Quite disappointed with Esketamine

[Marasmus1]

I have been referring many of my patients to esketamine (Spravato) center which opened up in my area a year ago. So far, I am quite disappointed with the results. I would say in the first four weeks or so ,many patients improve significantly (I guess a good news?). However, after the initial induction phase is over and once patients start once a week or once every two weeks administration, almost all if not all my patients relapse. What makes me worried is that some of them experience dsyphoria at this point even more than baseline. So I am wondering if these folks are actually withdrawing from ketamine ( not sure if that concept exists). I also had some patients who had significant suicidal ideations after induction phase with intent to kill themselves. With all this hype in the scientific community about ketamine being a miracle drug, I am quite disappointed. I am ending up sending most of these patients back to trial of TMS or ECT.

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[Sushirolls]

IV ketamine >>> Nasal Esketamine

 

[comp1]

I think we're going to see a lot more of this as the pharmaceutical industry cycles through the hallucinogens and various other party drugs...

 

[TexasPhysician]

Esketamine was a good try in theory, but it is much inferior to IV/IM ketamine. They aren’t withdrawing

 

[Marasmus1]

I think we're going to see a lot more of this as the pharmaceutical industry cycles through the hallucinogens and various other party drugs...

It is interesting you said that. Some of my patients told me that their depression is not better but they would like to continue if possible two times a week because they like the euphoria in the beginning of the adminstration. Is this any different than usage of drugs in controlled setting which already exists in Europe for years?

 

[mistafab]

One fundamental issue is that all the data saying that ketamine works in depression was used to approve a nasal route. But fundamentally, this is not the same treatment at all.

 

[wolfvgang22]

IV ketamine >>> Nasal Esketamine

Thing is, I've seen the exact same thing with IV Ketamine. Patients say they feel better for a few weeks, then once they are no longer getting IV ketamine it's right back to depression city.

They report once the novelty of the euphoria wears off, not much has changed. In this case should they be on IV ketamine treatment indefinitely?

Obviously, ketamine doesn't help problems like being poor, having relationship troubles, lacking support, or having chronic medical issues much. My patients with refractory depression have those problems, too.

 

[dl2dp2]

I have been referring many of my patients to esketamine (Spravato) center which opened up in my area a year ago. So far, I am quite disappointed with the results. I would say in the first four weeks or so ,many patients improve significantly (I guess a good news?). However, after the initial induction phase is over and once patients start once a week or once every two weeks administration, almost all if not all my patients relapse. What makes me worried is that some of them experience dsyphoria at this point even more than baseline. So I am wondering if these folks are actually withdrawing from ketamine ( not sure if that concept exists). I also had some patients who had significant suicidal ideations after induction phase with intent to kill themselves. With all this hype in the scientific community about ketamine being a miracle drug, I am quite disappointed. I am ending up sending most of these patients back to trial of TMS or ECT.

I have similar findings in my practice. In the end people with TRD are people with chronic personality disorders. It's be a miracle if "depression" alone is the problem.

Esketamine was a good try in theory, but it is much inferior to IV/IM ketamine. They aren’t withdrawing

I have patients who were on IV, and excepting a somewhat longer duration of response, the relapse phenomenon is consistent.

Thing is, I've seen the exact same thing with IV Ketamine. Patients say they feel better for a few weeks, then once they are no longer getting IV ketamine it's right back to depression city.

They report once the novelty of the euphoria wears off, not much has changed. In this case should they be on IV ketamine treatment indefinitely?

Obviously, ketamine doesn't help problems like being poor, having relationship troubles, lacking support, or having chronic medical issues much. My patients with refractory depression have those problems, too.

In theory these issues are practical (i.e. SDOH). In my practice (and I think in many others), a lot of patients (even patients who were born into bad situations) don't have these issues as their origins of pathology. Instead, they have personality disorders related to existential dread (some of which might lead to bad SDOH factors, i.e. they think jobs are meaningless, and therefore they quit their job), which is poorly treated by ketamine.

 

[Sushirolls]

Thing is, I've seen the exact same thing with IV Ketamine. Patients say they feel better for a few weeks, then once they are no longer getting IV ketamine it's right back to depression city.

They report once the novelty of the euphoria wears off, not much has changed. In this case should they be on IV ketamine treatment indefinitely?

