Is ‘K’ OK?

Amid the business complexes, parking lots and subtle landscaping in South Reno, the South Reno Medical Plaza occupies a boxy set of buildings. On the second floor, past dentists’ offices and testing labs, there’s a medical office that is doing something different than anywhere else in the region. This place is Sierra Ketamine Clinics. It’s a ketamine infusion center where patients are treated for major depression, mood disorders, chronic pain and substance abuse, among other conditions.

You may have heard of ketamine being used as a party drug—and you may have heard of a “K-hole,” a state caused by a large dose, which can cause vivid hallucinations, memory loss or extreme levels of dissociation.

The 2012 Ketamine episode of National Geographic’s Drugs Inc. series is a good source for more details. It examines how ketamine’s hallucinogenic properties lower users’ inhibitions as they dance to techno music. They appear euphoric, until they take too much, after which they appear to cognitively check out and drool on themselves like vacant-eyed zombies for the remainder of night.

This is that drug.

On the other side of the coin, ketamine has been on the World Health Organization’s list of essential medicines since 1985. In hospitals, it’s administered intravenously as an anesthetic, with drip amounts determined by a patient’s weight. The WHO has deemed it relatively inexpensive, available and safe.

Ketamine has a pretty noble history. Not long after its approval for human use in 1970, it was used as an anesthetic on the battlefields of the Vietnam War. A WHO fact file from 2016 on ketamine states, “Ketamine is safer to administer than other types of anesthetic agents and pain relief as it does not depress breathing or lower blood pressure and does not require expensive patient-monitoring equipment.” The file goes on to say that it’s rare for patients or abusers to overdose—though still possible. Today it’s widely used in emergency rooms and surgery centers, to put patients under before other treatments.

The founders of Sierra Ketamine Clinics, Dr. Brett Frey and Dr. Robert Watson, spend a lot of their time in a hospital. Frey is an emergency physician at Renown Health Systems in Reno, and Watson is a surgeon there. Frey said that he observed the profound effects of low-dose ketamine infusions in the ER as an anesthetic and recounted many instances of people receiving relief from neuropathic pain. Over the last three years, he’s researched different uses and applications of ketamine, specifically for behavioral health issues, and shared his findings with Watson.

“We’re friends outside of the work environment,” said Watson.

“Brett sharing this information with me got me inspired,” he said. “And so, when he brought up the idea of a ketamine clinic, there is obviously this major void in the community, and just whatever makes you want to be a doctor, you just want to help. It was just a natural development.”

The doctors found an office location, outfitted their comfy infusion rooms, hired staff and contracted with pharmaceutical companies. Watson said they observed a couple of ketamine clinics in San Antonio, Texas in the process. On Sept. 5, Sierra Ketamine Clinics opened its doors, ready to take on pain and suffering in many forms, including what the WHO has called the number one cause of disability in the world—depression.

Physician assisted dissociation

The calm waiting room and hallways at Sierra Ketamine Clinics have the sterile feel of a dentist’s office, as opposed to the warmth of a family therapist’s. The infusion rooms have nice leather chairs, and the small staff is personable with patients.

The doctors review each patient’s medical history and have patients fill out prescreening worksheets to determine whether their symptoms—emotional or physical—make them an appropriate candidate for ketamine infusions. Overall physical wellness is considered, too.

Once confirmed, the patient schedules an induction series, four treatments over the course of two weeks. The treatments are 40-minute IV infusions. Patients hang out in a leather easy chair and are encouraged to listen to mood-setting music. The lights are turned off, and the curtains are closed. It usually takes about five minutes for the drugs to take hold.

Some patients report instant relief from their pain.

This is your brain on ketamine

Whether in a clinical setting with an IV or on the couch experimenting with what the DEA calls a “schedule III controlled substance,” users experience a similar kind of euphoria. Ketamine immediately acts on neurotransmitters called NMDA glutamate receptors. These are the same receptors that PCP, nitrous oxide and other dissociative hallucinogens interact with. However, at the levels served up at Sierra Ketamine Clinics, out-of-body experiences and hallucinations aren’t likely. That’s not to say a psychotropic state doesn’t occur, however.

