Jack razors out 215 mg of white powder onto a mirror and snorts the pile using a rolled up "dollar" with his own face on it—an artifact left over from an old art project. He turns towards me and says, "Now is the sting-y part," and shakes his head. His hair is a blonde Mohawk with a turquoise streak, which almost matches his bright blue eyes. Through his window, the San Francisco lights flicker.
I'm here to observe and write about Jack's self-administration of ketamine—a dissociative hallucinogen—for depression. He's been using it for the last two and a half years intermittently with, according to him, resounding success. It's allowed him to burrow into the thought patterns that define his depression, gain perspective on them, and change them.
I'm doing this because Jack—a 28-year-old in San Francisco—will let me observe at-home ketamine treatment, something illegal but integral to understanding the variety of ways therapeutic ketamine is used, especially in a system where in-clinic treatment is legal but can be hard to find and expensive. Online communities are dotted with those suffering who have found relief in self-administered ketamine, often motivated by the expense of clinical treatments or barriers to mental health care. Some snort ketamine, but others have injected it. Unsurprisingly, medical professionals strongly advise against at-home ketamine use, citing the dangers of unsupervised use and the potential for addiction.
Because ketamine is approved medically as an anesthetic—but not a treatment for depression—most insurance won't cover the treatments. The costs are high. Both intravenous and intramuscular treatments cost about $600 per session, and those that include therapy run as high as $1,000 per session. Patients are usually treated initially with six infusions or injections over two to three weeks, which, including initial diagnosis, costs patients around $4,000. For ongoing maintenance, patients usually need treatments every two to four weeks. The treatments are available in many major cities and providers say many of their patients travel long distances to receive treatment.
Cheaper options are ketamine lozenges or nasal sprays, which can cost as little as $75 or 100 for a similar treatment schedule, but require an initial diagnosis appointment, which generally runs to about $375 to $500, costing patients at least $450 for an initial set of treatments, unless their insurance will cover the initial doctor's visit. In addition, the ketamine is significantly less bioavailable when administered in these ways.
The cost of the equivalent series of treatments, if bought on the street and snorted, would be about $80 to $120 according to Jack, depending how much dealers are charging. But self-administration is less safe, of course, since they're unsupervised. These sessions can also carry with it a risk for abuse or addiction. Jack readily admits that these days when he buys ketamine, he usually keeps doing it until his supply runs out. For this reason, he'll often buy a larger amount, but leave most with a friend for safekeeping, until he asks them for it.
Although he'd experienced other episodes, the depression that hit hardest for Jack was after he dropped out of graduate school. He'd lost his center. He was consumed with suicidal thoughts. Sometimes when he was on the subway to work, he could see himself hanging from the bridges while he was traveling beneath them. On the worst days, he could "feel the tightness of the rope around [his] neck." His girlfriend at the time was worried and so was Jack, though he didn't have health insurance to go to therapy. He also felt he should be able to handle his emotional problems on his own—something he chalks up to harmful ideas about masculinity.
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Jack's depression lifted when he found a job in his field, but soon after that his relationship with his girlfriend turned "mutually toxic" and they broke up. He responded by throwing himself headlong into an art project for a festival. It worked enough to distract him, but he was on emotionally shaky ground. This is when he tried the ketamine. He'd heard of its antidepressant effects before, but he'd only ever taken it recreationally. While camping with friends at an art festival, he snorted a couple piles of the white powder, and biked off into the desert by himself. His biking became wobbly, and eventually he lay his bike down and sat against it.
After sitting down, he felt himself "blast off" into dissociative hallucinations; he felt separate from his body. He's just broken up with a girlfriend and realized it was the first time he'd actually been on his own, without the guidance of parents or school or his girlfriend. "You are a man now," he thought to himself, and then asked himself, "Well, what kind of a man are you?"