Obviously, ketamine doesn't help problems like being poor, having relationship troubles, lacking support, or having chronic medical issues much. My patients with refractory depression have those problems, too.

I pre-counsel about the plop off of IV ketamine.
Some patients its 1-2 weeks - no logisticially worth it.
Others is 6-8 weeks, they stick with it, due to quality of life differences.
I've had so few since I had the training in residency that I've not bothered to offer it myself.

 

[Merovinge]

Best usage seems to be combining with RTC/PHP/IOP treatment to kickstart a strong treatment response and then maintain it through changes made during higher level of care treatment. I worry about it just being something to add onto outpatient care as though it's simply another antidepressant trial.

 

[whopper]

There's several problems with Eskatmine or Ketamine. Of course it might not work. It also might only work for a few days up to a few weeks. Insurance usually won't pay for Eskatmine for a long-term duration and these very same patients it won't pay for are usually treatment resistant so they'll likely need long-term treatment cause then they wouldn't have been referred in the first place.

A bright side, I've seen, however, and this hasn't been shown in studies (yet) is I've seen a type of patient benefit from Ketamine and over several months need less treatment before their depression returns. E.g. a patient needing weekly, then eventually monthly, then eventually every few month's treatment. If and when the Esketamine is no longer covered and they need IV Ketamine they need to pay for out of their own pocket an IV ketamine that's only 2-3x a year is within their price range.

 

[wellbutrin.girlfriend]

One fundamental issue is that all the data saying that ketamine works in depression was used to approve a nasal route. But fundamentally, this is not the same treatment at all.

Could you explain how they are fundamentally not the same treatment? (Sorry if obvious--I'm a med student)

 

[Ludwig2000]

Could you explain how they are fundamentally not the same treatment? (Sorry if obvious--I'm a med student)

The data on ketamine working for depression all came from studies using IV ketamine. That data was used to approve intranasal esketamine which is fundamentally different at least pharmacokinetically. Different routes of administration will not reliably lead to the same result

 

[SmallBird]

The data on ketamine working for depression all came from studies using IV ketamine. That data was used to approve intranasal esketamine which is fundamentally different at least pharmacokinetically. Different routes of administration will not reliably lead to the same result

That's just not true. There are esketamine trials and they were reviewed by the FDA when it was approved. They are available on Google scholar.

 

[PikminOC]

The data on ketamine working for depression all came from studies using IV ketamine. That data was used to approve intranasal esketamine which is fundamentally different at least pharmacokinetically. Different routes of administration will not reliably lead to the same result

I've just seen people get very poor with iv ketamine. $$$

 

[randomdoc1]

I think ketamine sucks.

At least when it comes to the role people were hoping it would serve. And I'm not surprised.

 

[Ludwig2000]

That's just not true. There are esketamine trials and they were reviewed by the FDA when it was approved. They are available on Google scholar.

Yeah you’re right! I was trying to expound/clarify the prior post but I hadn’t looked up whether it was actually true. Seemed true because the only studies I personally remembered were from the period of initial excitement around IV ketamine. But there were 4 randomized clinical trials (3 short term and one longer term) of the intranasal that the FDA reviewed. Rather embarrassing- my bad 🙏

 

[Marasmus1]

Yeah you’re right! I was trying to expound/clarify the prior post but I hadn’t looked up whether it was actually true. Seemed true because the only studies I personally remembered were from the period of initial excitement around IV ketamine. But there were 4 randomized clinical trials (3 short term and one longer term) of the intranasal that the FDA reviewed. Rather embarrassing- my bad 🙏

Yes but i have to state that only one out of phase three trials showed statistically significant difference with esketamine compared to placebo. Not to mention, effect size was mild (0.3). Recent meta analysis concluded that esketamine is no more effective than placebo in the treatment of TRD. So despite of the FDA approval, evidence at least for clinically meaningful evidence is not strong.

 

[TexasPhysician]

I think ketamine sucks.

At least when it comes to the role people were hoping it would serve. And I'm not surprised.

I’ve now added ketamine due to the huge benefits I’m seeing. In my experience, it is up there with ECT as the best options we have. Maybe better than ECT.

 

[Marasmus1]

I have similar findings in my practice. In the end people with TRD are people with chronic personality disorders. It's be a miracle if "depression" alone is the problem.




I have patients who were on IV, and excepting a somewhat longer duration of response, the relapse phenomenon is consistent.