“The patients often say it’s surreal, like a dream,” said Frey. He continued that some patients report detachment from reality, or, in some cases, feeling closer to their higher power.

On a podcast episode of the Joe Rogan Experience—a fair enough place to learn about drugs without trying them—Neal Brennan, co-creator of Chappelle’s Show and a self-proclaimed “depression correspondent,” described his ketamine-infusion experience as floating through a fantasy world that felt like a mix between “It’s A Small World After All” and the Korova Milk Bar in A Clockwork Orange.

“I couldn’t get over the fact this was happening in a doctor’s office—just like a regular fucking doctor’s office,” he told the audience. “Like, literally, waiting room with other physicians and their patients, old wierdos, shitty magazines, and you go in and trip your fucking head off.”

Neal Brennan wasn’t treated at the Sierra Ketamine Clinics.

One local patient who was—26-year-old Samantha Cobb from Gardnerville—said she simply falls asleep a few minutes into the infusion. Deep relaxation is encouraged at SKC. We’ll get back to her story in a bit.

An alternative to SSRIs

Ketamine for non-hospital therapeutic uses is gaining a foothold. The advocacy website ketaminesavedme.com lists 75 clinics in the United States—with a disclaimer stating that the site does not vet the legitimacy of each listing.

What’s making such a buzz in the medical community is that the ketamine reacts differently than most other drugs that doctors have, for decades, been prescribing to people for depression and mood disorders.

The current go-to antidepressants are called selective serotonin reuptake inhibitors, or SSRIs—Prozac, Zoloft, Paxil, Celexa and dozens more. Here’s what they do: In your brain, molecules of the hormone serotonin move between the synapses that are meant to regulate mood, appetite and sleep. Sometimes, those serotonin molecules go to waste or are destroyed by other chemicals, and this depletion leaves the brain feeling the horrible symptoms of depression. The theory is that SSRI block the part of the brain’s synapses that waste or destroy serotonin, so the usual serotonin levels can fill up in the brain, allowing normal cognitive function to return.

The National Center for Biotechnology Information reports the most common side effects associated with SSRIs are nausea, insomnia and sexual dysfunction. Therein lies the gripe against these kinds of antidepressants—the side effects often kick in before the serotonin levels can recover to normal function.

Evan Miller, a certified alcohol and drug-counselor intern at Quest Counseling and Consulting in Reno said, “A lot of the times people with really severe mental health disorders will have tried lots and lots of these drugs, and they will feel frustrated by it.” Miller explained how his clients can suffer through the trial and error of cycling or combining antidepressants, in search of a chemical strategy that’s effective and tolerable. The process may take weeks. It may take years.

With the help of SSRIs and other antidepressants, many people diagnosed with depression begin to feel better. In the largest and longest study ever conducted to evaluate depression treatment, the National Institute of Mental Health found that nearly 50 percent of participants became symptom free after switching their medications only twice. But, the odds of beating depression are diminished with every additional treatment strategy needed.

The study concluded that there’s a need for a better understanding of how different people respond to different depression treatments.

New use for an old drug

That SSRI and antidepressant study occurred back in 2006. Since then, not much progress has come in the way of mental-health solutions for mood disorders—apart from this new ketamine treatment that has popped up in cities across the country. Ketamine brings faster relief than SSRIs and other antidepressants, sometimes subduing depressive thoughts in a matter of hours, which could make all the difference in severe cases, like when a patient is suicidal.

Although ketamine is an FDA-approved anesthetic, its recoded history as a mood-stabilizer is short. At Sierra Ketamine Clinics, ketamine isn’t being used as a surgical anesthetic, but to treat conditions like chronic pain, major depression, PTSD, anxiety, bipolar disorder, OCD and substance use disorder.

It’s not perfectly clear what long-term use of ketamine may offer, for good or for bad.

Administering a drug for something other than it’s intended purpose might sound like a precarious disregard for liability, but according to the FDA, once a drug is approved, healthcare providers may prescribe the drug for an unapproved use if they’ve deemed that it is medically appropriate for their patient. So, Frey and Watson are legally offering a new use for an old drug based on their discretion.

