Ketamine Psychedelic Therapy?

[yoyoma8]

Here's the website of an addiction treatment facility in Florida doing ketamine psychedelic therapy:

www.eleusis.us

A lot of the science looks pretty promising, unheard of recidivism in addiction treatment, and especially given recent news items concerning research on ketamine as a magic bullet for treatment-resistant depression.

While more research certainly needs to be done, my question is about the feasibility/legality of using ketamine off-label like this in a private practice setting. Insurance reimbursement issues aside, why aren't more psychiatrists trying this? Especially with off-label use more a rule than an exception in psychiatry. I can't imagine many liability issues, given the low, sub-anesthetic doses used and the drug's very solid safety track record even at fully anesthetic doses. All in all, it seems like a really interesting way to combine psychopharmacology with psychotherapy.

Any thoughts?

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[dl2dp2]

I actually talked to the NIMH group who pioneered the ketamine for depression trial. there are a couple of pitfalls, one being that the effect doesn't seem to sustain. two being that infusion of ketamine requires pretty close monitoring. I think this is potentially a possible stream if further trails can bring this to standard of practice, then we can establish some protocol for psychiatrists to do emergent ketamine infusion, just like allergists have their desensitization protocol, rheumatologists have plasmaphoresis/IvIG protocol, etc.

But that's far in the future.

 

[billypilgrim37]

Ketamine is also one of the more common anesthetics to use w/ ECT. So you may have had pt's gettting ketamine therapy, thought they were getting better from the ECT, but were actually getting better from the combo. Speculation based on just a few cases, but neat to think about.

 

[RedPakotaSea]

Here's the website of an addiction treatment facility in Florida doing ketamine psychedelic therapy:

www.eleusis.us

A lot of the science looks pretty promising, unheard of recidivism in addiction treatment, and especially given recent news items concerning research on ketamine as a magic bullet for treatment-resistant depression.

While more research certainly needs to be done, my question is about the feasibility/legality of using ketamine off-label like this in a private practice setting. Insurance reimbursement issues aside, why aren't more psychiatrists trying this? Especially with off-label use more a rule than an exception in psychiatry. I can't imagine many liability issues, given the low, sub-anesthetic doses used and the drug's very solid safety track record even at fully anesthetic doses. All in all, it seems like a really interesting way to combine psychopharmacology with psychotherapy.

Any thoughts?

Thanks for posting. I didn't know this was being done.

The results are promising, but I'd like to see Krupitsky's research duplicated. I'd have to go to the library to look at the full study since I can't access it online. I'm certainly not surprised that a few small trials in Russia have failed to make a significant impact on mainstream psychiatric practice in the United States. That said, the results are no doubt impressive enough to warrant further study. There were loads of promising studies in the 1950s and 60s on psychedelic therapy for addiction and various other psychiatric diagnoses, but they didn't have near the level of methodological rigor that would be expected for publication in a peer-review journal today. It's still unfortunate that they've been disregarded due to Schedule I status, though research in this area is cautiously resuming.

Pilot study of psilocybin treatment for anxiety in patients with advanced-stage cancer.
The safety and efficacy of MDMA-assisted psychotherapy in subjects with chronic, treatment-resistant posttraumatic stress disorder: the first randomized controlled pilot study.
Psilocybin can occasion mystical-type experiences having substantial and sustained personal meaning and spiritual significance.

There are additional ongoing studies at NYU (psilocybin) and in Switzerland (LSD) for anxiety associated with advanced cancer.

The study using ketamine for treatment-resistant depression was no doubt groundbreaking, but as noted above, the drug-mediated relief appears to be short-lived. Also, the two uses of ketamine seem to be very different. First of all, the dose used in the treatment-resistant depression study was 0.5 mg/kg (light intoxication) compared to 2 mg/kg (full ego-dissolution) in ketamine psychedelic therapy. And secondly, the KPT protocol emphasizes a type of psychotherapy during reintegration (i.e. when you're back on Earth), to which it seems to attribute the lasting changes/abstinence.

 

[yoyoma8]

I guess what I'm specifically curious about is reactions to this treatment being currently implemented in a clinical setting, given that such techniques are years away from "standard of practice". Would you say it's any more radical for practicing clinicians to pioneer psychoactives as an adjunct to psychotherapy [as in these ketamine sessions] than it is to develop standard protocols for, say, off-label uses for Wellbutrin for ADD/ADHD?

