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About Ketamine: The Full Story – A Public Discourse

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About Ketamine: The Full Story – A Public Discourse

Situating our concern for the rising misuse of ketamine and the harm of ketamine dependency is the goal of this article. The problem is complex, multifactorial and deserves our full attention. As clinicians we are for a standard of care that continues to maximize the quality of care and the breakthroughs that ketamine assisted psychotherapy (KAP) provides to so many who are suffering. Misuse and the sensationalism of the press threaten the integrity and positive care we provide and seek to make more widely available. 

At the same time, we take seriously the harm ketamine misuse may engender and seek to educate and suggest a process for safe use.  

Ketamine use is on the rise because ketamine is attractive on so many levels, including as an experience that is hyped and pushed like so many substances that become treated as “drugs,” with money to be made as an impetus to deal and seduce. This article is an exposition of ketamine abuse and misuse, written with the hope that it broadens understanding and awareness. An informed public is our greatest resource. The authors of this article are all affiliated with the Ketamine Research Foundation

Dual Properties

Things often have a dual nature. Ultimately, anything and everything is a poison. It mostly depends on volume, but there are other variables, like mixing, adulterating or misrepresenting substances and impacting their e purity. In the world of mind altering substances, some, like opiates and ketamine, provide great benefits when used well, and cause addiction and harm when used carelessly and irrelevantly to their beneficial properties. Amphetamine is also bivalent, meaning it has both useful and addictive potential. But meth, cocaine, crack, and heroin are not. These substances involve real risks. While they have their allures, they take too many down for no real benefit. 

Fentanyl looks particularly bad as the deaths from its use and polypharmacy or its mixture with other substances mount. Over 100,000 dead from overdoses, propelled by trafficking and the spell of making money. But is fentanyl so worthwhile to medicine that we should be losing so many to it? 

Classical psychedelics – including LSD, psilocybin and DMT – appear less prone to dependency, although there are statistics, as well as many anecdotes, about the potential for harm when psychedelics are combined with other substances or taken in ways that can be more risky. For example, we hear that MDMA used in party settings  is now being injected, although some of this has happened in years past.  (there had been some injecting way back). Changing minds indeed is a best seller. The difficult balance we aim for is between proper prescribing and the risks that come with legal availability of medicines that have these dual properties – remarkable benefits on the one side, and the possibility of dependency and misuse on the other. This is the fulcrum on which, on one side, beneficial clinical practice sits, and on the other side sits prohibition, which has consistently led to proliferation and harm. Ketamine, benzodiazepines like Valium and Xanax, amphetamines and opiates, all share this dual dilemma. 

Public Health Concerns

We have great public health concerns for those suffering with severe depression, ADHD, trauma, anxiety, and more. At the same time, we have draconian regulations limiting access to the much needed medications to treat these conditions. Add to that the major inadequacies in our medical and educational systems in conveying understanding, training practitioners, and creating remedial and harm reduction programs. The latter includes providing practical information on drug testing, not sharing needles, the dangers of polydrug use,, adulteration, impurities and the gray market. 

Before we prescribe ketamine, we need to make people fully aware of the risks of ketamine dependence. The best patient is a well-informed patient. We need to eliminate the monetary incentives that support ignorance and hype for profits.

To be clear, we inhabit the ketamine assisted psychotherapy world and are practitioners who have been architects of its therapeutics and science. We have experienced KAP’s mostly amazing healing benefit on myriads of patients. We have seen countless patients regain their lives with safe ketamine care, often after years of failed conventional  treatments. We have also experientially trained nearly a thousand licensed practitioners in KAP practice. We are in the thick of it with ketamine, as well as being proponents and researchers for the availability of other psychedelic medicines. Our biases have been clear for a very long time. 

As practitioners with our ears to the ground, we are deeply concerned by the growing epidemic of illicit ketamine use and its casualties. We would like to deepen the conversation about its complex causes and sources, with the aim of harm reduction. We are especially concerned about the impact of this epidemic on the great good work that KAP Is providing, and how it colors the public’s view of KAP and ketamine. We seek to elaborate what we see as the truths of ketamine’s benefits, while providing as much clarity as possible on its risks.

