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Though it may sound like fodder for a fantasy novel, Dr. Evan Lewis of the Neurology Centre of Toronto wants to make the field of psychedelic neurology a reality. It’s an ambitious desire, given that psychedelics is a broad term which encompasses compounds ranging from cannabis to ketamine. Long relegated to the fringes of medical research owing to various nations’ longstanding federal prohibitions, psychedelics are now enjoying a renaissance of sorts.

In the last week alone, psilocybin — the psychoactive compound found in “magic” mushrooms — was all over the headlines: Canada gave the go-ahead to administer it to terminally ill cancer patients, a study found users of magic mushrooms were ‘less likely to develop opioid use disorder,’ and actor Oscar Issac hit “Late Night with Stephen Colbert” to talk about tripping in Budapest with Ethan Hawke.

Meanwhile, the legal framework for psychedelics is in flux as well. In the U.S., organizations like Decriminalize Nature continue to chip away at outdated laws on a state-by-state level. As Mexico mulls over the final language on a national framework for cannabis legalization, Canada appears to be firmly in the lead when it comes to supporting the push to explore psychedelic-based medical solutions. That’s why Dr. Lewis, a pediatric neurologist sub-specializing in epilepsy, recently merged his practice with Canada’s Numinus Bioscience.

These days, Dr. Lewis is specifically focused on encouraging his peers to embrace the prospect of psychedelic medicine as it relates to brain injuries and trauma. Can ketamine help a stroke victim? What’s the right dose of MDMA to give someone who may not be able to communicate their needs? These are just a few of the questions being explored by Lewis.

As laws continue to change for the better, there is also a ticking clock element at play here. Getting medical experts and the public prepared for this potentially radical shift in treatment options is no small task but Lewis sounds up for the task. Speaking with American Marijuana, he discussed his desire to see psychedelic sub-specialties in medicine, the importance of off-label use, and the value of psychedelics in treating brain trauma.

Let’s start with a little bit about your background. What led you to the position you find yourself in now, working in this field?

I’m a neurologist. I’m trained in pediatric neurology with epilepsy as my sub-specialization. I trained in Miami at Miami Children’s Hospital, then subsequently trained at SickKids Hospital in Toronto. That was where I focused on epilepsy, then, after a couple of years, I left to open my own clinical neurology center in Toronto. The idea was to open a multidisciplinary practice and to expand beyond some of the areas that I was working in. The key there was to leave the hospital setting, which freed me a bit to pursue some of the things I was looking to do.

At a time, that was cannabis medicine and treatments for kids with epilepsy. That remains a very big area of my practice and focus, but when I left the hospital and started to work with a lot of patients in the community, I started to see a lot more patients with brain injury. That wasn’t really heavily emphasized in my neurology training, interestingly enough, but it was something that I started to get more involved with once I was outside of the hospital. And that path, over the last 10 years or so, indirectly involved psychedelics. It’s hard to be in cannabis medicine and to not get exposed to psychedelics and the explosive amount of psychedelic research being published these days. There started to be conferences and papers on psychedelics, and I started to read them because I wanted to know more. As one of the few neurologists doing things outside of the norm with cannabis at that time, I just naturally gravitated towards psychedelics.

The brain injury aspect another route of entry to psychedelics for me. I started to read anecdotes from famous people, non-famous people, athletes, non-athletes, etc. and there seemed to be an underpinning to all these stories about psychedelics that really piqued my interest. As a result, over the last five years or so, those two fields led me to psychedelics and a desire to learn about them and to see how they could integrate with neurology. That’s something that I’ve really cultivated over the last 5-7 years.

You mentioned epilepsy. I know the FDA approving Epidiolex was huge, but would you say cannabinoids remain on the fringes in terms of being embraced by the larger medical research community? Like, did you learn anything about them in school?

Can you give me a bird’s eye view on where things stand with research efforts overall? I know laws vary by country, which doesn’t make things any easier. But as far as Canada goes, how are things looking these days?

