ketamine is a recurring concept in the Astral Codex Ten archive, appearing 11 times across 11 issues between March 16, 2021 and November 24, 2025. The archive places it in contexts such as "whether the effects of ketamine might change depending on what time of day you take it"; "risk of bladder injury from a normal psychiatric dose of ketamine"; "Ketamine is a new and exciting depression treatment". It most often appears alongside Adderall, Astralcodexten Com, COVID.
- Article page
- ketamine
- Mention count
- 11
- Issue count
- 11
- First seen
- March 16, 2021
- Last seen
- November 24, 2025
Outbound links
- http://web.archive.org/web/20221104130431/https://stevekirsch.substack.com/p/1m-bet-rules
- http://web.archive.org/web/20221129133112/https://blog.rootclaim.com/rootclaim-accepts-500000-challenge-on-covid-vaccine-safety-efficacy/
- http://web.archive.org/web/20221224061743/https://www.skirsch.com/covid/SaarWilf.pdf
- https://abc7news.com/post/graffiti-in-san-francisco-tagging-vandalism-street/13801629/
- https://alisoncrosthwait.substack.com/p/a-ketamine-addicts-perspective-on
- https://archive.ph/pY4gF#selection-663.103-683.190
- https://astralcodexten.substack.com/p/book-review-what-we-owe-the-future
- https://awaisaftab.substack.com/p/is-ketamine-as-good-as-placebo-or
- https://chicagoivsolution.com/wp-content/uploads/2019/12/acevedo-diazetal.2019.pdf
- https://medcraveonline.com/JPCPY/JPCPY-09-00598.pdf
- https://slatestarcodex.com/2019/03/11/ketamine-now-by-prescription/
- https://web.archive.org/web/20230104080248/https://www.rootclaim.com/
Issue trail
- Sleep Is The Mate Of Death
- Drug Users Use A Lot Of Drugs
- Peer Review Request: Ketamine
- Ivermectin: Much More Than You Wanted To Know
- Highlights From The Comments On Ivermectin
- The FDA Has Punted Decisions About Luvox Prescription To The Deepest Recesses Of The Human Soul
- Lavender's Game: Silexan For Anxiety
- Highlights From The Comments On Telemedicine Regulations
- Does Anaesthesia Prove Ketamine Placebo?
- Open Thread 303
- Open Thread 409
Related pages
Source context
Is this Rantamäki and Kohtala's theory? I think their real theory is much more complicated than this and involves a bunch of different types of sleep, differential synapse density in various brain regions, and 24 pages of speculation about whether the effects of ketamine might change depending on what time of day you take it. One day I would like to quit my job, abandon all my friends, and spend six months in a cabin in Alaska trying to understand it in full. But I think this post is a decent first stab at an oversimplification. Here are a few subtopics I hope to eventually learn more about:
If you look at any list of side effects for the FDA-approved version of s-ketamine (Spravato), you see things like urinary tract problems, bladder problems, pain on urination, feeling of urgency to urinate. You can find a bunch of papers like Ketamine: An Important Drug With A Serious Adverse Effect, where they say that ketamine is potentially great for depression, but that the risk of bladder injury needs to be taken really seriously.
When I first considered prescribing ketamine, the bladder injury stories scared me so much that I asked a bunch of veteran ketamine prescribers how I should monitor it. They all gave me weird non-commital answers like "I've prescribed ketamine to thousands of patients and never had a problem with this, so I guess don't worry". But why not? There are all these papers saying we should worry, and all these reports in the literature of ketamine-induced bladder injury!
A standard psychiatric dose of ketamine might be 0.5 mg/kg IV, 2x/week, for four weeks. So a 70 kg patient would get about 280 mg over the course of a month. This Chinese study and this UK study analyze recreational ketamine users, and both find they take about 3g daily, every day. That's 90,000 mg over the course of a month. Again, that's 280 mg for the psych patients and 90,000 mg for the recreational users (and you wouldn't believe how many hoops the psych patients have to jump through to get their 280, or how terrified their doctors are that something could go wrong). Drug users use a lot of drugs! So why don't psychiatric patients get bladder injuries? It's because you get bladder injuries when you're taking more like 90,000 mg of ketamine a month, and not when you're taking 280 mg.
