Does Ketamine Have a Dark Side?

“I was just coming out of a K-hole when you called,” says Hardy Brooklyn, a 50-year-old life coach and performance artist who lives in New York. His doctor recommended ketamine therapy to treat his hip pain and general anxiety disorder. He has undergone three infusions so far over the course of a year and a half, and if it weren’t so expensive—$400 per infusion—he says he would probably get one monthly, although he also occasionally uses a ketamine nasal spray at home prescribed by his doctor.

Indeed, ketamine is becoming increasingly popular, both as a recreational drug and as a legal treatment for a range of ailments, including PTSD, depression, and physical pain. “The versatility of this molecule—both in its delivery method and in the dosage ranges—[with] each dose [seeming] to do something different for each person, makes it a wonderful molecule to work with,” says Erica Zelfand, ND, a family physician in Portland, Oregon who uses ketamine to treat some of her patients. “We need something new in the field of psychiatry and ketamine’s mechanism of action is very appealing.” 

Although Zelfand prescribes the drug and teaches workshops on ketamine-assisted therapy for healthcare providers, she nevertheless has qualms about the growing number of ketamine clinics. “From a business standpoint, ketamine is a big money maker. The drug is dirt cheap and you can charge a hefty fee for administering it, and that gives me some concerns as a healthcare provider,” she says. “I suspect it’s being over-prescribed and over-administered.”

Access to treatment at specialized clinics remains limited due to its high cost (anywhere from $350 to as much as $1,250 dollars), which usually goes uncovered by insurance because ketamine is not approved by the FDA for any other use than anesthesia (although in legal clinics, it’s used off-label). But ketamine use is also prevalent among spiritual seekers, psychonauts, and in the party scene, where cases of abuse are frequent. 

“From a business standpoint, ketamine is a big money maker. The drug is dirt cheap and you can charge a hefty fee for administering it, and that gives me some concerns as a healthcare provider,” Zelfand says.

“In San Francisco it’s an epidemic of people using ketamine,” says Paul Abramson, MD, a California-based primary care physician in San Francisco who offers full spectrum medical care, as well as behavioral health and addiction treatment. He calls ketamine “one of the most addictive substances on the planet,” pointing to its psychological hold on the user, rather than physical. Many people enjoy ketamine for its psychedelic properties and for the dreamy and floaty feelings it provides, coupled with meaningful insights. Higher doses will make the user enter a k-hole, in which one may feel their consciousness leave the body. “For a subset of people, it is the most interesting thing they have ever experienced and something they feel like they have to keep doing,” says Abramson. “That can be a very powerful draw that can lead to daily use and hiding the use, and can eventually lead to paranoia and the loss of important things in their life like people, work, et cetera.” 

Ketamine’s Dual Nature

The current discourse around ketamine’s benefits in medical settings contrasts sharply with its well-known and lesser-mentioned risks when not used in such contexts. It has a dark side that manifests in the form of isolating addiction and heavy use that can cause damage to organs, especially the bladder. Horror stories about addiction, submitted by anonymous users to Erowid, and coverage in the late 2000s about the epidemic of abuse among young users in the United Kingdom are examples of how ketamine use can spiral out of control and have potentially irreversible consequences (such as bladder removal in extreme cases).

Dr. Zelfand explains that bladder damage is ulcerative cystitis: “It happens when ketamine starts degrading the lining of the bladder creating sores or ulcers,” she says, adding that most of our knowledge about the toxicity of this substance comes from the context of surgical interventions and anesthesia. “What we are seeing here, in abuse settings, is a totally different animal. It’s one large dose once -as in surgery- versus many lower doses taken repeatedly,” she notes.

“James” is a 38-year-old graphic designer living in New York. After being introduced to ketamine by a friend five years ago, it soon became his drug of choice. “It helps me get more creative and get more ideas, do artwork and design, and gives me energy,” he says. “For some people, it makes them tired and knocked out; for me I could stay up all night long doing it. It makes me wanna do work and stuff.” But soon he was spending $300 a day to sustain his and his girlfriend’s ketamine use. “Any time, anywhere, any place, with people, without people, it doesn’t matter. I haven’t done it in a couple of weeks because I have no money,” he tells DoubleBlind. “If I had more money right now I would probably go buy some.” Ketamine can cost around $80 to $100 a gram in the party scene or through dealers. James says he is currently experiencing intense cramps and bladder issues from his heavy ketamine use. “It messes you up, this drug messes up your body,” he admits.