I guess a more fundamental question concerns the place of an individual practitioner to explore treatment options like this, without waiting for universal acceptance in the academic community, especially given that full-blown ego dissolution doesn't really lend itself to the double-blind, placebo-controlled studies that a peer-reviewed journal usually demands, which of course was the same problem encountered in some of the scientifically "unrigorous" psychedelic studies from 50 years ago. Come to think of it, it's a "problem" in evaluating/comparing psychotherapeutic techniques in general, and a "problem" in all but the most stringently biomedical aspects of psychiatry.

In short, are Krupitsky and his team doing anything wrong? Can they get into any sort of trouble? Does the very fact of their practice existing lend any credibility to the practice, inasmuch as it's creating a large-scale testament to, if nothing else, the safety of the treatment?

Sorry if these questions seem demanding or frivolous. I'm a med student leaning toward psych, and I guess I'm still trying to get a handle on how the field actually works outside an academic setting.

 

[TexasPhysician]

This seems really interesting!

 

[zac16125]

It seems to me that the social stigma associated with pyschadelics will likely prevent their widespread use, both clinically and in research. Anyone interested should check out the book "DMT:The Spirit Molecule" by Rick Strassman, MD. Before he gets into his own research, he runs through a brief history of pyschadelics in pyschiatric research. You will see that throughout the years there have been a number of promising research endeavors with pyschadelics, all of which kind of, for lack of a better word, fizzled out, often for not very good reasons (governmental or social pressures of using "recreational" drugs in research for example). Its a shame really, that a potentially promising approach to helping mentally ill patients, or even grasping a better understanding of consciousness and perception, will likely never reach its full potential.

 

[Sneezing]

Ketamine infusions are in the research stages at various places in the country. Researchers can do what ever they want - as long as they have funding, IRB approval, and consenting patients.

As for private practice, it is an FDA approved medicine. You can use it however you want. You can use it to treat tension headaches if you wanted. However, to mitigate risk of any kind of lawsuit you had better document a lot detailing what side effects you discussed, its non-standard of practice status, and even get a patient signature of consent. Even then it might not be enough in a court case that becomes sensationalized. You'd want to also check your insurance policy to see if it covers such a treatment, if it doesn't, ask yourself, is it worth the risk?

 

[zac16125]

Ketamine is one thing, but citing the positive effects shown in one of the studies above, what about a substance like MDMA? I can't imagine the average psych doc being allowed to conduct MDMA-assisted psychotherapy, even if there is literature in the medical journals showing its effectiveness. Or am I wrong there?

 

[whopper]

From a forensic perspective...

Does giving out Ketamine meet the standard of care for the treatment of depression? No. It is not a standard practice. It has no endorsement from any of the recognizable groups such as the FDA or APA.

The data on this field is still in the early stages.

Factor in that Ketamine is a substance of possible abuse. That alone increases the risks of damages among other problems.

Would I consider this type of therapy? Only in the most extreme of circumstances. E.g. a treatment resistant and very dangerous patient and among other things having several other doctors consulted because it's a practice outside the norm.

In a long-term facility, you do sometimes encounter way extreme cases. E.g. Clozapine resistant and ECT resistant patients (I'm talking both together, not separately). It's rare and you'll pretty much never see that elsewhere because in other clinical scenarios, they'll merely just refer and transfer the patient to the next higher level of care. At a long-term facility, the buck stops with you.

Oh and by the way, how do you calm down a dangerous patient that is very manic and psychotic and ECT and Clozapine and pretty much every medication resistant? Sure and heck beats me. There's a patient that (thank the Maker), is not on my unit, but was a former patient of mine, and nothing works on her and she's dangerous. Whenever she screams and becomes threatening, all we can do is put her in restraints.

That is a situation where I'd consider doing something completely novel and out of the ordinary.

 

[loveoforganic]

Ketamine is one thing, but citing the positive effects shown in one of the studies above, what about a substance like MDMA? I can't imagine the average psych doc being allowed to conduct MDMA-assisted psychotherapy, even if there is literature in the medical journals showing its effectiveness. Or am I wrong there?

MDMA is schedule i, so I don't think there's any legal way for a doc to obtain it outside of research.