Inline links: This Chinese study, this UK study
Here's the page: Ketamine The short version: Ketamine is a new and exciting depression treatment, which probably works by activating AMPA receptors and strengthening synaptic connections. It takes effect within hours and works about 2-3x as well as traditional antidepressants. Most people get it through heavily-regulated and expensive esketamine prescriptions, or through even-more-expensive IV ketamine clinics, but evidence suggests that getting it prescribed cheaply and conveniently from a compounding pharmacy is equally effective. A single dose of ketamine lasts between a few days and a few weeks, after which some people will find their depression comes back; long-term repeated dosing with ketamine anecdotally seems to work great, but hasn’t been formally tested for safety. Some people also use ketamine-assisted psychotherapy, which is a very different form of treatment and can have impressive long-term results, but which is less explored and more idiosyncratic for each person.
The short version: Ketamine is a new and exciting depression treatment, which probably works by activating AMPA receptors and strengthening synaptic connections. It takes effect within hours and works about 2-3x as well as traditional antidepressants. Most people get it through heavily-regulated and expensive esketamine prescriptions, or through even-more-expensive IV ketamine clinics, but evidence suggests that getting it prescribed cheaply and conveniently from a compounding pharmacy is equally effective. A single dose of ketamine lasts between a few days and a few weeks, after which some people will find their depression comes back; long-term repeated dosing with ketamine anecdotally seems to work great, but hasn’t been formally tested for safety. Some people also use ketamine-assisted psychotherapy, which is a very different form of treatment and can have impressive long-term results, but which is less explored and more idiosyncratic for each person.
1. How can I get ketamine therapy? 2. How can I find a doctor willing to prescribe me ketamine? 3. How can my doctor prescribe me ketamine? 4. How safe is ketamine? 4.1: How concerned should I be about cognitive side effects of ketamine? 4.2: How concerned should I be about urinary side effects of ketamine? 4.3: How concerned should I be about hepatotoxicity from ketamine? 4.4: How concerned should I be about getting addicted to ketamine? 4.5: How concerned should I be about hypertension from ketamine? 5: How effective is ketamine? 6: Do I have to take ketamine IV? What about nasal and oral ketamine? 6.1. Do I have to take esketamine? What about regular ketamine? 7: What’s the right dose of ketamine? 7.1: What are the exact instructions for dosing ketamine correctly? 8: How long does ketamine work for? Do I have to keep taking it forever? 9: What is ketamine-assisted psychotherapy? 9.1: Where can I get ketamine-assisted psychotherapy? 9.2: Can I do informal ketamine-assisted psychotherapy on my own? 10. How does ketamine work? 11. Will you prescribe me ketamine?
Source. Real data would follow something like a bell curve. This is going to require a social norm of always sharing data. Even better, journals should require the raw data before they publish anything, and should make it available on their website. People are going to fight hard against this, partly because it’s annoying and partly because of (imho exaggerated) patient privacy related concerns. Somebody’s going to try make some kind of gated thing where you have to prove you have a PhD and a “legitimate cause” before you can access the data, and that person should be fought tooth and nail (some of the “data detectives” who figured out the ivermectin study didn’t have advanced degrees). I want a world where “I did a study, but I can’t show you the data” should be taken as seriously as “I determined P = NP, but I can’t show you the proof.” The second reason I think this, aside from checking for fraud, is checking for mistakes. I have no proof this was involved in ivermectin in particular. But I’ve been surprised how often it comes up when I talk to scientists. Someone in their field got a shocking result, everyone looked over the study really hard and couldn’t find any methodological problems, there’s no evidence of fraud, so do you accept it? A lot of times instead I hear people say “I assume they made a coding error”. I believe them, because I have made a bunch of stupid errors. Sometimes you make the errors for me - an early draft of this post of mine stated that there was an strong positive effect of assortative mating on autism, but when I double-checked it was entirely due to some idiot who filled out the survey and claimed to have 99999 autistic children. In this very essay, I almost said that a set of ivermectin studies showed a positive result because I was reading the number for whether two lists were correlated rather than whether a paired-samples t-test on the lists was significant. I think lots of studies make these kinds of errors. But even if it’s only 