Addiction Expert Dr. Howard Kornfeld Talks About Ketamine Dependency
As a specialist in the treatment of addiction, Dr. Howard Kornfeld MD has for decades taken an integrative and holistic approach towards physical and mental health. Dr. Kornfeld is widely known for being particularly skilled in the assessment and treatment of opiate and other chemical dependencies, chronic pain, problems with alcohol, and complex difficulties with benzodiazepine and sleeping pills.
A graduate of Northwestern University School of Medicine, Dr. Kornfeld teaches at the University of California, San Francisco School of Medicine’s Pain Fellowship Program as a member of the clinical faculty. A Diplomate in Pain Medicine, recognized by the American Board of Psychiatry and Neurology, he is a Distinguished Fellow of the American Society of Addiction Medicine and board certified in pain, addiction, and emergency medicine.
Dr. Kornfeld has long been an outspoken advocate for the use of buprenorphine, also known as Suboxone, for the treatment of addiction and pain. He developed his treatment approach into the Recovery Without Walls model for outpatient care and built a Mill Valley, CA-based practice around these ideas in collaboration with Inna Zelikman, PMH-NP.
Well-known in his fields of expertise, Dr. Kornfeld came to national attention when he sent his son Andrew Kornfeld on an overnight flight to meet with Prince to discuss a treatment plan. Andrew Kornfeld was among those who found Prince dead in an elevator at his Paisley Park estate on April 21, 2016. Emergency officials could not revive Prince who died of an accidental fentanyl overdose at 57. Carver County Attorney Mark Metz investigated Prince’s death and determined that Prince died from taking counterfeit Vicodin.
In addition to his work with Recovery Without Walls, Dr. Kornfeld participates in national discussions and community outreach around accessible chronic pain treatment. In 2011, Dr. Kornfeld founded the Alameda Health Systems Pain Management and Functional Restoration Clinic (PMFRC) where he took the Recovery Without Walls pain treatment model and adapted it for low income people and a safety net institution. He works with insurers as well as practitioners and facilities in Marin County, CA to improve the availability of buprenorphine pain treatment.
In addition to his clinical practice, Dr. Kornfeld was a Delegate in 1981 at the First Congress of International Physicians for the Prevention of Nuclear War, the organization that won the Nobel Peace Prize in 1985. In 2022, he attended the Nuclear Ban Forum in Vienna to support the United Nations Treaty on the Prohibition of Nuclear Weapons.
Dr. Kornfeld also provided early assistance to civil liberties organizations in the 1990’s in their lawsuit that led the federal judiciary to forbid the Attorney General of California’s use of the gas chamber in death penalty cases, as cruel and unusual punishment. According to his biography, Dr. Kornfeld studies “the role of societal addiction as a driving force in the global polycrisis of fossil fuel and armaments dependence, inequity, and biodiversity loss.”
In Part 1 of our conversation with Dr. Kornfeld we discussed his open letter in Lucid News to Robert M. Califf, MD, Commissioner of Food and Drugs at the FDA, concerning the administration’s imminent decision on whether to approve the Lykos Therapeutics proposal for MDMA-assisted therapy for PTSD. “I am writing to endorse midomafetamine-assisted therapy for PTSD because I believe that the benefits outweigh the risks,” wrote Kornfeld who says he still fully stands by his letter despite the FDA’s decision to deny MDMA-AT and possibly require a new Phase 3 study.
“Unlike other drugs with higher abuse liability, such as opiates, cocaine, amphetamine derivatives, or benzodiazepines, continued use of MDMA is rarely experienced as rewarding,” wrote Dr. Kornfeld in his letter. “The experience of pleasure or euphoria that can be seen as a risk factor for misuse with MDMA has been noted in my patient’s histories as reliably dissipating with frequent use.”
In Part 2 of our conversation with Dr. Kornfeld, we discussed his thoughts about ketamine. Recovery Without Walls provides ketamine-assisted psychotherapy and Dr. Kornfeld reflected on growing concerns about ketamine dependency and challenges presented by some ketamine therapy delivery systems.
