Ketamine Diaries #5
From the safety of ketamine to Survivors of Circumcision Anonymous
This is Part 5 of a series. To read from the beginning, start here.
We left off with Dr. K pausing our interview to let a patient into the office for a Friday night appointment. If you missed the last installment, you might want to read that first. Or just jump in here!
When I go down a rabbit hole, I really go down a rabbit hole, and accordingly: I’ve spent a lot of time over the past two weeks researching ketamine and trying to fact-check Dr. K’s claims. I’ll fill you in on the fruits of my research and explain how I ended up doing a deep dive on human-dolphin communication.
But first: back in the room with Dr. K. Picking up right after he leaves his patient in the waiting room and returns to me. To contextualize my first question - ketamine can be administered in multiple forms: intravenously, via intramuscular injection, oral, or intranasal. Or: if you’re doing it recreationally, you can….use any vein or orifice. (See, if you dare, the report of this Reddit user, who shot it up his urethra.)
In October, the FDA issued a warning about compounded ketamine - the kind Dr. K uses, which patients pick up for themselves at compounding pharmacies or have delivered through the mail. The warning focuses on the risks of misuse/unsupervised use/diversion. A risk that’s lower with IV ketamine because patients don’t have access to it or, generally, access to IV equipment.
Without further ado….
A Conversation with Dr. K, part 2:
- Why don’t you do IVs? Why just the intramuscular and lozenges?
- The extra three or four hundred bucks.
- For what?
- That it would cost to have that setup and to be in a space that was designated…you have to be in a designated type of space.
- What type of space?
- They’re most commonly referred to as post-op, more medically oriented, linoleum floor, um IV pole…
- But you can do the intramuscular in a space that’s not designated for IVs?
- Correct.
- You don’t need any medical designation to perform treatments with a needle but you do with an IV, is that what you’re saying?
- Yes, that’s what I’m saying.
- Interesting, I didn’t know that. Are there different precautions and emergency procedures that you need to have if you have an IV?
- The level of sterility needs to be higher. You…a number of things that one associates with um treatment requiring an IV, IV placement, nursing staff, etc etc.
- I find that interesting because the experience of being on the IM and the lozenge I found much more intense and terrifying than the IV. So I would feel that with the IM and the lozenges that I’d want more precautions in that case than the milder effects of the IV.
- Right. If I had to….having thought it through or talked with you more, I would have probably been more intently supervising of our experience, when we were together.
- You mean as far as not leaving me alone in the building?
- Yeah, there were a number of things that happened to have occurred that made that more –
- But shouldn’t you have been here regardless of if it’s me or just any patient? Like wouldn’t any patient want to be supervised?
- How would I put this…um…yeah, you’d be surprised. I’ve had people tell me, would it be okay if you just wouldn’t be here right now?
- But isn’t the whole point of coming to a doctor to have the doctor there?
- It depends. Um. Some people…for some people it becomes an intently internal process and they don’t cotton to being observed.
- I mean for me it was less about being observed than feeling like there was someone here in case an emergency should occur. And if an emergency should occur, say if there was an earthquake, and I’m in the middle of a ketamine trip and not cognizant and capable of you know handling things, that there would be someone here to like address that.
- I don’t…I don’t challenge that. And um I’m not mincing words when I say I apologize and that could have been handled better and I’ve ….approached things a bit differently since the time we spent together.
- How so?
- I …am in the room more frequently. And check in more frequently. And not everybody likes that.
- I mean, it wasn’t even in the room that was the concern, it was in the building.
- Ditto. Same thing goes.
- And I think you obviously know I was uncomfortable with that. But then it kept happening. And that made me feel increasingly—
- And that –
- And the last time, there was another guy here at the same time.
- Again, sometimes things get…sometimes you just have a series of things which lead to a bad run and again, my apologies for it, and I’ve probably had two patients in this suite like 4 times in 6 years. 3 times probably. And I say 3 because I know of 2 and I’m playing the odds that if it was 2 there was probably a third. I never do that.
- Why did that happen that time?
- Someone came in and said I really need to see you and I’m leaving tomorrow kind of a thing.
- I just remember walking in and he didn’t look well. It didn’t look like a normal..
- Well, that’s why I imagine was part of what informed his really needing to get in but yea but I remember that period of some number of weeks and you know, uh, I’m not sexing it up here but I thought about it while I was in the shower, so it wasn’t lost on me, and I was trying to construct deconstruct and come up with a better…a better way of figuring things out. So my apologies.