1%, these will make up much more than 1% of published studies, and much more than 1% of important ground-breaking published studies, because correct studies can only prove true things, but false studies can prove arbitrarily interesting hypotheses (did you know there was an increase in the suicide rate on days that Donald Trump tweeted?!?) and those are the ones that will get published and become famous. So if the lesson of the original replication crisis was “read the methodology” and “read the preregistration document”, this year’s lesson is “read the raw data”. Which is a bit more of an ask. Especially since most studies don’t make it available. The Sociological Takeaway I’ve been thinking about this one a lot too. Ivermectin supporters were really wrong. I enjoy the idea of a cosmic joke where ivermectin sort of works in some senses in some areas. But the things people were claiming - that ivermectin has a 100% success rate, that you don’t need to take the vaccine because you can just take ivermectin instead, etc - have been untenable not just since the big negative trials came out this summer, but even by the standards of the early positive trials. Mahmud et al was big and positive and exciting, but it showed that ivermectin patients recovered in about 7 days on average instead of 9. I think the conventional wisdom - that the most extreme ivermectin supporters were mostly gullible rubes who were bamboozled by pseudoscience - was basically accurate. Mainstream medicine has reacted with slogans like “believe Science”. I don’t know if those kinds of slogans ever help, but they’re especially unhelpful here. A quick look at ivermectin supporters shows their problem is they believed Science too much. @jonno_bosch I work in hospitality so I need things to return to normal ASAP. I am using Ivermectin as a prophylactic. Hugely influenced by Carvallo trail and Chala trail which showed huge protection","username":"Bannisterious","name":"Andrew Bannister","profile_image_url":"","date":"Fri Feb 12 16:21:14 +0000 2021","photos":[],"quoted_tweet":{},"reply_count":0,"retweet_count":0,"like_count":0,"impression_count":0,"expanded_url":{},"video_url":null,"belowTheFold":true}" data-component-name="Twitter2ToDOM"> @mtskullcrusher @HereComeTheJud @therealjosexy @joeycadre @PeegeRiley @dcwickedestcity @blaireerskine Read Raad. Or Mahmud. Or ICON study from Florida. Or Mexico City hospitalizations study. Or Niaee. Or...\n\nOr just type \"ivermectin covid\" in Google Scholar and read.","username":"fatlas6","name":"fatlas","profile_image_url":"","date":"Thu Sep 02 21:34:59 +0000 2021","photos":[],"quoted_tweet":{},"reply_count":0,"retweet_count":0,"like_count":1,"impression_count":0,"expanded_url":{},"video_url":null,"belowTheFold":true}" data-component-name="Twitter2ToDOM"> They have a very reasonable-sounding belief, which is that if dozens of studies all say a drug works really well, then it probably works really well. When they see dozens of studies saying a drug works really well, and the elites saying “no don’t take it!”, their extremely natural conclusion is that it works really well but the elites are covering it up. Sometimes these people even have a specific theory for why elites are covering up ivermectin, like that pharma companies want you to use more expensive patented drugs instead. This theory is extremely plausible. Pharma companies are always trying to convince people to use expensive patented drugs instead of equally good generic alternatives. Ivermectin believers probably heard about this from the many, many good articles by responsible news outlets, discussing the many, many times pharma companies have tried to trick people into using more expensive patented medications. Like this ACSH article about Nexium. Or my article on esketamine. Given that dozens of studies said a drug worked, and elites continued to deny it worked, and there are well-known times where elites lie about drugs in order to make money, it was an incredibly reasonable inference that this was one of those times. If you have a lot of experience with pharma, you know who lies and who doesn’t, and you know what lies they’re willing to tell and which ones they shrink back from. As far as I know, no reputable scientist has ever come out and said ‘esketamine definitely works better than regular ketamine’. The regulatory system just heavily implied it. I claim that with ivermectin, even the people who don’t usually lie were saying it was ineffective, and they were saying it more directly and decisively than liars usually do. But most people can’t translate Pharma → English fluently enough to know where the space of “things people routinely lie about and nobody worries about it too much” ends. So they incredibly reasonably assume anything could be a lie. And if you don’t know which statements about pharmaceuticals are lies, “the one that has dozens of studies contradicting it” is a pretty good heuristic! If you tell these people to “believe Science”, you will just worsen the problem where they trust dozens of scientific studies done by scientists