Ketamine Statistics

Situating ketamine use statistically is difficult. There are no reliable figures for whole numbers or differentiating dependent users from casual users. Relative to other psychedelics, ketamine use is in league with reports of 389,000 MDMA users in one month in 2022, 4% of young adults in the U.S. using LSD in 2019.Many more individuals consume opiates and meth and die and suicide as a result of using these substances. That does not in any way suggest that ketamine misuse and abuse is a trivial issue.

There are many interacting aspects to the ketamine imbroglio. They involve the general drug culture; ketamine’s availability and costs; the legal, the underground and the ketamine marketplaces; illegalization; the allure of tripping; who controls the market; the promotion of drugs in the sense of full disclosure, efficacy and risks; positive and negative sensationalism; and pharma’s marketing and selling of drugs. Pulling the camera back for a wider view, it is possible to see ketamine’s use being influenced by culture in general; economics, class, race and  gender; capitalism; the state of the world; climate change; institutional values and academia; personal values;  morality; community; education; recreationalism and pleasure seeking; personal exploration; sexuality; mental health and mental illness; addiction and dependency (how we create that, view it, treat it and don’t treat it); and our limited understanding of medicines, their workings, and their appeal.  

All of this is shaped by our inability to take all of this in and create a matrix of comprehension and action, clarifying what is truly in our self-interest that drives toward a sharing, love and connection and; the difficulties facing the reform of our broken system.  That absence of clarity is the crux of our problem. If it existed, we would sort out how to live, tolerate, and like together, and how to preserve our planet and not blow ourselves up in all the fashions we do and could do. You might think this is a bit utopian. But none of these challenges, including the abuse and misuse of drugs, is going away easily.

Safety and Therapeutic Utility

One notable quality of ketamine is its safety profile. While chronic abuse can have detrimental physiological effects, the acute use has been proven safe, with over 50 years of clinical administration. Nausea, sometimes vomiting, transient increase in blood pressure and heart rate are the most common adverse drug reactions. Like with other psychedelics when set and setting are disregarded, the acute risk with ketamine comes from the user’s environment and the lack of container and sitter.

A recent study of deaths related to ketamine concluded that “No cases of overdose or death related to the use of ketamine as an antidepressant in a therapeutic setting were found; most of the deaths occurred in the circumstances of polydrug use and overdoses left no sequelae. Conclusion: There is legitimate concern about the risks involving the use of ketamine and its analogues, especially in recreational settings. On the other hand, ketamine as medicine is considered safe and it is listed as an essential medicine by the World Health Organization. Although clinicians must remain vigilant, this should not deter appropriate prescription.”

By looking at ketamine’s properties as a substance, its therapeutic utility and its desirability become clear:

·       Flexible dosing for different levels of effects at subanesthetic levels — ranging from a mild alteration of consciousness to a full out-of-body psychedelic experience.

·       Anxiolytic, anti-obsessional, antidepressant, ego dissolving effects – and symptom relief.

·       Amplifying imagination and potential for vivid and thematic hallucinatory experiences that can be life changing, especially within a therapeutic KAP context that supports growth.

·       Reliable neutral to positive emotional experience.

·       Potential enhancement of intimacy and sensuality.

·       Reduces social distancing.

·       Short duration of action — an hour or so with variable recovery. So can be repeated readily and sustained with a sense of schedule.

·       Recovery is usually complete within two hours and most people have little residues — though sometimes some fatigue. Nausea is the most common adverse drug reaction, with a frequency of approximately 15%  or so of recipients.

·       Tends to leave behind the concerns and difficulties that preceded its use;  for some it “wipes the slate clean” so they can begin anew, a highly beneficial characteristic for therapeutic KAP work.

·       For most recipients, it requires a limited frequency and overall limited time frame for therapeutic use, and in clinical practices infrequent abuse of ketamine.

·       No respiratory depression. Taking too much leads to anesthesia, not a life threatening overdose.

Ketamine-Assisted Therapy

These factors are important in the clinical realm, and especially with KAP.  KAP stresses an intensive engagement with its individual patients, couples, adolescents, families and groups. It utilizes non-denominational ritual and meditation, comfort, music, at times two therapist dyads, and psychiatric and medical support to provide a setting conducive to healing and awakening the mind. The criteria necessary for a ketamine process to be considered “assisted psychotherapy” is the presence of one or more therapist practitioners, a delineation of the emotional and traumatic background, presence during the ketamine experience, and the processing of the actual ketamine experience in what is generally referred to as integration. Within that general framework, practices will vary in focus, methodologies, and time frames, with a variety of protocols adapted to the particular presentation and needs of the patient.