Read: There are 3 Types of Ketamine—Which One Works Best?

“Rebecca” is a 27-year-old, who having suffered from an opiate use disorder in high school, then found ketamine. She says she spent nine months of her senior year doing large quantities of ketamine daily, and even injected it intramuscularly several times at the peak of her use. She also sold ketamine to sustain her heavy use habit. “I was suffering a lot of anxiety and a lot of pain, from stomach aches to back pain and headaches,” she says. In the beginning, ketamine helped her stay off opiates and manage her pain. But then her use became problematic and she was caught using the substance at her high school. After sustaining bladder damage, Rebecca quit ketamine and went back to opiates without medical supervision.

Although the off-label, medically supervised use of ketamine is considered safe, it also comes with risks. In April 2018, a patient in Portland, Oregon suffered a ketamine-induced psychosis, attacked his wife, and assaulted the police officers who arrested him. The man, who was using a ketamine nasal-spray, was evaluated by a doctor who found that the amount of the drug prescribed to him was a “gross overdose.” He filed an $8.2 million dollar medical negligence lawsuit.

Depending on the set and setting, ketamine can be medicinal and/or recreational, but also potentially problematic—as is the case with any drug or medicine, with dosage and intention differentiating a therapeutic experience from a taxing one. But in the case of ketamine, this dichotomy is even more pronounced due to its large range of uses, effects and potential risks, some quite extreme. In his famous book Ketamine: Dreams and Realities, Karl Janssen, MD highlights these two sides of this dissociative psychedelic : “It both wakes people up and puts them to sleep. It over-excites the calm brain and calms the over-excited brain…It is both damaging and protective, pro- and anti-convulsant, addictive and a treatment for addiction…a source of both healing and harm, integration and disintegration.” 

Read: Treating Depression with Ketamine Under Quarantine 

Some of the existing scientific literature further reflects this duality, with articles given titles like “Peril or Promise,” “Use and Abuse,” or in the case of a chapter of Janssen’s book, “The Light Within vs. The Dark Side.” Ketamine’s dualism is also evident at the molecular level, with bottles of the medicine containing “right handed” and “left handed” K (more on that in Zelfand’s article here). 

Is Ketamine Psychologically Safe? 

According to Abramson, who like Zelfand also administers ketamine to some patients after a thorough screening process, despite the drug’s safety profile and low physical toxicity in a medical setting, “it is not psychologically safe” for self-administration. After talking “to many hundreds of people with ketamine problems,” Abramson affirms that ketamine addiction is very hard to treat and he thus advises against using it without medical supervision. “It’s not one of those psychedelics that is a good idea for people to self-administer or have their own supply,” he says. For patients with ketamine use disorder, “there is no drug that will reduce their interest in ketamine, [as] they are often dissociated from themselves and talk therapy is of limited use because, even though they express insight into the fact that there is a problem and have to stop, the other side of their brain that is in ketamine space doesn’t really connect with that.” 

Zelfand, who has written about ketamine to treat depression and mood disorders, points to frequency as an indicator of problematic use: “How much, how often, and why?” she asks. “I don’t want to paint a picture that people are irresponsibly partying, [although] some are—but a lot of people are taking underground ketamine because they are trying to help themselves. A lot of people struggle with anxiety, for example, and don’t have health insurance or access to mental health services and that means that people sometimes go with the hard hitting things when something gentler might work, and ketamine may not be the right drug for them.”

Abramson says it’s important that the perspective on ketamine’s risks and potential harm become part of the public consciousness. “It’s not talked about enough,” he says, noting that even so, K’s drawbacks “should not be considered as negative, [since] all things in life have pros and cons.”  
James says he hasn’t used ketamine in a couple of weeks and doesn’t plan on getting any help to stop using. Rebecca hasn’t consumed ketamine or opiates since October 2016, after undergoing treatment with ibogaine. “Haven’t touched any of them and have no desires, I have no cravings and have since developed better coping mechanisms and surrounded myself with better people,” she explains. Brooklyn plans on continuing his current ketamine treatments for the time being, but aims to stop using the drug completely after his hip replacement in a couple of months. All this to say, oftentimes the difference between a medicine and a poison is the dose and the intention: For many, ketamine can work wonders treating ailments like depression or PTSD, but for others, it’s more complicated.