using the scientific method over the pronouncements of the CDC or whoever. So “believe experts”? That would have been better advice in this case. But the experts have beclowned themselves again and again throughout this pandemic, from the first stirrings of “anyone who worries about coronavirus reaching the US is dog-whistling anti-Chinese racism”, to the Surgeon-General tweeting “Don’t wear a face mask”, to government campaigns focusing entirely on hand-washing (HEPA filters? What are those?) Not only would a recommendation to trust experts be misleading, I don’t even think you could make it work. People would notice how often the experts were wrong, and your public awareness campaign would come to naught. But also: one of the data detectives who exposed some fraudulent ivermectin papers was a medical student, which puts him somewhere between pond scum and hookworms on the Medical Establishment Totem Pole. Some of the people whose studies he helped sink were distinguished Professors of Medicine and heads of Health Institutes. If anyone interprets “trust experts” as “mere medical students must not publicly challenge heads of Health Institutes”, then we’ve accidentally thrown the fundamental principle of science out with the bathwater. But Pierre Kory, spiritual leader of the Ivermectin Jihad, is a distinguished critical care doctor. What heuristic tells us “Medical students should be allowed to publicly challenge heads of Health Institutes” but not “Distinguished critical care doctors should be allowed to publicly challenge the CDC”? Then what about “believe statisticians”? I’ve never heard anyone propose this before, but re-centering the mystique of scientific-expertise in study-analyzers and study-aggregators rather than object-level scientists is…one way you could go, I guess. Statisticians admittedly sort of failed us here: the first several meta-analyses said ivermectin worked. But the statistical process - the idea that studies are raw materials, but it takes skill to turn them into the finished good of scientific knowledge - sort of comes out looking good. If we need to summarize our takeaway in a slogan of exactly two words, one of which is “trust”, you could do worse than this one. (am I secretly suggesting that we make rationality higher status? Maybe, although rationalists did no better here during the early phase of “looks promising so far” than anyone else, and it was researchers digging into the nitty-gritty of the data who really solved this.) Or maybe this is the wrong level on which to think about this. Maybe there isn’t and can’t be a simple heuristic you can teach everyone in school or via a PR campaign which will lead to them having making good health decisions in an adversarial information environment, without having any negative effects anywhere else. But you also don’t want people to make bad health decisions. So what do you do? The Political Takeaway All of this is complicated by the impression many people (including me) have, that ivermectin boosterism and vaccine denialism are closely linked. The ivermectin evidence is complicated. There’s room for doubt. I can maybe see room for doubt on some marginal vaccine-related issues like how seriously to take the occasional reports of myocarditis in teens. But the basic issue - that the vaccine works really well and is incredibly safe for adults - seems beyond question. Yet people keep questioning it. I think it’s important to address ivermectin support on its own terms - as a potentially plausible scientific theory in a debris field of confusing evidence, which should be debated to the usual standards of scientific debate. I’ve tried to do that above. But this picture wouldn’t be complete without acknowledging the overlap with vaccine denial - a segment of people who are completely crazy and wrong and who happen to have fixated on this mildly interesting question as opposed to some other one with even less evidence. I’ve been trying to figure out a model where ivermectin support and vaccine denialism both make visceral sense to me, and here’s what I’ve got: Imagine that in 2025, an alien invasion fleet reaches Earth. But it got hit by a supernova on the way, the spaceships are partly disabled, and they’re only able to conquer some out-of-the-way place - let’s say Australia. There’s a few cycles of conflict and cease-fire, a few cities get nuked, and finally we settle into an uneasy peace. Over the next few years, humanity grudgingly admits the invaders into the world community. They get a seat in the United Nations. We sort of cooperate with them on projects that are important to both sides, like stopping climate change. We still hate them, but only at the level of ordinary international rivalries, like USA/USSR. In 2035, the aliens announce that a quantum memetic plague from the Andromeda Sector has reached Earth. Billions of people will die unless we let them put an immunity-granting cybernetic implant in all humans’ brain. The aliens admit we haven’t always been friends, and honestly they would still like to conquer us someday. But