Behavioral Addictions
Behavioral addiction treatment addresses compulsive behaviors such as gambling, internet use, or shopping. Programs focus on understanding triggers and building healthy coping mechanisms for recovery.
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KETAMINE-
Update on Ketamine via Telemedicine Delivery.
A breakthrough treatment for depression or a risky precedent? Here’s the latest.
Reviewed by Tyler Woods

In 2020, the federal government changed the rules to make it easier for providers to treat patients via telemedicine. One rule change allowed providers to prescribe controlled substances like ketamine without first seeing the patient in person.

The thinking was that, because the pandemic was raging, it was too dangerous for people to go to doctor’s offices for visits and to get their prescriptions.

Since that time, the number of people receiving ketamine via telemedicine has soared. The reason is clear. Several studies, as well as anecdotal evidence, in the last few years have shown ketamine to be highly effective for some people with treatment-resistant depression (TRD). It is also showing efficacy for bipolar disorder, PTSD, and certain other mental illnesses.

But depression seems to be the sweet spot. Many who have been suffering from debilitating TRD for years, and who have tried other medications with no success, are finally seeing their symptoms improve with ketamine. Some see a dramatic improvement over a period of days or even hours.

Another positive development? Ketamine obtained in this way—it usually gets sent in the mail in lozenge or tablet form when the prescription is filled—often costs far less than when a person receives the medication in person at a clinic.

So far, so good. However.
The risks of ketamine via telemedicine delivery
There are several serious downsides to this development. For one, when ketamine is taken chronically in high doses (which can happen when it’s taken at home in an unsupervised manner), it can cause severe bladder damage. In some cases, the damage requires surgical reconstruction of the bladder.

Ketamine can also be highly addictive for some individuals, and you can overdose on it. It can also dramatically raise heart rate and blood pressure when you take it, and it’s risky for those who live with certain kinds of psychiatric illnesses.

Maybe the biggest downside of all is that there is virtually no data on the long-term health effects of taking ketamine daily or every other day, as many who get it delivered via telemedicine do. (Many people receive their monthly dose of lozenges or tablets, take more of the medication each day than is prescribed, and run out early.)

Compare that lack of oversight to ketamine’s FDA-approved nasal spray form, called esketamine or Spravato. This is normally taken in a controlled clinical setting only once or twice a week for a set number of weeks under medical supervision.

Given all these upsides and downsides, what’s the best way forward with ketamine? Let’s start with the basics.

What is ketamine?
A synthetic substance, ketamine (pronounced “KEH-ta-meen”) was developed in the early 1960s as an anesthesia treatment to keep people from feeling pain from injury or during surgery. It’s still used today and is especially common in veterinary hospitals.

Classified as an anesthetic, ketamine causes feelings of dissociation and sedation in higher doses. It gained notoriety in the 90s as a club drug—people inject it, snort it, or add it to marijuana or cigarettes. Nicknames include "K," "Special K," and "Super K." Ketamine has also shown benefits in pain management for both chronic pain and acute pain in emergency room settings.

When taken to combat depression and other mental illnesses, ketamine can produce hallucinatory effects, visual and sensory distortions, out-of-body experiences, and euphoria or a “buzzed” state. Often, a ketamine “trip” lasts about two hours, though occasional side effects, such as unconsciousness and high blood pressure can be severe.

Many ketamine patients say that their sessions with the drug can act as a reset button for the brain. The drug allows them to detach from themselves, and many report profoundly pleasant thoughts and visualizations. Afterward, your daily problems can feel less oppressive, and the improved mood can last for weeks or longer.

A few cautionary words on telemedicine as a delivery method
As an addiction treatment clinician, I am wary of working remotely with patients, prescribing medications to them via telemedicine, and monitoring their progress and recoveries via videoconference. Why? Because it’s harder to do all those things remotely than if you’re seeing someone in person and can assess body language, attitude, hygiene, and other behaviors. It’s also easier for patients and providers to abuse the “virtual” delivery system.

So yes, in a perfect world where quality in-person care was available to everyone, that delivery method would win every time. But that’s not the reality. To extend our health and medical reach to those who otherwise wouldn’t access it, telehealth is vital, and it’s here to stay. On balance, that’s a great thing.

