Dr. Steven Reichbach on Matthew Perry & Ketamine Safety
The recent death of Matthew Perry has shined the spotlight on ketamine and its use in the treatment of certain mental health disorders. Like most drugs, ketamine can be used, misused, and abused by people wishing to do so. What we also know is that ketamine can be an effective tool in treating difficult cases of depression, anxiety, PTSD, and suicidal ideations in a relatively short period of time.
Ketamine is in a class of drugs known as dissociatives. It is a mind-altering drug even at relatively low doses. Treatment of mood disorders requires "subanesthetic doses" of ketamine. While the majority of patients undergoing treatment find the experience "warm, nurturing, and transformative," there are patients who do NOT wish to undergo any significant dissociation during the infusion. For these patients, infusing the medication over a longer period of time minimizes the dissociation or mind-altering aspects of the treatment. There is no difference in outcome for these patients. (Specific to ketamine at this point in time, it is not the experience as much as it is simply the ketamine working to induce physical changes in the mood centers of the brain that is responsible for positive responses. Over the past eight years in practice and over 16,000 infusions performed, this observation has been borne out time and again.)
Ketamine is a valuable drug for many reasons. Changes in heart rate and blood pressure are relatively minimal, as is respiratory depression in patients treated with subanesthetic doses. Having said that, even minimal changes can have negative consequences in certain patients. For this reason, I feel it is imperative for these treatments to be performed in the presence of a physician in a monitored setting, with necessary drugs and emerging equipment available, if needed.
Lastly, the route of administration in which ketamine is administered makes a difference. At our center, we perform intravenous ketamine infusions. IV ketamine infusions are the only route that allows for 100% bioavailability. What this means is if 50 mg of ketamine is given, then 50 mg reaches the brain. The goal with most treatments is to administer the lowest effective dose of medication. By utilizing IV ketamine, this is most easily achieved, which minimizes side effects such as increased dissociation and hemodynamic fluctuations. It is much easier to titrate to a responsive dose using IV ketamine when compared to other routes such as intranasal, oral, and sublingual.
To summarize, ketamine can be a very useful and lifesaving tool for many patients who have not responded to oral medications, transcranial magnetic stimulation, or in more extreme cases, electroconvulsive therapy. To achieve the best results, in the safest manner, the safeguards mentioned above should be employed. Of importance to note, the risk of abuse with ketamine, while small, is further lowered when administered in subanesthetic doses, in a monitored setting, under the care of a qualified medical professional.