance. So we also flesh that out and talk about the pros and cons of a patent approach. Alright, that's it for now. Let's dive into this episode with Dr. Reid Robison. I hope you enjoy our conversation.

0:03:28.9 Paul Austin: Hey, listeners, welcome back to The Psychedelic Podcast. Today, we are here with Dr. Reid Robison, the Chief Clinical Officer at Numinus. Reid, the last time that we spoke, we were in a Tulum-like backyard in Miami during the Microdose Wonderland Conference, and we had an absolute blast together. So it's good to be back with you over, I mean, we're recording this through Riverside, but virtually to go deep into your relatively new role as Chief Clinical Officer at Numinus.

0:04:00.9 Reid Robison: Yeah, it's good to be here. Thanks for having me.

0:04:04.4 Paul Austin: So we did a podcast together for the Psychedelic Therapy Frontiers Podcast that you co-host with Steve Thayer. This was probably last July that we did this, and we went deep into microdosing. Both of you had a lot of great questions. I'd love for you just to tell the story of how that podcast, as a lead-in for this podcast, how did that podcast come about, the Psychedelic Therapy Frontiers Podcast, and what have you enjoyed most about hosting that podcast?

0:04:30.1 Reid Robison: Cool. That's a fun question. So if you rewind maybe 13 years, 13 years ago, I started working with ketamine, not as a psychedelic, but in clinical trials, then Ayahuasca in the jungle, then working with MAPS on MDMA protocols, and eventually, a few years ago, started a clinic in Utah, in a small town in Utah called Springville, with a colleague named Seneca. We co-founded this clinic called Cedar Psychiatry, offering therapy, med management and ketamine therapy. And so that was pre-pandemic, but the need was already there, and then it was growing through the pandemic. We grew to, I think, four clinics and then got acquired. But around the time we were expanding from one clinic to several, Steve Thayer had joined us as a psychologist, and we were working down the hall from each other, training practitioners on how to do ketamine therapy, and these questions would come up in a recurring way of, "How do I do KAP? How do I work with ketamine and therapy? What does this combination look like?"

0:05:48.7 Reid Robison: We were developing training materials at the time, and it just kind of came as a random idea one day of, "Maybe we should put this in a podcast format," with our clinicians in mind, but thinking of the broad interest. And so we did it. We just started it a little nervously at first. And our podcast is mostly me and Steve having conversations. Occasionally, we'll bring on guests, like when we had you come on. That was a really fun conversation. So that's the origin story of the podcast. And it was really neat, surprising to see from there that people actually listened, and they actually listened even if it was just me and Steve sitting there chatting and having a conversation.

0:06:37.0 Paul Austin: When you and Steve chat, what are some of the common themes that often come up in your conversations? What are some of your favorite... 'Cause I noticed, I've hosted the podcast for six years now, and so I noticed that there are just themes that tend to, like almost archetypes of these podcast conversations around psychedelics. So what have you found to be some of those themes that have come up time and time again?

0:07:00.4 Reid Robison: As two scientifically-minded credentialed individuals that could be giving boring academic talks, we like to just talk about... We like to shoot the breeze and apply our reasoning by putting aside as much skepticism as we can to what's going on in the world, therapy topics, psychedelic medicines. Like we've gone through the medicines one at a time, we've gone through different therapy modalities, last week talking about what is going on with psilocybin legislation? What's rolling out? What's coming soon? Because that just passed through Utah, a bill that went before the legislature. So my favorite...

0:07:48.5 Paul Austin: It got shut down though, right?

0:07:49.8 Reid Robison: Yeah.

0:07:50.8 Paul Austin: Yeah, it didn't pass though.

0:07:51.2 Reid Robison: Well, I got tabled.

0:07:52.8 Paul Austin: Tabled? Okay.

0:07:52.9 Reid Robison: I went up and gave a testimony. I was an expert witness on behalf of mushrooms. Yeah, that was fun. That was fun. It was also interesting to see the counter-debates with people like the anti-drug campaign, still alive and well, presenting opposition.

0:08:15.4 Paul Austin: I'm curious about that. What were some of the anti-psilocybin sentiments that were talked about in the Utah legislature?

0:08:26.1 Reid Robison: Well, first, there was a lady from Drug Safe Utah saying, "You can't legalize this stuff. It'll run rampant." And then someone else gets on from some other addiction organization, a gentleman who's a physician, but had these views of, "You think this will be controlled, but it will create addiction problems in youth," which, it was a puzzling argument. It didn't make sense to me because this is a... I guess his argument was that legalizing it will tell the kids it's safe and they'll wanna go use it. That was his argument. And then the Utah Medical Association saying, "No, we wait for the FDA to approve things," was their stance, like it was on cannabis.