Cannabis has been legal, medically, for a while in Canada. Even before 2018, it was successful — just not in all shapes and forms. Certainly, once legalization happened, it really opened a lot more research opportunities but it’s still difficult to do research. It’s still very expensive, because it’s highly regulated and maybe, to some degree, over regulated, one could say, but for good reason. It’s new, it’s emerging, and we’ve got to be extra safe here if we want to see a lasting cultural shift.

The cannabis research in Canada has certainly expanded and opened a lot more opportunities with legalization. It’s funny because there are parallels with psychedelics. I think that will very much be the case for various individual compounds within psychedelics once legalization occurs. From the patient’s point of view, after cannabis was legalized, there was a lot more interest and a lot more questions being asked. I think people who were sitting on the fence before, who were worried that they’d be judged or whatnot, are now coming forward. There are always going to be people on the other side of the fence and who’s to blame for that? They grew up in a time where this stuff was very highly stigmatized. There’s a lot of misinformation out there.

Most of my day-to-day is spent speaking with patients and talking to them about cannabis and clearing up a lot of misinformation. That’s begun to emerge with psychedelics too in the last few years. I’ll have conversations with patients, and they’re so afraid to tell me that they’ve gone off and done psychedelics on their own or whatnot — again, for good reason. It’s about chipping away at it. People are being a little bit more open about it but it’s just going to take time for these things to happen.

On that note, do you feel like the progress we’re seeing with Decriminalize Nature and similar efforts in the U.S. and beyond adds pressure on the medical community to learn all they can about these compounds as quickly and as thoroughly as possible?

Definitely. You hit the nail on the head there. I joined Numinus in September, but it was an ongoing conversation for some time. When I would talk to colleagues or friends about it, they would ask why a neurologist would want to focus on psychedelics. It comes down to what you alluded to in your question. Having been in cannabis medicine for a while — and especially in Canada, where it’s been medically available for some time — I’ve seen where they have failed.

One such failure is that there are simply not enough experts within the various fields of medicine who understand cannabis. For instance, as a neurologist, despite epilepsy being our current best evidence for the medical efficacy of cannabis, there aren’t many neurologists who know a lot about cannabis relative to the medicines that come down the typical pharma pipeline. For me, that was when I teamed up with Numinus and came aboard. The concept was to build out this field, which we’re calling psychedelic neurology.

The idea there is for neurologists to become well-versed in the mechanics and actions of psychedelics. That way, these neurologists can provide insight into determining how psychedelics are utilized within their field of medicine as opposed to the bottom-up approach of patients going off, experiencing these things without guidance, then coming back and telling neurologists about it. I call it a combo top-down and bottom-up approach where the bottom is approached from the ground up, which is very important, but the top-down approach is equally important. You can’t have a system that’s heavily weighted on either side because there are advantages and disadvantages to both perspectives. There must be a good balance.

I imagine, in the next two, five, maybe eight years, that the expertise within individual medicine fields for psychedelics will evolve. What I don’t want to see are broad-based experts like the physicians working in cannabis now. Instead of broad-based experts covering psychedelics for all fields of medicine, I think a better model would be to have psychedelic neurologists, psychedelic gastroenterologists, psychedelic rheumatologists, etc. First and foremost, they’re experts in their respective fields of medicine, and then they’d have complementary expertise in how psychedelic medicines apply to the area of specialization. For me, that’s a very logical model.

That’s what I’m really trying to cultivate here: for neurologists to lead the charge in recognizing that psychedelics are important and that we, as experts in neurology, need to figure out how psychedelics integrate with our respective field.

Let’s talk about ketamine for a minute. How did we go from thinking of it as a horse tranquilizer to its present-day status as a promising medicine for depression?

Ketamine, specifically in Canada, has been used in general anesthesia for some time. It has a good effect in terms of disassociating an individual from a conscious state. It really helps with the memory loss piece, to some degree, in that case, and it seems to be that, through its actions, which are much different from psilocybin or LSD, that it has secondary effects with psychedelic properties and that it seems to work well for depression. That’s opening it up to other indications, like PTSD and other areas.