Encouraging off-label uses for drugs turns illegal when the drug manufacturers directly promote their drug for things other than what the FDA condoned. An example is the $2.2 billion settlement Johnson & Johnson paid in 2013 for marketing a schizophrenia drug to subdue elderly people who had become confused, agitated or hostile. The drug was also promoted as a safe treatment for disorders like ADHD and OCD in children. In a conference announcing the criminal misdemeanor, Obama’s Attorney General Eric Holder Jr. censured the company for “recklessly putting at risk the health of some of the most vulnerable members of our society—including young children, the elderly and the disabled.”

Indictments like that sometimes earn pharmaceutical companies the reputations as greedy masters of deception. But their products still require rigorous scientific testing over long periods of time before the FDA stamps them for widespread use, as is the case for ketamine. Of course, the major pharmaceutical companies are fast on track to go to market with something they can definitively call, “The first major breakthrough in depression treatment in decades.” At least two companies—Johnson & Johnson and Allergan—have ketamine in late-stage clinical trials.

Frey and Watson are closely following this movement right now. When the major companies bring ketamine to the mainstream, it will mean big changes for small practices like Sierra Ketamine Clinics, including different ways to ingest the drug without an IV—perhaps nasally or sublingually. Ketamine, which is already considered a relatively inexpensive drug, will also likely become much cheaper.

“We understand as a clinic we may have short life span of three to five years,” said Frey. “We don’t know what that looks like.” If ketamine is easily consumed and widely prescribed by psychiatrists, infusion treatment centers across the country may have to close their doors.

A patient’s perspective

When Samantha Cobb was in the Air Force, repeated physical training in combat gear left her with fractures in both shins. The fractures on her left shin healed improperly, and she said that a government doctor misdiagnosed the pain as “compartment syndrome.” She underwent a test that involved administering 16 spring-loaded needles into her shin, intended to measure the pressure in the leg. Instead, the needles went into deep tissue muscles, breaking open an artery, piercing a tendon and a skewering a grouping of nerves, she said.

The damage to her nerves resulted in a condition known as complex regional pain syndrome or CRPS.

“It’s a constantly burning kind of pain, and anything that touches it from a blanket or putting on pants is excruciating,” said Cobb. Since her disability discharge from the military four years ago, she’s walked with crutches and managed her pain with oxycodone.

Cobb is part of CRPS support groups on Facebook. That’s where she first heard about ketamine infusion therapy. She and her doctor, Nicholas Tannous, MD, of the Carson Tahoe Pain Institute, began keeping an eye out for ketamine clinics. He made sure she acknowledged that a new treatment could present unknown side effects or long-term health concerns.

When Sierra Ketamine Clinics opened, Cobb decided the pain wasn’t worth deliberating over anymore. The only hurdle was the cost. Because of its status with the FDA, insurance companies don’t cover ketamine infusion therapy. At SKC, the initial four treatments cost $2,000.

“We were able to scrape up the money for the first four, and [we said] we’ll see if it’s effective or not, and we’ll worry about it from there,” said Cobb. “But it was extremely effective. So, you know, I’m going to keep trying to find the money.” Her family has been helping with payments.

After her second ketamine infusion, she was off the crutches.

Now Cobb works part time as a gymnastics coach at Silver State Gymnastics where she was a competitive gymnast throughout her childhood. She’d spent the summer coaching sitting down, unable to spot her students or do much physically. Since her ketamine treatment, she’s back on her feet, leading the choreography. She calls this “her second chance at life.”

Just the K

Sierra Ketamine Clinics is fine-tuned to accomplish one task for patients—administering a safe, controlled intravenous infusion of ketamine. With no formal psychiatric or psychological tutelage, the doctors there prefer—but do not require—their patients also be working with a counselor. Their website claims free referral services to pain management, psychiatry and psychological affiliates and primary care providers.

“We’re not really equipped for that,” said Watson “We basically counsel on the importance of those other things, but when they leave, it’s pretty much up to them.”

“What people do between treatments is as important as the treatments themselves,” said Frey. “We view this as a leverage point in someone’s life. This could be a super highly effective therapy, but if they don’t change some other things they’re doing in terms of diet, exercise, staying away from bad environments, hanging around the right people that help you stay positive, doing mindfulness resilience exercises—those are all incredibly important.”