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Exploring the Frontiers of Ketamine Therapy: Insights from the 2023 ASKP3 Conference in Austin

The Innerbloom team was away last weekend at the American Society of Ketamine Physicians, Psychotherapists, and Practitioners (ASKP3) annual conference in Austin, Texas, a city that continues to “keep it weird”, much like I remember it when I moved away in 2019 after spending eight years completing my surgical residency and working at various hospitals in the community as a general, acute care, and trauma surgeon.

Although the attendance seemed slightly lower than last year's turnout, the conference was fantastic, featuring a wealth of exciting new research and scientific insights shared by leaders in the ketamine therapy world. ASKP3, a non-profit multidisciplinary group of professionals dedicated to the safe clinical use of ketamine for mental health disorders and pain conditions, is a relatively young organization, as this marked the 6th annual conference. The board of the facility includes the president and founder, Dr. Sandhya Prashad, who owns and operates a bustling ketamine clinic that also offers transcranial magnetic stimulation (TMS) in Houston, Texas.

Not surprisingly, Dr. Prashad once again impressed me this year with her vast experience with ketamine therapy, providing nuggets of wisdom on how to safely provide care with a focus on individualized patient-centered approaches to improve outcomes. Alongside Dr. Prashad were Dr. Jeffery Becker and Dr. Erin Amato, both of whom possess wisdom and firsthand experiences with ketamine therapy that most would consider expert level.

ASKP3 faculty board members sitting on a stage during a conference in Austin Texas
Faculty board members from left to right Kathleen Barrett, PhD, Jeffrey Becker, MD, Sandya Prashad, MD, Patrick Oliver, MD, and Erin Amato, MD.

Join me as I review the weekend and highlight the presentations and discussions that stood out as the most impactful during our visit in Austin and participation in the conference. Stay tuned as I share some of my observations regarding the ever-evolving field, along with the direction and future I hope for us to witness.

TL;DR: The conference was great, with a lot of new research and practical advice to bring back to my community and clinic in San Luis Obispo, California. However, I do have some concerns.

Ketamine: A Catalyst for Paradigm Change in Mental Health Care

After recovering from what I believe is likely another episode of COVID, given my brief loss of taste and smell, day one was a bit fuzzy with a head full of cold medicine. Nonetheless, I did my best to pay attention and am glad I did, especially during the opening and captivating talk by Dr. Scott Shannon titled "Ketamine: A Catalyst for Paradigm Change in Mental Health Care." Dr. Shannon is a key player in the psychedelic therapy space, perhaps best known for his work in integrative and holistic psychiatry. He has advocated for combining traditional psychiatric approaches with complementary and alternative therapies, such as psychedelics, to address mental health issues.

For a comprehensive overview of Dr. Shannon’s presentation, including insights from some of his published work, be sure to read the post shared earlier on our blog. The key takeaway is that, while classic psychedelics are poised for potential legalization for therapeutic purposes, ketamine maintains a strong position in psychiatry. Its advantages include a well-established track record with a robust safety profile, ease of use for patients concurrently taking antidepressants such as SSRIs, and a high efficacy rate for depression that often surpasses conventional forms of pharmacological treatment and other therapeutic modalities.

Insurance Coverage for Ketamine? How to Increase Access and Affordability

While I did not attend the small breakout groups discussing insurance coverage for ketamine due to conflicting presentations at the same time, it was great to see lots of interest from practitioners looking for ways to increase access to this transformative and legal medicine. While accepting insurance adds complexity, cost, and risk to any medical practice, it also serves to broaden access to individuals facing financial constraints that would otherwise limit their ability to receive such treatments.

From what I have heard, most health insurance companies will not approve ketamine therapy. The cited reason is that they believe ketamine therapy is experimental. In other words, unless it involves Spravato, ketamine therapy has not been approved by the FDA for the treatment of depression or related conditions. This does not mean that ketamine therapy is illegal or unsafe as I have written about before. Instead, it means that it's not logical to spend tens of millions of dollars just so that the FDA will approve a medicine that can be copied by any pharmaceutical.