What makes ketamine interesting is that it’s accessible right now in Canada. What happens when these things are available is that you can have doctors who can then use them off-label. As a result, you get people who have expertise in utilizing ketamine and expertise with the therapy who are starting to use it in other areas as well. There’s a lot of promise with ketamine in Canada since we have it available. Again, it’s label use is for depression, but it is being used off-label for other indications, too. There are quite a few ketamine-assisted psychotherapy clinics here now. It does hold great promise. We’ve also made good progress with other, likely forthcoming psychedelic medicines like psilocybin and MDMA too.

What do you make of the timeline for that? How fast do you see this all falling into place in the years ahead?

It’s so hard to predict. There’s a direction, I believe, that things are going in Canada. Right now, there’s a push to refine current studies. We’ve got solid evidence on some conditions, like PTSD and depression, but there are strong signals in other areas too, so I think the immediate future is about researchers defining what’s known already and then really crystallizing it in terms of safety and indication. Medical legalization for MDMA is pending and will probably happen very soon and psilocybin will follow suit. In terms of recreational legalization, that’s a bit harder to predict. I’m not sure how that happens.

Coming back to what we mentioned earlier, as soon as medical legalization with MDMA for PTSD happens, for instance, that’s going to result in off-label use. Then you’re going to have psilocybin: same thing. You’re going to have off-label use, and that’s not necessarily a bad thing at all. That will probably kick off a strong surge of proposed indications. There will be this big windstorm of everybody using it for totally different things but that will settle in time. That’s where, from my point of view, I really want to gear up from a neurology vantage. Knowing this is in the pipeline, that’s where we’re focused right now at Numinus.

In the short term, research efforts at our center are going to be focused on three main areas: safety, indications, and effectiveness within the context of individuals with neurological disease.

For instance, if you look at the studies and look at the characteristics of all the patients in [currently available] studies, outside of their psychological and psychiatric diagnoses, they are a relatively homogenous and healthy population. Where are the people with multiple sclerosis who also have concurrent depression? Where are the people who have Parkinson’s or ALS or another devastating neurological disorder that comes together, with significant psychological impacts?

They’re excluded from these studies because right now, the goal is to establish consistency amongst the population to prove these things work. So, logically, the next phase for me is to be able to help everybody, especially those patients in neurology who were marginalized out of these studies just because they have an underlying disease.

We also don’t know how psychedelics are going to affect people with underlying neurological conditions. That’s another area: what are the safety parameters for these populations? What are the indications? Are we treating the concurrent mental health conditions? Can we help with the neurological disease? Lastly: how effective are they? Circling back to the people from these studies, we’ve shown effectiveness in people who do not have brain conditions or brain diseases, right? Well, what if somebody has a stroke and has significant damage from the stroke or has a severe traumatic brain injury with long-lasting impact on the brain and its structure?

When you give somebody psychedelics in a situation like that, how effective is it? Can we knock out the area of our brains that will allow the psychedelic to be effective? Can we knock out the area of our brains that is possibly responsible for protecting people during psychedelic experiences, allowing them to tolerate higher doses? If so, does that mean maybe now those patients need lower doses because of, for instance, frontal lobe strokes? These are big, big questions that could affect a huge percent of us given neurologic disease is very, very common in our population.

I’m obviously no expert but given the side-effects and such for some of the currently available medications can be absolutely brutal, I have to imagine any new solutions in the field of stroke treatment would be desperately welcomed?

You’re right. Stroke is a good example because a stroke is a significant brain injury. We have about 15 million people a year who suffer strokes. That’s a lot. 5 million — about a third of those people — are left permanently disabled or have long-term disabilities. That’s one reason strokes are so devastating: it’s not a gradual disease. One minute, you’re functioning totally perfectly, and then instantaneously, the next minute, you’ve become someone totally different.

If a third of these individuals are ending up disabled, just imagine the mental health conditions that are associated with that. I see it all the time. Then the question becomes: can we help those 5 million people a year? Can we treat them? Right now, we don’t know, so we need neurologists who understand psychedelics, who can intelligently investigate this — and that’s just one example.