Usually when he examined himself, it would be through the lens of depression—self-critical, filled with anxiety, and degrading his own self-worth. But the ketamine wiped that away temporarily, and he was able to look at himself as if he were looking at another person. Objectively, he felt he was an interesting and worthy guy. He liked himself. It was an extraordinarily profound moment, with power that has stuck with him.
In the Ketamine Papers, a collection of essays that document both research and trip experiences, people report experiences with low amounts of ketamine as relaxing and dissociative—feeling like the mind is separated from the body. Some people see colors or lights, or hear buzzing or tones. Some may feel like they are floating or flying. People sometimes feel as if it takes their brain time to catch up with their eye movement. Their thoughts may slow and it may be hard to articulate ideas.
In higher doses, in what users call the "k-hole," people experience more hallucinations. They may feel they're floating out in the galaxy, or that their mind has left their body completely. They may see Earth from above. Some users report the dissolution of the individual, the merging of themselves with others around them. They may experience the complete loss of ego and awareness, not knowing who and where they are.
Jack sits on his bed, which is draped in a deep red blanket, talking to me with slow slurred words as the ketamine comes on. Ketamine, he tells me, has become a spiritual experience because it allows him to tap into a part of his psyche usually hidden.
Jack goes to his drug altar and weighs out an additional 125 mg of ketamine. He asks me if he will get to see the piece before it goes to print and I tell him no, that journalism doesn't work like that. He says he understands and snorts the pile. Altogether tonight he's done, he explains to me, a huge amount of ketamine. While SSRIs (selective serotonin reuptake inhibitors) like Prozac work on the brain's serotonin system—serotonin is thought to create feelings of happiness and well-being—ketamine affects the glutamate system. Glutamate is believed to help regulate information processing across neurons in the brain and to facilitate communication between the brain and body. Some scientists think that depression could wear down synapses in the brain; ketamine stimulates growth of these synapses.
The studies of ketamine as an antidepressant treatment are consistently promising. In meta-analyses of the data, more than half of the 368 patients who received a single treatment of ketamine showed some relief of depression symptoms at 7 days and, although there is less research on longer term effects, around 70 and percent of those who received multiple treatment sessions three times over 12 days showed some relief. Unlike other medications for depression, patients often feel relief immediately after the ketamine treatment session, which is especially crucial for suicidal people. Ketamine is getting more and more attention as an exceedingly safe drug. It's on the World Health Organization's Model List of Essential Medicines for its anesthetic effect and is commonly used on children for this purpose. In the Vietnam War, it was nicknamed the "buddy drug" because it was safe enough that it could be administered by a fellow soldier. Although an overdose is possible, when the drug has been given to children at accidentally high doses (5-100 times the typical dose) in hospitals, there have been few lasting negative effects.
The night I'm with him, Jack takes almost twice as much ketamine as needed to experience a K-hole. It is a large dose, even for him. He wobbles back to his bed and leans back. Jack has found in the past that the only way he can feel the full effects of the ketamine is to smoke a spliff, a joint of mixed marijuana and tobacco. This is how he potentiated his bicycle experience, and every other significant ketamine trip. He invites me to the roof of his warehouse while he smokes. He knows it's not a great idea to go onto the roof, but as he'll tell me later, he wants to show off a little, to demonstrate he can do large doses of ketamine and keep his cool in front of me.
In Santa Barbara, CA, Terrence Early runs a psychiatric practice where he offers, among other treatments, intramuscular and subcutaneous ketamine injections. Early says ketamine is "the best therapeutic advancement in psychiatry in [his] thirty years of practice." He's seen patients who have been unwell for ten, twenty years see remission of their depression, and he's been treating some of his patients for as long as four years with intermittent ketamine sessions.