However, given the undeniable safety and efficacy of ketamine therapy (when administered by licensed medical professionals and psychotherapists), some insurance companies are reimbursing ketamine therapy costs. I have heard that some insurance companies are reimbursing patients using what's known as a superbill. I have also heard that some are reimbursing providers.

Through conversations with others who participated in these group discussions, it seems that some providers have found success with reimbursement. By combining different Current Procedural Terminology or CPT codes, these providers have convinced some insurance companies to reimburse their costs. However, because insurance companies must deny claims to stay in business, I am skeptical and reluctant to apply the same techniques, at least for now. Therefore, we do not accept insurance but I will continue to keep a close watch on developments related to insurance coverage of ketamine therapy.

Ketamine vs. Electroconvulsive Therapy (ECT) – The Gold Standard for Treatment-Resistant Depression

When depressive symptoms persist or show minimal improvement despite undergoing multiple trials of different antidepressant medications or other therapeutic interventions—termed treatment-resistant depression—options become limited, with ECT being one of them and considered the gold standard for treatment. Besides the obvious discomfort of undergoing shock therapy, ECT has downsides, such as leading to acute cognitive effects like memory loss, confusion, and difficulties with concentration. Furthermore, relapse rates are high in the majority of patients at the 6-month follow-up.

Dr. Sanjay Mathew, a professor of psychiatry and vice chair for research at Baylor College of Medicine, highlighted a new study (Anand et al., NEJM 2023) representing the largest comparative effectiveness trial. The study supports the "non-inferiority of IV ketamine vs ECT for the acute treatment of treatment-resistant unipolar depression." Ketamine outperformed ECT with higher response and remission rates. This is good news for anyone hoping to avoid the electrocution chair.

When Ketamine Does Not Work

Doctors Erin Amato and Sandhya Prashad joined forces in a small group Q&A format to discuss methods for improving patient responses, preventing relapse, and extending the duration between depressive episodes. They also explored other options when ketamine falls short of providing sufficient relief. One interesting point raised was that patients who experience more anxiety during their ketamine journey are less likely to respond to the medicine itself.

An idea I will be taking back to our clinic is the concept of a mini-series (3 infusions over the course of 1-2 weeks). This approach could be beneficial for individuals experiencing a recurrence of symptoms who have completed the standard six infusion series but have had a long lapse of time since their last infusion, providing a means to get them back into a healthy, steady state of mental health. This method may also be applied to individuals who find that they require boosters more frequently than they are accustomed to. What I have noticed is that while the majority of my clients don’t require boosters, those who do typically return every 3-6 months. Therefore, for those who find themselves needing boosters more frequently, say within the 1-2 month range, this might be a valid option!

Understanding Ketamine for Chronic Pain: A Mechanism Distinct from Conventional Pain Medications

This was a fascinating discussion about how ketamine works for pain, highlighting that opioids are not a long-term solution but rather contribute to perpetuating more pain and inducing a chronic state of suffering. Charles Miller, a certified registered nurse anesthetist, was the presenter and eloquently described how ketamine does not block pain receptors but instead provides relief by changing the perception of pain signals and how they are received. Ketamine's primary applications include neuropathic pain (such as hyperalgesia and allodynia), migraines, CRPS, and cancer-related pain.

He emphasized that ketamine should not be used similarly to opioids like Percocet, often taken daily. The problem with daily or long-term opioid use is that it can lead to central sensitization. Central sensitization, in the context of prolonged opioid use, is a phenomenon where the nervous system becomes hypersensitive to pain signals. Extended opioid use can heighten pain perception, diminishing the initial therapeutic effects and potentially leading to a cycle of increasing pain, higher opioid doses, and associated risks.