- I appreciate the apology.
- Um, and I’m not just making it up.
Why did he feel compelled to tell me he was in the shower or use the phrase sexing it up? Unclear! Did hearing that make me want to take a shower? You bet. But I interject here mainly to contextualize the next twist.
Remember Dr. S? My mother’s psychiatrist, the one whose office Dr. K uses, and whose receptionist he shares? The one who referred us to Dr. K?
Turns out his medical license is on probation, with severe limits placed on his practice. Why? Good question. Guessing based on the restrictions placed on his practice, it seems to have to do with overprescribing controlled substances and also…marijuana? That part makes less sense.
According to the CA Medical Board:
Dr. S made no admissions but was charged with gross negligence, repeated negligent acts, and failed to maintain adequate and accurate medical records in the care and treatment of multiple patients; and prescribed without an appropriate prior medical examination or indication. Acceptance of this stipulated settlement is not an admission of guilt. Effective 02/11/2022, revoked, stayed, placed on five years' probation until the anticipated end date of 02/10/2027. Terms and conditions include, but are not limited to, prohibited from ordering, prescribing, dispensing, administering, furnishing, or possessing any Schedule II controlled substances and from issuing an oral or written recommendation or approval to possess or cultivate marijuana; maintaining a record of all controlled substances ordered, prescribed, dispensed, administered, or possessed and any recommendations or approvals to possess or cultivate marijuana; completing an education course, a prescribing practices course, and a medical record keeping course; obtaining a practice monitor; submitting proof of notification of Decision and Accusation to required parties; prohibited from supervising physician assistants and advanced practice nurses; submitting quarterly declarations of compliance with all conditions of probation; complying with the Board's probation unit; prohibited from engaging in the practice of medicine in Dr. S’s or patient's place of residence, unless the patient resides in a skilled nursing facility or other similar license facility; and paying costs associated with probation monitoring.
What he told my mother: that one of his patients’ ex-boyfriends complained because he was prescribing Tylenol to the patient. Does that add up? Absolutely not.
Back to our conversation:
- So addiction tolerance…why would any chem dep unit be introducing it. Why would anybody be using it actively? We certainly don’t use heroin.
- No.
- But sometimes it helps people by, I mean some people are so allergic that it doesn’t matter how much they pay, and they have the capacity to pay a lot…
- Allergic to what?
- To being in rehab. And to not being on whatever. I mean their family will eventually or their agent or their family or their band will just strong arm them enough so that they go.
- Another question I had and this is very concerning to me. I found out that Dr. S’s medical license has been limited for overprescribing. I’m concerned about that and curious what you know because she has had times when I ask her why she’s taking each of these medications…It seems like an immense amount of medication.
- She’s on a lot of meds.
- Right, and then to learn that Dr S has been under investigation for overprescribing makes me feel also uncomfortable.
- We can do a part 2 of this if you want, and…I…had actually asked not so long ago Dr S if he would be offended if I made some…because when a doctor refers you a patient for particular treatment…so the woman that reminded me of your mother.
- Is she a patient of Dr. S?
- Yeah.
- And is he giving her the methadone?
- Um. She was transferred to my care.
- But he was giving her the most methadone you’ve ever seen someone prescribe.
- Yeah, and….and…
- Was that part of the investigation, or was that separate?
- No. This may be a separate conversation, and I’m glad to have it.
- I guess I just don’t understand what your and Dr. S’s connection is. Because this is his office? Your office? But you share an assistant?
- We’re actually the same person.
- Well I know that’s not true. But I don’t know what the contours—
- Do you?
- I do, because I met Dr. S in here when you were not in the office the first time [I was on ketamine], so I do know you’re not the same person.
- Um. Uh. You gotta hand it to those makeup people. Um. So you’re asking a bunch of different things at once. A. The person on the methadone….uh…is really fucked. And it’s not the methadone. Like, she doesn’t deserve the autoimmune cards she’s been dealt, really. And she’s a really nice person. An attorney, married an attorney, has four children. Guess what they do? They’re attorneys. I talk to her, and half the time, she has to go because she’s in so much pain. She’s really in a lot of pain. A lot. She’s younger than your mother is. By a decade maybe. And really seems to be a very sweet person. And it sucks. So what did this conniving drug pushing like uh….it makes no sense that I would want to reduce my patients’ sentences but sometimes I can’t help myself. That’s the logic used, why would drug dealers put Fentanyl in their meds—in their drugs---to have the drugs kill the customers. Um, the only logic I can see is it, uh, makes them crave it more. So they’ll become more frequent customers.
