The Wild West of Ketamine

Ketamine is an incredible molecule, capable of alleviating treatment-resistant depression as well as facilitating psychological breakthroughs. However, due to a lack of regulation and capitalist pressures to sell large amounts of ketamine, a wild and unruly West has emerged.

As an owner of a ketamine clinic, I see firsthand how difficult it is for patients to navigate this Wild West of ketamine. Patients researching ketamine hear diverse recommendations for best practices of ketamine treatments. Dosing protocols vary from clinic to clinic, ranging from four to 12 intravenous (IV) ketamine treatments. Some clinics maintain the same dose throughout the induction period, whereas others increase the dose. Booster recommendations vary from two weeks to six months to unnecessary. And then there are multiple routes of administration, like sublingual and intramuscular ketamine. More and more, clinics are recommending combining ketamine with talk therapy in a variety of forms, but some clinics do not. In addition, some clinics are run by behavioral health experts, while others do not have any employees trained in mental health, even though they are treating depression, posttraumatic stress disorder (PTSD), bipolar disorder, anxiety, obsessive-complusive disorder (OCD), and sometimes addiction.

Company Profits

Perhaps the most concerning part of the Wild West of ketamine is the pressure on companies to prescribe more and more ketamine to increase profits. Some telehealth companies mail patients large quantities of ketamine for at-home use. Because generic ketamine is an off-label treatment for mental health disorders, it is not subject to U.S. Food and Drug Administration (FDA) regulations. Without regulations, the pressure to increase profits may lead to sketchy business practices, such as advertising ketamine to everyone and not just patients who need it. In addition, the risks of ketamine are downplayed, and the end goal seems to be selling large quantities of ketamine. I’ve seen some questionable practices, like creating monthly membership programs and advising daily home dosing of ketamine in an ongoing manner. This sounds to me like advising daily, ongoing Xanax as a first-line treatment for everyone. Not a great idea. I recently heard that daily injectable ketamine is now on the market. Also not a good idea.

Matthew Perry’s tragic death is perhaps symbolic of the worst parts of the Wild West of ketamine. It seems that licensed medical professionals sold huge quantities of injectable ketamine to Perry, knowing he struggled with addiction. There weren’t any medical personnel overseeing Perry’s injections; instead, it was his personal assistant injecting him multiple times a day. With no attention to a safe setting, Perry sadly drowned in a hot tub.

Benefits of Ketamine

I do want to emphasize that ketamine can be a miraculous treatment for many who are suffering with depression, PTSD, OCD, and other mental health issues, especially where other treatments have not been effective. And ketamine is a relatively safe medicine. It is the anesthetic agent of choice for the elderly and children since it does not depress respiratory or cardiac function.

Also, there certainly are many benefits to ketamine being so readily accessible. Perhaps most importantly, fewer regulations allow increased affordability and access to patients who may truly benefit from its multiple antidepressant and psychological healing properties. With off-label prescribing, patients have a choice in how they want to use this versatile medicine for their healing, whether as a chemical antidepressant or as an agent of healing similar to traditional psychedelics.

Risks of Ketamine

But ketamine is not safe for everyone. Although, for most patients, ketamine is not highly addictive, it still does have addictive properties. China had a huge ketamine addiction problem, partly due to a large supply of cheap ketamine. Interestingly, there is some solid research supporting how ketamine can be helpful for overcoming addictions and decreasing cravings in motivated patients, further complicating ketamine’s profile.

In contrast to generic ketamine, Spravato, an intranasal version of ketamine (esketamine), is FDA-approved and therefore is highly regulated. I’m amazed at the differences between the rollout of Spravato vs. generic ketamine. Firstly, a patient is required to have treatment-resistant depression and have failed multiple antidepressants to get approval for Spravato. Secondly, there are only two doses of Spravato, and treatments are delivered at standardized frequencies. Lastly, every Spravato session is required to be monitored in a clinic setting, and data are collected.

Making Ketamine Treatment Safer

What can we do as clinicians and concerned citizens to make this Wild West safer? I believe there needs to be more regulatory oversight to advise on ethical practices of off-label ketamine. I applaud ASKP3 (American Society of Ketamine Physicians, Psychotherapists, and Practitioners) for issuing ethical standards on their website. Companies must put medical and safety standards above corporate business interests. We do not want to create another opioid epidemic. I applaud certain CEOs, like Juan Cappello, for taking an ethical stance and bringing attention to this problem.

We need more concerned voices to raise awareness and reign in the unruly West, so that patients who truly benefit from ketamine may continue to seek its life-changing therapeutic effects. Furthermore, to understand optimal procedures for ketamine treatment protocols, we need ongoing research. Studies should continue to include comparing dosing protocols, frequency of treatments, routes of administration, and various psychotherapy combinations with ketamine.

I believe that psychedelic medicines, like psilocybin, MDMA, and DMT, herald a new age of healing in the modern era for those suffering from depression, PTSD, and other ailments. These medicines may also open up a spiritual dimension to our Western materialistic culture, and help people find fulfillment and meaning. Ketamine may be an important lesson about what can go wrong when commercialization forces are prioritized over patient safety. Looking ahead, I'm hoping that the eventual rollout of psychedelic medicine in our Western capitalist culture will proceed carefully, with patient safety taking priority over business interests.