Comment by lostgame | Hacker News Reader

Comment by lostgame | Hacker News Reader

I want to warn folks that the quality of street ketamine wildly varies and is not a suitable alternative to these kinds of treatments.

I have had on and off issues with dependency on this substance mainly due to my issues with depression and anxiety.

If anything, it works too well for these issues, and it’s incredibly easy to get used to the relief from the constant onslaught of struggle that these types of illnesses cause, just as I imagine an opiate would be relieving for someone with chronic pain.

I would urge a sense of critical importance to the understanding that the exciting part of these treatments is that in combination with psychotherapy they could cure, not treat these issues.

Unlike someone with chronic pain, it can be used, along with certain other properly-applied psychedelics like LSD, to help train the psyche into functioning without it.

It’s not, however, something for everyone, and while it worked for me, please excercise extreme caution in using this substance or recommending it to others.

I’ve had friends who did it for years and still killed themselves. Two of them.

So at the end of the day, I urge everyone with even the deepest-seated mental issues like this - this kind of change has to come from within, and any benefits an external tool provides should be for dedicated moments of healing and/or a focus on the mind, and, for lack of a better word, spirit.

I can create a throwaway email account to answer any questions anyone may have. Please don’t hesitate to reach out if you, or anyone close to you has problems with this substance.

The usage of ketamine in the trials for depression typically uses IV administration over a fairly long timespan with highly specific dosages. It is not comparable to street usage of the drug.

As with any psychotropic medication, one should do their research. Psychiatrists whom I’ve spoken with seem generally excited about the prospect of more rapidly acting agents for the treatment of depressive episodes, but with the caveat that data is not there yet to draw any conclusions. And, as with every other treatment for depression, psychotherapy + medication outperforms medication alone. There remains power in the talking cure.

> The usage of ketamine in the trials for depression typically uses IV administration over a fairly long timespan with highly specific dosages

That's surprising, I would imagine that therapeutically a longer term low dosage would be more interesting (that is, not through IV, though I'm not sure how Ketamine behaves in the digestive tract)

> (that is, not through IV, though I'm not sure how Ketamine behaves in the digestive tract)

The main problem with sustained use (abuse) of ketamine nasally are severe crippling stomach cramps (think agony, rolling around in pain screaming) and scarring of the bladder causing you to urinate every few minutes just a few drops due to bladder damage. In severe cases bladders stop functioning and in some cases removed altogether.

Urban legends are these are caused by the "drip" after snorting large amounts, so if you spit the drip out you are ok. No idea how true this is, but some people swore by it

The bulk of ketamine studies have used IV administration but that doesn't mean it's more effective than sublingual. There are several studies on oral, intranasal, and sublingual ketamine with positive results. There are also several doctors including mine that are prescribing it for use at home.

Also consider that many of the doctors administering ketamine by IV at $500 a pop are not psychiatrists. There is far too little written about these opportunists.

Very valid points. But keep in mind that ketamine therapy is generally considered a treatment of last resort, for refractory depression, often after even treatments like ECT have failed.

From the article:

> Dr. Michael Grunebaum, a Columbia psychiatrist who studies ketamine, thinks the drug should no longer be relegated to a last-line treatment.

I find this argument interesting. Going through depression myself, waiting for an SSRI to be effective 6 - 8 weeks feels impossible if you want to end it all RIGHT NOW. That's kinda the point of suicide, is to end the pain ASAP.

Here's the thing, the SSRI didn't work out for me, now I'm going to try another medication, another 6 weeks before it's fully effective (It's not an SSRI though). I don't know if I can wait that long.

I still haven't gotten to other tiers of treatment in terms of medication - Antipsychotics, rMAOIs, etc.

Point is: I'm not sure a tiered approach for medication works well for everyone with depression, it's too time sensitive.

I agree. I can imagine... well, I don't have to imagine, I've been there: the prospect of months or even years long carousel of medications, trying and discarding one after another, hoping to get lucky on the next try... It's awful. I'd like to see ketamine and some others in careful but wider use. (modafinil for example works wonders for me and is also fast acting, definitely keeps me functional during depressive periods)

Yes indeed. 6 to 8 weeks is an eternity for someone who is deeply suffering. I personally think we are way too stingy with medicines these days. I also had a friend commit suicide while suffering from intense depression. He would no doubt be alive today if he had been giving what he needed right away, instead of being made to start with Prozac and then worked through a bunch of different "starter" antidepressants. Just give people what they need. There are worse outcomes than over-prescribing (death at one's own hand, for example).

Sadly, we don’t know enough about the brain to have any idea which medications are going to work or what it is people need right away. While you certainly could sedate people to the point of utter apathy by giving every shmiel who walks through the clinic doors high powered anti-psychotics it would be akin to treating a broken toe with amputation.

First line treatments like sertraline and fluoxetine are used because they take time to work and have generally tolerable side-effect profiles. E.g. in the case of patients with undiagnosed bipolar disorder, you run a lower risk of triggering a manic episode.

Why shouldn't the person be allowed to make their own choice after being properly informed of their options and having received their doctor's suggestion?

It's unethical, just like if a patient demanded their leg be amputated for a broken toe.

If the broken toe was inside a concrete cast that no one could see into, and there was no such thing as an X-ray machine, CT scan, MRI, or any other machine that could be used to verify the toe being the part that's broken.

If the doctor didn't listen to, or at all believe at least half the the stuff the patient actually said, and didn't need to.

If others had leg amputation performed and the leg grew back and on top of it we had evidence that leg amputation caused long-term damage when performed for other reasons. (Ketamine has long been used as an anesthetic precisely because the data we have suggests no long term damage from that dosage.)