Telemedicine and ketamine
Here’s my take: Telehealth-based care (usually via video) works well for physical ailments like strep, skin rashes, or sinus infections. But things get more difficult with mental health because there are fewer physical symptoms to guide you. It gets dicier still when the medication that is prescribed for the illness is itself risky, as is the case with ketamine, because it’s harder to monitor remotely.

That said, the answer isn’t to shut down this delivery method for ketamine. Rather, we need to create regulations and safeguards that allow for the medication to be prescribed and monitored by a certified provider in a safe manner.

With that goal in mind, I offer the following.
4 recommendations on ketamine
Put clear, enforceable rules around that first visit with the provider. If the government doesn’t require a return to an in-person visit before prescribing controlled substances like ketamine, that first virtual visit must be comprehensive, recorded, and trackable by an oversight body. I hear all the time that these initial visits are as short as 30 minutes, and I can say with certainty that it is impossible to do a thorough mental health assessment with a patient in that amount of time.
Require certification of all providers and companies that offer ketamine via telemedicine delivery. This is how it works now with clinics that offer in-person FDA-approved Spravato nasal spray. Similar regulations need to be in place for the new providers offering ketamine via telemedicine.

Require addiction screening for all patients. Because ketamine can be addictive, providers and patients are playing with fire if patients aren’t thoroughly screened (this takes more than 30 minutes!) for addiction use past or present. This needs to happen, no exceptions. My recommendation is that a patient must be sober from drugs or alcohol for at least six months, if not a year, before a ketamine prescription is considered.
Make it mandatory that providers do frequent video checkups with their patients who take ketamine. This oversight is vital. Providers need to see how the patient is doing in order to make dosage adjustments. Video chats also allow for visual evidence to be shared, for example, the provider can ask to see a patient’s remaining dosages.

Key advice for patients
Always advocate for yourself, and remain vigilant about fraudulent or suspicious activity by your provider.

Remember, providers are not infallible. They sometimes make mistakes in judgment—or worse. There’s money to be made in this new-frontier area of medicine at the moment, which means you’re always going to get some bad characters involved.

If something smells fishy about the way medications are being prescribed by your provider, ask about it. Push back. Ask direct questions. Make inquiries. Do your due diligence. Google your provider to check on their credentials.

Bottom line: Be careful. Hold your provider to the highest possible standard. This is your (or a loved one’s) mental health we’re talking about, and there’s nothing more important than that.

ADDICTION-
This Underutilized Addiction Medication Can Save Lives.
Restrictions on buprenorphine have been removed, but broader access is needed.
Reviewed by Tyler Woods

KEY POINTS-
Buprenorphine is a safe, evidence-based medication for opioid use disorder that can control drug cravings and prevent overdose deaths.
Despite its safety profile, buprenorphine is under-prescribed, due to a lack of medical provider training, as well as stigma.
The federal government recently lifted a regulatory burden on buprenorphine, but patients still need to advocate for access the medication.
More than 100,000 people are dying of drug overdoses each year in America, driven chiefly by opioids.

Medications can prevent opioid overdoses by blocking the effects of deadly drugs while also controlling cravings to use those drugs. Yet, they are vastly underutilized. Less than one-third of people in need of medications for opioid use disorder (OUD) receive them.

One of the evidence-based medications for OUD is buprenorphine. Approved by the FDA in 2002, until recently it could only be prescribed by providers who took a special course and applied for a waiver, known as an X-waiver. At the end of last year, the federal government lifted this regulatory burden. It remains to be seen whether this change will save lives.

The two other FDA-approved medications for OUD, methadone and naltrexone, have more limited use. Methadone cannot be written as a prescription for OUD but rather must be dispensed by a federally certified clinic. Naltrexone is available as a prescription but is less effective than buprenorphine or methadone.

People in need of OUD treatment should seek treatment settings that offer medications, in particular, buprenorphine.

