COMMENTARY

My 'Ketamine Karma'

Drew Ramsey, MD

Disclosures

June 10, 2019

This transcript has been edited for clarity.

Hi. I'm Dr Drew Ramsey at Columbia Psychiatry, reporting for Medscape. I want to tell you about what I'm calling my "ketamine karma."

When esketamine became FDA approved, I was invited on the Today show to talk about it and I called it a breakthrough. Certainly, ketamine is a breakthrough. From a mechanistic standpoint, we just don't have anything like it that can quickly induce synaptogenesis and quickly resolve symptoms like suicidality.

However, after the show, I started receiving messages from folks saying things like, "Well, I'm going to try this with my grandmother," or "I have a family member with really resistant depression; should they try this?"

Certainly, although it is an FDA-approved approach, there's an underbelly to ketamine that I think we're all anxious about, so I would like to discuss it. My ketamine karma really came home to roost, so to speak, about a week after the segment on Today, when a patient came to see me. He was a very nice young man who was professional, successful, and he was snorting about 3 g of ketamine every day.

I'm a general psychiatrist, so I'm not focused on addiction; but still, I felt quite compelled to get involved. As I assessed this individual, he had a long history of substance abuse and a long history of untreated depression. In fact, I was the first mental health professional that this person had ever seen.

It reminded me of the underbelly of ketamine in that as we want to explain to the public the excitement about a new treatment, I also wonder what we are doing to avoid the next opioid crisis. Currently, ketamine is quite controlled and you can only receive it from a physician.

I was unaware of the extent of the underground ketamine market that exists. My patient told me about the very easily obtainable ketamine in London and in New York, and the growing scene of ketamine being used in clubs in America and around the world. He described the high, and I realized while I was sitting with him that he'd been using ketamine all day long, and it really struck me that I couldn't tell. His mental status exam was completely normal.

I also learned some of the effects of chronic, high-dose ketamine use from my colleagues. This individual leaks urine. He knows several people who have had chronic ketamine abuse issues and now have ostomy bags. It really struck me—how do we balance this, both bringing a new drug to market that has incredible potential for abuse and also protecting patients from that potential for addiction? I don't know that I have the answers.

I also wonder if it is a harm-reduction move for an individual like this who is snorting illicit ketamine to get involved in the ketamine protocol. Is there a role for esketamine? We can all agree that it would be much safer for this individual, under my supervision, to receive esketamine once a week. Those are the answers I don't think we have yet. I think we're on the frontier of trying to understand how medicines like this can be helpful to patients and what the dangers are.

It certainly has caused me to take a step back and think. I do believe that ketamine can be a breakthrough for patients, just like good mental health treatment can be a breakthrough, but there's also an underbelly to this medication and there is our tenuous reputation in the public that we really must protect.

Certainly, this is a treatment that is going to evolve. As we treat more people with ketamine, an unfortunate side effect of that is more exposure, which means that we're going to create more ketamine addicts. As we do that, let's make sure to pay very close attention to what's happening.

Let's make sure that we don't create another opioid crisis, where we're sharing with the public a breakthrough of science and a very powerful medication that also has significant potential for abuse. And as I learned from my patient, this medication is actively abused in a very dangerous way by many people who haven't received any treatment at all.

I'm Dr Drew Ramsey. I'm really curious to hear in the comments below what you're seeing in your practice, what you think about ketamine, and how you think I handled the situation.

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