Ketamine might be the current poster child for psychedelic medicine, but mainstream media has been missing an important reality about ketamine’s divergence and potential for addiction.
With the recent efforts to extend the exemption of the Ryan Haight Act, Dr. Julia Mirer has one question:
If people are going to lobby to extend the COVID exemption of the Ryan Haight Act (which states no controlled substance may be delivered, distributed, or dispensed by means of the internet (including telemedicine technologies) without a valid prescription), then we owe it to the general public to put up some guardrails. Can the extension as it pertains to ketamine telemedicine include the creation of a nationwide prescription drug monitoring program for ketamine?
Because ketamine is safely used as an anesthetic, it doesn’t seem to carry the same stigma as LSD or psilocybin. Somehow, “k-holes,” “k-bumps,” and designer drug blends like CK are brushed over, with the current narrative focused on highlighting its promise for revolutionizing mental health treatment.
A timeline about an anesthetic being used in the Vietnam War quickly jumps to schizophrenia research at prestigious universities. That’s all true, but too often quickly skims over mounting evidence that ketamine is still used for reasons hardly described as therapeutic. While we might assume the use stops when the party ends, that’s not always the case.
Potential for healing, yet diligence and responsibility are required
Conversations about ketamine’s potential for addiction and abuse have been surprisingly short-lived, despite an understanding that it interacts with dopamine and opioid receptors, which are associated with developing an addiction.
It’s a reality that Dr. Julia Mirer has witnessed first-hand in Miami. “People can get really carried away with recreational ketamine use,” explains the Director of Strategy & Impact at Nushama, a psychedelic wellness center that offers ketamine treatment.
Dr. Mirer resigned from her residency when she “stopped buying what she was selling” in 2018 and pursued a different path toward supporting health. When ketamine became a breakthrough therapy in 2019, she began noticing a common trend: physicians would become aware of ketamine’s potential and get excited for its use in treating their patients, without being fully informed of its full spectrum of effects.
“Ketamine has never been looked at in this context before,” she says, referring to the fact that ketamine is an off-label drug and has not been well-studied in loosely regulated home use, “the addiction data simply hasn’t caught up yet.”
Mirer is adamant that ketamine is an extremely beneficial drug, referencing its ability to remove suicidal thoughts in around 45 minutes, an unprecedented result in the field of psychiatry; but has growing concerns regarding a lack of education of practitioners and patients alike about ketamine’s potential dark side.
Dr. Jon Krystal (one of the first researchers to look at ketamine for mental health back in the late 1990’s) recently spoke to what happens with unregulated use on the Tim Ferris Podcast. He shares that “some people were given bottles of ketamine for home use, allowing them to take it whenever they “needed”. Some people ended up taking it every day, others 4-5 times a day to maintain their equilibrium. One of the things that happen when you take high doses of ketamine every day versus lower doses sporadically is that ketamine can actually increase your vulnerability to depression when used in this compulsive behavior.”
A nationwide prescription drug monitoring program for ketamine currently doesn’t exist, so what is to stop someone from going from clinic to clinic gathering ketamine prescriptions? Apparently, very little. With the ease of telehealth, they may not even need to leave the comfort of their home. Some companies are doing their best to track patients nationally and create some safeguards, but these records aren’t shared among organizations.
Mirer asks, “based on what empirical evidence do we suddenly believe that all patients will take the medicine exactly as prescribed?” driving the point home with rumors of people showing up to parties with ketamine nasal spray.
The combination of ketamine with therapy for depression has not been studied as extensively as ketamine for pain has been. Yet, high-quality information is crucial because Dr. Mirer says, “the only real way to move forward in a responsible way is to educate not just the consumer, but the providers as well.”
A nationwide prescription drug monitoring program for ketamine currently doesn’t exist, so what is to stop someone from going from clinic to clinic gathering ketamine prescriptions? Apparently, very little.
Many clinics use a protocol of twice a week for three weeks, which was established initially as a pain protocol, not a mental health protocol. With relief from symptoms of depression lasting, on average, for 7-10 days after administering ketamine in the clinic, there is an opportunity to research different dosing schedules that may be best suited for mental health conditions, which is something Awakn Life Sciences is working on in the UK.
Ketamine’s potential upside is very significant, but Dr. Mirer cautions that we need to avoid someone believing that ketamine, not necessarily the therapy or their own actions, is what consistently makes them feel better. “We are dealing with people who are suffering, many of them have suffered for decades, and here you have something effective at removing their suffering,” she explains.
When ketamine relieves the burden of depression or anxiety, a window is opened that, when combined with a therapeutic container, gives patients an opportunity to learn new coping skills and practice changing maladaptive behaviors.
Ketamine Research and Education are Needed
All this isn’t to say that something is inherently wrong with ketamine. In fact, in the right hands, with the right intentions, this medicine can revolutionize mental health care. Ketamine is being used effectively in practice day in and day out, with unprecedented results. At-home ketamine can be valuable too when there is an established therapeutic relationship with a patient and an understanding of appropriate use and a method for accountability.
However, Dr. Mirer also points to hastily refurbished botox and vitamin infusion clinics dishing out ketamine treatments simply because they can. “Some people are just trying to make a buck on this,” she cautions.
Dr. Mirer is not suggesting that ketamine should be taken off the table. Fast and effective results are, without a doubt, a tangible outcome of ketamine used in a responsible context, such as acute suicidality and depression. After all, the world still has a place for opioids. The comparison might seem extreme, but how we distribute ketamine can draw lessons from how we have handled previous potent compounds in the past.
How we collectively navigate the coming years as an industry will likely shape both the access to and efficacy of ketamine.
When used in a clinic setting, with the proper education and support, the risk of addiction is significantly reduced. Dr. Mirer draws the following parallel: let’s consider opioids, one of the most addictive and powerful substances. Just because they are addictive does not mean they are not often used in responsible ways. If you injure yourself and end up in the ER you will likely get morphine, if you ever need multiple surgeries you may receive opioid pain medication each time.
The likelihood that you will become addicted from this kind of exposure is low. Still, when you get sent home with Percocet without being educated about signs of dependence and have your prescription refilled every time you complain of pain…you may eventually end up with an opioid addiction.”
She goes on to say “I don’t believe that an opioid addict wants to be addicted to opioids any more than I believe a depressed patient wants to end up addicted to ketamine. But in both cases, the initial relief from pain (physical or emotional) can be intoxicating. As doctors, we take an oath to do no harm, and leaving out ketamine’s potential for misuse can, in fact, inadvertently lead to harm.”
Tim Ferris said it best in his recent podcast with Dr. Jon Krystal about ketamine: “an ounce of prevention is worth a pound of cure.”
Finally, Dr. Mirer concludes that “Ketamine is extremely unique. It has both a dark past as a drug of abuse as well as a promising future as a drug to treat addiction. How we collectively navigate the coming years as an industry will likely shape both the access to and efficacy of ketamine.
Mirier is clear, too, that ketamine isn’t just a stepping stone before expanding into MDMA or psilocybin. She says that even when other psychedelics are online, ketamine has unique properties and its own sweet spot, particularly in acute situations when someone is actively suicidal or catatonically depressed.
With the current deteriorating state of global mental health, it would seem irresponsible to ignore a drug as fascinating and potent as ketamine. Yet, equally irresponsible would be not listening to people like Dr. Mirer reminding us that to be on the right side of history, we may want to learn from the not-so-distant past.
Editor’s note: This piece was co-authored by Ashley Southard. Ashley is founder, CEO, and COO of companies supporting people and the planet via for-profit and non-profit ventures in the nutraceutical, mental health, and wellness sectors, including psychedelic medicine.
