Well, not really but something used as an anesthetic and abused as a club drug is now in trials to be used as an antidepressant.

My first thought is, “huh?” While I am a big fan of evidence-based medicine, the trials of “club drugs” makes me always skeptical. It’s weird to think about how progressive I am, I still have hang-ups about looking at the therapeutic value and these drugs as medications.  The hang-ups are things that as a provider, it is vital to “hang-up” and look at this objectively.  Let me tell you about Mildred and how she got over her “hang-up.”

Mildred had osteosarcoma and was in an endless amount of pain.  It wasn’t long before this that California had passed a medicinal cannabis law.  I walked into Mildred’s house (who was 82 at the time) and detected the strong odor of marijuana.  Mildred usually used the edible form, but only used the vapor form for immediate relief.

“Bad pain day Milly,” I asked.

“Really bad, I can hardly move without crying.” She replied.

“I can always tell; you are using the vaporizer,” I said.

Milly was known to use cannabis for pain relief, and it was on her formal medication list, in her medical record.  I remember when I saw this the first time and thought, “wow times are changing.”

As if she was reading my mind, she said, “you know I used to live close to the Haight (think Haight and Ashbury in San Francisco) in the 1960s.” “I used to bitch about all the damn hippies smoking pot and doing LSD, and here I am a great grandmother doing the same thing, and it actually works.” (seems she was a fan of Nixon and Ronald Regan, weird)

She faded back to using the vaporizer.

Change is change.  Sometimes it is painful and using things like Ketamine (the kids call it special K, although you sure get odd looks when you say that in a clinical setting) and MDMA (also called extasy, which is in an experimental phase for treatment for PTSD) seems weird because of their known current state of use and abuse.

Anyhow ketamine; from Medical News Today:

A phase 3 clinical trial testing esketamine nasal spray in the treatment of severe depression found the spray mostly safe and effective. The findings led to the recent FDA approval of this treatment.

Esketamine is a form of Ketamine, which doctors typically use as an anesthetic. Recent research has accumulated evidence that this substance can also quickly reduce the symptoms of severe depression, such as suicidal ideation.

These were the findings of a randomized, double-blind, placebo-controlled study from 2018, which suggested that an esketamine nasal spray could produce quick and positive short-term effects for individuals at risk of depression for whom traditional antidepressants had failed.

Nice, sounds super promising and the drug was approved after this stage 3 trial for what is essentially is an off-label use. However, some researchers are skeptics.

Even with these encouraging results that prompted the FDA to approve this therapy option for individuals with severe depression, some researchers still argue that this treatment requires an immense amount of caution.

In a commentary that accompanies the study paper, Dr. Alan Schatzberg from the Stanford University School of Medicine in California — who was not involved in the research — notes that the drug has the potential for abuse, and misuse and that there is much that researchers still do not know about its administration.

“So, where are we? Intranasal esketamine represents an easier method of administration than intravenous administration of Ketamine. Do we have clear evidence of efficacy? Maybe? How strong is the efficacy? Apparently mild. Do we have a real sense of how long and how often to prescribe it? It’s not entirely clear,” he writes.

Funny how they feel this could be a “drug of abuse” when any medication/drug that causes euphoria, dissociation, or level of consciousness has the potential for abuse.  In the case of Ketamine, it is quite honest by some reservations that, that is all its.

The concern is that the formulation used to create the internasal delivery will not be as capable of using it intravenously.  Well, of course, it won’t intravenous is the most rapid way to deliver drugs to the whole system.  The attempt is to make this mediation more available to situations where starting an IV is either not possible due to a restrictive unit setting or cost in the office setting (hey profits drive everything, why do you think insulin is $2000 a month?) or just lack of staffing to provide this infusion effectively.  The intranasal delivery allows this to be done on the quick and cheap (oh there is a, “your mom” joke here, but I will resist).  It is also less invasive with less chance of an infection or other complications.

The bottom line is that we all need to have skeptical research, and researchers should be suspicious.  Research data should be verified, and peer-reviewed to look for and point out flaws to help find the hypothesis correct or to disprove it.  Remember, a theory is something replicable and accurate time and time again in the same situation (oversimplified, but you get the idea). Be like Milly and realize, even out of necessity, that things can change and there can be benefit from valid research.