0:09:20.9 Paul Austin: And that was also the same, that has been the same stance as the American Psychiatric Association. The APA came out, I forget, in the last maybe three or four months and basically said, "Hey, we can't really say anything about this until the FDA has actually approved it to be medically available for TRD, MDD, PTSD, whatever it is."

0:09:39.4 Reid Robison: Yeah, so the debate resolved around that, is, is there enough evidence to support its use? Waiting for the FDA to approve something, what does that look like? I think people assume that once psilocybin is approved, you'll be able to prescribe it for whatever you want, but that's not the case. It's not what happened with Spravato, Esketamine. These drugs, psilocybin especially, I'm fairly confident we'll have a pretty tight REM system, risk evaluation management system, making it so you can really only give it for the condition approved for years.

0:10:20.6 Paul Austin: What were some of your points? When you got up, you were speaking for the mushroom. What did you choose to emphasize in that container, in that sense?

0:10:32.0 Reid Robison: I spoke about, the abuse liability is very low, and the risk of fatal overdose on psilocybin is essentially non-existent, and the evidence is there in support of, as an anti-depressant. Preliminary but growing, strong evidence. And that given that there is a mental health crisis among us, and Utah has consistently ranked high in suicide rate, really tragically. Like 10 years ago, when I was working at the University of Utah, I was part of a Utah suicide study, trying to figure out, "Why is this high? Why is it increasing?" And so my argument was that that I was convinced that the benefits of approving this would outweigh the risks and it would very likely save lives.

0:11:29.5 Paul Austin: I like that. I'm just writing that down. The benefits outweigh the risks. With psychedelics, as many of our listeners know, the risks are relatively minimal, at least in comparison to many other substances. David Nutt had published the study in The Lancet, I think in 2010, outlining that LSD and psilocybin are the two safest substances, either illegal or legal. And you'd think that would be common sense at this point in time, especially in the medical professional space, but clearly that isn't. And I'd love to root this even deeper into your story, when is it that you came around to the idea that psychedelics might actually be useful and efficacious? What was your aha moment or inflection point in that story?

0:12:18.1 Reid Robison: I went into psychiatry when it wasn't cool. I got almost made fun of for picking it as a specialty. There were a few of us in my class of 100 in med school. But I started doing clinical trials right out of the gates. Like joined, took an academic post, was studying medicines, looking for better treatments. 'Cause it was clear from before I even finished training that traditional anti-depressants don't work for way too many people. They leave a lot of people suffering. They're helpful for some in some ways. So I was getting discouraged as I do trial or study after study of these me-too drugs, like an XR version of something, a slightly modified version, until ketamine came along. And then I was just so intrigued by this non-daily approach, that you take a medicine once or a few times rather than daily, and it also seemed to be getting more at the root cause, like not just keeping symptoms at bay, so that just lit up a whole crusade in me that...

0:13:36.5 Paul Austin: When was this, Reid? Is this 2012, or...

0:13:38.1 Reid Robison: This is 2010. 2010.

0:13:40.2 Paul Austin: 2010? Okay. So you were somewhat early then even in the psychedelic ketamine space. This is 13 years ago now.

0:13:47.6 Reid Robison: Yeah, that was my first study with it, 2010. I even set up an infusion practice with ketamine. We were using an IV back then. Now, I gravitate more towards IM, but use all routes. But after that, I got a grant to study it for depression and suicide prevention and set up a protocol to give it, and just was getting more and more inspired by what was happening for clients, knowing that it doesn't work for everyone, there's a lot to be understood, but as a researcher, I was like, "I can sink my teeth into that," and started both giving it and studying it. And that's what lit up the interest, and that expanded into other psychedelics. I mean, ketamine was probably the first one I ever experienced. But my interest grew from there, and after having experience with psilocybin and Ayahuasca and other things, and research experience too, it just became clear that this is a field in need of more and more research and clinical effort, and that's what I could do with my role in the healthcare system and doing clinical research.

0:15:09.2 Paul Austin: Tell us a little bit about the difference between Spravato and generic ketamine. This is a pretty common conversation in the psychedelic space. Spravato, just as a bit of context before you launch fully into it, Spravato was developed by Johnson & Johnson. It's Esketamine. It's been approved, I believe, for depression. And because it has been brought through clinical trials and approved for specific indications, it's covered by health insurance, but it's much more expensive than generic ketamine. So I'd love for you to just help the listeners understand Spravato versus generic ketamine, health insurance versus off-label use. Break that down. Help us understand what's going on there.