- Are you implying that Dr. S is the drug dealer in this scenario?
- Oh no. I’m implying that this woman really did need major massive pain---
- But you thought she didn’t need that amount of methadone.
- Guess how I got it down?
- Ketamine.
- Yeah. So she’s on a third as much methadone as she is now.
- That’s good.
- I think so.
- Doesn’t make me feel better about Dr. S’s prescribing strategies.
- The short form on that is, and we can make another time, so for some reason, I haven’t addressed it with him, but the story is, you can apply for certain types of, I don’t even know what it is, you can get on certain lists that make you a go-to person for some particular type of problem. According to powers …according to what I know, Dr. S applied to be a medication a pain management sleuth, and apparently it was a big pain in the ass to do it but he got on the list. The situation may have been complicated by the fact that he is not board certified in pain management. That shouldn’t be here nor there. It so happens that there was a patient that alleged that Dr. S, something bizarre, like, he had taught him how to kill someone with a sword or something. Don’t ask me, I don’t know. I didn’t ask. But you have to…furthermore, I mean I rarely treat patients with psychotic features anymore. I’ve grown out of it. It used to be all I treated at [name of hospital]. But there was some allegation. The board is draconian, it’s like the second or third worst regulating agency among medical boards in the country.
- That particular pain management board?
- The medical board of California. Like doctors leave California because they’re such…by comparison they’re so aggressive. I can’t render an opinion about anything regarding any part of this but that is part of the backstory. What is clear is that Dr. S was not certified in pain medicine. That doesn’t mean you can’t treat people for pain. He got on a panel of go-to pain people. I’d never do that myself, but he did, and ended up having a large number of pain management patients, some of whom…and pain management…the standard of practice, or rather the consensus opinion will vary from time to time. When I trained and for many years thereafter, it’s been relatively recent that people are talking about over-treating pain. Most of the time, I was being messaged, we’re under-treating pain and people are suffering, and that sucks.
- Well yes, I know how we got to the opioid epidemic. That trajectory is clear.
- Things took on a life of their own.
- Yeah, but that was part of the ‘let’s treat pain more.’
- No, that was later on in let’s treat pain more. Early on, those guys weren’t around. Early on, I was walking around and like…life means different things to other people, but at some point, please pull my trigger. Some things just aren’t worth being around or awake for. Some people will say when would you rather not have been born, and there are academic arguments about it, and some people would say any year before they developed pain medicine. Pain can be really bad.
- I don’t dispute that.
- And you’re right about how some part of the you’re not treating pain enough got floated. But before, there really was not enough pain management…
- Yeah that makes sense.
- And now clearly, I talk to people and they say, my life is terrible, nobody will prescribe me any pain medicine.
- Do you have a patient? Am I keeping someone waiting?
- We’ll wrap in two minutes. I had a patient, high functioning…I saw her for depressive stuff, nothing complicated. 42, 41…went in, and I’m not saying you shouldn’t have a colonoscopy. You should have a colonoscopy, but things do happen. As was in her case. Botched.
- Like they perforated her colon botched?
- That alone would have been okay. But yes, that. And then further and then further. So four surgeries later, she’s two years out and still in chronic pain. Gave up her car, like is not doing well. Money has its uses. Having a P…what do they call it, a PPO?
- Yeah.
- Versus an HMO?
- Yeah.
- That has its value, as evidenced, just because I thought of it. This poor women, we’ll call her [first name], because her name is [first name], but you have no idea what her last name is. I think. I shouldn’t have said [first name], I should have called her Lee. But fucking her primary won’t send her to a pain doctor, won’t give her pain medicine. Will not send her to a shrink, knowing that she’s seeing a shrink out of pocket. Now for, I’ve seen her since…since my very first year out of training.
- That’s a long-standing relationship.
- Right, so she now pays $25 a month.
- This is the woman who had the colonoscopy at 42?
- Right. That was botched and botched again. And has this – if one is to believe the allegations – a relative dick, even being female because…I expect dickness from guys more than women, call me testosterone…
- They come in both forms.
- They come in both forms. I can attest to that. But you suspect a little more sensitivity, rightly or wrongly. But won’t send her to a shrink. You gotta get paid something, so she pays me $25 a month. She’s not completely without means, she owns her own home. But won’t send her to a pain doctor and prescribe any pain medicine. That is one of the ways that HMO arrangements can suck. So, any other question that was to the point…chem dep, does that automatically preclude someone from being treated with ketamine?