In theory these issues are practical (i.e. SDOH). In my practice (and I think in many others), a lot of patients (even patients who were born into bad situations) don't have these issues as their origins of pathology. Instead, they have personality disorders related to existential dread (some of which might lead to bad SDOH factors, i.e. they think jobs are meaningless, and therefore they quit their job), which is poorly treated by ketamine.

That`s something I have been arguing a lot with physicians in the academic community. I strongly believe that majority with TRD has underlying personality disorder. Obviosuly, I am a firm believer of the alternative dsm 5 model for personality disorders where the PD was described as disturbance in the experience of self (identity) and experience of others which lead to mal adaptive patterns of relatedness and behaviors. I also believe that in an alternative universe where for example BPD patient can magically set his/her own rules, they can be quite happy (An utopic world where they have A partner they can attach to and never leaves, freedom from all day to day responsibilities, somebody they can completely depend on, a figure who can be lifelong good enough mother etc.). The problem happens when they try to survive in the current society which obviously has certain rules and regulations.

Now I am wondering though whether one day we will be able to develop medicine that target the core symptoms of personality disorders which is identity disturbance. To me , everything is biology and what we call personality disorder is also the effect of psycho-social adversities on the biological disposition of humanbeing. Regardless, ketamine is not an answer for sure.

 

[the5thelement]

When i searched for iv ketamine + "city name" , this was the first hit. Mindbloom | Ketamine's Breakthrough Potential
They prescribe sublingual ketamine !

 

[splik]

When i searched for iv ketamine + "city name" , this was the first hit. Mindbloom | Ketamine's Breakthrough Potential
They prescribe sublingual ketamine !

they will send you ketamine to your home, to anyone, no questions asked (well you complete a PHQ-9)! It's ridiculous.

 

[dl2dp2]

That`s something I have been arguing a lot with physicians in the academic community. I strongly believe that majority with TRD has underlying personality disorder. Obviosuly, I am a firm believer of the alternative dsm 5 model for personality disorders where the PD was described as disturbance in the experience of self (identity) and experience of others which lead to mal adaptive patterns of relatedness and behaviors. I also believe that in an alternative universe where for example BPD patient can magically set his/her own rules, they can be quite happy (An utopic world where they have A partner they can attach to and never leaves, freedom from all day to day responsibilities, somebody they can completely depend on, a figure who can be lifelong good enough mother etc.). The problem happens when they try to survive in the current society which obviously has certain rules and regulations.

Now I am wondering though whether one day we will be able to develop medicine that target the core symptoms of personality disorders which is identity disturbance. To me , everything is biology and what we call personality disorder is also the effect of psycho-social adversities on the biological disposition of humanbeing. Regardless, ketamine is not an answer for sure.

I think a lot of people in academia KNOW TRD is mostly PD. It's just a biproduct that's not that interesting. First off, many studies of TRD exclude (severe) PD. I see bona fide TRD without PD, some responded to nortriptyline. Secondly I think that the effect of ketamine exists in TRD with or without PD. In fact, I suspect that the effect is stronger for people with PD.

The weird thing is that if you are on ketamine constantly, you sort of create this "utopia" world, as the salience of worldly disruptions becomes disassociated away from you. This is the narrative I get from some patients who use ketamine either recreationally or via medical treatment. The [subjective experience] of symptoms largely disappear. The functional recovery doesn't follow, but I'm not sure that matters.

I'm also REALLY not sure "everything is biology", or at least it doesn't mean the way that it's supposed to mean. Sometimes I stare at my own regimen and I just want to taper everything and start from scratch. OTOH, if you read something like "Listening to Prozac", certain patients do have a "change of personality" when they are put on various psychotropics. In practice, I find this to be a subtle, but DEFINITELY apparent effect. Classically, this is a patient who have chronic depression and ADHD who is put on Lexapro and Adderall. The result is the family says "he's a different person". This effect at times goes into identity formation.

 

[Merovinge]

they will send you ketamine to your home, to anyone, no questions asked (well you complete a PHQ-9)! It's ridiculous.

Funny, I knew a guy who had that same service 15 years ago and he only had to send a text message. He didn't have to fill out a PHQ-9 either!

 

[romanticscience]

I’ve now added ketamine due to the huge benefits I’m seeing. In my experience, it is up there with ECT as the best options we have. Maybe better than ECT.

