Introduction
Where you take your ketamine medicine is one of the essential aspects of ketamine therapy. There are two options:
This “where you take your medicine” issue is unlike every other medicine you have ever been prescribed.
In brief, if you:
- choose esketamine (Spravato). Your ketamine must be administered in a clinic.
- want or need IV, your ketamine must be administered in a clinic;
- want or need IM, your ketamine will, almost certainly, be administered in a clinic;
- choose a nasal spray ROA of racemic ketamine. You may administer it yourself at home. A few clinics administer racemic nasal spray in-clinic.
- choose SL/PR/PV ROA of racemic ketamine. You may administer it yourself at home. A few clinics administer lozenges in-clinic.
Why you might choose, want, or need any of these alternatives is discussed in the ROA – Route of Administration section and the Spravato section.
It’s unfortunate that each patient will have to do his/her own independent evaluation of the in-clinic vs at-home alternatives.
Study this section carefully so that you will be in the best position to make this choice. It’s probably the most important decision you will make about your ketamine therapy.
Generally, you can’t count on your provider to give you an unbiased explanation of the in-clinic vs at-home choice. Imagine yourself:
- Visiting a few clinics near your home; and,
- Calling a few tele-ketamine providers licensed in your state.
Would you expect the intake personnel to explain all the relative merits of each alternative?
- The clinic explains all the advantages of at-home ketamine therapy; and,
- The tele-ketamine provider explains all the advantages of the in-clinic experience.
The clinic’s owner decided to administer ketamine in-clinic because he thinks it’s the best option. The tele-ketamine provider decided to make ketamine available to her patients at home because she thinks it’s the best option for many patients.
You have to make this decision for yourself. We at KetamineTherapyForMentalHealth.com see significant advantages and limitations to each option. Neither choice is clearly the correct one for all patients.
Travel
To dose in the clinic, you must travel from home to the clinic and back. Therefore, you must consider the following:
- How far is the clinic from your home?
- What are the transportation alternatives available to you?
- The clinic will not permit you to drive yourself home.
- It might not allow you to be driven home by a taxi or Uber service.
Depending upon where you live, there may be no ketamine clinics operating within reasonable driving distance. Your initial course of treatment will likely be six administrations twice a week for two weeks. If the nearest clinic is hundreds of miles away, you might have to stay in a hotel for two weeks, incurring room and board expenses and travel costs. Subsequent “booster” administrations are apt to be on intervals of, initially, 2 weeks; then, 4 weeks; 8 weeks; 12 weeks; 24 weeks, and as needed thereafter.
Traveling hundreds of miles for a half-dozen additional administrations adds to the cost.
If you can’t make in-clinic ketamine therapy work for you – due to transportation or cost constraints – then what? Forego this most promising therapy? Or, consider at-home self-administration?
Environment
Mental health patients are typically not in a good mood. They are sensitive to interpersonal frictions. Think of it this way: you have to like your psychotherapist. You don’t have to like your psychiatrist. You will only spend a half-hour with your psychiatrist once a month. You will spend an hour a week, minimum, with your psychologist.
When dosing ketamine in a clinic, you will spend about 12 hours with the clinic personnel during the first six administrations—a time when you will be particularly agitated and vulnerable. The potential for a personality clash is acute.
Do you like the personnel in the clinic you are considering?
If you are fortunate, you may have multiple candidate clinics to choose from within a reasonable travel distance. Before choosing, it would be prudent to interview the doctors and a few nurses at each candidate clinic. Even so, the nurse attending to you at your dosings is probably not someone you met before you make your clinic selection.
Time
Dosing ketamine (regardless of ROA) is a process that takes a bare minimum of one hour and usually 2 to 2.5 hours. When a patient doses in-clinic, they take up space, using monitoring equipment and personnel resources for the duration. Someone has to pay for the office overhead and personnel, usually the patient. This is what makes in-clinic administration so expensive. If a particular patient needs IV or IM ketamine, then the expense is justified. Otherwise, the expense should be avoided by the cost-conscious patient. The alternative ROAs (nasal, sublingual or suppositories) are effective for the vast majority of patients.