- I think you answered that, the answer is no.
- And would you ever…I can take someone’s appendix out without anesthetizing them. There are stories of doctors taking out their own appendix. It can be done. Should it be done because they’re an addict? Most people will say no. Funny story, and then we’ll go. Recovery. Addiction. Big bandwidth. I did a subspecialty in it, so I went to a lot of meetings. You should see some of the meetings. Survivors of Circumcision Anonymous. Now there’s a group that you don’t run into a lot.
- Wait.
- We’ll have to talk more.
- They were at this meeting?
- It was one of the many meetings that I had to go to.
- For the chemical dependency unit?
- They said go to 14 ‘A’s. We don’t care what they are. So that you know what you’re talking about.
- But circumcision’s not a dependency.
- No, it’s…they…Underearners Anonymous. Check them out. They’re actually a pretty helpful group. Every hour on the hour, or at least it used to be, 45 minutes said and done, sure they talk about money in the beginning, but then it’s mostly ‘I promise to get to my doctor’s office’ and anyone can use that. I can use that.
- Right. But Survivors of Circumcision Anonymous is a real group?
- Unless they’ve since ended. You know, people are funny, and you know, you gotta laugh if you’re not going to cry.
- Yeah.
- Look them up if they’re available. There’s a book, there’s a short story at least.
- I don’t know that they’d welcome me there.
- You don’t have to declare. That’s the thing with online groups. You can be present. The code on your phone will show. But you don’t have to be present, video or audio. You can just listen.
- Fascinating. I’ll look them up.
- As…you always get the pronunciation right. Chuck…
- Palahniuk?
- Thank you. He will say, storytelling is nearly dead in this country. With one exception. The rooms of Anonymous groups. There is an art form, and there is a good place to go. You could do a lot worse than to go there to see how people that tell stories frequently – and captivate an audience – do their work. I thought that was compelling.
- I mean, I have a personal vested interest in believing that storytelling is not dead.
- No, but there’s a point, though. We don’t sit around, we don’t have dinner together, a bunch of reasons why that…
- No, for sure.
- My Christmas, Hanukkah, New Years--sometimes a present is simply a suggestion, or maybe think about. I’m looking at you and I’m thinking The Moth.
- Wait, your Christmas—I don’t follow.
- Sometimes a Christmas present, Hanukkah, or a New Years offering doesn’t have to be a toy truck or a present, it can simply be a passive suggestion or a mention. And so I say to you, I’m looking into your eyes, and I see The Moth.
- What about The Moth?
- In your future.
- That, like, I’ll perform there?
- Yes.
- Interesting.
- Or, go for broke, do a TedX.
- I’ll keep it in mind.
- Let me know when it’s being broadcast.
- I will.
- Think big.
And that was how our conversation ended.
I left in a state of muddled discomfort. Did I feel vaguely sad for Dr. K for thinking we were friends doing shop talk and a book exchange? Frustrated that I hadn’t pushed him harder? Confused because the way he talks about ketamine, he makes it sound as innocuous as marijuana and does that make me an uptight square? I love marijuana, after all. Did he really think that if I were to do a storytelling performance about my ketamine experience it would paint him in a positive light? What’s the difference between delusion and arrogance? How much of what he said was true? What was that about Dr. S teaching someone how to kill a man with a sword?
I told my mother about the sword anecdote. It turns out that Dr. S has done samurai sword training, is something of an expert at it, he claims.
My confusion about all of this underscores what an act of trust it is to place yourself in the care of a mental healthcare provider. The same goes for physical health, of course. But for internal medicine, there’s a lot more, well, knowledge about how things work and why. With psychiatry, the truth is we still don’t know exactly how and why many psychotropic medications work and what the long-term side effects might be. It’s often a process of trial and error. Guessing and checking and readjusting. In the meantime, you, the guinea pig, have to live with and adapt to the side effects.
I started taking psychotropic meds in the sixth grade. Every time I would come in and say that I was feeling down (which was…most weeks), my shrink would increase my meds or add another one to the cocktail. By the middle of seventh grade, I was gaining weight and incapable of keeping my eyes open for the duration of a 45-minute-long class. The last straw with that psychiatrist was when Rite Aid refused to refill a certain prescription because they judged it dangerous for a 13-year-old. At the time, I didn’t know better. How could I?
I would never have chosen Dr. K to be my primary psychiatrist, for talk therapy or medication management. But I let him shoot me up with ketamine. Because I didn’t know anything about ketamine, and he purported to know a lot, and I took his word for it. I didn’t know what my alternatives were.