Ketamine administration should always be directly supervised, with the integration of its effects treated as the centerpiece for healing and growth. Sessions tend to last three hours. Supervised and limited prescription of ketamine lozenges, with specific doses determined in clinic for at home use, may be part of a KAP program’s therapy. 

Depression comes from a matrix of causes and symptoms that vary from person to person. Too often at IV clinics, no inquiry is made to go beyond the depression label, concealing the impacts of trauma, poverty, and social injustice. Depression and all of the diagnostic labels that are potentially treated by ketamine, require an alternative paradigm with attention to the complexity of personal histories, attendant traumas, and the need for sharing of the ketamine experience.  

When delivered at an IV clinic, with no support or container, ketamine has a positive effect in terms of remission of TRD in less than 30% of recipients within a six session protocol, over two to three weeks of administration. Despite all the neuroscience claims, our sense is that this is primarily an emotional response. In contrast, ketamine as a medicine provided through the Ketamine Assisted Psychotherapy model sees improvements on depression’s many facets in the 80% range in the existent KAP studies.  Depression as a diagnosis is a grab bag for a multiplicity of causations, reactions, and ways of coping. Patients deserve full personal contact, a full inquiry, full therapeutics, and full social contextualization.

Insights that arise from ketamine’s use occur not only during the time of a ketamine journey, they also may present a slowly developing picture that takes time and effort to fully materialize. Like a photograph developing in a darkroom, the full picture is not what you see at first. It is essential to do the work of integration, journaling, meditating and reflecting to further deepen benefits derived from ketamine journeys.

With our patients, abuse of ketamine has been rare. It has occurred after KAP treatment concluded, and it has occurred in individuals with prior histories of substance dependencies who unfortunately relapsed .

Psychedelic Effects

The KAP world arose with full knowledge of the psychedelic effects of PCP at subanesthetic doses, and PCP’s profound and extended anesthetic effect. With a half-life of about 21 hours, PCP’s persistent psychedelic effects are notorious, with anecdotes of superhuman feats of violence occurring within hallucinoses. In comparison, ketamine is an analogue of PCP, with a very short half-life of 2.2 hours. Ketamine was found to have analogous anesthetic effects to PCP, without PCP’s respiratory depression. These characteristics made ketamine very desirable for human and veterinary use. 

So how was the accommodation made to ketamine’s psychedelic effects? For one, they occur within the waning anesthetic period; acting out is infrequent and limited, and the level of agitation is controllable. That remains an important consideration in our understanding of ketamine’s hallucinogenic acceptability. Ketamine at the sub-anesthetic doses used in KAP is safe and not life threatening. Agitation in the deep throes of a hallucinogenic journey is uncommon, short-lived and not personally directed. Rather, when agitation does occur, it is an enactment of the experience of the journey and its content, unknowable to any witnesses. In our experience, what may seem like agony is often reported as extraordinarily pleasant in the aftermath of the journey. 

Awareness of what came to be called ketamine’s “dissociative” effects was spread rapidly among those who hunt new consciousness, new “highs,” new molecules that produce these effects. Ketamine became available for personal experimentation by way of diversion from veterinary stocks. The injectable material was being cited for experimental use in the early 1970s. 

Somehow, society has come to regard these actions as disreputable. Yet they are the rule for substances that create altered states, not the exception.

Tasting As Exploration

All discoveries of this sort occur by tasting and sharing the tasting reports – positive and negative. This includes Albert Hofmann and LSD, Sasha Shulgin and MDMA, and the addicted John Lilly and ketamine, LSD, and isolation tanks. We should never forget our extraordinary patriarch, William James, who tasted four or more substances at the turn of the prior millennium. As well as the Huicholes, Mayans and other Native American medicine cultures, Siberian shamans, and perhaps also the Tibetan Buddhists. Peoples from all times and places have imbibed. Some have gone beyond intoxication and taken it too far, like the Nazis who fuelled the Blitzkrieg with pharma produced meth and cocaine, with millions of lives lost while under the influence. The same goes for the U.S. during the Korean War.