0:16:00.6 Reid Robison: Yeah, so from the get-go, even 12, 13 years ago, when I would give ketamine, insurance would not cover it. We've had a few victories and exceptions since then, but that takes a big battle, like single case agreements or maybe a little win with a little insurance plan to get it covered on an ongoing basis. But for the most part, ketamine is out of pocket, and that presents an accessibility challenge. So when Esketamine came along and was FDA-approved, 2019, I think it was March, I had this clinic set up already and we had the ketamine infrastructure and had to make the decision of, "Do we give it, given that it's like a $500 a dose medicine that we could use insurance for versus having someone cash pay their ketamine?" And this is a single session of ketamine. At the time, we were charging about $225 for an IM ketamine with basic day of therapy pre and post, and then your other parts of the therapy course would be separate and could potentially use insurance, versus Spravato that the patient could just use their insurance for most of it and pay a copay.

0:17:25.3 Reid Robison: And so it gave me a little bit of existential angst for the healthcare system to offer something that's so expensive to the system, but for the patients in the time of growing mental health needs almost to epidemic proportions, we just said, "We're gonna do it. If anyone can offer it, it's us. We have the insurance infrastructure, the ketamine infrastructure, the clinicians." And it has worked out quite well. I've grown to appreciate it more and more since then. We've given probably over 15,000 doses of Spravato in Utah alone since then, all covered by insurance, and many leveraging Janssen Patient Assistance program where the copayer of the medicine is $5. If your insurance doesn't cover all of it, Janssen will throw some in as one of their marketing strategies and accessibility programs.

0:18:30.0 Paul Austin: The follow-up question that I have to this is, what does this mean for the future of psychedelic-assisted psychotherapy? And the polarity that I'll set up there, Reid, is COMPASS Pathways, patented psilocybin, bringing it through clinical trials for treatment-resistant depression. Usona is bringing a form of psilocybin through clinical trials for major depressive disorder. MAPS, as we know, MDMA for PTSD. But to stay focused on psilocybin for a second, Oregon has now legalized psilocybin. Colorado has legalized psilocybin. The focus in these states and in local decrim is much more on the plant than it is around the synthetic, and yet what COMPASS Pathways is betting on is that health insurance will cover the use of psilocybin for these different clinical indications, because as we both know, the actual cost of that would be somewhere between $10,000 and $15,000 to go through a psychedelic-assisted psychotherapy process. I'm just curious to hear your reflections on, what are we learning from Spravato and health insurance that can be applicable to psychedelic-assisted psychotherapy as that's brought more into the mainstream and ideally covered by health insurance?

0:19:38.7 Reid Robison: Well, using the Spravato example to answer that, I've been surprised at, even though I prefer working with ketamine because I can pick the dose, I can pick the route of administration, and because it's generic and not costly for the medicine, even though that might be my preference and clinician preference, when we look at our data, and we've published this, because people can access Spravato, they do, and they get more treatment, and the outcomes are as good or better. So I think we need both. Even though I went up to Capitol Hill in Utah and spoke in favor of legalizing psilocybin therapy for mental health conditions, I'm also doing clinical trials with psilocybin enthusiastically because we need it FDA-approved for these to reach the people who need it. State legalization isn't gonna get us there alone fast enough, and FDA approval isn't going to reach everyone who needs it either and is also a painfully slow process. But combine both of those approaches and you have a little bit better than otherwise.

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0:22:51.0 Paul Austin: So your new role, and I'm gonna bring this full circle. But your new role as Chief... I shouldn't say new, reasonably new role as a Chief Clinical Officer at Numinus, I'd love for you... We already talked a little bit about your story in terms of how you got into ketamine and started doing research in 2010. Bring us a little bit deeper into how you really started to get involved in the new industry of psychedelics between Novamind and now, Numinus. Just tell us a little bit about that path for you.

0:23:28.0 Reid Robison: So after working with ketamine and after having some initial psychedelic experiences of my own that were profound, I caught wind... I was working a lot with eating disorders, where anorexia gets talked about in the psychedelic field and in mental health in general, of course, as one very scary condition to have that has zero FDA-approved treatment options. No medicines are approved to treat anorexia but has the highest mortality rate. And I was working with eating disorders with the treatment center and caught wind of an Ayahuasca ceremony that had a bit of a niche in working with these conditions, and so I volunteered to go out there and got brought on as medical support and one of the therapists, kind of paired up with the indigenous traditions and medicine team. And as a condition, I had to experience it. I had to drink the plant medicine myself, which I gladly agreed to do, and that was profound. That blew the lid off my...

0:24:35.8 Paul Austin: This is Ayahuasca, right?

