ketamine clinic

[gomavs]

Alright, seeing more and more of these not run by psychiatrists. Have seen some ABEM folks running them. Some of them claim to have some advance training in addiction/psych..... most don't. Not sure how I feel about it. On one hand, it seems ripe for easy money and you may be able to benefit some folks. Most of us feel pretty safe with ketamine given how frequently we use it in the ED. I can't get past a few things though.

1)Scope of practice
- Are we qualified to treat people with a psychoactive drug for mental health disorders? Sure, it's generally safe but...

2)Safety
-The drug isn't without risk. Most hospital policies still require an anesthesiologist or ED MD and RT to be in the room to administer more than a sub dissociative dose. I can't really find much info on what kind of dosing these folks are doing but, in a pay to play environment I'd guess they are being heavy handed.

3)Future ramifications
-If any of ya'll are younger out there or have friends that are in other fields...ketamine is getting pretty popular as a recreational drug. While it isn't known to be harmful outside of rare instances like laryngospasm etc, I feel like this could be a ticking time bomb effect if **** goes sideways and the public comes after these after some bad outcomes. That being said, we are in a time of increasing deregulation for psychedelic therapeutics with mushrooms etc.

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[Apollyon]

"Getting"? It's been a popular party drug for many years.

 

[bky3c]

"Getting"? It's been a popular party drug for many years.

Yep, we had a nurse who was found down in the ED bathroom after stealing some and using it during her shift about 10 years ago, and I assume she wasn't blazing new trails as far as recreational drugs go.

 

[jwk]

Doesn't have to be docs in a lot of states to open up these clinics. CRNAs and NPs are opening them right and left, frequently along with IV hydration, semaglutide, vitamin infusions, etc.

 

[sloh]

Doesn't have to be docs in a lot of states to open up these clinics. CRNAs and NPs are opening them right and left, frequently along with IV hydration, semaglutide, vitamin infusions, etc.

Semaglutide drives the effect of weight loss. Hitched on with a bunch of other shenanigans “you definitely need for the perfect cocktail.”

Cha-Ching.

 

[beebermd]

Ive been doing them in my office for about 2 years now. Its really not that big of a deal, assuming you are set up to handle any complications. It is only done while I am in office (not in the ER), I have a full crash cart and intubation/airway mgmt capability in my operating room. Ive never had to use them, as we are only using sub anesthetic doses, but its almost mandatory from a liability perspective. The more important part is using it in a way that is benefecial to the patient. There is a lot of information and studies out there. Its not a huge part of my practice as its really only indicated for like 5 condtions, so its really limited pool of patients. But ive had some great results in the patients that have undergone treatment. I see a lot of places that are dedicated ketamine ONLY clinics.........dunno about that. In order to sustain a buisness on ketamine alone, my first thought its they are treating everyone that comes through the door. Sketchy at best

 

[dozitgetchahi]

Note that nasal esketamine (Spravato) is now officially FDA approved for treatment resistant depression. It has a REMS and is administered in psych offices. I’m not sure what the advantage is of continuing with off label IV ketamine infusions for this, other than to generate $$$.

 

[VA Hopeful Dr]

Note that nasal esketamine (Spravato) is now officially FDA approved for treatment resistant depression. It has a REMS and is administered in psych offices. I’m not sure what the advantage is of continuing with off label IV ketamine infusions for this, other than to generate $$$.

Because not every psychiatrist does those.

 

[pazzer2]

Eskatamine (Spravato) is administered intranasally. It does have a 2 hour monitoring period (BP and respirations). Plus a lot of insurance providers will now pay for it. A lot easier than IV ketamine. I imagine that a lot of psych offices are not setup to handle the 2 hour monitoring so there seems to be a gap needing to fill.

 

[thegenius]

Eskatamine (Spravato) is administered intranasally. It does have a 2 hour monitoring period (BP and respirations). Plus a lot of insurance providers will now pay for it. A lot easier than IV ketamine. I imagine that a lot of psych offices are not setup to handle the 2 hour monitoring so there seems to be a gap needing to fill.