No government or society will ever rid itself of mind-altering substances. Governments will continue to exert their preference for control and repression. Humans, in turn, will break the government’s “rules,” to experience altered states, even with their attendant risks for punishment. “Tasting” a substance is more than vernacular for drug experimentation. Tasting implies the joy of a novel experience grown out of curiosity to “boldly go.” The issue is not in the tasting, but rather in the seduction to repeat a desirable effect which is multifactorial, and when overused leads to misery, distrust, the bitterness of social injustice personalized — while clearly achieving the aims of those who provide these substances to gain money, power, and social control.

Boundaries, if respected when they are located by trial and error, trail far behind the explorers who blaze new paths in an attempt to educate us and point toward where the greatest dangers in life are.

“Diversion” is the word preferred by those who hold the license, the IP, the legal right to prescribe these substances — a very recent intervention in society. Some prescribers and drug property holders get rich off their diversion. It is not the end user who “diverts.” A more appropriate word is “use.” Use is everywhere and all over, and as far as is known, has been present throughout history.

Tasting needs to be a format for safe, vital and thoughtful doing. Here are some practical considerations about tasting, based on our experience, which are too often bypassed to the detriment of the taster:

·   Not everything is worth tasting. Inquiry can open the doors to poisoning, habituation, stupidity, broken relationships, despair, drug treatment programs, loss of motivation — the list goes on. You know that drinking dish detergent is bad. Doesn’t the same apply to fentanyl with its 70,000 ODs reported in 2021?

·   Your goal is to enrich your life, not to denigrate and destroy it. Will what you are planning on tasting assist in that, or set you back and create a recovery process?

·   Will one taste lead to cravings and getting hooked?  Two tastes? Three? How often can I do this without getting hooked? Am I deluding myself?

·   I have a peer group and relationships that I take seriously, and I check in with them regularly and ask for their feedback and take it in. If my peer group is made up of fellow compulsive users, they will not reflect back accurately. I need a break and other friends who are not sharing my drug trip and I must let go of my dealer. This applies while I still have some judgment.

·       If I am losing my judgment, I need to get help before it goes too far.

·       Tasting is best served when it is done in safe and thoughtful settings, with preparation and support.

·       In party times, do I have a limit, or am I blowing past it? Do I make and take my limits seriously?

·       I am committed to inquiry, to understand what I am about, how I suffer and lust and how I am using substances for pain, avoidance, blotto. I will expose myself to others to explore this and know myself better and better. It is a tough world to live in and deeply confusing and too often hurtful to me and those around me. I am committed to living my precious life as thoughtfully and heartfully as I am able.

·       I may use substances for pleasure, sexuality, sharing and fun. I may use substances for my development, enhancing my imagination, seeing into myself and my relationships, my struggles and anger. I am curious to have altered  state experiences. In doing so, I will make sure I have support and be in the best possible settings.

·   If I seek help with a therapist or prescriber, I will do my best to make sure they are knowledgeable and thoughtful about substances. I recognize that getting thorough this is a process involving devotion to my life as well as the clinical and underground paths I may take.

While this matrix applies in general for all substances, here are important considerations that are specific to ketamine, based on our observations:

o   For the vast majority of ketamine recipients, no diversion or misuse occurs.This includes well supervised at-home use provided by in-person KAP clinics, and applies to in-office IV clinics as well.

o   Cravings for ketamine tend to occur with repeated ingestion intranasally (insufflation) and by injection. Repeated use is risky business – despite an awareness of the increasing harm and disability caused by emerging ketamine dependence.

o   There is a small subset of ketamine users who become dependent. In our experience, prior substance dependency constitutes one vulnerability to become a part of this subset. Other factors have yet to be defined. At this time, there is no neuroscience available to explain a biological source of ketamine’s cravings. Perhaps the closest analogy available now is the similarity of ketamine cravings despite awareness of their destructive force to the developmental factors responsible for alcoholism and its misuse despite awareness of its destructive force.

o   Ketamine dependence can be brutal, with cravings causing repeated relapses. Physical, cognitive, emotional, spiritual and motivational decompensation occurs. Cystitis and gastrointestinal symptoms may be severe. The delusion that one has a special mission and special access is part of a manic-like state, with self-inflation and grandiosity.

o   Recent studies are highly suggestive that prolonged high-dose recreational use of ketamine is associated with structural and functional brain differences

