Dissociatives in 2026: Texas Is About to Reshape Ketamine Care — and Other States Are Watching

The dissociative drug class — ketamine, dextromethorphan, PCP, nitrous oxide considered alongside it for some clinical purposes — is the part of the addiction-and-mental-health field where, in 2026, the federal government has mostly stopped writing rules and the state medical boards have started.

That is not stable. It is the focus of this week’s spotlight because the most consequential state-level move so far is about to come to a vote in Texas.

Where ketamine actually sits, federally

Ketamine remains FDA-approved only as an anesthetic. Its enantiomer, esketamine, is approved as Spravato for treatment-resistant depression and acute suicidality. Spravato carries a REMS program requiring administration at a certified site with two hours of post-dose monitoring.

Everything else — IV ketamine clinics, intramuscular protocols, the at-home oral troche industry that took off in the pandemic — is off-label. The FDA has warned in writing about compounded ketamine for psychiatric use but has not promulgated prospective rules. The DEA classifies ketamine as Schedule III, which makes it a controlled substance subject to telehealth flexibilities — flexibilities the DEA and HHS extended through December 31, 2026.

Between the FDA’s silence and the DEA’s expiring flex, state medical boards have stepped in.

What’s actually proposed in Texas

The Texas Medical Board’s draft rule — reported by the Texas Tribune on April 28, published May 8, and slated for a board vote in June — does two things. It requires a physician to be physically present during every ketamine treatment, and it bans in-home use of the drug entirely.

In the existing market, those are large changes. The industry grew from fewer than 100 ketamine clinics in 2015 to more than 1,500 by 2024, with the U.S. clinic market estimated at $3.4 billion in 2023. A meaningful share of that volume runs on protocols where a nurse or paramedic supervises administration and a physician is available by phone or telehealth. The at-home segment, where the patient takes a compounded oral dose with a remote provider on video, would be eliminated outright.

The Insurance Journal coverage captures the industry’s central objection: many clinics serve patients who are jobless or low-income, insurance does not cover ketamine therapy in most cases, and paying for on-site physician hours would push prices out of reach. The board has heard from both clinicians who back the rule citing safety, and clinicians who oppose it citing access.

Where the field disagrees

This is the part worth saying clearly. There is genuine, unresolved disagreement in addiction medicine and psychiatry about ketamine right now, and that disagreement is older than the regulatory debate.

The strongest position for prospective state regulation: ketamine carries real cardiovascular and respiratory risks, the at-home model removes the ability to monitor for sedation and dissociation in real time, and the clinic landscape has grown faster than the evidence base for off-label psychiatric use. Texas’s argument is that under the current system, the level of supervision varies too widely for a drug with this much potency.

The strongest position against: in-home protocols have served patients — particularly rural, disabled, and treatment-resistant patients — who could not otherwise access care. The evidence base for ketamine in treatment-resistant depression is real even if the protocol variation is concerning. And there is no FDA-approved at-home alternative for someone for whom Spravato is unaffordable or unavailable.

Both can be true. The next 60 days in Texas will test which the medical board weights more heavily.

What to watch

Three concrete dates and developments will shape this through summer.

June 2026: Texas Medical Board vote. If adopted, expect similar proposals to circulate in at least Florida, California, and New York — three of the largest ketamine clinic markets.

June 29, 2026: DEA cannabis Schedule III hearing. Not directly about ketamine, but the same DEA rulemaking apparatus is responsible for the controlled-substance telemedicine final rule that everyone in dissociative care is waiting for.

December 31, 2026: Telehealth controlled-substance prescribing flex expires. Without a final rule or fifth extension, the at-home ketamine model nationally is structurally untenable starting January 1, 2027.

Resources

If you are considering ketamine therapy in 2026, three questions are worth asking any provider, regardless of state: who is physically present during the dose, what monitoring happens during and after, and what is the after-hours protocol if something goes wrong? Reputable clinics will answer all three without hesitation.

If you or someone you love is in crisis right now, call or text 988. If you’re navigating treatment options and want help comparing what’s available in your area, our Find Help tool covers all evidence-based treatment paths, including the providers near you who are operating within current regulatory standards.

If you or someone you love is in crisis right now, call or text 988.