Psychedelic-assisted therapy is booming and as a result ketamine clinics are popping up all over Utah. What is ketamine and how do ketamine treatments feel? Ketamine is a schedule 3 controlled substance classified as a dissociative anesthetic (producing feelings of detachment from your environment and/or self). A side effect is that it can produce a psychedelic state under certain conditions (producing a mystical experience and expansion of consciousness).
Ketamine was first synthesized in the 1960s and is FDA approved for general anesthesia. It is listed on the World Health Organization’s list of essential medicines and has been commonly used in healthcare since 1970. Twenty years ago, it was discovered that ketamine (under the proper conditions) can relieve symptoms of depression. Many of the reasons we use ketamine today are considered off-label uses and not officially approved by the FDA. Ketamine is considered a controlled substance and must be prescribed to be used legally. It also found a street name of “K” or “Special K” when used illegally in the party/rave culture.
Ketamine is used for anesthesia, acute and chronic pain, treatment-resistant depression, and can relieve suicidal ideation. It is also being used for anxiety, addiction, PTSD, OCD, migraines, and eating disorders. Because all psychedelics (and ketamine specifically) act as a catalyst in the mind, they should be partnered with psychotherapy when used for mental health disorders. A trained psychedelic therapist or integration coach can harness the power of psychedelics to effectively reduce rumination (repetitive thoughts) and increase learning. This allows a patient to replace old dysfunctional patterns of thought and behaviors, with new and healthy ones.
Ketamine has many possible mechanisms of action and we likely don’t entirely understand them all. We know it is a NMDA receptor blocker that increases glutamate production. The increase in glutamate affects many complex pathways. It allows regrowth of brain connections and formation of new neural connections. This neuroplasticity has exciting potential for all psychedelic medications.
Ketamine also seems to increase something called Brain-Derived Neurotrophic Factor (BDNF). They are proteins important for neurons in our brain and research has discovered that lower BDNF levels are associated with depression.
Ketamine, like other psychedelics, decreases activity in our default mode network (DMN). Researchers are finding higher activity in our default mode network associated with depression and anxiety. The DMN is a group of brain structures where we process internal thought (or ruminate). It is engaged when our mind wanders and as activity increases in this network, we may be more self-critical, have rigid thought patterns and loop negative thoughts and feelings. Turning down activity in this area of our brain allows better access to new areas of the brain which allows us to boost creativity and problem solving. This is the mechanism for healing depression and learning new ways of thinking. Some people refer to the DMN as the ego and this “ego death” can be therapeutic. I like to compare this ego death to standing back and being able to take in a bigger picture. Ketamine may allow our brains to create new pathways and develop more positive thoughts and behaviors.
Ketamine is also a partial agonist at opioid mu-receptors which is how it helps treat pain.
All ketamine clinics have different protocols and treatment plans will be tailored to the individual patient but there are some common best practices.
You will first meet with a potential provider for an assessment. Your provider will help you decide if ketamine will be prescribed and they will evaluate you for any physical or psychological risks and help you prepare for your treatment and additional therapy. A treatment plan will be created that will likely include 3-6 prescribed ketamine treatments over the course of 3-6 weeks. Clinics will differ in the dosage forms they offer (IV, IM or nasal), how many sessions they recommend and how often. Your provider will determine doses based on age, weight and desired effect. It may take a couple sessions to find the correct dose.
During a session you will likely sit in a comfy reclining chair at the provider’s office while you’re hooked up to an ICU machine that will monitor your blood pressure and oxygen. You’ll be listening to a playlist of calming music and the lights will be dimmed. Some patients prefer to wear an eye mask or close their eyes. You may be given additional medications for nausea and anxiety along with ketamine. Treatments last between 2 and 4 hours.
A Ketamine treatment is basically “tripping” in a provider’s office in a safe controlled environment. Providers will monitor you throughout your treatment and chat with you after to help you process your experience. For certain conditions the ketamine provider should be providing therapy, or referring you to a trained psychedelic therapist. You should have someone to drive you home after a ketamine treatment and be monitored by another adult for up to 24 hours. The experience can feel exhausting and make you feel extra tired for a day or two.
IV/IM
Administering ketamine IV is the most common and studied route of administration because ketamine has historically been used during surgery and in hospitals. When administering ketamine IV or IM, a patient will feel effects almost immediately. Ketamine for injection is quite inexpensive but the office monitoring can be costly. Multiple IV or IM injections are often used at different doses and can be adjusted by your provider based on how you are responding. Some clinics will even provide IM injections for home use for experienced patients who don’t require as much monitoring or are taking smaller doses.
Nasal
Ketamine is a mixture of two mirror chemical compounds (R and S enantiomers). Nasal ketamine is not commercially made anymore and difficult to source unless you have it made at a compounding pharmacy. The FDA recently approved the S enantiomer (Esketamine available as the brand name Spravato). It is approved for in office administration for treatment resistant depression as long as the patient is on another oral antidepressant. Spravato is ridiculously expensive (over $700 for 2 sprays) compared to compounded nasal ketamine yet because of the FDA approval it may be more likely to be covered by insurance. A Spravato treatment is 1 spray in each nostril twice a week for one month then once a week for one month then as needed. When using Spravato you will be required to be monitored in the office for 2 hours after each administration.
Oral
Ketamine is compounded by certain pharmacies to be given orally as a lozenge or troche. Providers may give oral ketamine to patients to use at home in between office administration. Oral Ketamine is much less bioavailable (25-50%) compared to IV or IM administration (97%) and as a result you experience a less intense psychedelic experience at similar doses. Oral administration of ketamine much like cannabis can be variable in effects.
Integration/Therapy
For psychedelic experiences to be long lasting and most effective especially when treating mental health conditions, it is important to integrate the experiences you have during your treatment into your daily life. For this you often need a health care provider or therapist to guide you both before and after your treatment. According to Dr Parth Gandhi of Summit Ketamine Therapy many ketamine clinics in Utah are neglecting the crucial integration and therapy that should be used with ketamine.
Side Effects/Risks
Side effects include nausea/vomiting, dizziness, drowsiness, confusion, psychosis, and respiratory/cardiac complications. Too much and you can enter what is known as a K-Hole. A K-Hole is an extreme dissociative out of body state where you are unable to move yet experience vivid and sometimes scary hallucinations. There is a risk you can experience this K-Hole at high doses but it is usually avoided when you are under supervision in a provider’s office. Ketamine is not advised for anyone where increased blood pressure would cause complications and extra caution is recommended if you have underlying complicated neurobehavioral disorders such as Schizophrenia. As with all psychedelic experiences, risk vs benefit should be carefully considered and discussed with your provider. I often relate psychedelic therapy to a serious medical intervention such as surgery where the benefits may be tremendous but there are risks and these risks may be more psychological than physical.
