Ketamine: Navigating Risks, Mitigating Misuse, and Confronting Potential Addiction

Ketamine’s Safety

Ketamine has a long history of medical use spanning over fifty years, primarily being employed as an anesthetic for procedural sedation and used in emergency situations. It continues to be one of the most commonly used drugs in emergency departments and operating rooms, largely due to its safety profile. Ketamine is a vital medicine in the pediatric population, on the battlefield, and in hospital settings, earning its place on the World Health Organization's list of essential medications.

One of the key advantages of ketamine over other anesthetic agents is its preservation of airway reflexes. This means there is limited concern about compromising breathing, and it can even slightly stimulate heart rate and blood pressure, rather than dropping them to dangerously low levels, as seen with most other anesthetic agents (e.g., Propofol). Additionally, ketamine has minimal interactions with other medications, allowing for safe co-administration with drugs like antidepressants. Ketamine proves to be an attractive option when patients are experiencing both physical and psychological acute distress.

While ketamine is commonly used as an anesthetic due to its rapid onset, efficacy, and safety, (particularly in emergency settings) its application in ketamine therapy for the treatment of mental health disorders involves subanesthetic dosages—significantly lower, approximately one hundred-fold less. This substantially reduces potential risks for side effects or complications, explaining why ketamine therapy is offered in outpatient, or even home, settings. However, it is important to note that this doesn't eliminate all risks, and close supervision and monitoring during administration remain essential.

Paraphrasing the remarks made by Steven Mandel, M.D. of Ketamine clinics Los Angeles during a recent webinar, where he spoke alongside Sam Mandel; in a clinic, your caregiver assumes responsibility for most aspects of your care. As you distance yourself from that environment, the patient must increasingly bear the responsibility for potential risks. And when bad things happen, help is limited.

Side Effects And Risks

Nausea

Nausea is a rare side effect associated with ketamine, seen more with higher doses or when combined with movement or intense visual stimuli. With an incidence of approximately 1 in 50 patients specifically experiencing nausea at our clinic, it can be easily and effectively treated with oral or intravenous anti-nausea medications, such as Zofran (ondansetron). At Innerbloom Ketamine Therapy, clients wear eyeshades and remain still during sessions to minimize potential discomfort associated with movement or visual stimulation. Additionally, if patients have a predisposition for nausea, we may choose to administer anti-nausea medication prior to starting an infusion as a preventative approach to further lessen the potential for onset.

Anxiety

The infusion session is commonly characterized as a pleasurable experience, although certain sessions may pose emotional challenges. Ketamine has the potential to bring forth memories or internal issues that individuals may have consciously or subconsciously concealed or ignored. This is the stage where the healing process unfolds, and a certain level of anxiety is anticipated and considered normal. Ketamine, being a medication with psychedelic properties, may be perceived as unusual or unlike any experiences individuals have encountered before, particularly for those unfamiliar with altered states of consciousness. Some may undergo spiritual or mystical experiences, and others describe ketamine therapy as one of the most meaningful and profound moments in their lives.

Fluctuations in Vital Signs

Mild elevations in heart rate and blood pressure are typical responses to ketamine and usually do not require treatment. The ketamine experience may evoke emotional responses, and a psychological reaction is expected, at least to some degree, which may contribute to changes in heart rate and blood pressure. Monitoring is essential during ketamine therapy, and intravenous medications are available to address any concerning elevations, should they occur.

Airway Concerns

Other rare issues associated with ketamine include low oxygen levels (hypoxia) and laryngospasm. While hypoxia is uncommon, a medical provider in a clinic setting will be equipped with oxygen supplementation if needed. Laryngospasm, though even more rare, with an incidence of 0.3% when used at anesthetic doses and can be associated with rapid administration of the medicine. It can be addressed with a jaw-thrust maneuver; however, it requires immediate attention and an individual trained and prepared to perform this maneuver. The Innerbloom Ketamine Therapy protocol involves a slow intravenous infusion over forty minutes, along with supervision from myself, a trauma surgeon, to minimize risks. Although exceedingly rare, this unique potential risk makes me especially uneasy about the thought of at-home ketamine use or even in any other monitored setting without a trained professional able to swiftly respond should there be an immediate need.

Bladder Injury

Ketamine abuse, characterized by daily intake and high dosage can lead to a condition termed ketamine-associated cystitis or interstitial cystitis. This condition manifests with lower urinary tract symptoms such as lower abdominal pain, painful urination (dysuria), frequent urination, the sensation of needing to urinate more frequently (urgency), inability to urinate, or blood in the urine (hematuria). Complications may include impaired kidney function and bladder hardening with a decreased ability to hold higher volumes of urine.

Treatment involves discontinuation of ketamine, which may be sufficient to restore normal bladder function. In severe cases, surgical procedures such as stenting, placement of drainage tubes into parts of the urinary tract system, or reconstructive surgery of the bladder may be required.

To provide perspective, interstitial cystitis is observed in severe cases of recreational ketamine abuse, where users consume ketamine daily, often multiple times a day, and at dosages 50-100 times in orders of magnitude greater than those used in clinical therapeutic settings. At Innerbloom Ketamine Therapy, infusions are dispersed over a course of two to six weeks. Due to the vastly lower dose and infrequent use, in contrast to recreational abuse, interstitial cystitis is very rare and not expected to be encountered in a clinical setting.