As an expert on the treatment of addiction, I’d like to hear your thoughts regarding ketamine. You’ve said publicly that given the rapid expansion of ketamine therapy clinics, you would like to see perhaps a step back from some of the looser medical prescribing of ketamine to help ensure that it’s as medically supervised as possible. What would you like to see happen?
There is a conundrum of the field sort of generating, at the moment, ketamine addiction. Whether the freer use of the ketamine through mail order delivery systems and Internet based supervision may be generating a small but very problematic group of ketamine abuse or ketamine addiction which can be very challenging to treat. I’ve seen this even with ketamine clinics that give IV ketamine in a supervised way. So there’s complete supervision at the time, but then an individual can technically go from one ketamine clinic, to another ketamine clinic, to another ketamine clinic day after day. And none of these clinics would even know that they’re going to so many different clinics.
In California, if we prescribe a drug and the patient picks it up from the pharmacy, it’s registered in a database that doctors are obligated to monitor. But when ketamine is given within a medical office, it’s not reported to that database if the patient doesn’t take it home with them, so it’s not reported.
I’m also respectful of the fact that these databases, to some degree, are an invasion of privacy for patients. They’re also like a guardrail. We have in medicine now to be aware of not contributing to addiction, like with opiates or benzodiazepines or amphetamines by prescription.
I think the leaders of the ketamine societies – I’d be interested to know what discussions they’re having. In our practice we do ketamine-assisted psychotherapy, but we view it as a tool among many tools that we have. And we only use it intramuscularly in the office. So we don’t get involved with people taking ketamine home with them. And we know our patients quite well. Of course, we can’t know for sure that they’re not, going to other offices to get ketamine. But it hasn’t come up since we started and I would say 99 percent of ketamine is probably being provided in a safe way.
But it only takes that one percent to escape proper use and create negative stories like Matthew Perry’s death. And we don’t know what kind of backlash is in the works right now. I know that the Medical Board of California is most likely concerned and trying to figure out what to do when they encounter a situation they think is problematic and ketamine is being used.
The DEA announced their concern about ketamine in the last month or two. So one of my concerns is that fallout from the ketamine situation may make it harder for the FDA to approve the next psychedelic type drug that comes before them. So when Lykos creates this new Phase 3 study that is supposed to be much better, if there’s more of a backlash environment and people are pressuring the FDA against approving psychedelic drugs, it could be even a harder sell than it was this year.
In addition to people going from clinic to clinic to acquire more therapeutic ketamine, it’s widely available on the black market and consumed in non-clinical environments for personal use. Have you seen an increase in compulsive use of ketamine by patients coming to your clinic?
I have treated a number of ketamine use disorder or ketamine addiction patients and once that addiction gets going, it can be very powerful. We have to use all the tools at our disposal. Sometimes medications that will lower the anxiety of the craving and there’s an obsession that happens with it.
There’s an almost delusional system in the patient suffering from the addiction. And the delusional system is such that [patients think] “my brain needs ketamine.” It becomes like other addictions where the sought after substance becomes like a food, or oxygen and you can’t live without it.
There’s a cognitive delusion that I’ve seen in a number of patients where they create a rationale. Like “my brain needs this ketamine in order to stay creative, in order to move forward in my life on different projects.” So there’s more cognitive rationalization than let’s say with opiates or cocaine or methamphetamine that I’ve seen.
Serious bladder and renal issues with ketamine have been well covered and documented in the medical literature. People tend to be aware of that. But for people who are using ketamine in non-clinical environments, what do you think they should keep in mind about the potential risks of this material?
I’ve seen bladder issues come with even somewhat milder use of troches or of lozenges where someone is using them on a daily basis, but at a high enough dose. So I’ve seen problems. They’re milder urinary symptoms, but I had concern that they could be harbingers of a more serious process.
So I’ve asked people to pull back. There are some clinics that are providing lozenges, like for pain or for depression on a regular basis, but at higher dosages. So I think that could be risky, as well as the high dose intravenous use that might occur.
I’ve seen people get better when they’ve pulled back and there’s been stabilization. But I know that there are cases written about where the process was not reversible.
