Josh Short MD
First, do no harm.
Why don’t we prescribe Ketamine for home use? After all, it's safe, effective, and cheap, right?
Some quick background is warranted, in case you’ve arrived at this post without any information about Asheville Integrative Psychiatry, who we are, and why we exist. I am an emergency room doctor and integrative medicine physician. I have been using Ketamine in the emergency room setting for 20 years and was trained in its use by some very skilled mentors who embodied the healing mantra of “first, do no harm.” I have a great deal of comfort with the use of Ketamine but I have also seen its potential dangers.
Acknowledging the biases that come from being trained in western medicine, we founded Asheville Integrative Psychiatry with a goal of being able to offer Integrative Psychiatry and Ketamine therapies in the safest, most patient-focused fashion in a natural setting.
My wife, Dr Tiffany Sauls, is the founder, spiritual heart, and owner of Asheville Integrative Psychiatry. She is an adult and child psychiatrist with 2 decades of experience using nature as a healing modality and using non-pharmacological approaches to mental health treatment. She is a principal investigator and site physician for the expanded access use of MDMA for PTSD and is a pioneer in using psychedelic assisted nature-connection therapies for mental health.
Acknowledging the biases that come from being trained in western medicine, we founded Asheville Integrative Psychiatry with a goal of being able to offer Integrative Psychiatry and Ketamine therapies in the safest, most patient-focused fashion in a natural setting. We work hard to create a space that is nourishing to our patients and providers both. We collaborate with other providers in the community with a goal of establishing the highest possible standards of care for this evolving practice of psychedelic medicine.
It may be helpful to clarify a few things about the current state of Ketamine in mental health. Ketamine is broadly used in two very different ways; as a psychedelic, and as pharmaceutical. Ketamine, at very specific doses, is an evolving treatment for a variety of conditions. It has the most research for treatment-resistant depression and the evidence is good that it may be a viable alternative to typical antidepressants. Many Ketamine clinics offer ketamine infusions and nasal sprays (usually without associated talk therapy) for this purpose. Insurance can often cover this strictly pharmaceutical approach which makes these types of ketamine therapies more accessible.
However, there is a great deal of evidence that the psychedelic use of ketamine works best when paired with therapy by therapists specifically trained in psychedelic modalities. There is also increasing evidence that psychedelic therapies are more effective in natural settings. (Gandy, 2020). This approach of using patient specific doses of Ketamine in conjunction with preparatory and integrative therapy in carefully considered settings is known as Ketamine Assisted Psychotherapy or KAP. The ultimate goal of KAP (and other psychedelic assisted therapies) is resolving the symptoms of illness rather than managing symptoms indefinitely. Insurance does not completely cover this approach which limits its accessibility despite its known effectiveness.
While almost all of the data regarding ketamine’s effectiveness has come from studies performed in offices with medical providers or trained therapists, it has become an increasingly common assumption that ketamine is equally safe and effective when used at home and in the absence of a trained therapist or medical provider. There is very little data to support this practice and the unfortunate history of western medicine is that well-intended assumptions often lead to great harms.
Based on current evidence, the findings in our research, and the experiences of our patients and providers alike, we have chosen to use Ketamine only at our treatment center, only with a therapist specifically trained in psychedelics, and only with medical monitoring by a physician or nurse practitioner.
There is also increasing evidence that psychedelic therapies are more effective in natural settings. (Gandy, 2020).
Safety is an easy place to start a discussion about home ketamine use. Ketamine is an extraordinarily safe medicine. While training in emergency medicine, I was present when an intern mistakenly used ketamine instead of lidocaine to numb someone's finger before repairing a laceration. This resulted in the patient getting a dose of ketamine far greater than would ever be used for any reason other than general anesthesia. The patient was comfortably unconscious for 30 minutes and awoke cheerful and happy that their finger had been repaired so painlessly. In the 20 years since, I have used Ketamine in the emergency room for hundreds of procedures. It is my favorite agent for use in children due to its safety profile. It does not interfere with breathing and causes relatively small increases in blood pressure and heart rate. That being said, every single time we use Ketamine, we do so with a physician, a nurse and a respiratory therapist in the room and the patient is continuously monitored. Also, before every ketamine use, we consult a multi-page screening checklist to prevent accidents or side effects.