What is a standard, or range, of intranasal ketamine dosing? How many mg?

 

[pazzer2]

What is a standard, or range, of intranasal ketamine dosing? How many mg?

Not sure you can directly compare IV and intranasal dosing. The kinetics are a little different. But the Spravato label says that induction phase dosing is 56 mg on day 1, followed by 56-84 mg. Then either once weekly or every 2 weeks during maintenance phase.

 

[thegenius]

Not sure you can directly compare IV and intranasal dosing. The kinetics are a little different. But the Spravato label says that induction phase dosing is 56 mg on day 1, followed by 56-84 mg. Then either once weekly or every 2 weeks during maintenance phase.

Yea I figured there is no direct comparison. But there's about a 2:1 ratio between strength of IV vs IM, roughly speaking. That is...full induction dose of ketamine IV is 2 mg/kg vs 4 mg/kg IM. So giving basically 0.7 - 1 mg / kg IN...frankly...is higher than I expected.

What I was questioning is whether people need to have vitals monitored for 2 hours after getting the IN dose. that was the reason for my comment.

 

[pazzer2]

Yea I figured there is no direct comparison. But there's about a 2:1 ratio between strength of IV vs IM, roughly speaking. That is...full induction dose of ketamine IV is 2 mg/kg vs 4 mg/kg. So giving basically 0.7 - 1 mg / kg IN...frankly...is higher than I expected.

What I was questioning is whether people need to have vitals monitored for 2 hours after getting the IN dose. that was the reason for my comment.

Ok gotcha. Yes monitoring for 2 hours is required, even after a IN dose.

 

[Restart13]

Ive been doing them in my office for about 2 years now. Its really not that big of a deal, assuming you are set up to handle any complications. It is only done while I am in office (not in the ER), I have a full crash cart and intubation/airway mgmt capability in my operating room. Ive never had to use them, as we are only using sub anesthetic doses, but its almost mandatory from a liability perspective. The more important part is using it in a way that is benefecial to the patient. There is a lot of information and studies out there. Its not a huge part of my practice as its really only indicated for like 5 condtions, so its really limited pool of patients. But ive had some great results in the patients that have undergone treatment. I see a lot of places that are dedicated ketamine ONLY clinics.........dunno about that. In order to sustain a buisness on ketamine alone, my first thought its they are treating everyone that comes through the door. Sketchy at best

What generally are you practicing in the office as an EM trained doc? Urgent care, PCP/concierge medicine? weight loss clinic? I have a mild opportunity but too soon for me to branch off into weight loss, follow up appointments, etc.

 

[deleted1183938]

Ive been doing them in my office for about 2 years now. Its really not that big of a deal, assuming you are set up to handle any complications. It is only done while I am in office (not in the ER), I have a full crash cart and intubation/airway mgmt capability in my operating room. Ive never had to use them, as we are only using sub anesthetic doses, but its almost mandatory from a liability perspective. The more important part is using it in a way that is benefecial to the patient. There is a lot of information and studies out there. Its not a huge part of my practice as its really only indicated for like 5 condtions, so its really limited pool of patients. But ive had some great results in the patients that have undergone treatment. I see a lot of places that are dedicated ketamine ONLY clinics.........dunno about that. In order to sustain a buisness on ketamine alone, my first thought its they are treating everyone that comes through the door. Sketchy at best

Can you tell me about your results? Curious. Anesthesiologist here, not even thinking of this but my ICU friend is. Sounds like too much trouble to me as I don’t even have an office .

 

[beebermd]

What generally are you practicing in the office as an EM trained doc? Urgent care, PCP/concierge medicine? weight loss clinic? I have a mild opportunity but too soon for me to branch off into weight loss, follow up appointments, etc.

Can you tell me about your results? Curious. Anesthesiologist here, not even thinking of this but my ICU friend is. Sounds like too much trouble to me as I don’t even have an office .

