Ketamine: Can a party drug be the next Prozac?

In 1962, Calvin Stevens, a chemistry professor at Wayne State University, was looking for a sedative that could also relieve pain. He discovered ketamine.

It delivered.

First tested in the Vietnam War, ketamine, fast-acting and relatively safe, became the battlefield anesthetic of choice. Widely used in humans and animals, ketamine’s on the World Health Organization's Model List of Essential Medicines.

But in the 1970s, ketamine took a left turn and hit the club scene. Its “out of body” and “hearing angels” rep, and vile use as a rape drug, prompted the DEA to slap on a Schedule III controlled substance label.

Recently, a huge, unmet medical need – the alarming rise of depression and suicides in the U.S. – has rekindled an interest in ketamine.

Can ketamine go where Prozac fails?

Maybe.  

Before I go any further, you need to know ketamine is studied in patients who have treatment resistant depression (TRD); that is, those who’ve tried at least two drugs, talk therapy and still haven’t improved (about one-third of people with major depression) or who have active suicidal thoughts. Ketamine is not a first-line antidepressant.

Ketamine checklist:

First, ketamine supposedly works mostly with glutamate, a different brain chemical than what the current antidepressants work with. Diversity is good – Check.

Second, ketamine being ketamine, it’s a fast shooter. After dosing, the antidepressant response starts in hours, 60% shows some response. Relief is temporary but can last weeks. Antidepressants may take weeks to months to work. Speed, efficacy – Check, check.

Third, one study showed those maintained on ketamine for 4 to 5 months had a lower relapse rate. May work long-term – Check.

Finally, on March 5, 2019, a ketamine nasal spray (esketamine, Spravato) was FDA-approved for the treatment of TRD. It’s legal – Check.

The catch?

More research, especially on long-term efficacy, is needed. Even the current protocol is a cringing “let’s play it by ear.” Traditional antidepressants have low abuse potential: ketamine is – um, a [big yellow frowning emoji].

And, cost.

Spravato is only given in certified clinics (patients are monitored for two hours afterward). The starting dose: twice weekly for a few weeks. Then once every week or every few weeks depending on individual response. A Westlake clinic quoted $625 per treatment/visit. Medicaid, Medicare and some insurances will not cover it.

There’s an increasing number of roadside clinics offering ketamine infusion to treat pain, depression, fibromyalgia, migraine or whatever at $400 to $2,000 a pop. Dr. Jeffrey Lieberman, psychiatrist-in-chief of Columbia University Medical Center, said while ketamine “is not snake oil,” patients are “getting treatments they may not need or that don’t work, or they’re getting more than they needed.” He’s concerned about “people getting fleeced.”

What do I think?

I worry about the cost, the potential for abuse, misuse, tolerance. What if people figure they can get “Special K” for $25 on the street and start to self-medicate? Among other side effects, ketamine misuse can increase depressive symptoms.

But if ketamine toes the FDA line – used in patients with TRD in conjunction with proper psychiatric care – I believe the bad boy can reform, and be the next Robert Downey Jr.