0:24:37.5 Reid Robison: Yep, Ayahuasca. And so that was... Even though I'm not working on Ayahuasca in research studies and don't intend to, it was a profound experience of combining the plant medicines, indigenous traditions, with the best in Western psychotherapy that we could in a thoughtful way. Like I came back from that saying, "Never again will I work with ketamine without ceremony and without a sacredness that I learned from those experiences." So it was around that time that MAPS was working on their eating disorder protocol, and because that was an area of focus for me, they asked me to be coordinating investigator and help with that protocol and train the study teams. So I kind of expanded from the medicines from there, and as a clinical trialist, when Usona study came along, we were a site, MindMed LSD were a site for and actively enrolling for LSD for anxiety and psilocybin studies, active and DMT studies coming soon. So that's kind of how it evolved for me, in addition to the clinical work with ketamine that's alive and well also.

0:26:04.7 Paul Austin: And so now as your role as Chief Clinical Officer at Numinus, what are you most excited about? What is it that you're exploring and working on? And feel free to disclose as much or as little as you want. But what is it that you feel like is going to make the biggest impact? Why is it that you're involved in Numinus and what they're up to?

0:26:30.4 Reid Robison: Yeah, it's a good question. And now that we know that these medicines are safe and there's this growing of body of evidence on the effectiveness, I think it's time to get more specific around what pairs well with it in terms of therapy modalities format, set and setting. So I'm getting really hands-on with different ways of working with ketamine in clinic, like group work, family work, couples work, working with employee health0 programs, offering that, for example. And then in the research front, whenever we can, we'll design investigator-initiated studies and have a proposal into MAPS that they're keen on, like using a group approach to MDMA. So I'm working on the delivery models, the therapy modalities and the accessibility challenge.

0:27:41.8 Paul Austin: And what is different about Numinus compared to a COMPASS Pathways or compared to a Cybin or compared to some of these other publicly traded psychedelic companies? How is Numinus differentiated specifically from a clinical perspective in terms of the pathway that they are taking to either FDA approval or Health Canada approval or whatever that might be?

0:28:08.0 Reid Robison: So we're, first and foremost, a mental health service organization with clinics across the US and Canada; Utah, Arizona, and then some in Canada, and we'll do probably 100,000 client visits this year for mental health.

0:28:26.6 Paul Austin: Wow. Wow.

0:28:28.6 Reid Robison: And a minority percentage, maybe a quarter of that is ketamine, Esketamine-related. So we're working on the challenge from, within the mental health infrastructure of everyday mental health care, or if you have insurance, let's use it and let's expand access in the best way we can to as many people as we can, including these new modalities that are important, like ketamine-assisted therapy and the other medicines as they come or as we can. Like in Canada, we're able to give psilocybin, or even MDMA, under special access, like a compassionate use equivalent. In the US, that's harder. But we're working on it in those ways of offering in-clinic whatever we can. And as new ones get approved, we're ready with the infrastructure for this new era that you might call interventional psychiatry, like in-office delivery of medicine, where a therapist or therapists hold space and you come in for your preparation integration sessions, and we know the clients. Like this is being offered to people who have already come to us for their mental health journey for the most part.

0:29:57.4 Paul Austin: I wanna go back to that number that you mentioned, 100,000 client visits, 25% of which are currently utilizing ketamine or related to ketamine, Esketamine. Is the larger objective and goal of Numinus to make 100% of those client visits ketamine-related or psilocybin-related or MDMA related? Is that the trajectory, or is it more so, "Let's shift to a more integrated model, and still a percentage of people are gonna work with these psychedelics, but not necessarily everyone within our ecosystem will be utilizing them?"

0:30:37.0 Reid Robison: Yeah, it's the latter, and I appreciate the clarification because, in a world of ketamine clinics and ketamine organizations showing up, I really believe that in the importance of surrounding the ketamine with, not only psychotherapy, but with really good mental health support. And if someone's going to go get a dose of IV ketamine from a clinic where it's run by, say, only anesthesia, that may be fine. They know ketamine well, but they better have a mental health support team on board who knows they're doing that and is willing to support them through it, because as we both know, sometimes when you embark on a journey like that, stuff comes up or you might feel worse before you feel better, or you might have to confront some things that are difficult. But the other thing you mentioned, I think is a really important point as well, is that these medicines aren't for everyone, whether it's ketamine or psilocybin, and they're extremely important tools that we wanna use in the course of someone's journey of healing and growth when needed as catalyst, but support them on the whole journey.

0:32:01.7 Paul Austin: And on your website, you have a little thing that says that Numinus is aiming for a completely new standard in mental health care. How would you define that standard? Just building on everything that we've already talked about over the last several minutes.

0:32:20.8 Reid Robison: Yeah, so the example would be offering the best of the traditional mental health services that we can, like therapy, psychiatric evaluation, psychological testing, med management, group and individual therapy. And as things are both available and evidence-based, we'll bring them in and offer them in this infrastructure with attention to not just the quality, but the accessibility and meeting people where they're at and bringing the tools that they could actually access and afford and wrapping the support around that.