See Also

o   The allure of ketamine is complex and necessary to understand in order to comprehend the multiple reasons for its use and misuse. To begin with, it is a powerful psychedelic medicine, whether or not scientists differentiate it from the serotonergic psychedelics. The intrapsychic phenomena of ketamine cross over with the phenomena of psychedelics in general. Early on ketamine was embroidered into the psychedelic tapestry. Before it was understood that ketamine’s differentiation from other psychedelics as based on glutamatergic neurotransmission, it was simply referred to as a psychedelic or having psychedelic properties.

o   While some users prefer ketamine to other mind-altering substances, combination and polypharmacy are frequent. Well known ketamine abuse model subject John Lilly was fond of using ketamine and LSD either together or sequentially. 

o   Ketamine’s broad dosage range makes for a wide variety of effects and uses, as described above.

o   Prescription of lozenges for at-home use by virtual telehealth services to non-prescribing therapists for in-office sessions is variable in quality, cost and thoroughness. There are vastly different lozenge dosages, as well as varied recommendations for how long to hold the saliva from the dissolved lozenges in the oral cavity. It is the saliva that contains the ketamine that is absorbed through the mucosa. The end result is often calculated to be of economic benefit to the lozenge provider, rather than to benefit the patient. From our observations, too often prescriptions of ketamine are in amounts that are too large, and held in the mouth for periods that are too short. Monitoring also tends to be skimpy to almost non-existent in too many instances, and not specific to patient needs, variability of diagnoses, and presenting problems.

o   Ketamine withdrawal symptoms are relatively short lived and are differentiated from opiate withdrawal symptoms. Recovery of physical and brain manifestations may take weeks. Cravings are the enemy of clarity and relapse is a problem — despite an awareness of the increasing harm and disability caused by the possibility of ketamine dependence,

o   Party and club use of ketamine is on the rise, even to the point of injecting in public space.

o   Sources for ketamine include small amounts by diversion from clinics and prescribers; promiscuous prescription by minimally supervised telehealth providers (recipients may grind up lozenges for intranasal or injectable use); and high volume distribution of powder for intranasal or injectable use. The latter source can be domestic, Asian, and no doubt involves cartels. And the price is right to get both supplier and user interest.

The Ketamine Hype

The hype around ketamine has contributed immeasurably to an increase in recreational and underground use. One major influence is the sensationalist ads for at-home ketamine companies such as Mindbloom. These are placed in the public media, touting the wonderful benefits of ketamine, without sufficient warnings of ketamine’s effects, dependency potentiality, and proper dosage recommendations. This is a thinly veiled type of drug distribution operation, targeting those who want to try ketamine, or have bought into the hype to alleviate their suffering.  

In general, the mail order ketamine business underplays the challenges associated with the experience. But so too does the hype, couched in medicalese, of some IV clinics, which too often do not provide emotional support, and in essence are lucrative drug delivery facilities. Inducing psychedelic experiences also requires the responsible processing of them, and too often ketamine IV clinics pretend these psychedelic experiences have not occurred, or are incidental and inconsequential. Psychedelic experiences are intrinsic effects, not pretend side effects of the ketamine experience. They vary in intensity depending on the amount of ketamine administered and the particular individual’s sensitivity. 

Indeed, much of the promotion for ketamine creates the allure for sales and induction of desires at personal and public levels.

For example, a client called one of our clinics after using too much street ketamine. They had derealization and needed support. We asked them why they did it. From the perspective of psychedelic therapy, we were asking: what was their intention? They reported buying an 8-ball of ketamine because their dealer told them it was “the tits.” This is the illicit part of our culture. It leads to the kind of ketamine use that lacks safety and has no container, because it has to be in the shadows to exist. And exist it does.

Simply said, ketamine recipients, the public, and our friends and families deserve better.  

The most common diagnosis for ketamine administration has been for treatment resistant depression. A massive number of people who have been failed by conventional psychiatric and psychotherapeutic treatment suffer from TRD. Unfortunately, the medical field has taken too little responsibility for treating this condition. Anesthesiologists may possess the FDA’s indication to administer ketamine, but they do not have psychiatric or psychotherapy training. Because of their limited understanding, we have seen a voluminous proliferation of ketamine clinics run in a medical fashion – as if ketamine treatment is solely a medical procedure and does not also require a therapeutic component. From an economic perspective, this treatment model is a veritable goldmine, with 40-50 minute sessions and several patients receiving treatment at one time. It has led to an IV clinic explosion, now worldwide. Hence many suffering with TRD, and trauma, are not receiving the quality of  treatment they require and deserve. 

