Ketamine: Opportunities and Routes of Administration

In Part 1 of this Table Talk review, Rakesh Jain, MD, PhD, Sana Symposium and Psych Congress steering committee member, provides an overview of his experience with using ketamine, including opportunities and routes of administration. Dr Jain spoke to participants in a live Table Talk session at the recent virtual Sana Symposium. He began the talk with an expansion on his session entitled, “Evidence supporting psychedelic use in different mental health disease states.”

In Part 2 of this review, Dr Jain will discuss opportunities, challenges, integration, and recommendations.

Dr Jain:

A quick word of introduction about myself, if I may. My name is Rakesh. I am a colleague of yours. I am a psychiatrist. I am a clinical professor of psychiatry at my medical school. I’m also on the teaching faculty of the nurse practitioner program.

I have been very interested in ketamine for a long time. I would love to give you just a bit of background:

The first thing we have to ask ourselves is the very title of my conversation. This is “Challenges and Opportunities in Psychiatry.” What I actually had meant was opportunities and challenges in psychiatry and psychotherapy.

Ketamine does not belong just to the providers of medications. It doesn’t belong to the psychotherapists. It belongs to all of us. There’s 1071 of us at this conference. This is our first legal psychedelic. It is important that we get to know it very well.

I will have to quickly lay out for you my bias. I actually think ketamine is grossly underestimated by the psychedelic community. There is a bias against it amongst many. If you also harbor that bias, it may be worth exploring it in this public forum and privately.

I have seen ketamine act like an MDMA, if used properly, like a heart opener. I have seen it act like psilocybin, as a gentle teacher. I have seen it act like LSD, sometimes a substance that takes you into deep, dark places that you need to go to.

Ketamine appears to be incredibly polymorphic. It can be, in the right situation, utilized in a hundred different ways. Of course, it is a legal way to do it.

Opportunities

Let me lay out for you what I do believe are the opportunities:

• Number 1, is it’s a new mechanism of action. We have nothing like it in terms of NMDA receptor antagonism. We do not. Therefore, in itself, it becomes highly intriguing.
• Number 2, if you think about it in the medical model, it can be used as an augmentation agent without having to discontinue medications. That’s a big deal. For example, if you have clients on ayahuasca or are wanting to try ayahuasca and they are on a classic psychiatric medication, there could be life-threatening complications.

If you have someone who is on psychiatric medications and wants to try MDMA or psilocybin, expect them to have very little, sometimes no benefit from it. That’s not the case with ketamine. Ketamine with or without psychiatric medications appears to have near-equal efficacy. That, from a practical perspective, is quite important.

Also, please recognize that ketamine does wear 2 different hats:

• Number 1, let’s call it a psycholytic hat.
• The other 1 is the psychedelic hat.

Two remarkably different hats. It can serve both dramatically different purposes. I’ve had great success in both routes of administration.

Routes of Administration

Finally, routes of administration can be very different. I have had patients, at least in the clinical setting, use it sublingually. That’s typically the psycholytic, though it could be psychedelic as well. IM [intramuscular] is my preferred way to do it, perhaps because of my own experience, my own training. IV [intravenous] is perfectly legitimate. Different routes of administration would be perfectly open to our use.

In fact, there is a company trying to develop ketamine for continuous infusion subcutaneously. There are also now, studies of ketamine continuously infused intravenously for 96 hours. Those studies, again, if you have an interest in talking about it, I can tell you what happens both from a biological perspective and from a psychedelic perspective.

Reference

Jain R. Table talk: ketamine therapy in out-patient psychiatry – challenges and opportunities. Presented at: Sana Symposium; September 17-19, 2021; Virtual.