Ketamine Got Rebranded as a Miracle Depression Drug. The Bladder Surgeries Never Left.

Abigail Wilson spent years as the lead clinical pharmacist for WithYou, watching what ketamine actually does to a body outside a controlled dose. “We have seen young people under the age of 25 who’ve completely lost control of their bladders,” she told the Daily Trojan, “who have had to have surgery, including bladder removal.” She is not describing a street drug cooked in someone’s kitchen. She is describing the same compound a growing number of American clinics now market, legally, as a breakthrough treatment for treatment-resistant depression.

Ketamine is having two moments at once, and the industry built around the first one has no incentive to talk about the second.

That’s today’s Substance Spotlight, and it’s worth sitting with the contradiction directly: ketamine is a real, FDA-recognized anesthetic with genuine, replicated evidence behind its use for severe depression at controlled clinical doses. It is also, simultaneously, a recreational drug on a documented upswing, a growing contributor to toxicology reports, and the subject of a federal scheduling fight that its own harm reduction allies say is being handled backwards.

The clinic boom happened first — the oversight still hasn’t caught up

Ten years ago, ketamine clinics barely existed as a category. PharmExec counts fewer than 100 in 2015, ballooning past 1,500 by 2024, inside a U.S. market now valued around $3.4 billion. That growth wasn’t hype without substance — ketamine’s antidepressant effects are among the better-replicated findings in recent psychiatry, which is exactly why the boom happened so fast. But PharmExec’s own read on where the industry stands now is blunt: oversight is “increasingly being defined through audits, investigations, and enforcement actions… rather than prospective guidance.” Translation: nobody built the guardrails before the strip malls filled up with infusion suites, and now regulators are trying to retrofit them after the fact, one enforcement action at a time.

Meanwhile the same molecule is showing up in places that have nothing to do with a psychiatrist’s office. A national wastewater study out of the University of Adelaide — the kind of population-level measurement that can’t be faked by self-report bias — tracked excreted ketamine loads climbing from roughly 1.6 milligrams per day per 1,000 people in 2022 to 5.8 mg/day/1,000 by the end of 2025, with sharp weekend spikes that only make sense as recreational, not medical, use. “Patterns started emerging of substantially elevated excretion on weekends,” said pharmacy researcher Cobus Gerber, “suggesting an increase in recreational, or non-medical use of the substance.” Weekday ketamine is a patient in a recliner with a nurse watching vitals. Weekend ketamine, increasingly, is something else.

The bodies are a real number, not a moral panic

In Miami-Dade County, ketamine turned up in 33 deaths in just the first half of 2025 — up from fewer than 10 a year before 2017. “I’m like ‘there’s ketamine again, there’s ketamine again,’” the county’s toxicology director, Diane Moore, said of reading case after case. Ketamine doesn’t respond to naloxone — it isn’t an opioid, and the overdose-reversal medication that’s saved hundreds of thousands of lives in the fentanyl era does nothing here. Harm reduction worker Becca Smith, of the Florida Harm Reduction Collective, put the mechanism plainly: “We keep seeing tolerance build up, and the market keeps looking for more things to put in the dope to get the achieved effect.” And the highest-profile ketamine death of the decade is still working its way through federal court: a fourth defendant was sentenced in May for supplying the ketamine that killed actor Matthew Perry — a reminder that “medical-grade” and “safe outside medical supervision” are two different claims, and the second one was never actually made.

None of this makes ketamine equivalent to fentanyl. It is not driving mass fatality on that scale, and treating it as though it were would be its own kind of dishonesty. But “not as deadly as fentanyl” is a low bar, and the trend line — more clinics, more recreational use, more toxicology reports, less coordinated oversight — is real and worth naming before it gets worse, not after.

It is not driving mass fatality on that scale, and treating it as though it were would be its own kind of dishonesty.

The DEA’s fix is aimed at the wrong door

Faced with all of that, the DEA’s most aggressive recent move wasn’t aimed at the clinic industry, the recreational supply chain, or the enforcement gaps PharmExec describes. It was an emergency scheduling action against 2-FDCK, a little-known ketamine analog with all of 52 documented law-enforcement encounters nationwide since 2018. “Only 52 reports over eight years,” Denver attorney Robert Rush said. “In a country of 330 million, that’s a reach that borders on the absurd.” Kat Murti of Students for Sensible Drug Policy called it “drug policy by panic, not evidence,” arguing the scheduling will “push people toward increasingly unregulated and unpredictable markets” rather than the clinics and dosing consistency that actually reduce harm.

This is the same policy pattern the newsroom keeps documenting across substance classes this year: an agency reaches for the scheduling lever, which is visible and fast, instead of the harder work of regulating an industry that grew up with almost no rules. It’s the same instinct that gave ketamine its first scheduling moment 27 years ago — the Ketamine Control Act of 1999 moved it to Schedule III after it became a fixture of the era’s rave and club scene, the original “Special K.” That crackdown didn’t end ketamine’s recreational life; it just paused the story until the clinics gave it a second, more respectable act. Scheduling an obscure analog with 52 known encounters won’t end this one either.

If ketamine is part of your treatment plan under real medical supervision, that distinction — supervised dose, monitored setting, a clinician watching for the neurotoxicity risk that even ketamine’s own defenders acknowledge builds with frequency and dose — is the entire difference between the molecule helping you and the molecule becoming the next line in a toxicology report. And if you or someone with you ever needs help after any drug use, Good Samaritan laws in most states, including Arizona, protect the person calling 911 from prosecution for simple possession. That protection doesn’t expire because the drug involved doesn’t have a naloxone equivalent.

Abigail Wilson is still treating the after-effects of an industry that scaled faster than its own safety net. The DEA is still scheduling analogs nobody has heard of. Neither one, on its own, is going to close the gap between ketamine’s two moments — and until something does, that gap is where the next toxicology report comes from.