Comment by ninjakeyboard | Hacker News Reader

Comment by ninjakeyboard | Hacker News Reader

I was a ketamine user for a long time. My use turned into a problem but I'm realizing that my use patterns were basically: Use, wait until depression returned, crave a cure from my depression, use.

In a clinical setting I'm sure that it's very helpful but for me the "crave a cure" caused me to not getting around to dealing with my issues of depression until after I had issues with ketamine that required intervention and left me alone with depression again.

I hope other people never go down that path. She is a cruel seductress and the draw of the sudden emotional changes is a lot to put on someone's psyche. If they're suffering, and then suddenly they aren't and they feel happy for the first time in a long time it's easy to make the association to powder = happy and that's a very powerful association for an animal/human psyche to put together.

For most people, street ketamine would scare the shit out of them but for anyone else they might get drawn in to basically constant cycles of self medication.

How is a constant cycle of medication any different from using common antidepressants like SSRIs? Sure, it would be great if we could cure depression without drugs, but if that isn't possible, obviously medication is important for those people to be able to live good lives.

Well in the case of an nmda receptor antagonist, the harm can be pretty high. For example, alchohol is an nmda receptor antagonist and is considered to have one of the highest social costs of any drugs.

How does it compare to the side-effects associated with the other anti-depressants, including extreme suicidal ideation?

I'm not sure what you mean by "social cost".

social cost = effects on family, close friends and relatives, and occasionally society in general.

The doses are acute so the side effects at reasonable doses are primary psychotomimetic effects without physical harm or other behavioral impact - it has a very short half-life and people will be basically sober by the time they leave from a treatment and the body will clear it in a day. The effects last beyond that because they cause a systemic brain change and psychological effect, not because there is a drug present.

Alcohol is an issue mainly due to how it interacts with Gaba receptors. Alcohol (and benzodiazepienes) binding with those receptors is what causes tolerance, physical addiction and withdrawal. Nmda receptors antagonists don't cause the same kind of issues.

You generally can not physically get addicted to nmda antagonists like ketamine. In fact nmda antagonists and modulators are being studied because "research suggests that N-methyl-D-aspartate (NMDA) receptor neurotransmission contributes to mediating the behavioural effects of alcohol and other drugs of abuse" https://www.ncbi.nlm.nih.gov/m/pubmed/11060803/

I want to make clear that I mean physical in the biological sense. It is still possible to form an addiction to these drugs. I only mean to say that it's rare to have dangerous withdrawal effects, unlike with alcohol.

That is true - alcohol is both nmda antagonist (the stumbly ataxia) and gaba agonist (effect on anxiety.) GHB IMO is not nearly as gnarly of a substance as alcohol because it sort of has a ceiling but withdrawal from any gabaergic is uncomfortable and potentially life threatening and nmda agonists are not, there are a lot of causes of bladder damage especially from ketamine, drowning, falling off buildings, loss of jobs, friends, family. Despite it's rather low physical harm profile (aside from the bladder damage) it's incredibly addictive and many people go wayyyyy wayyyyyyyy too far. I have lived it, and I've seen it. It has a very dark side.

I know the IV user in this film (they call him Chris on camera). This user is atypical but there are many people with extensive bladder damage and negative social effects. You'll have to take my word for it. I'm sure there is more research from china especially as it's very common drug used there. Police note (anecdotally) the typical user in north america has changed to middle aged and affluent as the price of street ketamine has gone up from maybe $25/g to +$90 https://www.snagfilms.com/films/title/drugs_inc_ketamine

I believe in its power as an antidepressant. I'm just concerned about the effects a bit. It will fuel research - it seems it's not ketamine but metabolites and effects on ganglial growth that spur the sudden changes to a depressed mind. And a new objective view on life and reality.

> I know the IV user in this film (they call him Chris on camera). This user is atypical but there are many people with extensive bladder damage and negative social effects. You'll have to take my word for it. I'm sure there is more research from china especially as it's very common drug used there.

That's not pharma grade ketamine. We have no idea what these drug users are taking.

The illicit nature of street ketamine is what sets it apart from SSRIs, for mainstream society. A random primary care physician (PCP) isn't going to send a prescription for it over to the local CVS/Walgreens pharmacy for convenient pickup over lunch. Which often means resorting to desperate measures, at heavy markup, in order to procure any amount, with an unreliable supply.

Self-medication can be problematic because it's non-objective, but it can easily lead to (psychological) addiction. The brain optimizes/skips a step - not-being-depressed looks a lot like actually being happy when compared to being depressed, so then there emerges this belief that the user needs to be high on ketamine constantly, which is when it becomes a problem.

