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Respecting the Medicine: Ketamine and Safety

The recent tragedy of Matthew Perry’s death has made many people aware of the dangers of ketamine, and rightly so.  As a psychiatric practice that focuses on psychedelic therapies, including the use of ketamine, we would like to offer a perspective on how this tragedy could have been prevented and what can be learned from it.  

Before offering an opinion on the risks and benefits of using ketamine to support therapy, I want to briefly describe our background with ketamine and how this informs our approach to its use. Our practice is owned by two physicians, both 20 years into their careers: an integrative psychiatrist, Tiffany Sauls MD, and an emergency room physician (myself-Josh Short, MD).  Dr Sauls has a career-long interest in decreasing pharmaceutical dependence, increasing nature connection, nourishing our inner capacity for healing, and she is a researcher in MDMA-assisted therapy through MAPS’ expanded access program.  I have been using high dissociative anesthetic doses of ketamine in the ER for short painful procedures for the entirety of my practice; these doses are much higher than what should be used in psychiatric practice. Dr Sauls and myself are very familiar with the research on ketamine’s uses and have years of experience with the medicine both in the hospital setting and in outpatient practice. 

We are also familiar with the recreational use of ketamine and other psychedelics and have spent a great deal of time at festivals and transformational gatherings where all manner of substances are used and occasionally abused.  I have just happened to be around twice when someone accidentally overdosed on ketamine. In both situations, the person needed medical attention to keep from hurting themselves because they were briefly unable to maintain their physical safety in a chaotic environment.  Ketamine divorces bodily sensation from the experience of being, which can be part of a profoundly transformative experience, or explicitly dangerous, depending on the context and location.  

Our motivation for discussing ketamine and its risks and benefits is that, when used correctly, with appropriate medical screening and monitoring by trained medical professionals, it is a powerful tool to alleviate suffering.  We have seen so many clients who have “tried everything” but continue to suffer from depression, anxiety, PTSD or other conditions that prevent them from experiencing the joy of life.  When using ketamine in conjunction with nature connection and therapists trained in psychedelic therapies, we see people find lasting relief instead of settling for lifelong symptom management with daily medications.  

Because ketamine is generally safe, it takes a long time and a lot of clients for a doctor or therapist to have direct experience with its potential risks. Most therapists and physicians interested in ketamine make it through their first hundred or so clients without side effects or problems and overestimate the medicine’s safety based on their limited experience.  The more our society embraces ketamine and the more clients are treated with it, the more we will see its dangers.  In our practice, we have seen laryngospasm that would have kept a client from breathing without appropriate intervention. We have seen severe allergies to the medicine and the preservatives it is manufactured with. We have seen ketamine unmask undiagnosed neurologic disorders that lead to central apnea, or a loss of instinctual breathing.  We have seen profound vomiting which can be dangerous when in an altered state of consciousness.  With appropriate medical screening prior to ketamine use and when ketamine is used in an environment with medical monitoring and trained health care providers, the risks are vanishingly rare and manageable for the prepared clinician.  

The experience of using ketamine long enough and frequently enough to see its rare dangers has made us relatively conservative in the emerging field of psychedelic medicine.  Our medicalized perspective is not popular with some who disagree with the level of medical oversight we require for our clients.  It has also put us at odds with mail-order online ketamine companies who offer telehealth monitoring only.   We continue to recommend strongly against prescribing ketamine for home use without medical personnel or appropriate monitoring.  We lost a close friend due, in part, to the unscrupulous prescribing practices of a physician who failed to recognize the dangers of home ketamine use in patients with addictive tendencies, unresolved trauma and history of mood disorder.  We do not want to see this tragedy repeated.

This is an appropriate segue to discussing the unfortunate and unnecessary death of Mr. Perry.  One of the more distressing aspects of the press surrounding his death was the excerpt from the medical examiner that stated that ketamine directly contributed to his death.  This quote often does not include the context that Mr Perry was in a hot tub.  While it is possible for ketamine to briefly interfere with breathing at high intravenous doses, the reason we prefer to use it in the ER is precisely because people keep breathing very well while under its influence.  Ketamine does not generally interfere with breathing at all.  That said, ketamine should never be used while alone and in the absence of a trained monitor with experience in addressing airway issues. However, ketamine does reliably prevent you from responding to your environment.  No one should ever swim under the influence of ketamine.  We do not even allow our clients to drive within 12 hours of receiving ketamine.  Part of ketamine's value as a psychotherapeutic medicine is its ability to temporarily allow you to exist dissociated from bodily sensations, which means that its use requires meticulous attention to the setting in which it is used.    

Psychedelic medicine is moving too fast.  If we do not slow the pace and move with more caution we will see more instances of harm and death.  If we do not learn to temper our enthusiasm for these promising new therapies with rigid attention to caution, we will once again face the restrictions against their use that have hampered research and treatment since the early seventies.  

Unnecessary suffering is the root of tragedy.  Mr. Perry was likely using ketamine at home because it had worked well for him in the clinical setting and is generally safe.  Ketamine should not have been available for home use in an unmonitored setting.  We must do a better job of teaching how to use these medicines safely so that we can access their benefits while avoiding their risks.  Please reach out if you would like to learn more about our practice and how we address safety in our approach to ketamine assisted therapy.

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