this plague is an ancient enemy of all sentient beings, they dealt with it on their homeworld eons ago, and they want to help us out here. Humans apparently don’t have the ability to detect quantum memetic plagues, but mortality rates for over-65s do seem weirdly high this year, something like 10x worse than a normal flu season. Do you let the aliens put an implant in your brain, or not? If it helps, the aliens look like this. Surely anyone with a brain that size must know what they’re talking about, right? (source) Fine, you don’t have to decide immediately. The brain implants aren’t even ready yet. Some human scientists suggest wearing face masks in the interim. The aliens say no, that will never work, that’s not how you deal with quantum memetic plagues, if you do anything other than wait for the brain implants you’re anti-science idiots who are wasting precious time and will kill millions of people. Human nations try face masks anyway…and they clearly and conspicuously work. The aliens say whatever, we’re still the advanced spacefaring civilization here, maybe it works for humans but that’s not the point, the point is you’ve got to let us put implants in your brains. Some human scientists suggest reopening vital services. The aliens say no, millions will die, this is “mass human sacrifice”, humans apparently must care nothing about their families’ lives. The humans try reopening anyway, and…it goes kind of okay? Maybe the death rate goes up 10% to 20% or so, hard to say? The aliens say whatever, maybe their calculations were off by a few orders of magnitude, the point is, you have to let us put implants in your brain or you’ll all die. Then some human scientists suggest vaccinating against the plague. The aliens say this is idiotic, vaccines originally come from cowpox, even the word “vaccine” comes from Latin vaccus meaning “cow”, are you saying you want cow medicine instead of actual brain implants which alien Science has proven will work? They make lots of cartoons displaying humans who want vaccines as having cow heads, or rolling around in cow poop. Meanwhile, the first few dozen studies show vaccines work great. Many top human leaders, including war heroes from the struggle against the aliens, get vaccines and are seen going out in public, looking healthy and happy. The aliens say that human science is hopelessly flawed because of complicated statistical concepts that inferior life forms like us don’t even have words for. You need to ignore all the studies and meta-analyses showing that vaccines definitely work, and let the aliens give you brain implants instead. So do you let the aliens put an implant in your brain, or not? Obviously you think long and hard before doing this. And obviously this is an extended metaphor for vaccine denialism. So what’s the difference between the metaphor (where you’re presumably anti-implant) and the real world (where you’re presumably pro-vaccine?) For me, it’s a combination of: The aliens are hostile, so I don’t trust them no matter how smart they are
Inline links: Source, this post, this ACSH article about Nexium, my article on esketamine, https://substackcdn.com/image/fetch/$s_!1UIV!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F598d7d6c-de95-4b94-b13a-3c8a452b0409.jp2, source
I do think it’s occasionally possible to have genuine bottom-up medical research: ketamine seems to have worked this way. Even the trials that found fluvoxamine worked were funded by a random billionaire, which is sort of bottom-up in the sense of not being some established clique of experts with a vested outcome in the result. But I don’t think we know how to do this consistently yet, even though it would be cool if we could.
I faced the Devil the year before that, and I . . . well, let’s say it was a tie. I had a bunch of patients with treatment-resistant depression. Everyone knew ketamine was great for treatment resistant depression. But the only people using it were anaesthesiologists giving it IV, which was inconvenient and unaffordable for most patients. The FDA was trialing a new version of ketamine that could be given by psychiatrists via inhaler, and there was no reason whatsoever to think this wouldn’t work with normal ketamine, but nobody I knew was doing it and they all thought it seemed kind of weird. My severely depressed patients kept asking me for ketamine, and I kept saying “Sorry, I can’t prescribe that to you”, secretly ending the sentence with “…unless I use this one weird loophole I’ve never heard of anyone else using”. Finally I called up a compounding pharmacy near me and asked if anybody knew about this, and they said they knew a doctor who did, and did I want his phone number? I talked to him, and he said he’d been doing this for years and it had always gone well. For some reason, knowing that someone else was doing it was the permission I needed, I prescribed it to my patients, and it went well (I’ve since written up a guide for others). But I still didn’t have the courage to do the weird thing without knowing other people were doing it first.