My office is mainly Aesthetics, lipoplastic surgery, HRT and weight loss. I have an NP who handles most of the HRT. Im actually in office once or twice a week. I do all the aesthetics, like botox and fillers, and I do liposuction/Fat transfers (face, breast and buttocks) as well. I learned all these skills to specifically get out of the ER. Ive had some really good responses to the ketamine therapy as long as they are appropriate candidates. I usually do six sessions, at least one session a week, slowly titrating up to a max of .5mg/kg over 40 minutes. After the first six, it just depends on the pt, they may come get one every month or so when they start feeling bad again. Admittedly, there are some people that it hasn't had much of an effect on. I will usually suggest stopping treatment if they have no effect after 3 or 4. Also, they are only done while I am present in office for obvious reasons.

 

[HemorrhagicShock]

My office is mainly Aesthetics, lipoplastic surgery, HRT and weight loss. I have an NP who handles most of the HRT. Im actually in office once or twice a week. I do all the aesthetics, like botox and fillers, and I do liposuction/Fat transfers (face, breast and buttocks) as well. I learned all these skills to specifically get out of the ER. Ive had some really good responses to the ketamine therapy as long as they are appropriate candidates. I usually do six sessions, at least one session a week, slowly titrating up to a max of .5mg/kg over 40 minutes. After the first six, it just depends on the pt, they may come get one every month or so when they start feeling bad again. Admittedly, there are some people that it hasn't had much of an effect on. I will usually suggest stopping treatment if they have no effect after 3 or 4. Also, they are only done while I am present in office for obvious reasons.

Tell us more about how you grew the balls to start something like this and leave the ER. These are the ideas and stories we need around here. I love that you got out and are doing something clinic-based and awesome like this.

How did you pick up and learn the aesthetics skills? Did you one of these weekend CME-type courses, buy a bunch at wholesale, and just start doing it? Learn as you go approach?

Also, do you think the market for what you're doing is saturated now that PAs and NPs can do what you're doing solo?

 

[beebermd]

Tell us more about how you grew the balls to start something like this and leave the ER. These are the ideas and stories we need around here. I love that you got out and are doing something clinic-based and awesome like this.

How did you pick up and learn the aesthetics skills? Did you one of these weekend CME-type courses, buy a bunch at wholesale, and just start doing it? Learn as you go approach?

Also, do you think the market for what you're doing is saturated now that PAs and NPs can do what you're doing solo?

Basically, my np partner had a buddy who had a clinic that was doing it (with out lipo). We basically franchised from him and took the basic frame work. Premise is pretty simple. All cash, no insurance. Everything runs through clinic from the bloodwork to the meds. no scripts. I partnered with labs and compound pharmacies. I negotiate a really big discount for their services and medications. Pts pay for labwork (drawn in house and sent out to them) at the retail price to the clinic, lab sends me an invoice every month. The difference is the my profit. Same with meds.....pts pay for all meds at retail price to the clinic........Scripts is electronically sent to the pharmacy and shows up at the patients door 2 days later. I get an monthly invoice. The difference is my profit. Put them on an auto pay with auto refills with pharmacy and its prety much just touching base with them every month or so to monitor and adjust as needed.

The idea was to hire an midlevel to do the aesthetics as well, I started doing the botox and fillers at the beginning to save overhead, but there was a lot of positve feedback about people having these done by an physcian as opposed to a mid level. It had a lot of added value, so i kept at it. read a couple of books and had a friend who did it show me the ropes. Its really not that hard. Youtube has a ton of info on different techniques as well.

