Ketamine Leads Two Lives in America, and Nobody Is Watching the Door Between Them

Matthew Perry wrote a whole book about getting sober, and he meant every page. When he went looking for help with depression and anxiety in the last years of his life, he did what millions of people now do: he went to a ketamine clinic. According to the federal prosecutors who later charged five people in his death, he became addicted to the intravenous ketamine he was getting there, and when the clinic wouldn’t give him more, the other ketamine economy was waiting. A doctor sold him 20 vials, lozenges, and syringes for $4,500 about a month before he died. The medical examiner named the acute effects of ketamine as the cause.

Perry’s death is usually told as a celebrity scandal. It is better understood as a map. Ketamine lives two lives in this country, one in the clinic and one on the street, and the same person can walk from the first into the second without anyone in either place noticing.

We prescribe ketamine for despair and arrest people for it in the same zip code, and almost nobody is responsible for the person who crosses from one to the other.

This week, both lives made news

The clinical life had a busy stretch. On November 3, NRx Pharmaceuticals announced that the FDA had approved its generic, preservative-free ketamine ahead of its November 10 goal date. The company is pitching it into a long-running shortage of the injectable form hospitals use for anesthesia and pain, and arguing that a preservative in existing vials, benzethonium chloride, doesn’t belong in a drug given repeatedly for depression. Take the marketing with the usual salt: this is a company release, first shipments are reportedly not expected until January, and the preservative argument is NRx’s own citizen petition, not an FDA finding. But it tells you where the money thinks ketamine is headed: out of the operating room and into psychiatry, at volume.

Then the experts tried to say how that should work, and mostly couldn’t. In the Journal of Clinical Psychiatry on November 2, a task force of 21 academic psychiatrists convened by the American Society of Clinical Psychopharmacology, including some of the field’s best-known ketamine researchers, voted on 105 practical questions about using ketamine and its nasal-spray cousin, esketamine (sold as Spravato). They set the bar for agreement at 75%. They cleared it on 35 items, a third. They agreed on the basics: who shouldn’t get it, maximum doses, safety monitoring. They could not agree on high-dose infusions, on ketamine-assisted psychotherapy, on newer oral and injectable formulations, or on using it for conditions other than major depression. In their own words, “consensus agreement appears elusive for many key decision points.”

That is not a scandal; it is honest. A Delphi panel is a structured way of polling experts when the trial evidence runs out, and it ran out here. But hold that result next to the clinic on your local strip mall offering ketamine for PTSD, anxiety, and “wellness.” The people with the most expertise in the world agreed on a third of the questions. The market answered all of them.

On Veterans Day, WSHU’s Desiree D’Iorio reported that Long Island veterans are turning to ketamine for PTSD at clinics like Keta Medical Center in Garden City, where a 45-minute IV or nasal-spray session is followed by time with a therapist. The clinic’s psychotherapist, Stacey Blume Frankel, described what patients get from it: “You’ve got the power to pause, to stop, to not be as reactive.” The piece also noted, correctly, that ketamine is not FDA-approved for PTSD and its effectiveness there is still under study. Both of those things are true at once, and the veterans in the chair are living inside that gap.

Both of those things are true at once, and the veterans in the chair are living inside that gap.

The soldiers are back where ketamine started

There’s a historical loop here worth telling properly. Ketamine was developed at Parke-Davis in the early 1960s as a safer anesthetic, one that didn’t stop your breathing the way the alternatives did. Its first big real-world job was in Vietnam: the U.S. military used it as a battlefield anesthetic because it was forgiving at almost any dose, perfect for a field hospital with no time and no anesthesiologist. The FDA approved it in 1970. Over the next three decades it leaked into clubs, memoirs, and raves, and in August 1999 the DEA placed it in Schedule III, the same tier as anabolic steroids, as the agency’s worry shifted from the operating room to the dance floor. Now, half a century after it was used to put wounded soldiers under, it is being offered to their grandchildren’s generation of veterans to treat the wounds that don’t show on an X-ray. The drug never changed. What we decided it was for kept changing, and each time, the rules lagged behind the decision.

Britain is arguing over the same drug from the other direction. Rising use among young people, and a painful bladder injury that long-term heavy use can cause, pushed police commissioners to demand ketamine be reclassified alongside heroin. In January, the government’s own expert drug advisers recommended against it, warning that harsher classification would add stigma and discourage people from seeking help without cutting use. That debate is still open. The American version of it hasn’t really started, because here the clinical and street lives have separate trade associations.

What the gap looks like from inside it

If you are getting ketamine for depression right now and it is helping, nothing in this piece is an argument to stop. For many people the relief is real and fast, and the panel agreed it belongs in the toolkit for major depression. The point is narrower and more practical: ketamine is a drug with a known dependence risk, and the clinical system is not reliably screening for it. If you have a history with substances, you are allowed to ask your clinic directly what happens if you start wanting it between sessions, who on staff is trained to talk about that, and what their plan is if the answer is yes. A good clinic will have an answer. Perry’s apparently did not have one that held.

If you prescribe or refer for ketamine, this is a week to put two things on the agenda: add a substance-use history and a craving check-in to every ketamine intake and follow-up, and build a written referral path to an addiction-medicine clinician for any patient who asks for more frequent sessions. Our earlier look at the ketamine clinic boom found that most clinics weren’t set up to catch dependence; nothing in this week’s consensus suggests that has changed. You can follow the rest of our dissociatives coverage on the ketamine page.

Ketamine is not uniquely dangerous. It is uniquely divided. One version is a medicine in shortage that a company just won approval to make. The other is a felony. A person who is struggling can hold both in the same hand, the same month, and the only thing standing between those two lives right now is whether somebody in a white coat thought to ask.