(153) Ketamine, From the Comfort of Your Home?

Background: Changes in telehealth policies resulted in increased prescribing of controlled substances during the pandemic and an increase in online, for-profit companies for mental health treatments, including at home ketamine treatments. Many consultation-liaison (CL) psychiatrist are unaware of patients having access to such resources.

Case: 40-year-old male with a history of Major Depressive Disorder, Borderline Personality Disorder, Opioid Use Disorder in sustained remission, active stimulant and hallucinogen use disorders, and past medical history of well-controlled HIV who presented after being found down by his partner with an empty bottle of anti-retrovirals nearby. He was diaphoretic, was surrounded by bilious emesis, and unresponsive to stimuli. In the ED, he had significant fluctuations in alertness and experienced intermittent severe agitation requiring chemical and physical restraints. He was intubated for airway protection and admitted to the ICU. Initial labs were unremarkable with normal BMP and CBC, and negative acetaminophen, ethanol, salicylate, and tricyclics levels. Urine toxicology was positive for amphetamines and oxycodone but negative for benzodiazepines, cocaine, and opioids, including fentanyl. The patient self-extubated after 12 hours.

After thorough psychiatric interview and collateral, it was revealed that patient had attempted to end his life with toxic ingestion of GBL(gamma butyrolactone) /GHB (Gamma hydroxybutyrate) in the setting of interpersonal conflict with his partner and recent personal losses. The patient did not endorse any use of ketamine, but the Massachusetts Prescription Monitoring Program showed multiple recent dispensations of a variety of ketamine powder prescriptions, at variable intervals and doses.

When confronted with this information, the patient disclosed that he used an app, called “nue.life” to obtain “ketamine experiences.” He reported that he completed a series of questionaries but had never formally evaluated by a prescriber. He also did not know the name the prescriber or how to get in contact with them. Examination of the app and website revealed a company focused on increasing access to ketamine to individuals facing mental health challenges. During his admission, efforts were made to get in contact with the family medicine nurse practitioner listed as the prescriber, without any success. Two days later, the patient was medically cleared and transferred to inpatient psychiatric treatment center.

Discussion: This case highlights the impact that reduced regulations surrounding controlled-substance prescribing has had on at home ketamine therapy services. Concerns with at-home ketamine services such as these include 1) eligibility criteria that is not in line with the American Psychiatric Association Guidelines 2) concerns regarding efficacy given reduced bioavailability of oral formulations 3) safety concerns due to a lack of medical supervision during medication administration and minimal contact with prescribing provider 4) scarcity of data on the safety profile of oral formulations of ketamine and 5) Minimal training in psychiatric diagnoses and clinical management of psychiatric illnesses for prescribing providers.

Conclusions: CL psychiatrists need to be aware of resources through which patients are increasingly able to legally access a variety of medications, including ketamine and other psychedelics.