Ketamine for health conditions such as chronic pain syndromes, treatment resistant depression, and post-traumatic stress disorder (PTSD)
Ever since Ketamine therapy was granted breakthrough therapy designation by the FDA in 2019, there has been a flood of media coverage on the benefits of Ketamine for health conditions such as chronic pain syndromes, treatment resistant depression, and post-traumatic stress disorder (PTSD).
A 2016 meta-analysis of 9 clinical trials of patients with major depression or bipolar disorder revealed that following a single infusion of Ketamine, patients experienced relief from symptoms (as severe as suicidal thoughts) for up to 10 days.
Compared to current available treatment options, these results are outstanding, and offer a glimmer of hope to the millions of people suffering worldwide…
What there hasn’t been as much coverage on is what happens after those 10 days… I hope to shed some light on the history of Ketamine and why now is a pivotal moment for this medicine. Can we help Ketamine be integrated into clinical practice in a safe and responsible way or will we some day see the emergence of a Ketamine epidemic?
History of Ketamine: The Good, The Bad, and the Ugly
First synthesized in 1962, Ketamine was initially studied as a dissociative anesthetic. Following successful human trials in the mid 1960’s, the FDA approved Ketamine for anesthesia in 1970 and began using it on Vietnam veterans for acute pain…
Late 1970s U.S. reports indicated the emergence of Ketamine snorting among recreational users
In the 1990’s intravenous Ketamine was introduced as a treatment option for chronic pain.
2003 – World Health Organization recommends critical review of Ketamine as abuse is reported from a number of countries in Asia, Europe and North America
2019 – FDA grants Ketamine “breakthrough therapy designation” for treatment resistant depression, or put in other words, for emotional pain. Since then, Ketamine clinics have popped up throughout the country, and a variety of options suddenly became available for patients with chronic mental health conditions.
Given the aforementioned historical trends with Ketamine, where following the discovery of a new indication for its use it becomes misused, is it possible that over the next 10 years we risk seeing another trend of abuse and misuse?
All evidence points to inevitability unless we use this time as an opportunity to learn from the past and cultivate a more promising future through education and normalizing discussions about the topic of addiction.
Opioid Epidemic and Ketamine Parallels
Consider the current opioid epidemic. I personally do not believe that doctors set out to cause harm, however, a lack of understanding of the long-term side effects coupled with a failure to inform patients adequately left many patients vulnerable.
Currently, Ketamine is advertised as being able to treat the symptoms of depression and PTSD. This promise for healing is appealing not only to people who suffer from these conditions, but also to the doctors and therapists who spend their careers watching their patients suffer. It is not surprising that the popularity of off-label Ketamine use is rising.
Unfortunately, since there are no regulations yet for this off-label use, the therapy component is not yet mandatory with treatment, and this is where patients may once again find themselves as vulnerable as the opioid naïve patients of the 90s. Education changes that.
“The medicine is as important as the therapy.” – Veronika Gold, Co-founder Polaris Insight Center
Ketamine is currently the only legal psychedelic for psychedelic assisted therapy, and although it is not a “classic psychedelic” (see last month’s issue: Psilocybin 101) it does induce an altered, dissociated state. Similar to classic psychedelics, a dose of Ketamine can act as a catalyst for change when used in the right set and setting, with proper preparation before, and integration after. Unlike classic psychedelics however, Ketamine acts on the dopamine and opioid receptors, both of which are known to play a role in addiction.
The Difference Knowledge Makes:
The informed patient: knows that the Ketamine will temporarily alleviate depressive symptoms, which will allow the patient to learn new coping skills and lifestyle changes without the burden of extreme fatigue and hopelessness.
Those with chronic mental health conditions who may have given up on therapy are encouraged to use this 10-day window of opportunity to revisit therapy or remember coping skills that they now are better able to implement successfully.
They also know that although the symptoms will likely return and they may need another dose, the goal of the treatment is to maximize the time between doses. As with everything, practice makes perfect, and by integrating their new skills on a regular basis, they eventually may only need Ketamine every 6 months.
The uninformed patient: come expecting to alleviate their symptoms but are not aware of how intense the dissociative experience may be. They experience “ego death” which can be very uncomfortable and scary, but after the medicine wears off they feel “fine”. In fact, their mood is elevated and they finally have hope again.
Unfortunately, 10 days later the effects wear off and they find themselves with suicidal thoughts again, except this time it’s worse, because they thought they were “better” and now are left even more hopeless.
What do they have left to do? Ketamine treatments are expensive and require a physician visit. Once the patient is comfortable with using ketamine, they may be more likely to buy it in the streets – not dissimilar to what happens with opioid users buying black market narcotics. Another concern is that the dissociative experience may make a patient less afraid of death, therefore more likely to commit suicide during rebound depression.
There has been a tremendous rise in mental health conditions since the start of the pandemic, which means the number of people who may be helped (or harmed) by Ketamine is on the rise as well. It is our duty to recognize patterns and help eliminate any harm we can.
What I hope to avoid is a wave of uninformed patients by normalizing discussions about Ketamine’s downside, and collectively educating our patients and ourselves on best practices through collaboration and mainstream information sharing.