Stress
The experience – especially initially – of dosing ketamine is stressful for a significant minority of patients. Mental health patients are already under a lot of stress. The prospect of taking ketamine can be ever more unsettling. Some patients have a strong subjective preference for dosing under the supervision of medical personnel. Having one’s hand held by a doctor or nurse (wearing a white coat) is undoubtedly comforting.
The counter-argument is that many patients prefer to undergo the potentially stressful experience of dosing ketamine in the familiar comfort of their own homes. These may prefer their hand held by a loved one rather than a stranger. Many would prefer to maintain control of their environment while dosing. In the clinic, other patients and medical personnel are apt to come and go and interrupt one’s own psychedelic experience.
Yet, it’s also the case that some patients can’t control their home environment. One’s home might be in a noisy neighborhood. Noisy children or housemates might occupy it. The “loved ones” might be a significant part of the patient’s mental problems.
Accordingly, the choice of an in-clinic administration is a complex balance of cost; travel; environment and its control; the comfort of medical services; vs. the comfort of home.
IV ketamine must be administered in a clinic. IM ketamine is nearly always administered in a clinic. Only a very few providers will prescribe injectable ketamine to be administered by the patient at home.
Inserting an IV, and eventually removing it requires the skills of a nurse. These won’t be available at home. A patient can learn to inject ketamine himself. However, there are a couple of considerations that counter-indicate this practice. One is a concrete medical concern, the other a regulatory taboo.
IV and IM ketamine can, in rare cases, precipitate a laryngospasm, i.e., a transient and reversible spasm of the vocal cords that temporarily makes it difficult to speak or breathe.
“[A] laryngospasm is a problematic reflex which often occurs under general anesthesia. It is a primitive protective airway reflex that exists to protect against aspiration but can occur in light planes of anesthesia. Olsson and Hallen reported the overall incidence at just under 1% in adult and pediatric practice.” https://academic.oup.com/bjaed/article/14/2/47/271333?login=false
The response to a laryngospasm in anesthesia is beyond the capacity of non-medical personnel. And so, presumably, even with lower doses of IV/IM ketamine used for mental health indications, it’s arguably imprudent for a patient to self-administer ketamine via IM at home. That said:
- The risk of a laryngospasm using sub-anesthetic doses via IM might be lower/higher than IV. The IM/IV distinction probably turns on how the dose is administered. IM is necessarily a bolus dose; you get the dose in the syringe in one shot. This quick influx of the drug is probably the triggering aspect of a laryngospasm. The nurse can mitigate the quantity of the quick influx by dividing the dose into two or three smaller doses. For IV, the nurse can slowly ramp-up the quantity of ketamine introduced in the drip. Observe the patient is doing OK, then taper it off for the later half-hour of the IV administration. Nevertheless, the nurse could infuse a large bolus dose, larger than an IM injection. In any case, if you are considering the in-clinic experience, it’s worthwhile asking if the personnel on hand know how to respond to a laryngospasm. If they don’t know what you are asking about, that’s a sure sign that they don’t have the capability to respond to such a crisis if it should occur.
- The merits of the IM ROA might be compelling in a particular case. Some patients don’t seem to respond to lozenges, nasal spray or suppositories but they do respond to IM. We’ve read a couple of curious reports where a patient didn’t respond to IV but did respond to IM.
- A patient might have a household member with applicable medical training. If so, IM at-home administration might be feasible.
All these contingencies may lead to a provider prescribing at-home injectable ketamine to a particular patient. It’s also possible that physicians prescribing at-home injectable ketamine are unaware of laryngospasm risk or discount the probability of an incident.
Ketamine is a Schedule III Controlled Substance. Therefore, there is a taboo about its use for recreational purposes. The DEA and state medical boards are apt to look askance at licensed doctors prescribing injectable ketamine for at-home use out of blind fear that the prescribed patient might use this form of ketamine for a recreational rather than a medical purpose. We construe this to be overwrought and unjustified. Nevertheless, doctors will be reluctant to prescribe injectable ketamine for at-home use out of fear of defending their decision before a regulatory tribunal.