Inline links: a guide for others
(When I finally got around to prescribing ketamine, one of my patients told me I’d given her her life back. Usually I love hearing that kind of thing. This time it was bittersweet, because I knew I could have given more patients their lives back if I’d done it earlier. There are a couple of people who had six months of terrible depression that I maybe could have prevented if I had more courage. That’s partly on the FDA for making poor decisions such that optimal treatment required virtue on the part of individual doctors. But mostly it’s on me, for not having it.)
(by the way, when the other psychiatrists in my clinic learned I was prescribing intranasal racemic ketamine, they all said that was cool, and a few asked me to walk them through the process).
Not many treatments in psychiatry have a large effect size. There’s stimulants for ADHD, ketamine for depression . . . and now Silexan for generalized anxiety disorder.
If for some reason that doesn’t work, go to a different psychiatrist and try again. You don’t have to tell them you already tried. Since everything about ADHD diagnosis and treatment is already security theater, it’s hard to say what pill mills are doing except kind of smirking under their breath while going through the rituals - as opposed to real doctors, who go through the rituals with sincere faith. Don’t get me wrong, I do think there’s a difference here. But the regulatory state isn’t set up to say “And you have to sincerely believe in the rituals or they don’t count”. So instead they punish unrelated groups, like telepsychiatrists. See also my old post Bureaucracy As Active Ingredient. The security theater doesn’t work because it’s effective. It works because it’s inconvenient enough to weed out the less motivated fakers, and some of the remaining fakers get cold feet about lying to a nice sincere psychiatrist who seems to be trying to help them. Pill mills remove the inconvenience, and seem to be nod-and-wink cooperating with liars, so the theater stops working. The only solution is to inject some inconvenience and shame back into the process somewhere, which the DEA has chosen to do by restricting telepsychiatry. They could accomplish the same goal by making you attend your appointments naked, but I guess clothing companies have better lobbyists than telepsychiatrists do. 4: Comments About Forcing Blind People To Fill Out Forms Before They Can Access Braille I analogized forcing patients to see an in-person doctor before they could access a teledoctor to forcing blind people to fill out forms before they could access Braille. Several blind people and their friends pitched in to say this was a real problem. For example, Mikolysz: Blind person here, this kind of thing is actually much more common than people imagine. Many government agencies (regardless of which particular government you mean) just assume that anybody who needs to fill a form can read and write print and/or lives with somebody who does. This is often a problem even when the form in question is specifically targeted at blind people. Non-governmental organizations, including those who specifically serve the blind, aren't much better at this either. This issue is slightly more pronounced in civil law countries, where what constitutes a legally-binding signature is clearly defined in law and you can't just Docusign your way out of the problem, but it exists everywhere, including the US. I literally had to file this kind of document today, while the main form could be filled electronically, I was required to attach a few extra documents, for GDPR and such, and those had to be printed, filled in by a sighted person, signed and scanned. The same problem exists with physical mail which you're required to read and respond to, but which is almost never available in an accessible form, a few exceptions like the American IRS notwithstanding. 5: Comments About My Caricature Of A Doctor Who Refuses To Prescribe Psych Drugs Because People Just Need Jesus Jon Cutchins writes: You don't want psychiatrists and liberals in general to be accused of an unreasoning hatred towards Christianity you should probably be more judicious in your use of anti-Christian tropes when describing everyone who is skeptical of mind-altering drugs. Mike writes: I’ve been a primary care nurse practitioner in the Bible Belt for 20yrs and not once have I even heard of a provider telling a patient they should substitute religion for psychiatric (or any) medication. It’s so easy for some people to throw around these tropes as if Christianity is some exotic, weird tribe with horrifying anthropological traits. On the other hand, fluxe writes: I am a young Christian--in my life, I have -been told by my PCP not to get an IUD because it carries "a significant risk of causing infertility or death" -had a pharmacist refuse to fill an old, male family friend's ulcer medication because it's also an abortifacient -been told by a therapist to discontinue the SSRI a different provider had prescribed and just trust in the man of the house