GP post isn't arguing that no one should use ketamine, or any other medication that works. They are giving first-hand perspective that ketamine addiction is real, and having heard stories myself, I'm inclined to believe GP. It would be great if ketamine had to be prescribed by a doctor to avoid addiction, and that such a requirement didn't end up excluding those outside of mainstream society (often because of mental problems like, say, depression).

FDA approval of ketamine for depression will go a long way to improving the situation but for now one choice is to pay some $1500/session (not covered by insurance), to a clinic run by medical professionals risking their license. (Each session uses less than $20 of ketamine, so it's quite the markup!)

The other option is to buy street ketamine, which is a move of desperation, but looks a lot better than committing suicide.

I don't understand the objection int the article about the possible necessity of "booster" treatments though.

> A random primary care physician (PCP) isn't going to send a prescription for it over to the local CVS/Walgreens pharmacy for convenient pickup over lunch.

Most GPs won't write you a scrip for ADHD medication on a whim, either, but I wouldn't describe Vyvanse as "illicit." They just "know what they don't know" and so don't trust their own evaluation of you and think you should get a professional evaluation by a specialist (i.e. a psychiatrist, in this case.)

They're usually perfectly willing to continue prescribing after you've gotten a previous scrip from a psychiatrist, though. I suspect ketamine would be much the same, except that you'd need to get your scrip filled at the pharmacy of an inpatient hospital (since that's where they'd have it in stock), rather than the corner store.

It's the same story as, say, methamphetamine. Scheduled drug—but that doesn't mean you can't just get a prescription and get it filled. It's a lot of work to get that prescription (since methamphetamine is also a last-line treatment), but once you have it, any hospital pharmacy should have some in stock.

Where a future hypothetical ketamine prescription could be filled from, I can't say, but clinics charging $1500/session have it in nasal sprays and lozenge form, I'm hopeful that a corner store would eventually be able to fill it easily once one of the pharmaceutical companies manage to package it up in a form they deem lucrative. (Which will involve patenting some part of it, possibly the delivery mechanism, since ketamine itself is past patentable date.)

Depression is an insidious disease, and being able to fill it at the corner store, rather than having to go all the way to hospital (which can be a scary and frustrating experience) might make the difference between having the medication, and not.

Ketamine is hugely psychologically addictive though. It is like saying that opioids should be available to everyone that is in any pain. The level of addiction caused may be different because the opioid user has to contend with the negative association with withdrawal as well as the allure of the high itself, whereas ketamine is only one of those two. Dependence and addiction are not the same and ketamine is powerfully re-enforcing. I don't mean to trash this - I'm just trying to show a counterpoint and another perspective because there WILL be misuse as soon as prescriptions become available, and people (doctors) will not understand the degrees to which it can draw people to misuse until much later. There is already a black market to supply to the demand. If droves of people start acclimatizing themselves to ketamine, the market demand will increase and the black market will be there to fill that new demand, just like it did with heroin/fentanyl when pain was over-treated with opioids and droves of mom's and yuppies suddenly thought heroin sounded like a pretty good idea because they had already lost their opioid naivety.

So in turn, I put forward that we should hope a discovery of the mechanism of action and a way to put it to use without ketamine. Ketamine's action itself is assumed to _not_ the primary mechanism of action but rather a metabolite is (the experience has a part of it I'm sure - it's pretty fairly a psychedelic but the yin to LSD's yang) and scientists are working to find a drug that will have the same effect without the psychedelic dissociative qualities of ketamine (and it's monstrous allure which some people notice and fall for - but many don't)

Seems to me that only certain personalities thirst for ketamine after experiencing it. But that will all come to view in time because the black market is ready to supply to an increase in demand and it will happen that way once people start diverting ketamine. The black market will compete in that market. It will offer a product of similar quality (most clandestine on the street is close to 100% purity) but will find its competitive advantage is price and availability.

Yet another strong case for legalization.

> (Each session uses less than $20 of ketamine, so it's quite the markup!)

Are you sure? That is a lot of ketamine

You're right. An upper bound of $3/session is a better estimate.

Dosing regimens for ketamine to treat depression are still being worked out, especially because that still considered an "off-label" use by the FDA. Using the upper bound of 0.75 mg/kg [0] and a person weighing (again, upper bound) 300 lb, I calculate 100 mg dose/session, which is roughly $3 of ketamine (when procured by a doctor).

[0] https://www.ncbi.nlm.nih.gov/pubmed/28749092

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