Opportunities, Challenges, Integration, and Recommendations for Ketamine Treatment

In Part 2 of this review, Rakesh Jain, MD, PhD, discussed opportunities, challenges, integration, and recommendations. Dr Jain spoke to participants in a live Table Talk session at the recent virtual Sana Symposium.

In Part 1 of this Table Talk review, Dr Jain provided an overview of his experience with using ketamine, including opportunities and routes of administration.

Dr Jain:

More opportunities [for ketamine], it is anti-suicide … They seem to be very specific. They seem to be independent of the effect on mood. At the moment, we don't have a single psychedelic where the anti-suicide properties are so well-documented.

PTSD. I know we do a lot of PTSD conversation with MDMA because we should. Don’t ignore. I published 2 papers so far. If you get a chance, look them up. PTSD intervention was, in 1 study, IV ketamine. In another study, IM ketamine. The anti-PTSD effect have an effect size of 0.9.

Ketamine does wear a lot of different hats. Of course, it is able to counteract the depression as well. It can also have a specific role in treatment-refractory OCD. That point, however, is not well-articulated.

How about challenges? Let’s talk about challenges. The first challenge, the greatest challenge I am facing and I keep changing my mind regarding it on a weekly basis, which model do I use? Do I use the medical model?

Do I use the, it’s a modulator of neurotransmitters? That leads to synaptogenesis. That leads to scaffolding proteins being increased. That leads to depression improving and inside developing. Do I use that model? Do I use the psychospiritual model? Do I use the pure psychological flexibility model?

Do I use the model of integrating all of them? Depending on the day, I lean towards one or the other. The truth may be ketamine may be the 1 psychedelic at the moment that can wear all of these 4 hats that I described to you.

Is it legal? It is legal. Ketamine is legal. Prescribers can definitely off-label prescribe ketamine. We do have [esketamine] which is, as you know, an enantiomer of ketamine, which is legal, which has good data. I don’t think we should harbor a bias against it in appropriate patients. I’ve seen it. You have seen it perhaps too. It can be profoundly effective.

The risks are, to some degree though it is a medication that can be potentially addictive. I have now seen consultations of individuals who clearly became profoundly addicted, there’s no other way to describe it, addicted to ketamine.

It’s not common in the clinical study, but it is happening out there. I’ve also now heard quite a bit of diversion of Trokies that we clinicians sometimes prescribe to their best friend or to their husband or their wife. It is happening. We’ll be talking about take-home doses, etc. in just a second.

I have 5 specific suggestions to offer you, 5, if you’re just starting out.

• Number 1. Take about 6 months to prepare. Don’t jump into it right off the bat. Yesterday you were thinking about using ketamine in your clinical practice, and by Monday you want to start using it. Don’t do that. Take a little bit of time. What will you do in these six months, though? I'll tell you more about that.

• Number 2. Take a formal training program. There are many. It’s not just because you will read papers. That’s not it. You want to get to understand how the experts are using it. You want to hear the diversity of opinion. You want to understand the different medical opportunities we have to use ketamine, but also integration work, preparation work, the journey work. There are many ways to do it. By knowing those ways and taking your time in understanding it, you will develop your own style. Your style should be your style. It should not be a replication of someone else’s. That’s suggestion number 2. Take a formal class, or a series of classes.

• Recommendation number 3. Get a mentor, or my preference, get several mentors. I did that. I continue to do so. I’m both a mentor to others, and I’m being mentored by others. I intend to continue that for as long as I continue doing psychedelic work. I recommend you get mentors of different stripes. Prescribers have different styles. Get to know the ones who like IV, like sublingual, who like IM. Get to know them. Also, the nonprescribing community of psychedelic therapists also come in very many different styles. Some are highly psychospiritual, some of them are more the internal family-systems–oriented. Some of them may be oriented towards the ACMA. Doesn’t matter. The more exposure you and I have, the more complete we become as clinicians.

• Recommendation number 4. Create a tribe. Look, you just created a tribe, you’re here at Sana. Don't stop the tribe here. Join a Facebook group, join a Google group, join something where you have people who are having good conversations, agreements, disagreements. They’re bringing cases of great success and bringing cases of unexpected failures.

• Number 5. Expect to change your understanding and attitude towards ketamine and ketamine-assisted psychotherapy on an ongoing basis. There simply is no such thing as, “I got it.” There’s simply no such thing. Ketamine is a wonderful teacher, not just to the patient, the client, but a wonderful teacher to the clinician. It shows a different face with every single treatment.

It is perfectly OK if there are times where you feel more spiritually inclined about it, perhaps more biologically inclined about it. It could happen, and it will happen.

Reference

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