I know in the past you've described some of the logistical constraints for a practice. Any tips on how you made it work for your PP?

 

[docksan]

Seems to paint a picture of dependence and not quite withdrawal. It might not be the depression getting better so much as the lack of euphoria making it worse.

 

[TexasPhysician]

Seems to paint a picture of dependence and not quite withdrawal. It might not be the depression getting better so much as the lack of euphoria making it worse.

Lack of euphoria? Never seen euphoria with it. In fact, dosing too high makes the experience absolutely miserable.

 

[TexasPhysician]

I know in the past you've described some of the logistical constraints for a practice. Any tips on how you made it work for your PP?

It’s a work in progress still. Esketamine is a hard pass. Racemic ketamine is possible and more effective.

 

[docksan]

Lack of euphoria? Never seen euphoria with it. In fact, dosing too high makes the experience absolutely miserable.

Lack of euphoria with not having it in your system.

You know, missing the high.

 

[mistafab]

That's just not true. There are esketamine trials and they were reviewed by the FDA when it was approved. They are available on Google scholar.

pretty damning for esketamine. Not the same drug.

Comparative efficacy of racemic ketamine and esketamine for depression: a systematic review and meta-analysis

Ketamine appears to have a therapeutic role in certain mental disorders, most notably depression. However, the comparative performance of different formulations of ketamine is less clear.This study aimed to assess the comparative efficacy and tolerability ...

www.ncbi.nlm.nih.gov

 

[claypigeon]

Do you know how the treatment center does their process? I ask as this can vary heavily center to center and screening for appropriate esketamine cases and setting realistic expectations is very important.

Full transparency and putting my biases on the table, but I run a hospital based esketamine program and was skeptical and reluctant at first. But have been pleasantly surprised by how well it's worked.

The vast majority of cases are internal referrals from our outpatient clinic (either I know them previously or can screen them very well). Of these our internal numbers show

~8% had full remission and were able to stop maintenance therapy (I follow them and can confirm the depression is in remission)

~1/3 fully remiited (PHQ9<5) but continue on maintenance therapy

~1/3 responded way more than the equivalent average 6-9 points improvement on MADRS seen in the studies with most of these down to a PHQ9 between 5-7 from a starting score in the 20s and

~1/4 had no response

Of those who didn't respond, ~50% are geriatric which goes along with the trials showing less effect in this population, ~25% have significant other comorbidities/SDOH issues/major personality components, and ~25% were complicated by a history of dual diagnosis and relapse.

The effects aren't immediate unless treating SI and even then, it's short lived for ~2-3 days until they've had a few weeks of it. I wish we could do thrice weekly dosing for the first week with MDSI.

I haven't seen much non-SI related antidepressant response until week 3 of treatment. I'm also pretty conservative with dosing and don't typically increase it to 84mg until week 4 after we've seen if there will be a response to the lower dose and have a good split at the lower dose and higher dose.

I think treatment environment plays a larger role than thought and the more successful local programs have big open rooms with good views, relaxing music, staff to help do GUIDED basic relaxation techniques, etc. Not the anarchy of in-home treatment and Spotify playlist stuff Mindbloom is pushing.

 

[PikminOC]

I’ve now added ketamine due to the huge benefits I’m seeing. In my experience, it is up there with ECT as the best options we have. Maybe better than ECT.

Iv ketamine? Really?

 

[Marasmus1]

Do you know how the treatment center does their process? I ask as this can vary heavily center to center and screening for appropriate esketamine cases and setting realistic expectations is very important.

Full transparency and putting my biases on the table, but I run a hospital based esketamine program and was skeptical and reluctant at first. But have been pleasantly surprised by how well it's worked.

The vast majority of cases are internal referrals from our outpatient clinic (either I know them previously or can screen them very well). Of these our internal numbers show

~8% had full remission and were able to stop maintenance therapy (I follow them and can confirm the depression is in remission)

~1/3 fully remiited (PHQ9<5) but continue on maintenance therapy

~1/3 responded way more than the equivalent average 6-9 points improvement on MADRS seen in the studies with most of these down to a PHQ9 between 5-7 from a starting score in the 20s and

~1/4 had no response

Of those who didn't respond, ~50% are geriatric which goes along with the trials showing less effect in this population, ~25% have significant other comorbidities/SDOH issues/major personality components, and ~25% were complicated by a history of dual diagnosis and relapse.