the PCP wasn't even particularly Christian herself, but since all of her patients are she hadn't updated on IUDs since the scare back in the 70s. Our horrifying anthropological traits become everyone's problem--it might be worth listening to those who "throw around these tropes" so you can understand what they have to deal with Unfortunately I only mention this possibility because it’s happened to several of my patients. The best I can offer in terms of being unbiased and apolitical is to signal-boost posts like this one about overly woke therapists being another big problem. Alien on Earth writes: I generally like your writing and ideas, hell, I just re-uped for a year. However, in an otherwise near perfect post, you took a cheap shot at a steriotyped view of one religion thst is not popular amoungst coastal elites, that really detracts from your core point. "The worst-case is that you get one of those doctors who think that Psych Drugs Aren’t Real Because You Just Need Jesus, and then the patient has to keep looking until they find someone else." In my experience, it is the new age(y), non-religious, doctors who are least likely to like prescribing psyc. meds or who tend to give them at too low a dose or for too short a time. Certainly, I've found little correlation with their religion, if I even know it. The only correlation I've observed is that this perscription reluctance is, perhaps, slightly more common amongst middle career doctors. Perhaps it is more common in deep red areas, I don't know. However, even there, I would suggest, it is less due to religion, per se, than to "old fashion" "grit your teeth and bear it" thinking. I agree that there are many reasons people recommend against psychiatric drugs (a few are even good). Psychiatric drugs have lots of side effects and are clearly imperfect options, and I see people object to them more often when they think they have a perfect option as an alternative. Sometimes that option is Jesus. Other times it’s the trendy new somatic yoga reprocessing kundalini trauma dianetics therapy. Other times it’s LSD or ketamine or Dr. Bob’s 24-In-One Internet Nootropic. All of these work for some people, but not as much as the people pushing them think - which I guess is also true for psych drugs. I’m nervous about people who think they’ve found the answer and pressure people towards one alternative or another without presenting evidence. I’ve seen this happen enough in religious contexts that I think it was a fair thing to use as an example. 6: Comments About Which Part Of The Government Is Responsible For This Regulation ProfessorE writes: I’m not sure that what Scott wrote is even completely accurate. I have a relative who is an MD in this space, and it seems that the underlying problem is not the DEA but an actual law passed by Congress. Aren’t telemedicine regulations limited with respect to controlled substances by the Ryan Haight Act of 2008 U.S.C. § 829(e)… there may be interpretations of this act by the DEA and other agencies, but, where controlled substances are prescribed by means of the Internet, the general requirement is that the prescribing Practitioner must have conducted at least one in-person medical evaluation of the patient. It seems like a colossal overreach to ask an Executive Branch agency to overrule the plain text of the act. There are some exceptions, which Scott noted. A different way of looking at things was that the Executive Branch was highly responsive to the emergency situation of Covid. Now that it’s not an emergency, they are obligated to return to the legal framework that exists. Congress needs to change the law, not the DEA. The *data* from covid should be used as part of a cost-benefit analysis to determine whether it is reasonable to regulate telemedicine, and, if so, what regulations might address whatever problems arose. Followed by: Actually, Scott is even more off-base than I thought in my initial post. Apparently the DEA & DOJ are already proposing new changes to the 2008 Act (which seem like they violate the clear text of the act), but the act and the changes are summarized here: https://www.legitscript.com/2023/03/27/proposed-changes-ryan-haight/ Sounds like government is aware of the issue. See https://www.federalregister.gov/documents/2023/03/01/2023-04248/telemedicine-prescribing-of-controlled-substances-when-the-practitioner-and-the-patient-have-not-had For the actual changes that are being proposed. End of the day, this should be modified by Congress, not the agencies. Everyone should remember that the law was written in 2008. That’s 1 year after the very first iPhone and 2 years before the first iPad. Zoom didn’t exist (2011). None of the other technologies for video conferencing existed. Congress was attempting to fight opioid pill-mills. At the time of passage, I am willing to bet that ≈0% of patients were “Telehealth” using videoconferencing. More like phone calls and email a few times to get drugs. The law should have been amended, and it hasn’t been, but it is far from clear that it was a crazy law in the