When it looked like this could turn into pretty good exit strategy, i decided to do lipo to specifically so that NP and PAs CAN'T do what im doing. I took about 6 days in bayonne, NJ to train in the artform from a physician who openely offers and trains other physicians in lipolasty. By only doing Lipoplastics, it has become my niche. If I have to cut, I refer you to one of my plastic buddies. People will come to me for lipo over a plastic surgeon because it is the only thing I do. I specialize in that one procedure. If i did more, it would put me in the same realm as plastics and at that point there would be no reason to chose me over a plastic surgeon. Doing more would dilute my market advatage, so to speak. Its all done under local anesthetic, in my office. Its very profitable. Take 1L of NS, throw in 50cc of 2% lido with epi and 15ml of bicarb and start infiltrating the area. I may use 3L during a case. thats pretty much my overhead. Other than the initial cost of the equipment, maybe (10k) and some drapes/tubing. I started with this book........SUPERFICIAL LIPOSCULPTURE: MANUAL OF TECHNIQUE By Marco Gasparotti & Carson M. literally, doing liposuction with no machines, just a disposable syringe with local infiiltration. I was amazed and hooked on the procedure ever since.

So im not really worried about the market bieng saturated. My market is exists in an area that midlevels cant reach, and is not enough of a turf invasion for the plastics to really care about. Being a phycian doing these things brings value patients are willing to pay for, and if they arnet, then they are probably not the patients i want honestly.

 

[HemorrhagicShock]

@beebermd Amazing post. Simply amazing. Can't thank you enough! Keep it coming if you have more stories about building a medical business.

One question: what do you mean that your market "exists in an area that midlevels can't reach"

Could they not do this solo?

 

[beebermd]

@beebermd Amazing post. Simply amazing. Can't thank you enough! Keep it coming if you have more stories about building a medical business.

One question: what do you mean that your market "exists in an area that midlevels can't reach"

Could they not do this solo?

they cant do liposuction and fat grafting. eveything else, sure

 

[TooMuchResearch]

they cant do liposuction and fat grafting. eveything else, sure

I sent you an overly long private message if you have a chance to take a look

 

[betamale]

Matthew Perry’s Assistant and Doctors Charged With Getting Him Ketamine

Five people have been charged with a conspiracy to distribute the powerful anesthetic that led to the death of the “Friends” star. Three of them are pleading guilty.

www.nytimes.com

Careful, ER guy arrested. Medicolegal minefield. Can’t imagine working in the ED and moving onto an even riskier practice and worse patients

 

[Kryptocoin]

Matthew Perry’s Assistant and Doctors Charged With Getting Him Ketamine

Five people have been charged with a conspiracy to distribute the powerful anesthetic that led to the death of the “Friends” star. Three of them are pleading guilty.

www.nytimes.com

Careful, ER guy arrested. Medicolegal minefield. Can’t imagine working in the ED and moving onto an even riskier practice and worse patients

Rookie mistake: selling and distributing a controlled substance. That's what they got busted for.


As long as you inject/administer the ketamine in your clinic, I don't see any issues. I personally won't work in a ketamine mill but it's fairly safe and legal.

 

[Tiger26]

Rookie mistake: selling and distributing a controlled substance. That's what they got busted for.


As long as you inject/administer the ketamine in your clinic, I don't see any issues. I personally won't work in a ketamine mill but it's fairly safe and legal.

Another rookie mistake is doing it for a celebrity. How many drug dealers does our government not care about until a celebrity or child of a congress person dies?

 

[BoardingDoc]

Another rookie mistake is doing it for a celebrity. How many drug dealers does our government not care about until a celebrity or child of a congress person dies?

You don't know when the random crackhead is some senator's kid though. Just do everything above board. Even in loosely regulated industries there are usually generally accepted practices.

Don't be the guy that does doses multiple times higher than the other clinics in the area.

Don't distribute/Rx meds, administer in clinic only.

Have appropriate monitoring.

I don't personally see the appeal of running a ketamine clinic but I also don't see how you're likely to get in trouble for doing so as long as you can point to some evidence based practice guidelines and actually stick to them.

 

[EMhawkeye]

Sounds like he was selling him the vials from what I was reading. No different than a doc selling rx’s for narcotics. Just as stupid and illegal.

