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Comment by mabbo | Hacker News Reader

There's an interesting risk to all of this: legitimizing the illegal drug.

Let's say my doctor says to me "you're depressed, I'm prescribing esketamine, go to this clinic and pay them $3000". Well, I do my research and learn that really this stuff has the same antidepressants effect as ketamine. And the same number of doses of ket on the darknet markets are going to cost me a heck of a lot less.

Sure, there's the question of legality. But if I can't afford esketamine but can afford dodgy internet ket, and I'm desperate for something, anything, to help with this nagging constant psychic pain weighing down my life...

Suddenly I appreciate my Canadian single payer health care system a lot more, even with the small problems it has.

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What's the risk of legitimizing ketamine? The majority of the research and meta-reviews support ketamine as a treatment for depression too. The S-isomer may be better in some ways, but maybe not $3k better if you're poor.

On a risk/harm scale, it's comparable to alcohol or cigarettes[1].

[1]: https://en.wikipedia.org/wiki/Drug_harmfulness#/media/File:D...

When you get ketamine from a doctor, it is in metered in sub-psychedelic and sub-anesthetic doses.

When you get ketamine from the internet, you're getting a mystery powder that is, at best, a potent form of an addictive drug in quantities that are not metered and are ripe for abuse. At worst, you're getting some form of fentanyl because internet drug dealers are inept.

You have a lot of opinionated adjectives in that second sentence that aren't related to the chemical, which is the same one as in the first sentence.

> a potent form of an addictive drug

It's literally the same chemical; you didn't use those adjectives when you described it earlier.

> quantities that are not metered

Readily fixed for < $20: https://www.amazon.com/dp/B07D1NNGM6/

https://erowid.org/chemicals/ketamine/ketamine_dose.shtml#or...

> At worst, you're getting some form of fentanyl because internet drug dealers are inept.

That's not a ketamine problem; it's a prohibition problem.

> Readily fixed for < $20: https://www.amazon.com/dp/B07D1NNGM6/

My friend had one like this. It was barely accurate enough for all the funny RCs we had.

> It's literally the same chemical; you didn't use those adjectives when you described it earlier.

I would talk the same way about treating ADHD with Desoxyn prescribed by a doctor versus buying a pile of methamphetamine online to self-medicate with.

> Readily fixed for < $20: https://www.amazon.com/dp/B07D1NNGM6/

If you're going to make bad choices, volumetric dosing is one of the less bad choices.

> That's not a ketamine problem; it's a prohibition problem.

It's a regulation problem. The supplement market is full of bunk or outright fake products. It took the FDA to reel actual medicine in.

Interestingly, at least in the US, a take-home prescription for ketamine is already suprisingly cheap - $38 USD for 100ml: https://www.drugs.com/price-guide/ketamine

At least near me, there are "ketamine centers" that already to ketamine clinics - $500 per session, and insurance doesn't cover it. Ends up being around $3000. I haven't done it, so I can't comment on its effectiveness.

It's pretty lame that the cost difference is so large. I guess the barrier is a psychiatrist's willingness to prescribe. Maybe all of this research will open up psychiatrists to prescribe take-home ketamine more readily?

Basically most clinics will give u a month supply after 6 sessions for 80$ a month

No, they won't, because the only form available is the IV form. There are no ketamine pills or tablets. Some doctors will prescribe ketamine nasal spray or lozenges to be made by a compounding pharmacy, but the vast percentage of doctors who are willing to administer ketamine in their offices are not at all willing to prescribe a take home dose, and if they are, it's in a very different form with different effects than the IV session. I get regular IV sessions and have compounded lozenges that I take daily, and in my experience neither the nasal spray (which I hated) nor the lozenges are anything like the infusion, and it was extraordinarily difficult to find a doctor in the Boston area that would write any kind of take home prescription. No clinic anywhere is going to give you a bottle of ketamine and some syringes, and neither is CVS.

That's what I meant by maintenance dose . A nasal spray or lozenge. The maintenance doses are great for the vast majority but if you feel that they don't do it for you and able to get a nasal formulation you can do your own IM injection which I know a few people personally that do it once a month

> Suddenly I appreciate my Canadian single payer health care system a lot more, even with the small problems it has.

