Kitty Flipping: Ketamine and MDMA Stimulant Combinations

"Kitty flipping", the practice of combining MDMA (ecstasy) and ketamine, is often confused with the term "candy flipping," in which MDMA is combined with LSD. Historically, kitty flipping refers to the use of MDMA and ketamine within the same short time period, but new drug seizure data suggest that MDMA and ketamine are also pre-mixed and sold for "kitty flipping".

"Recently, we observed an increase in the prevalence of ketamine in decedents that also tested positive for other drugs, such as MDMA," said Dr. Diane Moore, director of toxicology at the Miami-Dade Medical Examiner Department. "It kind of clues us in that it's something we should be paying attention to and track.” Dr. Moore said the 2025 deaths in Miami so far follow a national increase of ketamine-associated deaths. Until 2017, ketamine was identified in fewer than 10 deaths yearly. But in the first half of 2025 in Miami-Dade County, coroners reported 33 fatal toxicology reports implicating ketamine—a sharp rise highlighting an alarming trend. Illicit forms of ketamine are most often mixed with MDMA.

Ketamine has been a permanent fixture at clubs and festivals since the 1980s. The dissociative/dream-like state that ketamine induces appeals to users in a club context. Concurrent use with stimulants like cocaine, methamphetamine, or MDMA is regularly reported. Ketamine use increased through 2015 when the drug became a mainstay of nightlife/club settings.

By the early 2020s, surveys showed rising levels of ketamine use among nightclub attendees. A National Drug Early Warning System (NDEWS) alert in 2024 described increased online mentions and incidents of ketamine with other drugs, especially MDMA. The term “kitty flipping” or use of ketamine plus MDMA can lead to tachycardia, hypertension, and hyperthermia. And death. Ketamine overdoses cannot be reversed by naloxone (Narcan), an opioid-overdose reversal drug.

"We started noticing there's a lot of ketamine in our cases that also involve other drugs," said Dr. Moore. "I'm like 'there's ketamine again, there's ketamine again,' and reading the history and there's a pending toxicology case for a drug overdose."

Until 2017, ketamine was identified in fewer than 10 cases per year in Miami. In 2023, there were 68 cases. Moore said she's been told ketamine spray is sometimes passed around in Miami-Dade clubs. Some users believe (or hope) that combining ketamine with MDMA may allow them to reduce doses of one of the drugs or offset MDMA’s adverse effects. They sometimes gamble their lives on this plan.

How Are Ketamine and MDMA Typically Used Together?

The ketamine/MDMA combination is taken simultaneously (in the same pill or drink) or sequentially—many users take MDMA first and snort or ingest ketamine later. There is no standard dosing, and the variable potency of these illegally used drugs adds to their unpredictability. The drugs are often adulterated or mislabeled, further increasing risks. Effects vary by dose, user physiology, purity, and the timing of when the drugs were taken.

Considering Drug Combinations and Effects

MDMA produces drug-induced euphoria, emotional warmth, empathy, heightened sensory perception, and energy. In contrast, ketamine adds dissociative, hallucinogenic, sedating effects—users may feel detached from their surroundings or experience a partial disconnection. When these two drugs are combined, users hope for an intensified experience blending empathogenic ecstasy with dissociative introspection.

However, dissociation can lead users to take dangerous risks and make them immobile, disoriented, or fail to call for help during emergencies. Adulteration of these drugs (with fentanyl, xylazine, methamphetamine, etc.) is common—each batch may differ drastically in composition.

Ketamine Is a Good Medicine When Prescribed, Supervised and Used Correctly

“Ketamine is a safe and effective medication when used in a hospital or clinic setting,” said Bruce Goldberger, Ph.D., clinical professor at the University of Florida College of Medicine. He is alarmed by self-administration of ketamine and co-use of ketamine and MDMA. “Ketamine and MDMA are elements of the party scene," Goldberger said.

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Looking Back

For a long time, ketamine, a Schedule III anesthetic, was notorious as a “date rape drug” that could be slipped into a drink to facilitate sexual assault. In 1999, the Drug Enforcement Administration (DEA) said street sales were rare, and the drug was primarily distributed at parties, raves, and nightclubs.

The Ketamine Situation Today

Intranasal esketamine was FDA-approved for treating depression in 2019. But ketamine is also abused, and can cause a ketamine use disorder as well as overdose deaths like that of Matthew Perry. While use has increased with ketamine clinics and even home administration, self-medication and poly-drug use have caused the current concerns. Acute intoxication with ketamine may cause agitation, hallucinations, nausea, tachycardia, and hypertension. Frequent use is associated with long-term complications, including ketamine-induced urinary-bladder disease. Adulterants and unpredictable drug compositions (especially fentanyl-included cocktails) are major drivers of overdose and death in South Florida and elsewhere.

Recreational use of ketamine has risen significantly, particularly among young adults in nightlife settings. This trend was accompanied by an increase in first aid incidents involving ketamine, often in combination with other substances like alcohol or MDMA, leading to increased toxicity. Medical professionals responding to drug emergencies frequently deal with critical conditions like hyperthermia, serotonin syndrome, cardiovascular collapse, or loss of consciousness, with limited antidotes available.

Pink Cocaine — Ketamine Plus

I previously described club drugs and "pink cocaine" (also known as “tusi”)—a designer drug cocktail, with little or no cocaine, and comprising ketamine, MDMA, and other dangerous additives like fentanyl, methamphetamine, opioids, or xylazine.

Use of ketamine + MDMA and pink cocaine is another reminder of the ever-changing landscape of illicit drugs, where entrepreneurship, social media trends, and risk-taking behaviors combine to create major drug threats.

Summary

Kitty flipping is mixing the dissociative effects of ketamine with the entactogenic effects of MDMA. Some people who use it report that this combination may reduce the negative "comedown" effects of MDMA. Deaths and emergencies are increasing. The DEA’s One Pill Can Kill program reminds the public about drug risks, and medical experts caution that taking dangerous, counterfeit pills, or unknown drug combinations is like playing Russian roulette. Of course, for some, that is part of its appeal.

Ketamine smuggling, poisonings, pharmaceutical diversion, and DEA seizures have increased. Ketamine misuse and the club landscape are rapidly changing. At the same time, ketamine is being legally administered by clinics as an at-home off-label drug used for psychiatric treatment. Routine inclusion of ketamine in toxicological screening could improve diagnostic precision and better address health risks associated with ketamine’s growing illicit prevalence.