can anyone prescribe ketamine lozenges?

[psych]

Hi, I just started a new clinic. I am inheriting patients from another doctor. Today I saw someone who takes ketamine lozenges 100mg PRN. She is trying to taper off but is this something I can refill? Without any certification? I just want to make sure if I do research and feel comfortable prescribing it, I'm not breaking any law... I'm in CA.

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[PikminOC]

Hi, I just started a new clinic. I am inheriting patients from another doctor. Today I saw someone who takes ketamine lozenges 100mg PRN. She is trying to taper off but is this something I can refill? Without any certification? I just want to make sure if I do research and feel comfortable prescribing it, I'm not breaking any law... I'm in CA.

I wouldn't prescribe that.

 

[psych]

I wouldn't prescribe that.

It's a women in her mid 50s who uses it ~1x/month at this point but was on it weekly 2/2 psychosocial stressors. I'm not worried she's abusing it but this surprised me today so I don't know if I tell the clinic no, or what...

 

[psych]

It's a women in her mid 50s who uses it ~1x/month at this point but was on it weekly 2/2 psychosocial stressors. I'm not worried she's abusing it but this surprised me today so I don't know if I tell the clinic no, or what...

& on no other meds

 

[whopper]

If you're licensed yes you can but do you want to do so? Your pharmacist if they have at least some vigilance will highly question what you are doing.

I have 2 colleagues who used to do Ketamine IM. Their insurance companies told them they will no longer be covered by their insurance if they continued Ketamine IM, and that they must use Spravato or else.

 

[TexasPhysician]

First get malpractice approval as ketamine isn’t standard on what is covered. As someone who uses ketamine, I don’t provide outside of monitored clinic use. Esketamine is FDA approved, but in my experience, it doesn’t work near as well as racemic through non-nasal options. Esketamine did set the bar on REMS requirements though in my opinion. If esketamine must be monitored, it will be hard to show how ignoring expert recommendations to Rx racemic for home use is appropriate.

 

[psych]

Okay this is helpful... I guess since I switched to all telework because of COVID, I wasn't sure if I was missing something... Like, is this common practice and I'm behind the times...

 

[whopper]

It's not common practice. It wouldn't be standard of care if you offered it. One could argue that you're within safe territory weaning someone off of it, but this is arguable.

 

[hamstergang]

who uses it ~1x/month at this point

She is trying to taper off

What does it mean to be tapering off at this point if she only uses it about once per month?

 

[whopper]

Exactly why this is arguable.

 

[psych]

What does it mean to be tapering off at this point if she only uses it about once per month?

she was on it weekly but would take it less and less and reports now it's only once a month if there are stressors (last was divorce mediation)

 

[comp1]

This is outside of the standard of care. It might not be wrong, but it's not standard. It's not even available commercially, right? You have to get it made at some sort of compounding pharmacy.

 

[psych]

I'm going to tell the clinic not to schedule patients who are on ketamine. I'm going on maternity leave in Nov/Dec so after that I probably will ask this patient establish care with a new psychiatrist if she wants to continue the medication. She has #8 lozenges so she shouldn't use them before then....

 

[allantois]

what is she gonna wean off to - once a year? at this point just substitute for another prn medication

 

[adiradirim]

Psychiatrists in my area regularly prescribe ketamine lozenges, troches, and nasal sprays to patients with depression. It is much cheaper than esketamine. It requires a DEA license since it is Schedule III, but legally it is fine. On the pain management side I have personally prescribed ketamine compounded pain creams as well as oral ketamine for palliative patients.

There was an online startup I heard about where a PMR doctor was selling "ketamine experiences" for $300 a dose with a psychotherapy session included with an LISW virtually.

 

[nexus73]

Psychiatrists in my area regularly prescribe ketamine lozenges, troches, and nasal sprays to patients with depression. It is much cheaper than esketamine. It requires a DEA license since it is Schedule III, but legally it is fine. On the pain management side I have personally prescribed ketamine compounded pain creams as well as oral ketamine for palliative patients.

There was an online startup I heard about where a PMR doctor was selling "ketamine experiences" for $300 a dose with a psychotherapy session included with an LISW virtually.

is there an evidence base for this dosing route of ketamine? And patients just take it home?

 

[adiradirim]

is there an evidence base for this dosing route of ketamine? And patients just take it home?

Last time I reviewed the literature for depression, the articles say "it works!" with absolutely no standardized dosing regimen. Articles fluctuated between once a month and TID dosing with dose ranges from meager to heroic.

Compounding pharmacies have to make it, so patients will either have to pick it up or the pharmacies will ship it to patients' houses.

I think it is within the scope of a psychiatrist, but really recommend extensive research into it before prescribing it.

 

[clozareal]

Psychiatrists in my area regularly prescribe ketamine lozenges, troches, and nasal sprays to patients with depression. It is much cheaper than esketamine. It requires a DEA license since it is Schedule III, but legally it is fine. On the pain management side I have personally prescribed ketamine compounded pain creams as well as oral ketamine for palliative patients.

There was an online startup I heard about where a PMR doctor was selling "ketamine experiences" for $300 a dose with a psychotherapy session included with an LISW virtually.

I've seen psychiatrists in my area prescribe ketamine troches and gummies from compounding pharmacies as well. The patient that I saw was taking them on a daily basis.

 

[hamstergang]

she was on it weekly but would take it less and less and reports now it's only once a month if there are stressors (last was divorce mediation)

But at once per month there's no physiologic tapering going on anymore. And if she's just using it as a prn, then there's no guarantee of increasing or decreasing frequency of use. Why would you expect her to need it less and less frequently over time at this point?

 

[smalltownpsych]

Knowing how this type of thing goes, it’s going to be everywhere soon and it’s going to cause lots of problems and eventually there will be backlash. I’m so jaded that at this point I don’t even care. Just not going to be a part of it and will continue to focus on helping my patients. Sad because I have been part of highly effective ketamine treatments so I know it works.

 

[deleted1100659]

I agree with the majority in that it seems kind of pointless to prescribe it, I dont really understand the goal. Especially not being on anything else? So she has severe depression once a month but is perfectly fine other then that? Divorce is stressful, I know that all too well, but I question how helpful ketamine would be for that. I think therapy would be a more effective route +/- a SSRI.

 

[Stagg737]

Never seen anyone on PRN Ketamine before. She actually sounds like the kind of patient I'd consider starting on Xanax #15 tabs as at this pace she'd only need to fill once a year. If she's needing something more frequently, gabapentin is probably most similar in terms of NMDA-like effects that would be an acceptable option. She doesn't sound like someone willing to take a daily antidepressant, but if she were I'd probably consider fluoxetine given she's not taking anything else and its effects on NMDAr sub-units.

Also agree 100% that she needs to be doing therapy if she isn't or hasn't. She sounds like a pretty ideal candidate for CBT.

 

[SeniorWrangler]

I used to prescribe ketamine nose spray once in a while for pain but I wasn’t really impressed with the results. Ketamine has significant abuse potential and street value so I would be very cautious about this, especially lozenges and injectables.