Ketamine and Esketamine FAQ’s
Please browse the following sections. If you have questions that aren’t answered below, please feel free to contact us. While we can’t provide medical advice without a consultation, we can address general questions.
What is Ketamine?
Ketamine is most commonly known as an anesthetic agent used for general anesthesia and sedation. It was FDA approved for anesthesia in 1970 and is on the World Health Organization’s List of Essential Medicines.
It is also known as a recreational drug of abuse because of its hallucinogenic properties. Ketamine is a derivative of phencyclidine (PCP) and was originally synthesized for its shorter duration of action and decreased psychotropic effects.
Based on research that showed low doses of ketamine administered intravenously produced rapid and robust antidepressant effects in clinical trials as early as 2000, subsequent studies have shown that repeated dosing can sustain initial improvement in symptoms. While not yet FDA-approved for the treatment of mood disorders, there is ample research to warrant making these treatments available to the public.
What is Esketamine or Spravato?
Esketamine is the S(+) enantiomer of racemic ketamine and is already used as an anesthetic in Europe. It can be viewed as a purified form of traditional ketamine. The FDA has recently approved esketamine specifically for use in treatment-resistant depression. It is available in a nasal spray, marketed as Spravato. However, because it still has the same potential psychotropic effects and changes in blood pressure and heart rate as racemic ketamine, it is restricted for use in certified centers.
Part of the conditions of this fast-tracked FDA approval requires both providers and patients to be registered with the pharmaceutical company in order to monitor effectiveness and potential side effects. There will be no off-label use of esketamine due to these restrictions so this will be offered only for treatment-resistant depression. We have been certified by Jannsen Pharmaceuticals to provide Spravato treatment as an option to our patients.
How does Ketamine work?
The exact mechanism of action is still being explored (see our section on ketamine and the glutamate system). Ketamine is a potent, noncompetitive NMDA receptor blocker. The current leading theory is that the administration of ketamine and esketamine result in increased levels of glutamate in the prefrontal cortex (PFC) of the brain by blocking NMDA receptors on inhibitory GABA neurons, which results in glutamate release downstream. This glutamate cascade stimulates postsynaptic AMPA receptors which then create remodeling of synaptic connections by the expression of synaptic proteins and rapid induction of dendritic spines, resulting in greater connectivity in the brain by promoting new synapses.
We have developed protocols based on key pharmacodynamic and pharmacokinetic principles provided by the scientific community.
As ketamine’s mechanism of action is elucidated, the focus may shift to new pharmaceutical agents to develop, including oral agents. However, the intravenous route offers the greatest and most reliable bioavailability.
Is it safe?
Dosages used to treat mood disorders are far lower than that used for clinical anesthesia. It is very safe when administered in a controlled setting by licensed personnel. We follow current recommendations for monitoring during the infusion and the immediate recovery period.
As a Schedule 3N non-narcotic, there is a remote risk of dependence to both ketamine and esketamine. This is minimized by the low dosages that we use. Because of this risk of dependence and the potential for abuse as a recreational drug, we support restricting any form of ketamine only for administration under direct observation. We apply the same clinical standards from our hospital based experience.
Is it legal?
“From the FDA perspective, once the FDA approves a drug, healthcare providers generally may prescribe the drug for an unapproved use when they judge that it is medically appropriate for their patient.” Because ketamine is already FDA approved as an anesthetic agent, its use in the treatment of mood disorders is entirely legal as an “off-label” use.
Esketamine is FDA approved but with the limited indication for Treatment-resistant Depression.
We are a legal entity approved by the Secretary of State and registered with the Medical Board and the Board of Nursing.
What are the side effects?
The most common side effects of both ketamine and esketamine include dissociative psychiatric symptoms, confusion, inebriation, anxiety, dizziness, headache, euphoria, elevated blood pressure and heart rate, and increased libido. Chronic ketamine use can also have deleterious effects on liver and urinary tract function. Please refer to our patient informed consent for an extensive listing of possible side effects.
You will be closely monitored throughout the process. Most side effects dissipate soon after the infusion is complete and do not require any treatment.
How long do the results last?
The duration of relief is highly variable. Most patients have reported significant improvements in their mood and ability to function from days to a week after a single infusion. The induction period with repeated treatments is meant to solidify those gains and increase the duration of relief.
If the response is appropriate, we will help establish a maintenance schedule for ketamine and esketamine with you and your other health care providers. There are some patients who do not require maintenance treatments but that is the exception.
Is this covered by insurance?
Because this is an “off-label” use of ketamine, insurance plans will not cover these treatments. Once ketamine becomes FDA-approved for the treatment of mood disorders, we will be able to work with insurance plans to decrease your out of pocket expenses. Unfortunately, this process may take years due to the funding and research necessary. We strongly believe that there is sufficient research already done to warrant making these treatments available as soon as possible as long as we can do so safely.
The FDA has recently approved esketamine specifically for use in Treatment-resistant Depression. Once the patient has registered with the pharmaceutical company, Spravato will be released for use with that patient. At that point, this treatment should be covered by most insurance plans. We will help with the insurance PreAuthorization process.
How much do treatments cost?
We have some of the lowest rates posted locally and nationally. We want to make these services as widely available to the public as possible.
On May 1, 2020, marking our one year anniversary at our current location, our rates will increase to $425 for each One-Hour ketamine infusion for mood disorders. We will offer 2 protocols for chronic pain: $675 for each standard 4-Hour ketamine infusion for chronic pain and $550 for each 2 and 1/2-Hour ketamine infusion for chronic pain that has been more readily acceptable to client’s lifestyles.
For our established clients, the current rates will not be increased.
Please see our scheduling page for prices and availability. We also have discounts for Military, Law Enforcement, and First Responders.
Patients receiving Spravato for Treatment-resistant Depression will not pay at the time of service as their insurance will be billed first.
What payment forms are accepted?
We accept electronic payment at the time of service: EVM chip cards, Apple Pay, Google Pay, and all magstripe cards.
Insurance plans will be billed for esketamine only. Patients will be responsible for traditional copays and deductibles.
Financing plans are available for all other treatments. We have partnered with Advance Care to help with financing.