Now, as I wipe my bleary eyes and emerge from the fog of the past weeks’ research, part of me wishes I could go back, armed with the info I have now, and ask harder-hitting follow-up questions. Call him out on some of his claims. Another part thinks…what’s the point?
Is anything Dr. K is doing actually against the law and/or dangerous? Or is he just negligent in a benign way?
On the legal front - I really don’t know. Because of the weird grey legal space therapeutic ketamine is operating in right now, there really aren’t many hard and fast laws. According to one other ketamine provider I spoke to recently, there are in fact strict regulations about how ketamine must be stored in a doctor’s office, and it’s obviously not out and about on cabinets and desks, to be used for whichever patient, regardless of who it’s prescribed to. Seems unlikely that there are no sterility requirements for a medical office where syringes and needles are used. (E.g. what about those sharps containers you find in doctors’ offices?). My own psychiatrist, who is in Massachusetts - I’ve been seeing her since college - said that according to MA laws, if she were to give injections in the office, she’d need a procedure room with linoleum floors and other sterility precautions. Dr. S’s office is fully carpeted.
At a certain point this seems like splitting hairs.
The bigger question is: how safe is ketamine? What precautions are necessary?
What Dr. K said about its safety as an anesthetic - that’s absolutely true. Ketamine was synthesized in 1962 as the result of efforts to develop an anesthetic that was shorter acting and had fewer side effects than PCP. (Yes, that PCP: angel dust. Apparently they used it for surgery, back in the day. It was, needless to say, not an ideal choice.) Unlike other anesthetics, ketamine does not cause respiratory depression, which means it can be administered by someone who doesn’t have special anesthetic training. Crucial for, say, emergency surgery or in locations with limited medical personnel. It’s also a good choice for young children and the elderly.
Broad consensus: ketamine does not need to be administered by an anesthesiologist. That’s different than saying there’s no need for any kind of medical supervision.
The greatest risk of ketamine appears to lie not in what it does to your body but in what you might do while on ketamine. The setting, and what you combine it with.
At doses much lower than the anesthetic dose, you lose coordination and feel very detached from your body. Which creates a major fall risk.
Nausea is a common side effect. If on the off chance you do, say, throw up, you want to ensure that you don’t choke on your own vomit. If you’ve combined ketamine with other drugs, the health risks multiply.
The more ketamine you do, the more blasé you’re likely to get about safety precautions. What Dr. K said about ketamine not being habit-forming, and your body not developing a tolerance for it? False. Ketamine doesn’t cause physical addiction - your body will not go through withdrawal if deprived of the substance. But craving is a different story. Plenty of people don’t get hooked on ketamine. But some do. All it takes is a quick look at the Ketamine forum on reddit to confirm that.
And: the more you take, the more the drug’s effect on your mind changes. According to a British psychiatrist named Karl Jansen, who wrote a book called Ketamine: Dreams and Realities, with repeated long term use, the effects of ketamine may come to resemble “a mixture of cocaine, opium, Cannabis, and alcohol, and become less and less psychedelic.” The diminished psychedelic effects can lead to the use of higher doses to achieve dissociation. It could also lead someone to seek out other ways of triggering a more dissociative high. Such as: floating in water.
Matthew Perry is far from the only ketamine user to gravitate towards the water.
Ketamine’s most prominent early researcher and experimenter, the Timothy Leary of ketamine, if you will, was a man named John Lilly. Lilly in fact introduced Leary to ketamine. Lilly was a neuroscientist with training in medicine, psychoanalysis, and biophysics, and he was most famous for his efforts to communicate with dolphins, a pursuit that reflected his interest in transcending human consciousness and earned him the nickname “the dolphin man.”
He also nearly drowned in a pool while on ketamine. More on him coming up next. Stay tuned.
Also: I can’t find any evidence of Survivors of Circumcision Anonymous being a real organization. Obviously I Googled. Throughout my brief searching, I kept thinking of a brilliant segment from an episode of How To With John Wilson, in which Wilson meets an anti-circumcision advocate and visits him at home, where the two men chat about recent movies while Mr. Anti-circumcision demonstrates his foreskin-stretching device on himself. Mr. Anti-circumcision is also a musician, and he has written the anthem “Grow it Back Again.” You can listen to that here.
On that note, happy Wednesday to all, and thank you for reading!
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THOUGHT ABOUT IT IN THE SHOWER. I'm guffawing