Ketamine, a molecule belonging to the class of arylcyclohexylamines, has seen a remarkable evolution from its initial synthesis in 1962 by Professor Calvin Stevens. As the third iteration in a series of compounds, ketamine distinguished itself by becoming a safe and effective anesthetic, known for its unique ability to disconnect the thinking part of the brain from the feeling part. This characteristic, known as dissociation, is why ketamine has been labeled a dissociative anesthetic. Now, we’re seeing a psychedelic renaissance nationwide including the rise of ketamine therapy in Canada.
Anesthetic Use and Safety Profile of Ketamine
For over five decades, ketamine has been a cornerstone in anesthesiology. Its safety profile is exceptional, primarily because it does not significantly impact breathing or cardiovascular function. This makes it particularly valuable in settings where maintaining these functions is crucial. Initially approved for anesthetic use, ketamine is now a generic medicine, which means its original patents have expired, reducing the financial incentive for pharmaceutical companies to pursue new regulatory approvals for other uses.
Expanding Horizons with Modern Medicine: Ketamine for Mental Health and Chronic Pain Treatment
In the past two decades, the scope of ketamine’s application has expanded dramatically. Low, sub-anesthetic doses have been found effective for treating various mental health conditions, including treatment-resistant depression, anxiety, PTSD, and chronic pain. Research indicates that ketamine, when combined with psychotherapy, enhances therapeutic outcomes and provides more enduring benefits.
A landmark 2023 study highlighted ketamine’s efficacy, demonstrating that it is non-inferior to Electro-Convulsive Therapy (ECT) for treatment-resistant depression, without the cognitive side effects associated with ECT. This positions ketamine as a potent alternative for patients who have not responded to traditional treatments.
Off-Label Approved Use of Ketamine in Canada
In Canada, ketamine is officially approved only for anesthetic use. Its application for mental health treatments is considered “off-label.” Despite the lack of formal approval for these uses, clinical trials have consistently shown ketamine’s effectiveness in mental health and chronic pain management. This gap in regulatory approval is largely due to the expiration of patents, which diminishes the commercial incentive for pharmaceutical companies to invest in the necessary regulatory submissions.
Ketamine Routes of Administration and Bioavailability
Ketamine can be administered in various ways, each affecting its bioavailability—the amount of medicine reaching the bloodstream. The routes include:
- Intravenous (IV)
- Intramuscular (IM)
- Subcutaneous
- Intranasal
- Sublingual
- Oral
Intravenous administration offers the highest bioavailability, while oral administration provides the least. Depending on the jurisdiction in Canada, certain routes like intravenous administration may require special regulatory permissions. However, intranasal or sublingual formulations can achieve similar therapeutic effects, inducing a mild dissociative state and improving mental health outcomes.
Ketamine as a Psychedelic Treatment Medicine in Canada
The rapid and robust effects of ketamine on mental health have led researchers to categorize it as a psychedelic medicine. It is the only legally available psychedelic that must be prescribed by a healthcare provider. Clinics such as Field Trip Health integrate ketamine with psychotherapy to maximize its therapeutic potential. Despite the lack of coverage by provincial health insurance plans like OHIP in Ontario and MSP in British Columbia, many private and employer-sponsored health insurance plans in Canada include ketamine-related treatments.
Legal Access and Benefits of Ketamine Therapy
Ketamine is legally accessible and used in Canada for both anesthetic and off-label mental health treatments. Clients across the country benefit from ketamine-assisted psychotherapy on a daily basis. In contrast, substances like MDMA and psilocybin are only available under compassionate grounds via Health Canada’s Special Access Program (SAP). The SAP allows healthcare providers to request access to drugs not yet approved in Canada for patients with serious or life-threatening conditions. However, the application process can be lengthy, often taking several months for government approval.
Ketamine therapy is also more cost-effective and sessions are of shorter duration compared to other psychedelics, making it optimal for clinical use. This accessibility and efficiency make ketamine an attractive option for those seeking alternative treatments for mental health conditions.
Ketamine-assisted Therapy and Insurance Coverage
Many private insurance plans in Canada cover ketamine-related treatments, particularly when combined with psychotherapy. Veterans can get ketamine treatments covered for depression, recognizing the significant mental health challenges faced by this population. For psychedelic-assisted psychotherapies, approximately 50% of the costs are associated with the psychotherapy component, which is often insurance-eligible under most benefits plans. This makes such therapies more accessible to a broader range of patients.
The Spravato Esketamine Story
In an attempt to monetize an already generic medicine, Janssen Pharmaceuticals, Inc. split the ketamine molecule into its two enantiomers—R-ketamine and S-ketamine—and patented esketamine (S-ketamine). Marketed under the brand name Spravato, esketamine has been promoted as a novel treatment for depression. However, this effort has largely failed to gain traction in Canada and elsewhere. Many clinical trials have shown that the generic racemic ketamine (a mixture of both R- and S-ketamine) is more effective at treating mental health conditions like depression than its half-molecule counterpart, esketamine. Consequently, Spravato has not seen widespread adoption, and generic ketamine remains the preferred choice for many clinicians.
Other Psychedelics in Mental Health: MDMA, Psilocybin, and LSD
Ketamine is not the only psychedelic gaining attention for its therapeutic potential. Other substances, such as MDMA, psilocybin, and LSD, are also being researched and used in clinical settings under controlled conditions:
MDMA:
Known for its empathogenic effects, MDMA is currently in Phase 3 clinical trials for the treatment of PTSD. The FDA has granted it Breakthrough Therapy Designation, indicating its potential for significant improvement over existing treatments.
Psilocybin:
The active compound in magic mushrooms, psilocybin is being studied for its efficacy in treating depression, anxiety, and end-of-life distress. Early trials have shown promising results, leading to its designation as a Breakthrough Therapy by the FDA.
LSD:
Research on LSD for mental health is less advanced but ongoing. Studies suggest potential benefits for anxiety, depression, and addiction, although more research is needed to fully understand its therapeutic potential.
Conclusion
Ketamine’s journey from an anesthetic to a powerful tool in mental health and chronic pain treatment underscores its versatility and therapeutic potential. As research continues to evolve, ketamine’s role in medicine is likely to expand, offering new hope for patients with challenging mental health conditions. Dr. Mario Nucci’s insights provide a comprehensive overview of ketamine’s past, present, and promising future in Canada.
For those considering ketamine therapy, consulting with a healthcare provider and exploring reputable clinics like Field Trip Health Canada can provide valuable guidance and support in navigating this innovative treatment option.
As leaders in the field, we are committed to staying at the forefront of this rapidly evolving industry. This article will be regularly updated to reflect the latest advancements and regulatory changes in psychedelic medicine.
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Field Trip Health, operates the largest psychedelic therapy clinic network in Canada with clinics in Toronto, Montreal, Vancouver, Ottawa, Hamilton, Kitchener-Waterloo, Thunder Bay, and Sault Ste. Marie, and an at-home program for those who live more than an hour from the nearest clinic.
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