The effects aren't immediate unless treating SI and even then, it's short lived for ~2-3 days until they've had a few weeks of it. I wish we could do thrice weekly dosing for the first week with MDSI.

I haven't seen much non-SI related antidepressant response until week 3 of treatment. I'm also pretty conservative with dosing and don't typically increase it to 84mg until week 4 after we've seen if there will be a response to the lower dose and have a good split at the lower dose and higher dose.

I think treatment environment plays a larger role than thought and the more successful local programs have big open rooms with good views, relaxing music, staff to help do GUIDED basic relaxation techniques, etc. Not the anarchy of in-home treatment and Spotify playlist stuff Mindbloom is pushing.

It is good to hear. Well I have to be honest, most of the TRD folks I refer to esketamine clinic have co-morbid PD. Male population tend to have antisocial and narcissistic traits while females have bpd traits if not full blown borderline personality disorder. The reason I do not exclude them though is because to the best of my knowledge they were not excluded in the phase three trials of esketamine. Also I have to mention majority of my time is spent in trauma clinic where patients have significant childhood adversities in the form of sexual abuse, physical abuse, early maternal neglect, exposure to domestic violence, multiple foster home stays etc.

 

[Stagg737]

I think a lot of people in academia KNOW TRD is mostly PD. It's just a biproduct that's not that interesting. First off, many studies of TRD exclude (severe) PD. I see bona fide TRD without PD, some responded to nortriptyline. Secondly I think that the effect of ketamine exists in TRD with or without PD. In fact, I suspect that the effect is stronger for people with PD.

The weird thing is that if you are on ketamine constantly, you sort of create this "utopia" world, as the salience of worldly disruptions becomes disassociated away from you. This is the narrative I get from some patients who use ketamine either recreationally or via medical treatment. The [subjective experience] of symptoms largely disappear. The functional recovery doesn't follow, but I'm not sure that matters.

I'm also REALLY not sure "everything is biology", or at least it doesn't mean the way that it's supposed to mean. Sometimes I stare at my own regimen and I just want to taper everything and start from scratch. OTOH, if you read something like "Listening to Prozac", certain patients do have a "change of personality" when they are put on various psychotropics. In practice, I find this to be a subtle, but DEFINITELY apparent effect. Classically, this is a patient who have chronic depression and ADHD who is put on Lexapro and Adderall. The result is the family says "he's a different person". This effect at times goes into identity formation.

Interesting thought and something I usually try and tease out with my patients who have "dysthymia" and teach to our residents/med students. Like Marasmus I'm an advocate for the AMPD but think doing away with depressive PD was probably a mistake. I also disagree with the commonly used criteria of TRD (failure of 3 antidepressant meds). There is a population of people who have legit TRD episodes that don't fit the criteria for depressive PD and who I think would probably be the best candidates (biologically) for something like ketamine. Your post is interesting though, the idea of disruption of distress salience would be a pretty cool area to explore. I would argue that functional recovery would be relevant though, otherwise we'd just be achieving the same thing most potheads do sitting in their basements lighting up all day.

 

[TexasPhysician]

Iv ketamine? Really?

One example: Failed 10+ meds for depression. Spouse and I convinced patient to try ketamine. Fast forward to q4-6 month maintenance infusions. Full remission. Spouse dies during Covid. Patient shocks me by scheduling to see me just to tell me these life updates. Admits that if we hadn’t convinced him/her of a ketamine trial, 100% guarantees me that suicide would have occurred immediately after spouse’s death. Processing grief well in counseling without me.

This is my first patient to pay my typical follow-up fee unnecessarily on purpose to essentially tell me how grateful they are.

 

[Liquid8]

Interesting.

Have had the reps come out to spruik esketamine, but the proposed price of $12000 AUD for a course of treatment is very expensive and naturally, most patients aren’t interested or won’t have the capacity to pay. My understanding is that there’s also the need to have some level of patient monitoring so it’s not clear where this is going to take place or who will stump up the costs for the infrastructure required.

 

[FlowRate]

We have a guy we contract with for both TMS and esketamine. He thinks he's seen much more reliable response to TMS than to esketamine. I think the data I've reviewed for both is not particularly compelling but that's ultimately true of a lot of what we do in comparison to what we see in clinical practice.