It's been a long time since I lived in Canada, but one of the "small problems" was that prescription medicine wasn't covered. You need private health insurance, or you need to be covered by one of many confusing provincial health care plans. Generally, you can find a way, but at least 15 years ago (when I left) it could be pretty dicey. I remember several of my friends having difficulty affording their insulin when I was in university -- too rich to qualify for aide, too poor to be able to pay for their life saving drugs without hardship. My dad (who still lives there) tells me things have improved, but he still pays more for prescription drugs than I do (living in Japan) I think.

The UK's NHS seems to be a better system to compare to ;-) I lived there for 2 years and was really surprised at what the NHS covers. Interestingly they will even pay for emergency treatment for non-residents who happen to be in the country!

>The UK's NHS seems to be a better system to compare to ;-) I lived there for 2 years and was really surprised at what the NHS covers.

The caveat is all of the stuff that the NHS won't cover. The service is largely free at the point of use, but there has always been some element of rationing which has drastically increased in recent years due to Conservative government cuts.

Mental health gets the short end of the stick in this respect - it represents 23% of the disease burden but only 13% of NHS spending. Most patients with a mental health condition will never see a psychiatrist and receive no more than six half-hour sessions of psychotherapy. If esketamine does prove to be effective, the NHS is exceedingly unlikely to offer it to more than a handful of patients until the patent expires.

https://www.nuffieldtrust.org.uk/resource/rationing-in-the-n...

As well as emergency care being free for non residents, contraceptives and STI treatment are too [1]

[1] https://www.nhs.uk/using-the-nhs/nhs-services/visiting-or-mo...

Ketamine isn't an illegal drug, it's been FDA-approved for decades. They're both schedule III.

It was not legal to prescribe as an antidepressant outside experimental setting.

This is completely wrong. For quite a long time it has been legal for doctors to prescribe FDA approved drugs off-label, that is, for reasons other than what they're FDA approved for. But if it's not FDA approved, insurance companies won't pay for it. That's what this ruling changes, for this one form of the drug.

Although that's not necessarily true either. Insurance contract typically pay for FDA-approved indications, but they also usually have some process where they will pay for off-label use if you can submit evidence that it's scientifically justified and cheaper alternatives would not work. Of course this is pretty stressfull, but it's really necessary in the U.S. because getting FDA to approve a new indication is really expensive for the drug companies, so there are a lot of drugs which are not approved for some of their main uses. For example, SSRIs are commonly used for anxiety even though this is off-label.[1] And monoclonal antibody-based immunosuppressives like adalimumab are often only approved for a few conditions, like Crohn's and arthritis, even though they are useful for auto-immune diseases in general.

In the specific case of ketamine for depression, some people do seem to have successfully gotten insurance companies to pay for it.[2] Even without FDA approval, this would probably get easier over time, as more studies show effectiveness.

[1] https://www.aafp.org/afp/2003/0801/p498.html [2] https://www.ketaminewellnesscenters.com/getting-insurance-to...

If insurance companies will pay for esketamine anyway, wouldn't they be more inclined then to also just pay for ketamine if it's cheaper?

Probably not directly, but I'm pretty sure it is legal to prescribe medicines for off-label use as well. Is there some sort of restriction on this particular drug that I'm not aware of?

False. Off label prescribing is perfectly legal.

That is exactly why there is a massive h eppidemic in the us. Drug companies lied about oxys , everyone got hooked, couldn't afford it and moved onto h. Now that's laced with fent and everyone is dying

I don’t know if it’s changed recently, but back when I was clubbing, street ketamine was mostly just stolen from vets offices and dried into a powder.

I wouldn't call it a risk but rather a benefit, in which it makes impossible to not see the absurdity of prohibition laws.

Most people probably lack the technical aptitude to use darknet markets, so this is probably more relevant to hacker news readers than the general public.

No . It does not have the same anti depressant effects as racemic ketamine .

>single payer health care system

is just a system that forces healthy people to pay for unhealthy people.

This is what insurance and health care does, though. Do you think your premiums are really based on how healthy you are currently? Especially when you have insurance through your employer?

In this last case, you might pay more for certain markers (smoking, uncontrolled high blood pressure, and other wellness marks), but not if you have asthma or migraines, for example. Part of your premium is literally paying for folks that are sick. Paying for other people's pregnancies and children and stuff like that.

Or, you know, themselves when they get unexpectedly ill.

Yes, just like we're forced to pay for police even if we've never been robbed...

That’s literally what insurance is.

If you truly care about costs, and not punishing the sick, single-payer systems are cheaper than private insurance by an average factor of 3[1].

[1] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...

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