5 Common (Negative) Misconceptions About Ketamine

Misconception #1: Ketamine Is Illegal

Ketamine is on Schedule III of the Controlled Substances Act. This means that Congress believes ketamine has, “a moderate to low potential for physical and psychological dependence,” and the DEA controls who can manufacture, sell, and possess ketamine, among other activities. In other words, as long as it is administered (and prescribed to you) by a licensed medical provider, ketamine is legal.

Misconception #2: Ketamine Is a Horse Tranquilizer

Not quite. But you may have heard of some medications which are used in both humans and non-humans. They include amoxicillin, Prozac, tramadol, prednisone, ivermectin, and ketamine. Crucially, all of these medicines are formulated and prescribed with different concentrations, inactive ingredients, dosing protocols, and uses.

According to the FDA and anyone with common sense, “Never use medications intended for animals on yourself or other people.” The reverse is also true: Don’t give Fido medicine intended for humans. You can be confident that ketamine administered by a licensed medical provider is fit for humans.

Misconception #3: Ketamine Is “Off Label” Meaning Not Approved by the FDA

Ketamine Is FDA Approved

The FDA has approved both ketamine and its enantiomer, esketamine or S-ketamine. The former was approved over 53 years ago on February 19, 1970, under the brand name Ketalar as a fast-acting general anesthetic. Whereas the latter was approved much more recently on March 5, 2019, as a nasal spray under the brand name Spravato for Treatment Resistant Depression (TRD).

“Off label” Use Is Common

The phrase “off label” refers to when a medication is prescribed for a different purpose than what the FDA approved. In other words, its prescribed use literally differs from the package insert or label. Medical providers commonly prescribe drugs “off label” because:

1. Many drugs are effective treatments for more than one condition with new uses discovered all the time, often, after a drug has been approved. For example, the FDA approved Viagra to treat erectile dysfunction but it may also be an effective treatment for high blood pressure in the lungs as well as female sexual arousal disorder.

2. It is not profitable to seek FDA approval for drugs which are no longer protected by patents like ketamine.

In Summary

Ketamine is FDA approved and prescribed “off label” when administered by a licensed medical provider to treat conditions like depression, anxiety, and chronic pain. (Its “on label” use is as an anesthetic.) The newer esketamine nasal spray called Spravato which was developed and patented by Janssen (part of Johnson & Johnson) is also FDA approved for TRD.

“Off label” does not imply unsafe or ineffective. In fact, some have argued that because of bad incentives, ketamine—a safe and effective mental health treatment—could be displaced by the less effective but more expensive esketamine nasal spray 😤

Important: There may be drawbacks associated with “off label” use. For example, it may be that an “off label” prescription proves ineffective or brings unwanted side effects. Therefore, always ask your medical provider why they believe an “off label” prescription is right for you. Another issue is that the cost may not be covered by health insurance. So you may need to rely on your FSA or HSA (if you have a HDHP).

Misconception #4: Ketamine Is Really PCP… Which Makes People Violent

In the 1950s, Parke Davis (now a subsidiary of Pfizer) synthesized phencyclidine or PCP while researching its use as an anesthetic. Soon after however, scientists noted that PCP produced a drunken state, delirium, and catatonia in various animals as well as signs of delirium or psychosis in humans. Searching for a shorter duration and less disruptive analog, Parke Davis published its findings related to research drug CL-581 (aka Ketalar and ketamine) in 1965.

In 1983, researchers first discovered that both PCP and ketamine work by blocking the N-methyl-D-aspartate (NMDA) glutamate receptor. However unlike PCP, they found that ketamine was about ten times less potent, therefore less likely to produce unwanted side effects, and shorter lasting.

Lastly, PCP does have a storied reputation, some of which is sensational and some which may have a kernel of truth. Rather than making people more violent or giving them superhuman strength, however, it appears that its users are succumbing to its strong hallucinogenic and numbing effects.

Misconception #5: Ketamine Is a Dangerous Party Drug With Widespread Abuse

When The Partnership for a Drug Free America (now Partnership to End Addiction) put out this misleading and simplistic public service announcement in the 1980s, it bolstered existing anti-drug sentiment in parents and scared kids like me. Instead of educating us on why people might abuse drugs, legitimate uses of drugs (both legal and not), and ways to prevent or minimize harm, drugs were simply labeled “bad” by government campaigns like Just Say No in 1986 and DARE in 1991. Unfortunately, ketamine got swept up into this and has been fighting to rebrand itself ever since.

Ketamine Is Safe When Administered By A Licensed Medical Provider

Ketamine was first synthesized in 1962 by Calvin Stevens who was working with Parke Davis. Following FDA approval as an anesthetic in 1970, ketamine has been used in emergency and operating rooms worldwide. Ketamine has been on the World Health Organization’s Model List of Essential Medications for decades alongside penicillin, lidocaine, and morphine. This is to say that ketamine has a relatively long history of widespread use which has proven its safety when used properly.

I first learned about ketamine in my surgical residency where we commonly used it to anesthetize and sedate patients in the emergency room. One of the main reasons we relied on ketamine was because like opioids, it is an anesthetic. But unlike opioids, it does not decrease breathing or heart rate. Furthermore:

• It has few contraindications; namely: psychosis, active substance abuse, severe liver dysfunction, significant coronary disease, poorly controlled hypertension.
• Its interaction with other drugs like benzodiazepines is well understood.

• It is not physiologically addictive and withdrawal symptoms are rare. (This is in contrast to antidepressants like SSRIs where there is potential for rebound effects when abruptly stopping these medicines.)
• It can cause a slight rise in heart rate and blood pressure. And while this rarely requires intervention, close vital sign monitoring of patients undergoing ketamine therapy is important.

Like Many Medicines, Ketamine Can Also Be Misused and Abused

Unsurprisingly, given its psychoactive properties and purported feelings of euphoria and dissociation, there are reports of ketamine addiction and abuse around the world. Misuse and abuse in the UK, east and southeast Asia, and possibly the US has been reported. When combined with other substances like alcohol, cocaine, or other medications, there is a greater risk of injury or death compared to when misused alone. Without close monitoring by licensed medical providers, addiction is possible.

For these reasons, it is important to use ketamine under the supervision of a licensed medical provider who is trained to prevent and watch for signs of misuse, abuse, and addiction. Licensed medical providers are also equipped to respond to medical emergencies, however rare they may be in a clinical setting where ketamine therapy is practiced.