The study where ketamine lost effect when patients were given naltrexone does make me wonder exactly what sort of effect and potential vulnerabilities we're introducing to patients.

 

[Marasmus1]

We have a guy we contract with for both TMS and esketamine. He thinks he's seen much more reliable response to TMS than to esketamine. I think the data I've reviewed for both is not particularly compelling but that's ultimately true of a lot of what we do in comparison to what we see in clinical practice.

The study where ketamine lost effect when patients were given naltrexone does make me wonder exactly what sort of effect and potential vulnerabilities we're introducing to patients.

I read couple of articles/critiques Alan Schatzberg wrote when there had been all this hype about esketamine being a miracle nasal antidepressant spray. He hypothesizes that ketamine either directly binds to opioid receptor or stimulates the release of endogenous opioids that bind to opioid receptors. He does not seem convinced about all this hype about NMDA receptor and its role in depression. The reason he conducted naltrexone study was to show that once the opioid receptor is blocked, ketamine stops being a ''miracle drug''. Now, if ketamine is somehow binding these opioid receptors there should be some withdrawal symptoms in theory. Despite the dysphoria, I have not seen any physical withdrawal from ketamine. Now obviously it may not be occupying the MU receptors long and strong enough for the withdrawal symptoms. Many many clinically relevant questions out there but not many answers yet.

 

[wolfvgang22]

I read couple of articles/critiques Alan Schatzberg wrote when there had been all this hype about esketamine being a miracle nasal antidepressant spray. He hypothesizes that ketamine either directly binds to opioid receptor or stimulates the release of endogenous opioids that bind to opioid receptors. He does not seem convinced about all this hype about NMDA receptor and its role in depression. The reason he conducted naltrexone study was to show that once the opioid receptor is blocked, ketamine stops being a ''miracle drug''. Now, if ketamine is somehow binding these opioid receptors there should be some withdrawal symptoms in theory. Despite the dysphoria, I have not seen any physical withdrawal from ketamine. Now obviously it may not be occupying the MU receptors long and strong enough for the withdrawal symptoms. Many many clinically relevant questions out there but not many answers yet.

People usually don't have withdrawal from short term courses of opioids, and it is doseand frequency dependent, so I wouldn't be surprised that ketamine isn't causing withdrawal. Opioids often cause euphoria. I'm not convinced by the NMDA hypothesis for ketamine at all, given my patients describe euphoria followed by a return of depression. I'm going to keep an open mind, but I'm also taking the claims of anyone already making money by offering ketamine with a large grain of salt. I think more research is needed.

 

[PikminOC]

When i searched for iv ketamine + "city name" , this was the first hit. Mindbloom | Ketamine's Breakthrough Potential
They prescribe sublingual ketamine !

How much?

 

[ObsequiousAplomb]

How much?

From their website: $386/month, billed monthly for 3 months. That includes 6 doses, 2 "clinician" visits, and a bunch of other meaningless drivel.

 

[Mad Jack]

Thing is, I've seen the exact same thing with IV Ketamine. Patients say they feel better for a few weeks, then once they are no longer getting IV ketamine it's right back to depression city.

They report once the novelty of the euphoria wears off, not much has changed. In this case should they be on IV ketamine treatment indefinitely?

Obviously, ketamine doesn't help problems like being poor, having relationship troubles, lacking support, or having chronic medical issues much. My patients with refractory depression have those problems, too.

I'm waiting for pharma to just start making ketamine infusion pumps similar to insulin pumps lol

 

[Mad Jack]

Lack of euphoria? Never seen euphoria with it. In fact, dosing too high makes the experience absolutely miserable.

Many a clubgoer would disagree with the latter statement. Typically at doses clinically used there are no real dissociative or euphoric sensations from what I've heard, aside from maybe some mild visual distortion and noises seeming a bit more sharp, not really a high to chase

 

[TexasPhysician]

Many a clubgoer would disagree with the latter statement. Typically at doses clinically used there are no real dissociative or euphoric sensations from what I've heard, aside from maybe some mild visual distortion and noises seeming a bit more sharp, not really a high to chase

You just highlighted that it doesn’t create euphoria in the average person and is much less addictive. Clubgoers are already excited and happy at the event. They use psychedelics to enhance a good experience with visualizations, reduce anxiety, and/or dissociate. They don’t transition to taking them regularly outside the club because they aren’t creating euphoria. Have you worked in an addiction center? How often are you seeing people addicted to LSD or ketamine as the preferred drug of choice?