So when I think of Ketamine as “safe,” I am thinking of it in the context of being used by trained providers who know how to manage any likely complications. As an example, I have seen the rare side effect of ketamine induced laryngospasm which interfered with a child’s breathing and required immediate intervention. The thought of encountering this in a living room or on a zoom session is frankly terrifying. Ketamine’s side effects are vanishingly rare but, if we drastically increase the number of people using Ketamine, then they will become increasingly common.
Another aspect of safety needs to be considered as well. Ketamine, when used orally or nasally, has widely varying bioavailability depending on a person’s individual metabolism. This means that the effects of ketamine, when given nasally or orally, cannot be predicted with great certainty. Given that ketamine has very different effects with small changes in dose, this can lead to very unexpected outcomes which is not ideal when dealing with mental health conditions in settings without a medical monitor physically present.
There are also safety considerations that come into play in the home environment. When a client has the opportunity to use ketamine by themself or with only a telemedicine monitor, the opportunity exists for the client to make dangerous decisions while in a non-ordinary state of consciousness. It is easy to imagine a home ketamine session interrupted by an unexpected minor daily emergency which required the client’s full faculties to manage. The degree of perceptual distortion created by a psychedelic experience can also create imagined emergencies that could lead to dangerous situations in the absence of a physically present provider and monitor.
From the standpoint of effective therapy, there is strong evidence that the setting for a psychedelic experience is very important. Regardless of what the home environment looks like, it is still the home environment and carries with it the habits and mindset of day to day life. This is why we go away on vacations even if we like our house. The utility of a psychedelic experience, in part, depends on being able to distance oneself from the ordinary state of affairs. For our practice, this means spaces immersed in nature, but at a minimum, a client should ideally be in a setting where they are removed from all the distractions and reminders of daily life.
From the standpoint of effective therapy, there is strong evidence that the setting for a psychedelic experience is very important. Regardless of what the home environment looks like, it is still the home environment and carries with it the habits and mindset of day to day life.
Lastly, it is important to recognize that Ketamine has the potential for abuse. It is one of the few psychedelic compounds that can lead to dependence. And while dependence is essentially nonexistent when Ketamine is used in clinical settings, having access to it in large quantities at home makes the likelihood of abuse or misuse much higher. We have seen this in the community and there are prescribers who unflinchingly prescribe inappropriately large quantities to patients with very little screening or oversight. This type of prescribing is unethical and dangerous to the safe progress of psychedelic medicine. There is evidence that ketamine overdoses are increasingly common as prescribing laws were loosened over the last few years due to COVID telehealth regulations.
At-home ketamine use is more affordable and accessible and those are benefits that cannot be overlooked. It is also very profitable and poorly regulated which creates an environment that can be predatory and dangerous for patients. The solution to accessibility and affordability should be solved by requiring insurers to pay for Ketamine Assisted Psychotherapy, not by making Ketamine widely available in unmonitored settings. The psychedelic revolution of the late 60s failed because enthusiasm outpaced caution and forced the government to respond with poorly crafted legislation around the use of psychedelics. It is certainly not proven that making our broken model of healthcare the single pathway to the safe use of psychedelics is the best idea. But as long as medical providers and therapists are charged with being the gatekeepers of these new therapies, we must ask ourselves difficult questions about how we profit from them and what is truly in the best interest of those we take care of.
The solution to accessibility and affordability should be solved by requiring insurers to pay for Ketamine Assisted Psychotherapy, not by making Ketamine widely available in unmonitored settings.
In summary, with psychedelic therapies, the context and setting of their use is related to both their safety and effectiveness. To me, and our staff at Asheville Integrative Psychiatry, this argues against the home use of Ketamine for the treatment of mental health issues. Accessibility remains a challenge, but is one that is best approached by improving insurance coverage, not by lessening standards of care or tolerating unnecessary risks. If you are interested in learning more about ketamine services at AIP, please reach out. We would be happy to discuss what options would best be suited to your needs.