Ketamine Addiction

Ketamine, when associated with recreational or at-home misuse, has the potential to be addictive. Consider it a red flag when other ketamine clinics or providers deny this fact.

While one should not expect physical withdrawal symptoms as in the case of alcohol, benzodiazepines (e.g., Xanax), or opioids (e.g., Percocet) cessation, ketamine misuse and abuse in a recreational or at-home setting can lead to psychological addiction, which may be particularly challenging for individuals to overcome. Several factors contribute to its potential for addiction:

• Psychological Dependence: Individuals may develop a psychological dependence on ketamine due to its mind-altering effects. The dissociative properties of ketamine can create a sense of detachment from reality, leading some users to seek the euphoric and altered state it induces. Ketamine's dissociative effects may be appealing to individuals seeking an escape from stress, anxiety, or other emotional challenges. The desire to escape from reality can drive repeated use and, eventually, addiction, should an individual have access to a constant supply.

• Improper Form and Dose: One primary concern with oral and nasal ketamine is ensuring the appropriate dose reaches both the blood and the brain to produce antidepressant effects. Simply put, it's challenging to know whether these forms of ketamine reach the minimal threshold (0.5mg/kg) for therapeutic effects. Providing transient relief with a subtherapeutic dose of ketamine may offer an anxiolytic effect without addressing the underlying depression. Consequently, a patient might feel better momentarily, but once the ketamine dissipates from their system, their distress returns. This can lead to a dangerous cycle: the depression remains untreated, yet the short-lived relief prompts individuals to consume increasing amounts of ketamine. Ultimately, this pattern might predispose individuals to addiction.

• Tolerance: With regular use, individuals may develop tolerance to the effects of ketamine, requiring higher subsequent doses to achieve the desired sensations. This escalation in dosage can contribute to the development of dependence.

• Recreational Context: The recreational use of ketamine often occurs in social settings, and peer influence can play a role in the development and continuation of ketamine abuse. Social acceptance and normalization of drug use in certain circles may contribute to its addictive potential.

• Lack of Regulation: When used recreationally or at home, individuals may not adhere to safe dosages or frequency guidelines. Recent reports reveal more than 50% of Americans misuse at-home ketamine, oftentimes accidentally, or purposefully using more than the recommended dose. Uncontrolled and excessive use increases the risk of addiction and adverse health effects.

• Misuse and Self-Medication: Some individuals may misuse ketamine as a form of self-medication to cope with mental health issues or emotional distress. I have witnessed this firsthand with individuals who were prescribed an at-home oral form of ketamine. They initially begin using ketamine during a depressive episode, then in anticipation of a depressive episode or stressor, and finally as a means to "relax" or escape their normal life and often responsibilities. This self-medicating behavior can lead to an unhealthy reliance on the substance, much in the same way that alcohol can be misused.

Three Ways to Avoid Ketamine Misuse and Addiction

1. Medical Supervision: Ensure that ketamine is administered under the supervision of a qualified healthcare professional. When seeking ketamine treatment, choose clinics with staff members who possess specialized training in both administering ketamine and managing mental health conditions. Prioritize safety by inquiring about a provider's safety protocols and guidelines for ketamine administration. A reputable clinic will have stringent measures to monitor patients during sessions, respond promptly to any adverse reactions, and maintain a controlled and secure environment. Only use ketamine when it is administered by a licensed medical practitioner for a specific condition, following appropriate screening to rule out contraindications. This ensures a safe and tailored approach to ketamine treatment, minimizing risks and maximizing the potential therapeutic benefits.
2. ‍Therapeutic Monitoring: Regularly monitor the therapeutic effects of ketamine and consult with healthcare providers to adjust the dosage or treatment plan as needed. This helps prevent the misuse of ketamine for non-prescribed purposes and ensures that the medication is providing the intended benefits.‍
3. Integrated Mental Health Care: Combine ketamine treatment with comprehensive mental health care, including therapy or counseling. Addressing the underlying mental health issues through a holistic approach reduces the likelihood of relying solely on ketamine for emotional relief. Integrated care can provide coping mechanisms and support to manage mental health challenges effectively without resorting to self-medication and overuse.

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About the Author

Dr. Ray Rivas, a former general and trauma surgeon with over a decade of experience utilizing ketamine, became a ketamine therapy specialist to treat mental health and pain after witnessing its profound impact on his hospital trauma patients and his own mental health. As the founder and medical director of Innerbloom Ketamine Therapy in San Luis Obispo, California, Dr. Rivas applies his extensive medical expertise to provide safe, evidence-based ketamine treatments for mood disorders, including depression, anxiety, PTSD, and chronic pain. His passion lies in helping patients find relief and rediscover hope through personalized, compassionate care.

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Resources for Help

If you or someone you know is struggling with drug addiction please seek help. If you are experiencing a medical emergency please call 911.

Substance Abuse and Mental Health Services Administration Hotline: 1-800-662-4357

American Addiction Centers – Recovery.org 24/7 Hotline call or text 1-539-208-1422

California Addiction Hotline 1-866-210-1303

Avila Heights Recovery

Aspire Counseling Services

Morro Bay Recovery