0:33:12.2 Paul Austin: Although Numinus is focused a lot on psychedelics, you mentioned other things that become available that are evidence-based. As we've gotten to know each other, I know that you've done a lot of yoga, you've worked with meditation, you've worked with some of these other modalities. What are some exciting modalities that are sort of on the pioneering front edge when it comes to this, that are not necessarily psychedelics, but that Numinus and that other even practitioners who are listening to this, may want to explore or be aware of or do more research on? Like as an example, I don't know if this is necessarily pioneering, but EMDR is something that a lot of practitioners are looking into or have looked into as something... So I'd be curious to hear like what other modalities are you looking into or thinking about, or what's sort of coming online that might be interesting?

0:34:09.8 Reid Robison: Yeah, so you mentioned some examples that I think are good ones, and I'll throw in some more, but there's a lot of evidence, of course, to support mindfulness, mindfulness-based stress reduction, any kind of approach. There was even that recent study comparing mindfulness to Lexapro, a traditional anti-depressant for certain conditions. And so we've done mindfulness groups that... Like cohorts that go through a mindfulness program out of our clinics. We offer, EMDR, many of our therapists do, but we're working on how does that pair well with ketamine and like a psycholytic ketamine, a lozenge, for example? Another example that's less in the integrative alternative modality but worth mentioning is TMS, Transcranial Magnetic Stimulation. We offer that in most of our clinics as an FDA-approved treatment option for treatment-resistant depression and OCD, for example, where it's a non-medicine intervention, or we leverage insurance and offer this alternate way of working on your healing and growth and your mental health.

0:35:33.5 Paul Austin: I've heard that mentioned a few times, TMS, Transcranial Magnetic Stimulation. Can you tell us a little bit more about what that involves, what that entails?

0:35:45.2 Reid Robison: Yeah, I remember when I first read about it like 15 years ago, I was like, "This seems like sci-fi." But it's been around for quite some time, and it's basically an MRI strength magnet in a helmet where it delivers an electromagnetic pulse that causes a certain pathway of neurons to fire and does it repeatedly, under the idea that neurons that fire together, wire together. And if we bring someone in 30 different times to clinic for, say, a 20-minute session, and we put this magnet on and fire it 2000 times every time they come into clinic and aim it at the dormant depression pathways, we're not only waking those up, but we're training it to be awake. It's almost like you're going to the gym and doing all these repetitions, practicing the euthymic or positive mood pathways over and over. So that's kind of an over-simplified version of it. But when someone comes into our clinics and they have depression that hasn't responded to traditional meds, we might fine-tune their meds, we might try a new one, but we might also put them into a course of TMS, or Spravato, or ketamine therapy, or a clinical trial with psilocybin, for example, all available treatment-resistant depression options right now out of our infrastructure.

0:37:30.0 Paul Austin: And who makes that decision? Do you as the medical director or the medical professional make that decision? Does the individual who's coming in make that decision? How does that process work?

0:37:43.1 Reid Robison: It's the individual and their clinician. They're sitting there in a visit and exploring the options with the clinicians' guidance and experience, and then I oversee our clinicians and we're always talking about these algorithms and keeping up on the evidence. I just had a meeting this morning, in fact, with all our clinicians in the US, where we'll go over some of these things. Like what's our latest psilocybin study look like? What's the protocol? What's the latest evidence? When might one think about referring a client to that versus, we also had a talk on TMS and some of the new indications. It's even approved for smoking cessation right now. So just keeping up with the latest evidence and bringing the options into clinic so you don't have this problem of one-size-fits-all, or if you're a ketamine clinic, people come in, you're just gonna give them ketamine. It's you either give them ketamine or turn them away. But when they come into a clinic like ours, we can look at all these options with them and make a really conscious decision of what's the best next course of action.

0:39:15.5 Paul Austin: So to go back to TMS, can you combine... 'Cause when you're talking about TMS, what it reminds me of is that Imperial College brain imaging scan, the FMRI scan that they published, which showed a placebo in psilocybin. Placebo, there's not a lot of cross-hemisphere communication. You have a high dose of psilocybin and all of those things are firing, and finally, there's parts of the brain that are brought online that maybe haven't been brought online in decades, for some people, returning it to a childlike phase. Is there similarity then between TMS and these high doses of psychedelics? Could TMS be used as an integrative modality after a high dose experience to help elongate the benefits of a psychedelic experience, or is it best to to look at those as totally separate modalities that don't have any type of overlap?

