Ketamine was first synthesized in 1962 by Calvin Stephens, an organic chemistry professor at Wayne State University, who was working as a consultant for Parke-Davis. Dr. Stephens was tasked with finding an alternative anesthetic to phencyclidine (PCP) which was used as a general anesthetic from 1953-1965 and was causing issues when patients were sometimes waking up from surgery with prolonged psychotic emergence reactions. Ketamine was first tested on humans in 1964 in Jackson, Michigan by Dr. Edward Domino who tested it on one of the prisoners at the State Prison and when he described the prisoner’s reaction to his wife, she coined the term “dissociative anesthetic” which is what ketamine is commonly known as today. Ketamine earned a reputation as an excellent battlefield anesthetic during the Vietnam War partly because it did not cause cardiac or respiratory depression. Ketamine was available by prescription in 1969 in the form of ketamine hydrochloride by the trade name “ketalar” and in 1970 the FDA approved it for human consumption.
Ketamine was used as a general anesthesia for surgical procedures but again, some patients were regaining consciousness reporting extremely unusual psychological and emotional experiences that most medical staff found to be a complicating factor (for the staff) post-surgery. Eventually, ketamine was mainly used as an anesthetic for children and continues to be widely used in veterinary medicine. Currently, ketamine is a Schedule 3 drug which means it is regulated by the DEA and it is only available by prescription from a licensed medical practitioner. The potential for ketamine in sub-anesthetic doses to facilitate psychotherapy was first reported in 1973 by Korrhamzadeh and Lotify and in 1974, Fontana was the first to publish on ketamine as a pharmacological adjunct to psychotherapy for depression. However, in the last several years, we have been witnessing a relative explosion of interest in using ketamine in sub-anesthetic doses to treat depression, PTSD, chronic pain, addiction and other mental health-related issues.
There are variations in how ketamine is administered to these patients and these variations can have significant effects on treatment experiences and outcomes. Some providers seek to minimize or avoid the psychedelic effects of ketamine and these providers typically offer intravenous infusions of ketamine which is designed to get the maximum amounts of ketamine into the system and this route of administration is sometimes recommended for patients seeking treatment for chronic pain and those less interested in psychedelic explorations as part of their ketamine treatment. The only route of administration currently that may be covered by some insurances is intranasal in the form of a spray called “Spravato” and this too tends to minimize the psychedelic effects. Spravato uses a different form of ketamine, esketamine, and research is showing that this form of ketamine may be slightly less effective than racemic ketamine which is the form of ketamine typically used with other routes of administration.
Other routes of administration include sublingual troches and intramuscular (IM) injections and these are both designed to not only introduce ketamine into the system but to also potentially produce a psychedelic experience. As the Pearl Psychedelic Institute introduces ketamine-assisted psychotherapy (KAP) services, the focus will be on these two routes of administration because we feel that the experiences that these methods can afford patients often play an important role in their healing. The information that patients receive while under the influence of ketamine can be in the form of images, memories, emotions, and/or somatic sensations and remembering and making sense of these after the experience is over is one of the most important aspects of KAP. This information is originating from the deeper aspects of the Self of the patient and it is critical that there be a period of integration following these excursions so that the potential wisdom imparted to the patient is not lost.
Carl Jung was a Swiss psychiatrist whose revolutionary contributions to our understanding of the unconscious were generally minimized or dismissed by mainstream psychiatry up until his death in 1966. However, as this current psychedelic renaissance continues, some of his ideas are extremely relevant for informing an understanding of the contents of psychedelic experiences. According to Jung, the Self was the central force in guiding our psychological development and an ”inner companion perpetually reorienting us towards balance and guiding us into greater wholeness.” Psychedelic-assisted therapies talk about the “inner healing intelligence” that we all have inside of us that seems to “know” what we need in order to heal ourselves and Jung’s conceptualization of the Self and its inherent purpose seems to dovetail nicely with the inner healer concept.
Research has demonstrated that about 70% of patients have a therapeutic response to ketamine and about 30% are considered to be “non-responders.” There is some thinking that these non-responders may just require higher doses or more frequent sessions but with the generally high cost of KAP, most people cannot afford to test this hypothesis. However, it is clear from the research that there are several aspects of KAP that are critical if one is to maximize the potential benefits and these include a sufficient preparation period where the patient’s history is examined, rapport and trust is established with the provider and the patient’s intentions for the KAP work are articulated. During the administration of the ketamine, it is important that the patient have someone with them who can hold space and offer support or guidance if needed. However, most critical is the integration work immediately following the ketamine experience and in the days following the session. Without integration, the most profound insights and realizations can fade over time until they become remote distant memories or lost altogether. There are endless variations and modalities for integration work but if this work is not done, the chance that the patient may return to baseline within a few weeks is quite possible.
In conclusion, if you are considering seeking out a KAP provider, make sure they offer preparation, ketamine-assisted session support and, perhaps most importantly, integration support. Without these elements you will be solely relying on the ketamine to do all the work and this can be a set-up for, at best, short-term benefits. Whenever a potential patient is curious about KAP, I tell them that “the real work” is actually between the KAP sessions and that effort may be the factor that most determines the outcome.