Microdosing Ketamine: Daily Use of Ultra Low Dose Oral Ketamine

While I'm not a fan or much of an advocate of oral ketamine for reasons extensively discussed in other posts, I found this discussion lead by Dr. Angelo De Gionnis intriguing regarding the non-traditional application of ketamine. It essentially involves compelling individuals to learn and practice mindfulness as a method of self-soothing, with the ultimate aim of gradually reducing and eventually discontinuing daily ketamine use. Allow me to elaborate on the approach and rationale behind this innovative treatment option:

Individuals take a daily ultra-low dose of oral ketamine, typically before bedtime, in a subperceptual dosage range (i.e., 15-30mg). To provide perspective, this is equivalent to 3-6mg intravenously (IV), whereas most infusions at our clinic range from 40-100mg IV. The theory posits that when patients take a nightly dose, they wake up the next morning at a healthier level in terms of their depressive or anxious symptoms—a lower baseline, so to speak. If they experience a depressive or anxious episode during the day, they are instructed to engage in mindfulness activities such as meditation or breathwork, along with taking a "rescue medication" which could include Benadryl or Tylenol—essentially functioning as a placebo. This approach aims to prevent individuals from relying on ketamine during acute episodes, avoiding the risk of dependence on it to rescue them from a downward spiral.

With consistent daily practice, their mindfulness skills improve, potentially eliminating the need for a rescue medication as they learn to find relief independently without a drug. Subsequently, the dose of ketamine is gradually tapered and eventually discontinued entirely. This method aims to prevent misuse and addictive tendencies, as the subperceptual nature of ketamine, along with closely monitored dispensing and use, reduces the likelihood of adverse effects. The concept is quite intriguing, especially considering Dr. De Gionnis’ seven years of experience with this technique, reporting no adverse serious side effects and positive outcomes.

Jason Wallach: The Psychedelic Maestro - Unleashing Genius in a Lab Coat

A scientist standing behind a podium, giving a presentation
Nicotine-fulled genius, Dr. Wallach talking about synthesizing the world's most potent psychedelics.

Jason Wallach, PhD, an assistant professor at Saint Joseph’s University, first captured my attention during his appearance on the Hulu television series called Hamilton's Pharmacopeia, where Hamilton Morris, a VICE journalist, chemist, and psychonaut, explores the world of psychoactive substances, delving into their cultural, historical, and pharmacological aspects. It's a highly entertaining show.

Jason is a brilliant scientist working in his chemistry lab, synthesizing the most potent psychedelics in the world. His objective is to comprehend the workings of our current classic psychedelics and create new compounds that target specific biochemical pathways to enhance potency for therapeutic effects while minimizing or eliminating undesired side effects. For instance, envision a drug with a structure and mechanism like morphine that provides robust pain relief without causing constipation, drowsiness, or respiratory depression. Fascinating, isn't it?

His talk proved to be the most entertaining to watch. Jason paced back and forth on the stage, waving his shaky laser pointer in every direction, offering a glimpse into his ingenious, mad-scientist-like mind. One of my favorite moments was when he halted mid-presentation to pop a Nicorette gum, humorously announcing to the audience that he needed a nicotine fix. Another memorable instance was when he discussed the psychedelic substances synthesized in his lab, emphasizing that, while these substances hadn't been confirmed or published as psychedelic, he turned to the crowd with a mischievous grin, saying, "Oh, trust me, they're definitely psychedelic." This reminded me of the history of Dr. Albert Hofmann, intentionally testing his own batch of LSD and embarking on that famous bicycle ride while high as a kite.

Reconnecting with a Ketamine Therapy Legend and Meeting a True Pioneer

a group of doctors posing for a photograph at social gathering
The Ketamine Startup community with doctors Sam Ko and ASKP president and founder, Dr. Prashad at the center.

One of the highlights for me was reconnecting with Dr. Sam Ko from Reset Ketamine. As someone called him during an event he hosted for fellow colleagues, the "content king," Dr. Sam runs and co-owns an IV ketamine clinic in Palm Springs, California, alongside his wife, Dr. Kim Ko. Not only does he contribute to the online community with exceptional education on ketamine and ketamine therapy, but he crushes it in on this YouTube channel, teaching us everything about ketamine therapy and best practices. Sam, (we're on a first-name basis now :), runs Ketamine Startup, a course focused on teaching physicians how to start a ketamine infusion clinic, providing them with knowledge on owning and running a successful medical business. Having done the course myself, I can certainly say that Sam is pursuing this with obvious good intentions to help foster the safe and responsible practice of ketamine therapy.