In-Clinic Providers Prescribing At-Home Ketamine
Eventually, an IV or IM patient completes a an initial course of treatments in-clinic by those ROAs. Thereupon, they go on “maintenance.”
Many maintenance patients return to the clinic for “booster” IVs or IM doses. Others are prescribed lozenges, suppositories, or nasal sprays to self-administer at home. In these cases, the patient enjoys continuity of care by the same practice that started them on IV/IM in-clinic ketamine and follows up with at-home ketamine using less expensive ROAs.
When considering the in-clinic alternative, ask the provider whether they offer at-home self-administration for maintenance. You will likely be much more comfortable undertaking at-home maintenance after your initial course of loading doses in-clinic.
At-Home
We strongly believe that at-home ketamine administration is where most mental health patients should consider ketamine therapy. Nevertheless, at-home self-administration is not for everyone. Thoroughly read and consider the discussion at the end of this section.
All the counter-indications for in-clinic administration are resolved by at-home administration. Cost and travel favor at-home administration. Environment and its control will favor at-home more often than in-clinic. Only the physical safety and psychological comfort of medical services favor the in-clinic venue.
The most fortunate patient might be able to choose from a few ketamine clinics within a reasonable driving distance. Every at-home patient may choose from among many telemedicine ketamine providers—the telemedicine ketamine providers’ business model augers for maintaining licenses in multiple states.
Taconic Psychiatry is licensed in almost every state. Joyous is licensed in 24 states. The numerous other telemedicine ketamine providers are licensed in many states. So, depending on your state, you can choose among at least a few, and usually many, alternative telemedicine ketamine providers.
Just as each ketamine clinic has its proprietary practice model, each telemedicine ketamine provider has its respective practice model. You might find a particular telemedicine ketamine practice model particularly appealing. So, for example, suppose you were fortunate enough to choose among:
- three ketamine clinics within driving distance; and,
- six telemedicine ketamine providers licensed in your state.
You are more likely to find a highly desirable telemedicine ketamine practice than a ketamine clinic that appeals to you.
A few telemedicine ketamine providers provide both medical consultation and ship the ketamine medicine to your home themselves. (Or, they work directly with a pharmacy closely affiliated with the medical practice.) Most telemedicine ketamine providers will call in your prescription to a compounding pharmacy of your choice. Usually, they will recommend one of several compounding pharmacies with whom they are familiar and which are licensed to ship to your state. You may have a choice among several pharmacies licensed in your state and prefer one pharmacy’s price, lozenge taste, or service over another.
The compounding pharmacy will ship your ketamine to your doorstep by air courier. Therefore, there is little reason to choose one pharmacy because of its location’s proximity to your home.
Nevertheless, there are many compounding pharmacies throughout the US and there is a fair chance that a compounding pharmacy is within driving distance of your home. Check the availability and pricing of compounding pharmacies near you. You will probably enjoy a better customer service experience from a local pharmacy vs. the customer service and shipping hassles of a national pharmacy.
Some telemedicine ketamine providers’ operations are entirely, or nearly entirely, virtual. As such, their overhead is minimized, with many employees working from home. There may be just one or two offices where some employees perform management functions. Others are hybrid telemedicine ketamine practices, with some patients appearing in their offices for face-to-face consultations. In either case, the cost of maintaining the overhead is shared across a much larger number of patients than in a typical medical practice where virtually all patient contact is face-to-face.
Telemedicine ketamine providers almost entirely serve the at-home patient population. Nevertheless, a small number of physicians prescribe at-home ketamine to patients they consult face-to-face. These non-telemedicine-ketamine at-home providers are difficult to identify. We will include them in the Providers directory as we discover them. However, in doing so, our outreach to these face-to-face providers will be limited. They are not numerous. They are scattered throughout the country. Visitors to this site have a relatively low probability of residing within 100 miles of one of these face-to-face at-home self-administration providers. So, only a few will benefit from listing them.
These face-to-face providers, in some cases, represent a hybrid of the in-clinic and at-home alternatives. Some may include in their practice models a provision for patients to take their first few doses in-clinic. And, thereafter, prescribe ketamine to be taken at-home.
At-home self-administration is not for everyone!
