Ketamine In My Practice

I have been training in the use of ketamine since early 2021, both experientially and through structured lectures spanning medical safety and implementation to ketamine-assisted psychotherapy (known as KAP). I want to clarify two distinct uses of KAP. In one setting, sub-anesthetic doses are used that can place a patient in an altered state of consciousness; there is no discussion or therapy happening in this state. Instead, the psychotherapy portion may come immediately after the ketamine experience during recovering or, ideally, within a 48-hour time frame following drug administration when the window of neuroplasticity is heightened. This is different from the use of even smaller doses of ketamine, often provided sublingually or via nasal spray, that keep the patient in a state where they can easily converse with their therapist while they are actively under the influence of the drug. The influence of ketamine often allows for a more open state of exploration. I do not practice KAP directly with my patients as I am not a licensed therapist, but it is important to understand what it offers and how it can be implemented, as for many it can be integral to ketamine‚Äôs benefits. 

My own explorations with ketamine have been my greatest teacher and I highly encourage anyone seeking ketamine therapy to choose practitioners and administrators that have experienced it themselves; you would be surprised at the number of providers that have not experienced what it is they are providing and I believe this does a disservice to patients. With first-hand experience and careful observation from patients undergoing treatment, I have curated a ketamine experience often elevated from other places from needle choice and placement (no reason to use large needles here!), to eye mask and music choice, to how the ketamine itself is dosed. Many places are also often prophylactically dosing patients with medications that aren’t necessary for them, sometimes without understanding this is taking place, which risks creating a less enjoyable experience (for example, an anti-histamine is often dosed leaving patients more groggy and tired than needed after treatment). These are options in my practice, and no-one is a getting a one-size-fits all experience. Patients that have had ketamine experiences elsewhere often cite their experience with me to be superior.

Many clinics administer ketamine via intramuscular (IM) injection or oral lozenge (also called a troche), largely for logistical ease in comparison to intravenous (IV) administration, delivered through the vein. For a variety of reasons I am partial to IV ketamine and this is what I choose to offer in my practice; I find it has a more gentle onset, longer duration of experience, and is more quickly cleared by the body (observational, not studied). It also provides patients a sense of comfort and control knowing the administration of the medicine can be stopped at any time (to date, I have had no patients ask for this). 

One of the difficulties mainstream medicine has with ketamine is that there is no real standard dosing when used for therapeutic reasons –  the amount needed to achieve psychotropic effect is not always dependent on weight (even though this is what determines dose in most medical settings), gender, or age, and a lack of standardization is a bane to the conventional medical paradigm. That being said, there is a range to work within in ketamine therapy and a skilled ketamine provider will assess an individualized starting dose for each patient and increase as appropriate. There are ketamine clinics across the country that give every person the same, fixed dose. While I believe those patients can still achieve therapeutic benefit, I imagine it could be much greater if overseen by a practitioner or clinic that is attuned to the dosing nuances of this therapy.

In my practice, I personally administer all ketamine IVs, not a nurse, and check in with patients at certain points in the treatment, adjusting dose as indicated to curate the most beneficial experience for them. I also sit in on sessions when requested.  Patients are otherwise equipped with a button that alerts me if they need assistance. Music plays a large role in the ketamine experience and a specially curated playlist is offered along with a high-quality eye mask to limit external distractions. Patients drip anywhere from 40-45 minutes and then provided an hour to recover and contemplate their experience post-treatment. Before leaving, we have a debriefing period. Patients may receive as many as 10 sessions within a 5-week period, or less frequently depending on need and response.

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photography: courtneypaigeray.com