There is an obvious economic motivation for some to avoid high fees for an experience that can be bought for a few bucks on the street. All psychedelics carry this procurement possibility. The challenge comes from the lack of insurance for psychiatric applications of ketamine. Those of us doing KAP may assist with some insurance reimbursement as we provide compensable psychotherapy. The true difficulty is that anyone relying on U.S. insurance for mental health coverage will receive very little or nothing to cover therapy of any kind with almost all policies. As a consequence, more and more psychiatrists do not accept insurance. That means a lot of money out of pocket for patients if they go the medical route. Within this framework, the most expensive route by far is the IV clinic, even though it has less potential benefit. The cost and accessibility issues lead to the temptation to find other means to obtain ketamine.

We have prepared a graph that shows the options for ketamine availability and costs, which can be viewed here.  

Because legally sanctioned use is expensive, a common alternative ketamine path has been termed the “underground,” in which ketamine is provided, either by itself or in a polypharmacy psychedelic format, by unlicensed practitioners or licensed practitioners who do not follow the legal route. There is no standard of care and no ethical allegiance. As many practitioners are not licensed, there is no recourse for recipients to report and sanction poor performances or unethical behavior. There is a mix of competent, trained, and untrained practitioners. Ethical violations occur relatively frequently (although, certainly, some legal practitioners have also misbehaved and caused harm). Bad behavior — primarily involving money and sex — occurs in all fields of endeavor, even in those where the avowed obligation is to “do no harm.”  The Ketamine Psychotherapy Associates Code of Ethics is a valuable statement, but it has been promulgated for voluntary participation and unfortunately is unenforceable. So patients have to take their chances. 

Underground practices are also quite expensive, with fees for sessions generally running $1000 or more for a single session. The underground is appealing to those who seek ritual and want to avoid formal clinical formats and diagnoses (as well as have the availability of multiple substances in a single session).  The underground experience, with its high cost and usual lack of a therapeutics, also tends to encourage recipients to find their own sources.

Finding your own source has historically been, and continues to be, the dominant path for drug use. For those of us who cut our teeth in the emerging drug culture that took root in the early 1960s, and was in full bloom by 1965-1968, experimentation, community building, consciousness raising, antiestablishmentarianism, personal freedom, social justice, anti-war politics, the rupture of coercive political control over mind and behavior, creativity, and just plain fun were – and remain – hallmarks of what was erroneously labeled “the drug culture.” Erroneous because it is not about drugs. Yes, the freedom to use, explore and not get busted for doing so was critically important. But this was part of a realization that politics are personal, just as our spiritual lives are personal, as well as our right to live with others as we choose, to share and connect. While far from always being obvious, because of its many distortions and conflicting tendencies, the “movement” has always boiled down to creating love – and healing from its opposite, the pervasive absence of love in a traumatizing, atomizing, profit driven, and trust destroying culture. Alternative medicines have been fundamental contributors to the personal and group recognition of prejudice and intolerance, and the unfairness and imbalance of our social formations. 

The problem that we call dependence or addiction is caused by drug induced cravings that exist in the nature of certain drugs – certainly opiates, meth and alcohol.  With ketamine, we are not yet aware of a neurological basis for its allure. So far, it appears to be consistently related to its induction of hyperinflated mental states. An additional motivation could be expressed this way: “I feel a need and am going into hiding. I don’t know when or why or how I will come out of this deep pit.” The vast majority of us who do these substances do not go down the addiction path. So it would seem that dependency does not come from the drug alone, whatever actual potential it has for inducing neuronal and psychological desire with cravings and dependence.

Views on the Motivations to Use Ketamine

As practitioners we are exposed to and probe the personal bases for ketamine dependence. We offer the following as an attempt to offer compassionate understanding, and to bring awareness to individual susceptibilities and experiences. To approach this through a personal lens turns the inquiry into a personal exploration: “Is this me? Is this how I suffer and seek alleviation? Is this why I get caught in ketamine dependence – or a way to view how I might get caught?”