Too high of a dose and you go down “the k hole”. For the select few that have become regular users and experienced this, they’ll tell you that it is a terrible experience. They avoid high doses. It feels like you died and aren’t returning. These rare individuals of frequent use typically have high anxiety and want to escape life - forget.

 

[SmallBird]

You just highlighted that it doesn’t create euphoria in the average person and is much less addictive. Clubgoers are already excited and happy at the event. They use psychedelics to enhance a good experience with visualizations, reduce anxiety, and/or dissociate. They don’t transition to taking them regularly outside the club because they aren’t creating euphoria. Have you worked in an addiction center? How often are you seeing people addicted to LSD or ketamine as the preferred drug of choice?

Too high of a dose and you go down “the k hole”. For the select few that have become regular users and experienced this, they’ll tell you that it is a terrible experience. They avoid high doses. It feels like you died and aren’t returning. These rare individuals of frequent use typically have high anxiety and want to escape life - forget.

One could respond to your anecdotal experience with different anecdotal experience - ketamine is absolutely a drug of abuse although I don't know how often people seek treatment, which may impact how often one is exposed to it being used this way. But it is a very commonly used drug in clubs and is absolutely used to induce euphoria. There is a spectrum of experiences that patients report on ketamine ranging from a very mild high to more extreme dissociation - I have conducted primary research on this topic and interviewed many patients receiving ketamine, and factor analyzed the CADSS from a large data set. It is safe to say the ketamine has a heterogeneous toxidrome but the experience you describe is not reflective of all patients.

 

[TexasPhysician]

One could respond to your anecdotal experience with different anecdotal experience - ketamine is absolutely a drug of abuse although I don't know how often people seek treatment, which may impact how often one is exposed to it being used this way. But it is a very commonly used drug in clubs and is absolutely used to induce euphoria. There is a spectrum of experiences that patients report on ketamine ranging from a very mild high to more extreme dissociation - I have conducted primary research on this topic and interviewed many patients receiving ketamine, and factor analyzed the CADSS from a large data set. It is safe to say the ketamine has a heterogeneous toxidrome but the experience you describe is not reflective of all patients.

I’m not saying it can’t be abused. I’m saying that it is just incredibly uncommon. Anything that creates true euphoria (maybe our definition is different) would be highly addictive. What research have you done?

I’ve yet to see any clinical data demonstrating that clinical use of ketamine leads to addiction or abuse. In fact, there is research demonstrating that it may help with alcohol and opiate misuse. Clinical use has been around for quite some time. If this was causing euphoria, I suspect that I’d see at least a couple of patients get addicted. I’m addiction boarded. I’ve been through ketamine assisted psychotherapy training which entails trials on ketamine. While I don’t have a mood disorder, I did not experience anything that would lead me to want to do it recreationally. Nothing close to euphoria. I’ve since treated 100+ patients. No one has reported euphoria or addiction.

Ketamine has been so successful clinically that significant research is now focused on psychedelics. This is just going to get bigger in my opinion.

 

[FlowRate]

You just highlighted that it doesn’t create euphoria in the average person and is much less addictive. Clubgoers are already excited and happy at the event. They use psychedelics to enhance a good experience with visualizations, reduce anxiety, and/or dissociate. They don’t transition to taking them regularly outside the club because they aren’t creating euphoria. Have you worked in an addiction center? How often are you seeing people addicted to LSD or ketamine as the preferred drug of choice?

Too high of a dose and you go down “the k hole”. For the select few that have become regular users and experienced this, they’ll tell you that it is a terrible experience. They avoid high doses. It feels like you died and aren’t returning. These rare individuals of frequent use typically have high anxiety and want to escape life - forget.

According to vice, there is an abuse problem in the UK.

 

[Mad Jack]

You just highlighted that it doesn’t create euphoria in the average person and is much less addictive. Clubgoers are already excited and happy at the event. They use psychedelics to enhance a good experience with visualizations, reduce anxiety, and/or dissociate. They don’t transition to taking them regularly outside the club because they aren’t creating euphoria. Have you worked in an addiction center? How often are you seeing people addicted to LSD or ketamine as the preferred drug of choice?