first place. I mostly accept this correction, although I’m still a bit confused - a lot of the analyses by lawyers I read said things like “Unquestionably, the DEA’s proposal is not what most industry stakeholders were anticipating. The initial reaction is the rules are more restrictive than necessary and impose concerning limitations and burdens on clinicians and the patients they treat”, and I’m confused why industry stakeholders weren’t anticipating it if the DEA had to do it in order to follow the law. And JR writes: Meanwhile, the DEA was instructed by law in -2008- to develop a special registration process for telemedicine to allow providers to prescribe controlled substances remotely. The DEA has simply failed to do so in that time, despite repeated Congressional demands to act. Don't worry, though - the DEA has said about this proposed rule that it feels this will be 'less burdensome' for providers than any kind of special registration, so it feels it has discharged its legal responsibility to create a special registration process. I am a psychiatrist having to deal with this idiocy with my patients too, and renting an office temporarily is not going to cut it. So I am going the letter route. I will probably a lose a reasonable chunk of patients I was prescribing controlled substances to. The only possible saving grace is that PCPs in this country are used to being asked to sign and complete all kinds of nonsense forms and documents so probably most of them will just do it with minimal fuss. I'm more concerned with the new requirement that all telemedicine scripts now have to be recorded by the prescriber with the date and time they were written, the PHYSICAL ADDRESS of the prescriber and patient at the time of the telehealth encounter, and have an explicit note on them that they are telemedicine prescriptions. I am less concerned about PCPs balking at writing an idiotic referral than I am skittish pharmacists refusing to fill scripts that they might interpret as being labeled equivalently to FAKE SCRIPT FOR DRUGSEEKERS Based on that comment and this, my best guess about what’s happening is: Congress passed restrictions on telemedicine in 2001, and asked the DEA to come up with a way that trusted providers could avoid those restrictions. Now that there is videoconferencing, etc, most people now believe those restrictions were too severe.
Inline links: Bureaucracy As Active Ingredient, Mikolysz, writes, writes, writes, to signal-boost posts like this one about overly woke therapists being another big problem, writes, writes, Followed by, https://www.legitscript.com/2023/03/27/proposed-changes-ryan-haight/, https://www.federalregister.gov/documents/2023/03/01/2023-04248/telemedicine-prescribing-of-controlled-substances-when-the-practitioner-and-the-patient-have-not-had, said things like, JR writes:, this
The psychiatric study everyone’s talking about this month is ”Randomized trial of ketamine masked by surgical anesthesia in patients with depression”.
Inline links: ”Randomized trial of ketamine masked by surgical anesthesia in patients with depression”
Ketamine is a dissociative drug - it produces weird drug effects like feelings of bodylessness and ego death. Recent research suggests it’s a powerful antidepressant. Usually we would try to run placebo-controlled trials. But it’s hard to run a placebo controlled trial of a dissociative. Either you feel bodylessness and ego death (in which case you know you’re getting the real drug) or you don’t (in which case you know you’re in the placebo group). Sometimes researchers try to use an “active placebo” like midazolam - a drug that makes you feel weird and floaty. But weird and floaty feels different from bodyless and ego-dead.
The authors of the recent study go further. They recruited depressed patients who were going into the hospital for routine surgery requiring anaesthesia. When they were anaesthesized, they gave them either ketamine or placebo. Then after they woke up, the researchers asked the patients how depressed they were. These patients had no way of telling whether they got ketamine or not (since they were unconscious at the time). Here are the results:
2: And some good comments on the ketamine post. Thomas Reilly says the study was underpowered. Awais Aftab compares to a recent very positive trial of ketamine vs. ECT. Eremolalos on a meta-analysis. Nate Praschan argues that anaesthetics might block ketamine directly.
2: Qualia Research Institute announces their spinoff effort ClusterFree. Cluster headaches (aka “suicide headaches”) are probably the most painful medical condition known to science, which makes them a natural priority for some utilitarians. They seem to be extremely treatable by psychedelics like psilocybin and DMT (including sub-hallucinogenic doses), so ClusterFree is working on getting governments to research this further and maybe get these drugs into the medical pipeline (cf. ketamine for depression). There’s an open letter here, and you can contact them here. The information for patients is at the bottom of this page.