 

[TooMuchResearch]

Matthew Perry’s Assistant and Doctors Charged With Getting Him Ketamine

Five people have been charged with a conspiracy to distribute the powerful anesthetic that led to the death of the “Friends” star. Three of them are pleading guilty.

www.nytimes.com

Careful, ER guy arrested. Medicolegal minefield. Can’t imagine working in the ED and moving onto an even riskier practice and worse patients

Did you read it?

What happened: Supplied him with ketamine.
Not: gave him an appropriate dose in a controlled setting.

 

[calvnandhobbs68]

Fellas whatever you decide to do it's gonna be better than this

https://www.wsj.com/health/wellness/ketamine-shots-at-home-test-limits-of-unproven-treatment-60346d10?mod=hp_lead_pos5

"Mindbloom started offering faster-acting injectable ketamine in addition to lozenges in February.

Customers receive a blood-pressure cuff along with supplies for injecting the drug. Mindbloom tells them to monitor their blood pressure and have someone watch them while they are under the influence of a drug that can impart out-of-body sensations or depress breathing. No training is required for the person watching them."

 

[southerndoc]

Matthew Perry’s Assistant and Doctors Charged With Getting Him Ketamine

Five people have been charged with a conspiracy to distribute the powerful anesthetic that led to the death of the “Friends” star. Three of them are pleading guilty.

www.nytimes.com

Careful, ER guy arrested. Medicolegal minefield. Can’t imagine working in the ED and moving onto an even riskier practice and worse patients

ER guy? Is that what we're calling a med/peds doc who worked a few shifts in an ER and now staffs an urgent care clinic?

Probably wouldn't have been arrested had he not texted wondering "how much this ***** will pay" and using code. Calling ketamine Dr. Pepper and vials cans screams of dealing drugs.

 

[betamale]

ER guy? Is that what we're calling a med/peds doc who worked a few shifts in an ER and now staffs an urgent care clinic?

Probably wouldn't have been arrested had he not texted wondering "how much this ***** will pay" and using code. Calling ketamine Dr. Pepper and vials cans screams of dealing drugs.

ya, Dr. Mark Chavez, ABEM doc from Cali, runs a Ketamine clinic.

 

[southerndoc]

ya, Dr. Mark Chavez, ABEM doc from Cali, runs a Ketamine clinic.

Ah, I was thinking of the other one (Perez).

 

[BJJVP]

His commentary is a little inaccurate and unfair to doctors but I think his overall criticism of America's faith in medications being able to fix all ailments is not wrong

 

[nexus73]

His commentary is a little inaccurate and unfair to doctors but I think his overall criticism of America's faith in medications being able to fix all ailments is not wrong

He said some garbage about how there is no opioid fairy. But in reality there is, or something akin to it, via the immensely powerful forces of opioid manufacturers fraudulently manipulating data about how Rx opioids are not addictive when used for legitimate pain, marketing to doctors to push to higher and higher doses for patients (Purdue pharma's Oxycontin 160 mg tablet...anybody think this was a stroke of genius? For the stock price probably), and getting the whole pain as the 5th vital sign (so you better treat it you idiot doctor, or you're gonna get sued and board sanctions until the cows come home).

We are in the mess with opioids because of the Rx opioid push caused by Purdue pharma. The DEA cracked down on Rx opioids, so people switched to heroin, and now to it's cheaper and more potent cousin, Fentanyl. Bill Maher should know this and not blame doctors as a whole. If doctors prescribed take home doses of ketamine for Mathew Perry, they're obviously idiots, unethical, blinded by celebrity and likely the money they're getting paid. That is not all doctors.

 

[EMhawkeye]

Yeah, he definitely painted us with a broad brush, but he loses me frequently when he starts talking about healthcare and goes down an anti-VAX rabbit hole. He also loses me when he goes down some of his COVID-19 rants. He likes to critique how we handled Covid completely ignorant to the fact of the hell we went through for almost 2 years. Coding patients in the hallway.
Also ignorant to the fact of the mortality rate, the first six months of the pandemic. He likes to point out the mortality rate similar to the flu. Well, it wasn’t in the first six months genius