Among those with ketamine dependence, despairing inner talk is common. The refrain often goes like this:  “I give in to ‘giving up,’ give in to ‘what’s the use, why bother, no one loves me.’ I give in to ‘I am nothing, there is no hope for me, I hate life.’ I give in to ‘I will never escape the drudgery,’ give in to my anger over my situation, to the hatred and brutality I face physically, emotionally and spiritually. I give in to ‘there is no god, I am doomed, fuck it all.’ I give in to ‘I know you ain’t got nothing for me, that it is all bullshit, I don’t belong.’ I give in to ‘I can’t do it, I want out, I give up.’ I give in to… (fill in your own head trip).”

In any context, clinical or illicit, the ketamine experience is a multifaceted jewel. While the experience often has psychedelic themes of love and oneness with the cosmos, it is not without its dark side. Ketamine has the unique effect of offering the unity of all things and the sensation of finding a truth to life that feels, in the moment of the experience, like the one final answer to all one’s ailments, needs, or desires. The trickster effect fools the user into thinking that taking one more dose, or just a little higher dose, is all that is needed to finally grasp this life shattering revelation. For some users, this desire holds an incredible allure. Unfortunately, it is a mirage that appears at a crucial moment, as the experience fades and the medicine is metabolized. This is when the user is returning to their ordinary mind and the difficulties of life. 

Ketamine use within a container that lacks standardized medical and psychotherapeutic psychedelic care, such as intention setting and integration, combined with the patient’s own suffering, mental illness, or otherwise, is a setting ripe for chasing this faux truth. And it can lead to doing more and more. Because psychedelic experiences are a fractal of life, the supreme truth will either be just out of grasp, or found, lost, searched for, found, lost and…..

We have witnessed over a dozen high functioning individuals, ages 40 to 60 with long histories of manageable psychedelic polysubstance use, who began using ketamine recreationally. This came after exposure to IV ketamine for clinical use and then going on to insufflation with easy access to powder through their peer groups. To our dismay, we observed a rather rapid onset of increasing habitual ketamine use with increasing dysfunctionality over a one to two year period. Their loved ones became concerned and reached out to friends and providers for help. The response was a disturbing period of denial by the users, eventually leading to insistent ultimatums about any further use.

Finally, and with great reluctance, treatment was accepted under duress, as ketamine became a problem leading to cognitive impairment, bladder and gastrointestinal symptoms, confusion, disorientation and impairment in the activities of daily living and work.

The psychology of this ketamine dependent state is remarkable for inducing grandiose feelings of universal wisdom and cosmic connections, including a conviction in their capability to solve the world’s major problems. The symptoms have a strong resemblance to a manic disorder, with the psychological gain from feeling omnipotent, all knowing, and super intelligent. We have observed that this hyperinflated state takes time to wear off, as it is held to be the truth of their existence, and is not challenged by an ability to internally reference reality. This state, and the cravings for more of it, is a constituent component of ketamine withdrawal. There is a sudden lack of the fun of being all knowing and certain of oneself and one’s mission. This sense of mission is a core compulsion for chasing this dragon.

The Road Ahead

Psychedelic medicines continue to lead a unique cultural conjuncture. Western culture lacks the elders, ritual, ceremony, and community container of our human ancestors. Perhaps psychedelics are a social level corrective mechanism in response to our out of control short sighted colonizing culture consuming everything in its path. Regardless, we will do well to honor our past by creating and educating about safe psychedelic containers. Our society already knows how to do this. For example, we have created a cultural accord, however imperfect, for safe driving and not driving under the influence. The society at large will benefit from harm reduction public safety campaigns. The strategies of abstinence, criminalization, and pathologizing have shown the fruit of that labor. They don’t work, and in fact make things worse. The time to act is now.

It is the goal of this article to inform and voluntarily limit use that is inevitable and will not be suppressed by further prohibition, as if that were even possible. Clearly the so-called War on Drugs has been a colossal and destabilizing failure. Only an awakened and educated community can challenge the hype and the temptation. The growing commodification and distribution of ketamine to the public is as inevitable as the lure of money, which is an all too familiar part of living in America. 

Ketamine is of great value therapeutically and experientially. That needs to be understood and handled with care and consciousness.

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