Too high of a dose and you go down “the k hole”. For the select few that have become regular users and experienced this, they’ll tell you that it is a terrible experience. They avoid high doses. It feels like you died and aren’t returning. These rare individuals of frequent use typically have high anxiety and want to escape life - forget.

I don't know, the people I know that have used ketamine have described it as providing an intense sense of wellbeing at the right dose but not something you feel like you need to do again. It's not euphoria in the dopamine sense like one gets from stimulants/MDMA but just a general lightness to the world that makes everything feel pleasant in a way that they find difficult to express, with a persitent presence that just makes one feel generally okay for the next few days rather than euphoric. K-hole stories vary, but they're more unpredictable than something like diphenhydramine that is universally a bad time. Meeting God and other profoundly positive experiences all the way down to feeling as if one is in a living hell tend to pop up. Most of the people you see in addiction treatment are not typical recreational users of ketamine, they are individuals with polysubstance use and often significant trauma histories and disprove issues in their lives that have experiences that skew to the negative compared with those outside of the addiction world. I don't want to get too identifiable, but I do have quite a bit of experience working in outpatient addiction treatment at a center that specialized in and was recognized by the state for high-quality care of same.

Just an example of some of the varied ways high-dose ketamine hits people:

We Asked People About the K-Holes That Changed Their Lives

"Crazy that it took a K-hole for me to see how important love was."

www.vice.com

But I feel like we're getting into semantics- my only point is ketamine can make you feel good. It's a different kind of feeling that isn't addictive for most, though some people do develop a problem and get ketamine-associated hepatic and bladder injury from the extent of their use. High dose ketamine doesn't always make you feel bad, and there's a good number of people that use it in the same way that others might use DMT. I think it's a great therapy and relatively low risk overall so long as you're staying on liver enzymes and the like.

 

[Mad Jack]

According to vice, there is an abuse problem in the UK.

There's also a pretty big abuse problem in the gay community in the Northeast

I’m not saying it can’t be abused. I’m saying that it is just incredibly uncommon. Anything that creates true euphoria (maybe our definition is different) would be highly addictive. What research have you done?

I’ve yet to see any clinical data demonstrating that clinical use of ketamine leads to addiction or abuse. In fact, there is research demonstrating that it may help with alcohol and opiate misuse. Clinical use has been around for quite some time. If this was causing euphoria, I suspect that I’d see at least a couple of patients get addicted. I’m addiction boarded. I’ve been through ketamine assisted psychotherapy training which entails trials on ketamine. While I don’t have a mood disorder, I did not experience anything that would lead me to want to do it recreationally. Nothing close to euphoria. I’ve since treated 100+ patients. No one has reported euphoria or addiction.

Ketamine has been so successful clinically that significant research is now focused on psychedelics. This is just going to get bigger in my opinion.

At the doses utilized clinically I see virtually no abuse or addictive potential. I've never seen anything resembling drug-seeking behavior in the course of esketamine or ketamine treatment.

 

[SmallBird]

I’m not saying it can’t be abused. I’m saying that it is just incredibly uncommon. Anything that creates true euphoria (maybe our definition is different) would be highly addictive. What research have you done?

I’ve yet to see any clinical data demonstrating that clinical use of ketamine leads to addiction or abuse. In fact, there is research demonstrating that it may help with alcohol and opiate misuse. Clinical use has been around for quite some time. If this was causing euphoria, I suspect that I’d see at least a couple of patients get addicted. I’m addiction boarded. I’ve been through ketamine assisted psychotherapy training which entails trials on ketamine. While I don’t have a mood disorder, I did not experience anything that would lead me to want to do it recreationally. Nothing close to euphoria. I’ve since treated 100+ patients. No one has reported euphoria or addiction.

Ketamine has been so successful clinically that significant research is now focused on psychedelics. This is just going to get bigger in my opinion.

Maybe we agree and are just focused on different points. I guess my point is: many people love how ketamine make them feel, including patients, club goers and others. The experience is diverse and some people describe feeling connected, empathic, light, and happy. I agree the phenomology is not the same as ascribed to stimulants, but it is definitely enjoyed by many. There is extensive literature on the ecology of ketamine abuse. I don't know how common it is but it is certainly being used extensively in the LGBTQ community and I think diversion is a major issue based on how easily people can get it online for poorly diagnosed depression. I don't know how common it is for patients with true MDD to develop a true addiction but there is absolutely a significant amount of abuse going on.