How Does Buprenorphine Work?
Buprenorphine is a partial opioid. It attaches to opioid receptors in the brain, just as heroin, fentanyl, and other full opioids do—but relative to other opioids, buprenorphine activates those receptors weakly. Think of a lackluster opening act when you go to see a show—it’s enough to keep you in your seat, but it’s not the main performance.

Buprenorphine can control cravings to use other opioids, but as long it is dosed properly, it does not cause intoxication or suppress breathing, which is the mechanism of opioid overdose. Now, imagine if that bland opening act refused to leave the stage, keeping the main act stuck behind the curtain. That is how buprenorphine prevents overdoses: it clings more tightly to the opioid receptors than full opioids do. When people use other opioids while on buprenorphine, they do not get high or stop breathing.

Why Is Buprenorphine Underutilized?
For most of history, addiction was stigmatized as a moral failing. It was not until 1997 that the National Institute on Drug Abuse introduced the concept of addiction as a brain disease, and not until 2012 that a landmark report connected the growing issue of untreated addiction to a dearth of medical training. Even today, many drug treatment programs consider recovery to mean abstention from use of all opioids; they do not consider a person who is taking buprenorphine to have achieved recovery.

The recently revoked X-waiver also posed a barrier; fewer than 100,000 clinicians in the country had one as of January 2021. Given the irony that no such waiver was required to prescribe the oxycodone, Percocet, and other full opioids that delivered us an epidemic in the first place, the X-ing of the X-waiver is a cause for celebration.

Yet it is premature to declare victory in the struggle for broad access to buprenorphine. One study that assisted clinicians in obtaining an X-waiver, including providing the requisite training course, found that the majority did not use the waiver. Medical training curricula have a gaping hole when it comes to addiction, one which a single course cannot fill.

Starting buprenorphine can be tricky. If initiated too soon after the last use of a full opioid, it will displace that full opioid from its receptor in the brain, precipitating a sickness known as withdrawal. Sometimes described as “leaking from every orifice,” withdrawal involves watery eyes, a runny nose, vomiting, diarrhea, and more. Imagine if the boring opener pushed the headliner off the stage mid-act—the audience would be pretty miserable. On the other hand, if the main act suddenly left mid-performance, the opener could step in to fill the time, cheering everyone up. Similarly, once a person with opioid dependence is already experiencing significant withdrawal, buprenorphine can soothe the symptoms.

How Can These Barriers Be Overcome?
With appropriate education, patients can start buprenorphine at home without precipitating withdrawal. Inpatient and residential facilities can observe patients until they have reached the appropriate stage of opioid withdrawal for buprenorphine to alleviate rather than exacerbate their symptoms.

Many rehab facilities do this already—only to stop buprenorphine once the withdrawal has resolved. They may claim that at this point the patient has completed “detoxification,” or “detox,” but the use of these terms can perpetuate the stigma that a person who uses drugs needs to be “cleaned” in some way. Moreover, addiction is a chronic medical condition that warrants treatment with maintenance medications, just as, for instance, diabetes management may require long-term use of insulin. Limiting the use of medications to the withdrawal phase disregards clinical reality and undermines recovery.

Rehab facilities bear a special responsibility to not only start buprenorphine but also to link patients to a community prescriber who will continue the medication after discharge. Buprenorphine can control the cravings to use drugs that are triggered by the stressors of returning to the real world after rehab. Moreover, while sequestered at rehab, people lose their tolerance to opioids. With their bodies no longer accustomed to using the amount of street drugs that they used before, they are especially vulnerable to a fatal overdose—which can be prevented with buprenorphine.

How Can People With OUD Access Buprenorphine Treatment?
If a patient with OUD is safe in their current home environment, they can start buprenorphine while remaining in the community. You can find outpatient buprenorphine prescribers here.

If you or your loved one is seeking inpatient or residential treatment for OUD, inquire about each facility’s policy on buprenorphine. This means asking not only whether they provide short-term buprenorphine for withdrawal management (or “detox”) but also whether they support long-term use, including providing a bridge prescription to last until patients establish with an outpatient prescriber.

By asserting a right to evidence-based treatment, patients and their loved ones can erode the stigma against medications that has clung to the addiction treatment world for far too long.