0:40:07.2 Reid Robison: Well, I think it's a really astute question pointing at research that needs to be done. There are a couple of studies that have looked at ketamine plus TMS, which is interesting to think about how would those be combined? What do you give first? Is TMS, like you said, the integration, the neuroplasticity enabler, and what pathways do you target? Or, are they happening at the same time? There was even one study that I always found intriguing where they had ketamine on board and TMS, and that would be a rather weird ketamine session, in my opinion, because this helmet, it's loud. It doesn't hurt, but it's like a tapping noise and sensation, like a mild jackhammer or woodpecker noise in a way. It's interesting, the way we map that to make sure we have the right intensity of magnetic pulse is we'll aim at first at the motor cortex, specifically at a place that will make your fingers move and then we'll watch the hand and we'll crank up the intensity until we get the fingers to twitch and we know, okay, we've got a strength that will fire that person's neurons.

0:41:25.0 Reid Robison: We may need to adjust it because caffeine lowers that threshold, alcohol raises it. But then we aim it towards, say, the dorsolateral prefrontal cortex for depression and hit that 2000 times each time they come in. But yeah, I think there's a lot to explore there, and it's not going to be figured out any time soon because of what we were talking about earlier with the big task ahead of getting these medicines FDA approved and or legalized and figuring out the best ways of giving them the optimal number of doses and therapy sessions. So to throw TMS in the mix is another variable that no one really has the funding and imperative to figure out soon.

0:42:21.4 Paul Austin: And this is, I think, in many ways, the benefit of having a more decentralized ecosystem is, you're right, when it comes to a more centralized medicalized approach, the minimizing variables is key to the approval of certain modalities. So we know TMS works, we know psilocybin works, we know MDMA works. And I think what's happening in, let's say, I would even go so far as to say the bio-hacker underground, is there a lot of people who are experimenting with different integrative modalities in conjunction with Ayahuasca, psilocybin, MDMA, ketamine, and I think what I'm... And I've talked about this on the podcast for years, and I'm still excited about it, is, what is the future of personalized medicine look like? What can Oura Rings teach us? What can blood work and lab tests teach us? What would it look like if we all had the capacity to do an FMRI scan of our brain to see it before and after a psychedelic experience to see what impact it had?

0:43:29.6 Paul Austin: Because I'm in full agreement with you that the ability for an organization like Numinus to spend $40 million to do a study on TMS and psychedelics is quite difficult. And yet I think we would both agree that going back to this concept of interventional psychiatry, that the optimal approaches are multi-modalities. It's not just a single thing that we're reliant on, but we're really looking at, as you said before, the entire person, the entire self, and we're not looking at a single moment in time, but we're really looking at a month, three months, six months, a year, in terms of what could be helpful and efficacious.

0:44:20.6 Reid Robison: Yeah, no, it's an excellent point. And the way we're approaching that is clinical trials on the FDA path are one thing, but once they're approved in clinic, like with Spravato for example, we've given it so many times now that, and we have our electronic health record, that we've done this already and published probably half a dozen papers on our clinic data in the last year of... We've been able to, with the IRB approval, the ethics approval and the right confidentiality approach in place, query the data in an anonymized way, ask questions of it, and we could... Once, psilocybin is out in clinic, there may be people who are getting it at the same time they're getting TMS or right after, right before or whatever, and we can look at that data like we've done for Spravato. In fact we have people who have been getting TMS and ketamine in parallel, not in the same day, but in parallel, and we could extract that as a subset, compare it to another subset and take a real world data approach to at least point signals of what needs to be really explored seriously.

0:45:39.2 Paul Austin: And I think that naturalistic approach is becoming more feasible with emerging technology. So the first example that often comes to mind is with Paul Stamets and what he's carried out through Quantified Citizen, this app, where he's been able to get data from 6500 people who have been microdosing, and what's interesting now is that naturalistic data that he's collected through Quantified Citizen, it actually is mimicking a phase 1 clinical research trial that Suresh has done in New Zealand that shows that the core variable that actually dictates success when microdosing is, am I doing it in a neutral hospital setting or am I doing it in my natural everyday life? 'Cause the way that Suresh had set it up in New Zealand is you could take 10 micrograms of LSD home with you. You could take it at home, and they found that that was actually the main variable that caused a shift.

0:46:34.7 Paul Austin: So I think optimally or ideally, some of these questions can inform a naturalistic or observational research path, and then as it becomes less and less expensive to actually carry out clinical research, because these aren't Schedule 1 substances anymore because they're legal in certain jurisdictions, then potentially that multi-modality approach is actually feasible to study.

0:47:02.0 Reid Robison: Yeah, I love the study you mentioned with all the Quantified Citizen, did you say, is it? Quantified Citizen platform.

0:47:11.7 Paul Austin: Mm-hmm. Quantified Citizen.

0:47:12.8 Reid Robison: Yeah, I heard Paul Stamets talk about it in his talk at the MAPS Conference in Austin back in 2019.

0:47:20.2 Paul Austin: Announce it.