Critics of ketamine treatment say that there's not enough long-term data on the treatment to determine whether or not it's safe for patients but Early says this is true of many treatments for those with treatment-resistant depression. In order to secure more positive results during clinical trials, most pharmaceutical companies exclude those with treatment-resistant depression from their trials. In addition, Early says long-term trials are more expensive and have a higher dropout rate. Currently, ketamine is the only psychedelic drug to be approved for medical use, though MDMA and psilocybin have made their way into clinical trials. Because it's is no longer available for patent, and thus not profitable because anyone can produce a generic version of it, no one is motivated to push the FDA to approve of it as a treatment for depression.
Jack and I walk up the stairs in his warehouse and across a painted floor surrounded by rafters. We climb up onto a ledge, through a skylight, and out onto the roof. The roof slopes slightly down all the way around, ending in a waist-high ledge. He sits down with his back against a small wall at the top of the roof, and invites me to sit beside him. Beyond the edge of the roof, the city rises up, its hills dotted with lit windows and street lights. He lights his spliff and puffs it, the singed smell wafting over me.
As he'll report later, he is spinning through other dimensions, cycling through our world, spinning through others, then back to our own. He lets out a primal yell that echoes back off of the buildings around us. The echoes fade. A few people on the street below hoot in return.
"Who are you?" he asks me. I can't tell if he's completely lost in the spiritual worlds, or if he's asking a deep question about who I really am. "I'm Rachel Cassandra. Who are you?" He yells out his four given names. "What are we doing?" "I'm writing a piece about your experiences with ketamine." "Your story," he says. "Really, it will be a bit more like your story," I say. "Our story," he says, still looking off in the distance. "I think I did too much ketamine."
"Do you think you can make it downstairs?" I ask Jack. He says he can. "Do you need help getting to the skylight?"
He tells me no, then wobbles over to open the hatch. I am acutely aware of the dangers of walking around on this angled roof and I don't let Jack get farther than an arm's reach away. He wants me to go down first, so I climb down onto the ledge, then lower myself down to the floor.
"Are you okay?" I ask
"Space makes no sense," he says, so I reach my hands up in case he needs to lean on me. Suddenly, he relaxes his entire body, heaving his full 175 pounds onto me.
Jack tells me he wished he hadn't gotten so high around me. He is deeply ashamed. He says, "And you're a reporter!"
I tell him it's okay.
He says he thinks it would be better if he was alone. He has systems in place so that he can take care of himself if he's very high. His alarm is set for tomorrow, which is a workday. He will be okay. He doesn't want to kick me out, but he also can't manage the feelings of shame and anxiety with me watching over him.
Jack says ketamine allows him to watch his emotional patterns without actually getting absorbed in the tumult of them. For about eight months, he did ketamine every three to four weeks. His depression would lift for a while, then when he would feel himself starting to backslide into harmful thought patterns, he would seek out another experience.
These days, Jack doesn't keep a regular ketamine schedule but uses it for maintenance, meaning if he feels himself sliding back into depression, he will take a dose. He understands that there's this "cognitive space" he can access through ketamine, where he can deal with the root problems instead of the symptoms of anxiety and depression. It acts as a "reboot button" for him, breaking his anxiety loops and allowing him to start fresh. He's been treating himself for more than two years.
Jack and I debrief on the phone a few days later. He regrets the whole experience and tells me his depression actually intensified for the next few days after our meeting because he was so thrown by the incident.
"After you left," he says, "I felt really ashamed and I realized that I should be doing ketamine alone, at home, in my bed, listening to Chopin. That's how it should be used." The quality of the trip, the texture of the hallucinations, are integral to changing his mood and lifting depression. He can't be reckless.
Jack does ketamine in what he calls a "cowboyish manner" because he feels incredibly comfortable with psychedelics, after years of use. Jack's not opposed to trying a more controlled, guided ketamine trip, though. He's considered trying it in a clinic, or with a shaman trained to facilitate hallucinogenic trips.
But for now, the treatment is cheap for him and he doesn't need to funnel his medication through a therapist. He's willing to take on the risk of taking too much or being tempted to take more than he needs. He'll continue with what he calls his "gonzo psychedelic experiences."
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