I don't contribute here as much as I should, but I'm a longtime lurker. I have substantial personal experience with ketamine, having first used it in the late 90s by way of pre-ban Ketaset "Yellow Label liqs", and throughout most of the years since (with a few notable periods off). I was typically a secretive user, opting for solo k-holes vs public use at parties/raves or whatever. I definitely experienced a wide range of experiences, though the economics of my life ensured that I rarely had more than 3-4 grams onhand at any time, and could only purchase every so often. I largely managed to avoid the urinary complications that high dose users begin to experience, as I would typically limit my use to late at night, straight for a hole, with a xanax or ambien after I came out of it to go to sleep. I eventually stopped using it due to some pretty destructive adverse experiences with 3-ho-PCP, namely extended mania and emergent delusional symptoms that lasted for weeks after I ceased using it. All told, my relationship with ketamine is the longest and most in depth of all of my drug experiences. In retrospect, the mood elevation from ketamine was likely something I was unintentionally relying on to manage my own need to escape, and also seems to be a much shorter-lasting and limited intensity version of the effect that lead to mania from 3-ho-PCP use.
Due to my experiences with substance use and eventual opioid addiction/recovery, I eventually went back to school and became a psychotherapist in the early 2010s. I've worked with people who use drugs almost exclusively in the time since. I remember in the first few years of working in clinical settings, I started to hear people mention Ketamine as something that they were expressing interest in. I'd often react a bit cheeky when asked if I had heard of or knew anything about it. Everyone I have worked with is pretty aware of my *historical* substance use. I initially was a pretty big advocate for it, as I liked the drug personally, and wasn't blind to all of the research that was being released about it's benefits. I saw it is as one more step in the vindication of psychedelic spectrum drugs having positive impacts on the lives of users, something I had believed and expressed throughout most of my adult and professional life.
During the course of this, I also reconnected with traditional psychedelics, and began to move away from my focus on and use of ketamine. I was initially pretty stoked when psilocybin got slotted for clinical trials, and began to contemplate how I could someday integrate something like that (ideally mescaline) into my clinical practice. At the same time, cannabis legalization had taken firm root, and the *green rush* came to my state. Suddenly there was a whole bunch of cannabis related "wellness" advertising showing up around the city, and people who I would never have pegged as drug users would casually acknowledge their cannabis use, their interest in psilocybin retreats ("Have you seen that goop episode!?!"), and their increased curiosity about ketamine use. As I work in the public health side of health care, serving mostly homeless folks on medicaid or medicare, we rarely have the means to connect people to ketamine treatments. So most of this stuff remains the topic of conversations, rather than patient referrals.
I've really started to step back and question how this stuff is moving forward. The focus on profit alone is troubling, as well as the normalization and "part of a holistic wellness approach - namaste!" promotion that has gone on.... scares the shit out of me. I've even stepped back from seeing psychedelic assisted therapy as a future path to explore, and really think that I'd rather focus on psychedelic integration work, (you do your trip on your own time, we just talk about it before and process it after, figure out how to integrate it into your day-to-day life and apply it to whatever personal goals may be applicable). I think about the MDMA trials that got called out (and somewhat hushed up) for having an unlicensed "therapist" couple delivering an MDMA intervention that lead to the male "therapist" snuggling with a very distressed patient, as part of a grounding practice, but was really much closer to
sexual assault.
I think about how fragile the therapeutic relationship can be when working with folks who come in with significant trauma. Earning trust is only part of the process, you have to maintain that trust over time. It also becomes much, much easier, for clinicians to shift into autopilot once the initial challenge of a case has subsided, or the excitement of novel treatments or interventions bleeds away. I think about this with ketamine as well, it's a hot topic right now, and as mentioned in the article (thanks for sharing btw), most of the discussion is focused on the potential for benefit. The dirty, yet open, secret from our collective Street PhDs is, however, that this is the same stuff that used to be nicknamed psychedelic heroin. I remember the transition from kids I knew using MDMA on the come-up, and ketamine on the come-down, and a few years later it was coke to come up and dope (or benzos) to come down.
I also think about a concept "entering the mindset of a patient" when it comes to drug use. When we recreationally take powerful drugs that are addictive and also fun as fuck, we are drug users, and often see ourselves as such. We think of the consequences of our use through a lens of that behavior being recreational in nature. When the drugs stop being fun, that is when we might start to see trouble brewing. I was at a family party some years ago, right after medical weed became a thing here. I have this kooky aunt who used to have an addiction to benzos and percs, but had been in recovery for 15+ years. I had heard she had gotten into the medical weed, and generally seemed good with that, (maybe a bit kookier, but no worse for wear). Her brother was talking with her about the process of starting with medical cannabis and he asked "what is it prescribed for" and her response was "well the doctors, they're really nice, they find something to diagnose it for - they really want to help you!". Obviously, that may be true for some subset of physicians, but my guess is that it's more about having an easy side hustle that generates a tidy 250$ in billing with absolutely no subsequent patient care, or case involvement. Medical cannabis operates in an entirely different space than health care provision. It's not prescribed, there's no follow-up to determine efficacy, no dose recommendation, or significant quantity limits. If an eighth a week isn't enough, try a quarter! Throw some tincture, gummies, and lozenges into the mix while you're at it! Imagine that's how we approached adderall?
Except, there is a relationship between adderall and medical weed. The *the mindset as a patient*. 'I am taking this because it's medicine, and medicine is good for me, it's treating my <problem>.' It feeds into a pathological mindset that makes us see ourselves as sick, broken, or disabled. If we have side effects of our medicine, we may respond to them differently than having side-effects from a recreational drug experience. We also think about cessation much differently when discussing treatment of <problem> vs recreational use.
With ketamine, all of this stuff comes to mind, and it scares me. It's the next miracle cure in a long line of them, but as we explore deeper into the realms of psychedelic spectrum drugs, the consequences could be pretty dark, and those consequences could profoundly change core parts of a person. The potential for coercion, manipulation, and even the insidious ways in which grandeur can creep into provider/patient power dynamics, all exists as risks that we can't measure. How many self anointed acid gurus will be birthed by VC backed psychedelic medicine.
Finally, when it comes to ketamine, I worry about a much more difficult to nail-down effect of use. Psychopathology categorizes symptoms as "positive" and "negative";
Positive symptoms – any change in behaviour or thoughts, such as hallucinations or delusions.
negative symptoms – where people appear to withdraw from the world around then, take no interest in everyday social interactions, and often appear emotionless and flat.
With ketamine, especially when used chronically, there is definitely a risk of negative symptoms creep that can happen in ways that are much harder to identify and notice. What part of your personality becomes consistently deadened by ketamine use? As the article notes, we don't have any reliable data on long-term chronic ketamine use. Even if we did, we may not always be looking for the kinds of things that dissociatives can take away from a human. It's like, when people start on SSRIs, their mood may improve, but their libido takes a significant hit. What's the impact, over time, that that effect has on an intimate partner relationship? If your lover suddenly starts to feel less depressed, but also doesn't really want/need to have sex, that's gotta be a tough thing to wrangle with. Further, with SSRIs, I sense that they deaden more than just unpleasant parts of the emotional experience of a human. I worry that ketamine may have it's own version of phenomena as part of it's profile. Hard to nail down changes that could also profoundly alter intimate relationships. We're already a lonely bunch, moreso now than ever before, I worry that the enthusiastic marketing of dissociation may result in some unintended consequences.