0:47:20.6 Reid Robison: And then it's really neat to see data coming out, but you know what I encountered recently when reading about this case of psilocybin for anorexia from the 1950s? Is I went down this rabbit hole of the first hospital-based use of psilocybin ever documented was in France in the '50s. And the way they gave it there, it wasn't very successful because of the setting. It was in a hospital room where you'd get this medium-sized dose, say 10 milligrams of psilocybin, and then you'd go from room to room at these different psychology interviews where they'd be staring at you, asking questions, writing things down, and people's comments from that experience were like, "This was a little bit uncomfortable. Are they scrutinizing me?" And yeah, it was just, in hindsight, they didn't have any clue about set and setting and how to dose this stuff, but no wonder it didn't work. And it reminds me of the microdosing study, the New Zealand work you mentioned.

0:48:28.6 Paul Austin: Yeah, that naturalistic setting, right? We're so sensitive, especially when we take psychedelics, even at a micro-dose level, that that environment that we're in actually matters quite a bit, and even to that... Okay, so that's even a good transition into the next question that I wanted to go into you with you, which is earlier you mentioned that you're starting to experiment with ketamine in clinic with groups, families, couples, but also employers. And I know there was an announcement, I don't know if... I think this was just right after Numinus had acquired Novamind and you really joined the Numinus team. There was an announcement that Numinus was pairing up with Lucid, which is...

0:49:15.3 Reid Robison: HempLucid, yeah.

0:49:16.2 Paul Austin: HempLucid, which Chase, who's the CEO, went through our training program for coaches, great guy. So this was during that. So I saw that, so I'd love for you to tell us a little bit about whether it's that specific concrete example with HempLucid and more broadly, what does that look like in terms of employer mental health relationship? What's feasible to do? What's legal to do when it comes to that?

0:49:43.4 Reid Robison: Yeah, and Chase and HempLucid are a great example because this is pretty early on. This is like 2020 or so, when Chase and I connected, because we're both in Utah and HempLucid wasn't too far away from our clinic, and we connected on the shared vision around wellness and bringing psychedelics into both health care and the wellness world. And he had this vision of if supporting... This theory that if he supports his employee mental health, it's not only good for them, but good for their work too. If they can thrive in every day life, they can thrive in the workplace, and it was a worthwhile expenditure to invest in their mental health, and so we did. And what that looked like was setting up a program with us where HempLucid employees, if they wanted to and needed to, could come in to us for a course of ketamine-assisted therapy once per quarter, the way he set it up. You have to put some reasonable container around it in the real world, given economics and everything else.

0:51:07.7 Reid Robison: And then from our end, we had to make sure we follow a process that keeps us in good standing with the fact that ketamine is a controlled substance and we need to give it for a mental health condition, and so that's how we've approached it. If someone needs it, they come to us for an evaluation and we can see them. From there, we've done it mostly in individual ways, but sometimes in groups. And the neat thing is, the culture that Chase has set up at HempLucid, beyond this and including this offering, has really created a close group of individuals who support each other. They're vulnerable, they're vulnerably doing this work in parallel and sharing with each other and cheering each other on. What that translates to, in their openness and sense of community and the work they do, is really inspiring. It's really been neat to watch.

0:52:16.7 Paul Austin: Do you sense that this will become more and more prevalent in other workplaces? Has there been... I know there was some media around that. Has there been more interest from other companies or do you think it's still early days to talk about ketamine as a mental health benefit?

0:52:35.2 Reid Robison: No, I think it's a great time to talk about it, and I think more and more people should adopt it or should test this theory out because I'm convinced that if set up in the right way, it's going to be a pretty strong return on investment for employers and health plans for that matter. And yeah, like you mentioned, Dr. Bronners announced a program that they rolled out since then as well, that has created a lot of good kind of awareness and attention on this possibility. But the fact of the matter is, no, we don't see employers lining up at the door asking to set this up. We're still in this Western healthcare mentality of swatting away disease as it arises, and I think what we need is a little bit of evidence to convince more employers that this is a really positive return on investment, this is a wise move, and more ways of doing that. So in that sense, it is early days, but I think it's ripe for the picking and needs to be done more.

0:53:55.1 Paul Austin: And I think there's a company called Enthea Healthcare that's working with Dr. Bronners on that initiative.

0:54:02.0 Reid Robison: Yeah, they're great. I was just meeting with them recently and was part of their ketamine advisory panel with a bunch of other ketamine experienced, ketamine clinicians, and I really like the thoughtful approach they took to setting up these kind of programs and the angle they're taking. That's what we need to pave the way to access, is tackling that big beast of the US insurance part of the healthcare system.

0:54:38.0 Paul Austin: Yeah, and it goes back to what we talked about at the very beginning in this conversation, right? The difference between Spravato and generic ketamine, what that might look like as psilocybin and MDMA are approved for clinical use. And although there's a lot of criticism about the medicalization, I think in terms of accessibility and affordability, ensuring that these treatments can be covered by health insurance is gonna be so key to widespread use of the medicines.