If the patient had suicidal ideation and intent, because something hurt so much and we had no way of doing anything other than leg amputation, then why shouldn't we?

Until humanity manages to develop and deploy brain scanners that can actually see how much physical and emotional pain a person is actually in, then the leg amputation analogy is lazy and unhelpful because we simply don't have the same tools to address mental health because it's largely invisible.

Most doctors are still humans who negatively judge patients who drink heavily, who frequently miss appointments, who can't manage to get lab work done, who self-medicate with street drugs; those patients are judged as degenerates, not deserving of their help because they can't manage to take a pill, that doesn't seem to work for 6-8 weeks.

I mean, it's great that a hospital's ethic's board has reviewed the situation and determined that the best course of action is for people to suffer because they don't want the liability of, in this analogy, leg amputation, but in the meanwhile, people are being discarded by the mental health profession.

But what treatment are you thinking of here? Ketamine? Maybe after more research, trials and long term tracking of patient outcomes it can become a front line treatment. For now there's a reason it's a treatment of last resort. It's use in this way is not as well understood as traditional drugs. Use as an anaesthetic is a one-off. As with most substances, chronic use carries more complications. There's potential for cardiovascular issues. Also cognitive issues like impairments in creating new memories, accessing old memories, verbal memory, forgetting words, names... It makes sense to attempt treatments with a lower risk profile first, not for legal liability but patient well being. In the meantime there already is an immediate treatment available for those at risk of self harm: short and medium term hospitalization, which allows for more rapid trials of different medications at higher doses because the patient is under regular monitoring. Yes it still sucks, it's a crappy experience, but it is effective in getting most people stable enough to wait for longer term treatments to reach peak effectiveness.

> It's use in this way is not as well understood as traditional drugs

Traditional drugs are often a crapshoot anyway, and there's been plenty of harm from them. In the end, it should be the patient's choice in what path to take.

Yep, traditional drugs have their pitfalls too, but have had the advantage of rigorous trials that something like ketamine has not yet undergone. I'm glad it's an option, but there's really not a strong enough body of research for it to make it a first-line option. Yet. I hope that changes.

And, in the end, it is the patient's choice, within a certain circumscribed set of options. A good doctor works with the patient's needs. But it would be a very poor doctor that jumped to riskier options and less proven options first. The level of patient choice you're suggesting implies a level of informed patient that is frequently not the case. I rigorously research every single treatment option, discuss each one with my doctor, and we arrive at a course of treatment. But my doctor has indicated that I am, unfortunately, in the small minority in this respect. Your level of patient choice would invite all sorts of bad prescriptions to patients ill informed and, often, self diagnosed incorrectly-- a frequent issue leading patients to skew their conversations with doctors towards that incorrect diagnosis. In theory, in a perfect world, what you propose is fine. But we don't live in that place.

How do you know what he needed? There aren't "starter" antidepressants and "high-strength" ones. Prescribing him prozac first was giving him what he needed. I'm sorry you lost your friend, but it's not because he was denied some wonder drug.

Secondly, it's ridiculous to suggest we're underprescribing antidepressants. Completely the opposite. Mental health disorders require complex treatments involving therapy and lifestyle changes as well as medicines, but doctors will completely ignore that in favour of just writing a prescription after a 5-minute conversation. I say this with a lot of experience of mental health treatment: doctors hand out antidepressants far too easily.

I know it is trite, bit stay strong, things can get better. I have schizoaffective disorder and I did find a mix of medication that helps a lot, but it literally took 13 years to find the mix with a couple suicide attempts during that period. Check out some of the mental health subreddits, I am the founder of /r/schizoaffective.

Maybe ketamine is treatment of last resort, and LSD, because they’re most likely to actually work and the pharmaceutical-insurance industrial complex wants to rinse as many people through the ineffective drugs and therapies first.

Maybe I’m just being cynical, but if the standard treatments were effective perhaps we mental illness wouldn’t be so prevalent.

Of course, it’s complex and multifactorial, and there’s societal and cultural issues, and generational issues, we need to address too.

Exactly my thoughts.

Check out the book Ketamine for Treatment Resistant Depression.

It's a safe drug with a low incidence of serious side effects that could help a lot of patients. Researchers have shifted much of the research to Ketamine metabolites.

Their reasoning is that these metabolites have a lower side effect profile than the parent compound. It has been almost 20 years of small scale ketamine trials for depression with not much to show for it. Now, they would like to explore a diversion that may be less safe than a drug with a long history of safety.

I think there are a few reasons for this: 1) Depression isn't seen as a serious disease like cancer and 2) Ketamine is a cheap drug.

I thought because of its rapid efficacy it was moving towards, being proposed as being a Frontline intervention to reset.

SSRI are hugely problemmatical because they take time to ramp up and flush down. Mental health sometimes needs a course correct not a long-term hand on the tiller.

MDMA and psylocibin likewise: brief, sharp reset goal.

(That's what I read)

This is very misleading. Patients are seeking out this treatment from independent clinics that do not take insurance. They don't need a referral. The biggest consideration is patient ability to pay a lump sum up front.

Additionally, it appears that the different isomers have different properties potentially for anti-depressive effects. The R- isomer seems to work better for it from what I’ve read. Know what isomer you’ve got is less common from street. A lot of people prefer S+ isomer for recreation though but it doesn’t help as much

Katamine may actually /be/ an opiate: http://slatestarcodex.com/2018/11/08/ketamine-an-update/

It is not an opiate, even if it has an affinity for the mu receptor (it may or may not) it is absolutely classified as an NMDA antagonist.

It has effects on the opioid receptors but is definitely not an opiate or opioid.

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