Notwithstanding the clear-cut advantages of at-home self-administered ketamine, the at-home alternative is not appropriate for a significant minority of patients.
What’s your capacity to function? To use ketamine responsibly?
When we patients start ketamine therapy, we are not at the top of our game. Even the highest functioning of us is very likely to be not up to the demands of self-administration. Take this fact very seriously.
The “bad trip” Risk
You will – sooner or later – have a profound psychedelic experience. Are you up to handling this? Are you squeamish about your response to an inevitable psychedelic experience?
To understand this risk of “a bad trip” we have to explain an apples-to-oranges comparison. Titration in-clinic is much more aggressive than titration is apt to be at-home. The clinic is trying to give you your money’s-worth for each treatment. They are apt to titrate you at 0.5 mg/kg from your first dose. Or possibly somewhat higher. It is highly likely that you will have a profound psychedelic experience in-clinic from your first dose. You would not want to go through this experience alone at home; not even with a trusted sitter at-home.
In contrast, when you begin your ketamine voyage at-home you are free to titrate your initial doses as slowly as you desire. Joyous starts from a very low dose and titrates slowly. Their maximum dose is 120 mg sublingual; 100 to 120 mg sublingual is low-dose. It’s very unlikely that you will experience a profound psychedelic experience from Joyous’ protocol before you have become accustomed to the ketamine experience.
Other at-home prescribers are apt to titrate you more aggressively than Joyous. A typical protocol is two introductory doses of 100 mg sublingual followed by weeks of 200 mg doses. Then 300 mg doses. That step from 100 to 200 is 100%; and, from 200 mg to 300 mg is 50%. So large a change in dose can be exciting. Nevertheless, you are at liberty to break up your doses on a titration schedule such as:
50, 50,
75, 75, 75,
100, 100, 100, 100,
150, 150, 150, 150,
200, 200, 200, 200,
250, 250, 250, 250,
300, . . .
In so doing, you are much less likely to experience a trip you can’t handle at-home as compared the trip your clinic might treat you to.
A dose of 0.5 mg/kg in-clinic is a vastly more profound experience than 50 mg sub-lingual at-home. It is simply nonsense to equate these two quantities of doses. Yes, if you really want your first few experiences to be profound then seriously consider starting in-clinic. Conversely, if you prefer to titrate slowly from a low dose there is little reason to fear at-home self-administration.
When you dose at home you must take responsibility to dose in accordance with your prescriber’s instructions. You are free to negotiate a less aggressive titration schedule than your prescriber recommends. But you must not titrate more aggressively than your prescriber instructs you.
If you are impulsive, it would be prudent to leave your supply of ketamine in the hands of a responsible household member who will dole out your doses according to your prescriber’s instructions. If you can’t or won’t control your impulsivity, then you would be wise to pursue the in-clinic alternative.
Your provider, PCP, or cardiologist should evaluate your blood pressure and clear you for ketamine therapy prior to your first dose. Nevertheless, you can not know how your blood pressure will respond to ketamine before you dose ketamine. And your blood pressure is apt to respond differently – more adversely – as you carry on your ketamine journey.
In-clinic, you have little to be concerned about. The clinic personnel will monitor your blood pressure, and they will respond if it spikes dangerously. At-home, you are responsible for monitoring your own blood pressure.
Again, in-clinic your provider is apt to titrate you aggressively from the beginning. If you are going to face high blood pressure problems because you want an aggressive titration, then it’s best to begin in-clinic.
Conversely, if your preference is to titrate from a low dose and escalate gradually, then you have little to concern yourself about your blood pressure getting out-of-control. You can monitor your blood pressure as you titrate up and respond when you see your blood pressure rise faster than you are comfortable with. You are not going to go from 120 to 180 systolic at your first low at-home dose.
A 50 mg sublingual dose is not likely to have the impact of a 0.5 mg/kg dose in-clinic. To equate these two, as respects blood pressure, is utter nonsense.
It’s true. If your blood pressure spikes on an IV in-clinic your nurse can cut the ketamine feed and give you clonidine intravenously. Why would that happen? It’s because she is giving you a relatively high dose of ketamine intravenously (or by injection).