There are cases where ketamine is said to have caused or amplified chronic pain issues, especially when it’s boofed or taken rectally. Do you have thoughts on that information?
Yeah, I don’t think that ketamine is safe for indefinite use in chronic pain. I think it can be used for periods of time, but ideally it’s better to start pulling it back. Because I think tolerance develops to the therapeutic effect, and then there could be an anti-therapeutic effect in terms of pain.
One of the nice things about buprenorphine, if someone truly has chronic intractable pain, it can stabilize their system for a long course of treatment and then decisions can be made about tapering off or staying steady.
That being said, there’s some patients that probably do okay on low dose daily ketamine. But I prefer that our patients not use ketamine daily, but for the worst parts of a breakthrough pain. And that they use other drugs more on a daily basis for the pain otherwise.
If somebody comes to you and says, “‘I feel like I’m in an unhealthy usage pattern with ketamine” or they are using it compulsively in a nonclinical way, what kind of treatment or therapies do you offer people in those situations?
In treating any kind of addictive disorder, one question to ask is, “what’s the right setting for them to be in?” Is it living alone by themselves, grappling with this on their own, is that a good setting? Most of the time it’s not. There might be certain cases that would be okay if other support was there. But we know addiction is also a disease of isolation often.
Again when I say a disease, the one thing we don’t know is what addiction really is. There’s a lot of definitions out there. There’s this sort of scientific definition that we have that is sponsored by the major organizations. It’s a brain disease. It’s a loss of control. One of the thinkers I do respect, Gregory Bateson, spent the last 10 years of his life grappling with “what is addiction?”
I think if we have humility about that, we’re better off. In that sense, I like what Alcoholics Anonymous says, which is that “alcoholism is cunning, baffling, and powerful.” And to me, that is sometimes as scientific a statement as the ones that might come from our official scientific agencies. So we don’t really know. We have to have humility, but we know that people generally are social animals. And addiction is often a reflection of the broken bonds in their life with other people.
So then we think of a residential rehab environment, which would be like the ICU of treating addiction, where the most resources are available. There’s therapists and counselors available around the clock. There’s the possibility of creating connections with peers that might be going through the similar process.
And then there’s the protection from impulses to go get the drug that one is trying to stop. So there’s a spectrum of environments that need to be looked at. And then as [the] field of recovery gets a little more sophisticated, there’s gradations. There’s places that are called sober living environments that provide housing and group activities, group meals. But may not confine the person 24 hours a day to a center. And then there’s IOPs, intensive outpatient programs and partial hospitalization programs.
And then there’s just people creating a nest for themselves with their friends or their family that is their inner circle of openness and support. So we have to pick the right environment depending on how severe the condition is. But then once the environment is selected and everybody is comfortable, then how do you support someone in that environment?
So some kind of protection from your own cravings and your own impulses could be developed in a family setting, in a home setting and then medications. We can provide safe medications that would make the withdrawal process easier ranging from classical, like sedatives. There was a case where we actually used buprenorphine because the patient had quite a bit of pain from a previous injury and the ketamine was addressing to some degree the pain. But ketamine we know hits the opiate receptor also among other receptors.
So there might be a rationale for using this drug, buprenorphine which I mentioned earlier. I have heard a couple of cases already where people had an addiction to another drug, like cocaine in particular, and they went for ketamine treatment specifically to get off the cocaine, or to deal with the cocaine. But then they became dependent on the ketamine. So that’s another thing to keep in mind, yes.
Some social communities have noted a steep increase in the number of people using ketamine for non-clinical personal use, some of whom feel that their relationship with ketamine is unhealthy. Some communities have started ketamine users support groups to give these people a place to talk about their ketamine use and receive support from their friends and community. Do you think this is a useful approach?
Yeah, I think it could be a very useful approach. And I think if there’s a peer support group, I think it’s instructive to try to understand how, let’s say, the 12 step programs actually work. One of the things I appreciated about Gregory Bateson’s work – in the decade before he died or so he published a very interesting article called The Cybernetics of Self: A Theory of Alcoholism where he examined the principles or the steps of AA, particularly the first few steps. And he compared them to a kind of a hitting bottom, that we can view as what we’re doing as a planet right now.