0:55:08.4 Reid Robison: Yeah, and by working on this, by adopting Esketamine or Spravato and giving ketamine in clinic and doing psilocybin studies, I'm in no way saying that it shouldn't be illegal as well for religious purposes or people's consciousness expansion or microdosing for enhanced well-being in day-to-day life. But yeah, like you mentioned, that's a big hurdle to access, and when people have a serious mental health struggle, and when we can help with course of psychedelic therapy, we wanna be able to. We're working on that challenge with the infrastructure and the protocols and jumping through these insurance hoops.

0:56:00.6 Paul Austin: Yeah, and one supports the other. I was interviewing Hamilton Morris, which we haven't published that interview yet, but a few months ago at The Microdose Conference, and he was making the point that there are a lot of people who are upset about COMPASS Pathways and a tie and the patent model. And yet, the awareness that that is helping to facilitate the clinical research that's being carried out, the approval process by the FDA will inevitably make legalization in places like California, New York, Texas all over the United States, much more likely. Because there's then, like you said, when you were speaking in the Utah Legislature, one of the core people who spoke out against it was saying, "Hey, this isn't approved by the FDA yet, so why should we approve it here?" And so I think that would be a huge bellwether, once MAPS and whoever, whether it's Usona or COMPASS actually gets these Schedule 1 substances finalized and completed through phase III clinical trials.

0:57:00.6 Reid Robison: Yeah.

0:57:03.9 Paul Austin: So we're nearing the end point. I'd love, just as a final question, to hear about, in your role as Chief Clinical Officer at Numinus, what is the next year look like for you, for the team that you're working with, for the growth and development of Numinus, whether it's research, whether it's expansion through clinics, whether it's... Yeah, I just love kind of like, what is 2023 into early 2024 hold for you and what you're up to?

0:57:44.2 Paul Austin: So like I mentioned earlier, we're approaching it from both the research front, which helps us build infrastructure, get the right infrastructure in place. Knowing the research protocols gives us a sense of how it's going to be when it's approved and how we need to set up our clinics and train clinicians. But I'm excited to see what comes of these pilot programs we're doing. We did one of group ketamine for healthcare workers coming out of the pandemic with burnout, stress, trauma, and we got that data accepted for publication. It hasn't come out yet, but it's exciting to see people's trauma scores plummet. Their resilience increased through the course of a six-week group program with peers, like healthcare worker peers, and three doses of ketamine, and so we're starting another group program next month. I've got a few retreats planned for the year, like bringing people in from wherever in the country, outside of the country, to receive ketamine plus a whole lot of therapy for a given indication, addiction, eating disorder.

0:59:03.8 Reid Robison: Even, we've got some dates planned for one for postpartum depression that hasn't been done yet, but where we need more tools. There's an FDA-approved medicine approved in 2019 as well for postpartum depression that costs like $80,000. It has never been given in Utah. And you have to be hospitalized for 48 hours to get this IV. When people are suffering that much and there's suicidality risk and things, we need to really take these tools that we have and make them available in a good way, and so that's what I'm excited about, that we're doing the work in a way that we're constantly iterating and figuring out how to offer it in better and better ways for various conditions and contributing to that, both research base and accessibility challenge.

1:00:07.1 Paul Austin: Well, I wish you the best of luck in all of that.

1:00:09.3 Reid Robison: Thank you.

1:00:11.1 Paul Austin: I know Numinus is really focused on this and there's an entire ecosystem that is behind you, and even an entire, I would say, cultural movement or awakening that is happening. And what I've always loved about Numinus, what I've loved about your work is it's grounded, it's balanced, it's evidence-based, it's informed by science, and it's also compassionate, caring and accessible. So you've really helped to pioneer this. We talked about over 100,000 visits, 25,000 potentially involved in ketamine, which is a huge number, and as we both know, that is only going to continue to increase as these medicines become more accessible.

1:01:00.3 Reid Robison: Yeah, no, thank you for what you're doing. I love the movement, the collaborative spirit of this, where we're rallying together, walking each other home to the better way of living, thriving, supporting each other.

1:01:17.2 Paul Austin: It's what being human is about. It's what relationships are about. It's better to be collaborative, to do it together, and that's usually one of the core teachings of psychedelics, is that to go at it alone is not nearly as fun as to be in collaboration.

1:01:36.8 Reid Robison: That's true.

1:01:38.7 Paul Austin: Well, now we have an IG live that we're gonna pop over to do. So, Dr. Reid Robison, it was great to have you on the podcast today. Thank you for joining us.

1:01:48.8 Reid Robison: Thanks, Paul. Wonderful questions as always. Fun conversation.


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