If you are self-administering a very-low to low sublingual dose of ketamine at-home, you will not run the risk of a precipitous rise in blood pressure.
The comparisons of in-clinic vs. at-home administration – as respects the intensity of the trip and the impact on blood pressure – are an apples-to-oranges comparison. The risks are much higher in-clinic because the titration is much more aggressive; and, therefore, the need for a medical response. The risks are low at-home because the titration is much less aggressive. Therefore, the prospects for a medical response is much lower.
The come-up on a lozenge is much slower. If you start to become uncomfortable, you can spit your remaining dose and saliva. That will soon begin to slow your response to the drug. You are in complete control to spit on impulse. In-clinic, you have to wait for a nurse to respond to your call.
Concern for spiking blood pressure is often overwrought. Does your PCP or cardiologist warn you not to exercise for fear that your blood pressure might spike? Of course not! Nothing could be more ridiculous.
Your PCP or cardiologist should instruct you to keep your blood pressure spikes within limits of pressure and time appropriate to your cardiovascular condition. A young football player can safely endure peak pressures for long durations that would threaten an elderly patient with a heart attack.
If you start ketamine therapy with high blood pressure, you must get that under control. Whether you undergo ketamine therapy or not, hypertension is a serious health threat. So, we presume that your PCP/cardiologist has your blood pressure under control.
Ketamine will spike your blood pressure. Initially, at very-low to low doses, the spikes will likely not be interesting. Comparable to moderate exercise.
As your dose is titrated up, spikes will become more exciting. Your subconscious traumas will start to emerge into consciousness. Spikes are apt to increase in intensity and duration. It’s not so much the physiological effects of the ketamine. Instead, it’s the psychological effects of the ketamine unearthing the demons buried in your unconsciousness. This is why you must continuously monitor your blood pressure throughout your ketamine voyage. Because the ketamine is working, your spikes are apt to get worse.
Clonidine is a relatively fast-acting hypertension medicine. If and when you see your blood pressure spikes threaten the guidelines your PCP/cardiologist has set for you, ask for a prescription for clonidine. Take a dose of clonidine 30 – 60 – 120 minutes before your dosing session to get ahead of the spikes. Clonidine starts to take effect in 30 minutes. The peak response is from 2 – 4 hours. Learn to time your dosing of clonidine relative to ketamine to manage your book pressure spikes.
If you see your spikes still sometimes threaten your PCP/cardiologist’s guidelines, ask for a prescription for a compounded sublingual clonidine formulation to keep on standby. Be prepared to take a sublingual clonidine dose in accordance with your PCP’s/cardiologist’s instructions when you see a significant spike in your blood pressure.
Conclusion
You have to make your choice between in-clinic vs at-home ketamine therapy according to your own assessment of your preferences and needs. If you are a relatively well-functioning, responsible, adult than an at-home prescriber will probably clear you for self-administration. If you, your PCP, or your candidate providers have reservations about your capacity to self-administer ketamine, then, by all means, consider starting with in-clinic ketamine therapy for the first few doses. You can switch to at-home self-administration when you feel you are ready.
Sanacora, G., Frye, M. A., McDonald, W., Mathew, S. J., Turner, M. S., Schatzberg, A. F., … & Nemeroff, C. B. (2017). A consensus statement on the use of ketamine in the treatment of mood disorders. JAMA Psychiatry, 74(4), 399-405. (This consensus statement provides expert opinions on the use of ketamine for mood disorders, including safety concerns and administration methods.)
Krystal, J. H., Abdallah, C. G., Sanacora, G., Charney, D. S., & Duman, R. S. (2019). Ketamine: A paradigm shift for depression research and treatment. Neuron, 101(5), 774-778. (This paper discusses the paradigm shift that ketamine has introduced in the treatment of depression, touching upon administration methods and future research.)
Andrade, C. (2017). Ketamine for depression, 4: In what dose, at what rate, by what route, for how long, and at what frequency?. Journal of Clinical Psychiatry, 78(7), e852-e857. (This article reviews available literature on ketamine dosing, administration routes, and frequency for depression treatment.)