Do you know what I mean? That we’re engulfed in an addictive process and we’re hitting bottom. And only when you hit bottom, can you change your epistemology. Can you shift from one that is in error, to your detriment, to one that might be more accurate and offer a solution. In his view – one view of alcoholism and his view – was that it was a process of the self being, in a way, in a delusion. That the self was not connected intrinsically with so many other processes, with people, with ecology. And that it came to some degree from Western civilization that has this error that the individual is solely responsible for themselves and shouldn’t be dependent on other people.
And he quotes a poem: “My head is bloody, but unbowed,” as the way part of us all go through life having been inspired by the sort of Western culture we’re in, versus more of an Eastern culture that we’ve lost touch with. Which is that we are integrated at all levels, at many levels. So that when the alcoholic hits bottom, they realize that although the step of AA was, “we admitted we were powerless over alcohol and our lives had become unmanageable.” Bateson would say, “we admitted that the system of ourself and alcohol is far more powerful than we are, and we need help.” And then the second and third step, where we admitted, we reach out to a greater power. We came to believe that a greater power could bring us to sanity.
And I would say that the ketamine user groups – I don’t think they need to become like AA – but maybe if they can adopt the part of AA that really works and maybe not some of the dogmatism or some of the fundamentalism that comes in that. This could be a strength for these kinds of groups to adopt. There are psychedelics in recovery groups also that, of course, see psychedelics as a path to avoid addiction. There would be a connection with those groups, too, I would imagine.
Do you see psychedelic-assisted therapies, as they become available in the future, as a potential treatment for ketamine use disorder?
Yes. I would imagine a different psychedelic, given in a different context, could help the person with ketamine addiction shift their consciousness to help them overcome what they’re embedded in. But also, to what degree is there a trauma cycle? If somebody is in a trauma cycle, one might say there might be an addictive process in the thinking, in the trauma cycle.
To some degree, Bateson might say at some points that all pathology has an addictive component, all pathology could be viewed that way. Why do some organisms, some species, become extinct? Because they became addicted to a certain niche, ecological niche, and then conditions changed and they couldn’t adapt to the change.
I think maybe this field of psychedelic healing can open up our eyes to think more deeply even about what addiction is.
This is a very interesting conversation Howard. What haven’t I asked you that you feel is important for people to know about your work in the field of addiction therapy or psychedelic-assisted therapies going forward?
I made reference to the world, to the global situation. When I was asked to give a eulogy for Ann Shulgin, I thought about how I met Sasha and Ann Shulgin years back. I was at Esalen and I was already involved in the prevention of nuclear war. At the time, through medical associations. I read that Sasha had given this talk at a psychedelic conference in Santa Barbara in the early 1980s. You might be familiar with this transcript or this talk. Some people call it, “Why I Do What I Do,” but I think it’s also called “Drugs of Perception.” And he pointed out this coincidence of very violent, destructive things in human history to health giving things that are, rather than thanatos related, eros related.
And the ultimate one, of course, is the invention of the chain reaction that led to the nuclear atomic bomb having occurred just a few months before Hoffman discovered the psychedelic effect of LSD. So he was very impressed with that, but he gave other examples in human history going back to alchemy and the Dark Ages. When I was asked to give one of the eulogies I thought a lot about that and I’m really interested in exploring that further.
Even as I also fear that psychedelics could be subverted, to create more thanatos in the world, as well as being the necessary tool to create an eros that pulls us out of where we’re at. So somehow I feel as healers and as practitioners, to the degree that we could keep these realities simultaneously in our consciousness, that as we work with people we’re also working to somehow shift the planetary trajectory from the madness and the pathology that is happening in greater circles right now. Through our work with individuals and ourselves, to somehow create a resonance of healing and of life giving principles.
So I think my message, my last message would be that I think that this is really important. To think about those things and to not let too many days pass while we’re immersed in this healing work, to keep the planetary work in mind. And those of us who are working at planetary levels need to keep the individual healing in mind. That’s the thought I would leave you with.