I was also pleased to meet Dr. Carlene MacMillan, the Chief Medical Officer of Osmind, the ketamine-focused Electronic Medical Record (EMR) system we use at Innerbloom. What I appreciate most about Osmind is their online forum for practitioners around the globe. In the field of ketamine therapy, community is crucial, especially now, with regulatory boards—ahem, the DEA—closely monitoring us under a microscope. This platform allows us to discuss challenging cases and seek expert advice from others in the field, ultimately enabling us to provide the best care for our patients. Psychiatry, particularly in this realm, is rapidly evolving with the constant influx of new research. Therefore, it was reassuring to meet the virtuous person behind the leadership of this online community.

My Observations from the Conference and Potential Concerns Identified

As mentioned previously, attendance seemed light—not what I was expecting a year later, especially with ketamine being the only legal psychedelic spearheading the movement, often coined as the “psychedelic renaissance” (before someone calls me out, yes, I recognize ketamine isn’t technically a classic psychedelic, but does the label matter? Perhaps a discussion for a later time).

Where was Dr. Steven Mandel from Ketamine Clinics Los Angeles?

I was most surprised not to see Dr. Mandel this year, the founder and owner undeniably overseeing one of the busiest ketamine centers globally, located in Los Angeles, California. Dr. Mandel’s clinic has been open since 2014, administering over 10,000 infusions. Needless to say, he is a prominent figure in the field of ketamine therapy—someone we want to hear from and lean on for advice, given his extensive experience and wisdom.

When are we getting standardized guidelines for the practice of ketamine therapy?

What I was most hopeful for this year was some progress in establishing a new certification process for ketamine providers. This could involve coursework or evidence of implementing safety measures, including basic practices such as requiring a comprehensive history and physical examination, or checking vital signs such as heart rate and blood pressure before ketamine therapy. It seems like a no-brainer, yet there is still far too little oversite or guidance on best practices in this regard. This is urgently needed, especially with the increasing prevalence of online at-home ketamine prescribing platforms and clinics that are evidently not adhering to ethical and standards guidelines drafted and encouraged by ASKP3. There should be a mechanism to distinguish and eliminate those in the field who prioritize financial gain over the best interests and safety of patients.

In conversation with Dr. Prashad, I've learned that this isn't an easy feat; it's more complicated than it appears on the surface. However, she did mention the idea of starting local state chapters for ASKP3, and that excites me greatly. Please do pass the torch so we can share the workload, as the ASKP3 faculty is clearly working very hard behind the scenes, in addition to managing busy practices themselves.

Closing Remarks

two men standing in from of an ASKP3 banner posing for a photograph
My longtime best friend, Matt, who is the brains behind the business side of Innerbloom, and I (on the right).

All in all, the 2023 ASKP3 Annual Conference in Austin proved to be a valuable and enlightening experience for the Innerbloom team. It was great to see familiar faces and meet new individuals in this exciting field of medicine. The conference provided a wealth of new research, scientific insights, and practical advice that will undoubtedly benefit our community back home.

On a personal note, I am excited to share my experiences and newfound knowledge regarding ketamine practice with my team, patients, and network of therapists and other healthcare providers in San Luis Obispo. They, too, share my enthusiasm for the emerging psychedelic wave and the exploration of novel and effective treatments for mental health. I was quite impressed with the presentations and in-depth discussions, signaling a positive shift in treatment approaches.

Despite the optimistic outlook for the evolving field of ketamine therapy, I do harbor some trepidations. Once again, my primary concern is the need for standardized guidelines to ensure ethical and safe practices in the expanding landscape of ketamine providers. As we persist in navigating this paradigm-changing journey, stay tuned for additional insights, opinions, and reflections on the future direction of ketamine therapy.

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