Dangers of nonphysician ketamine infusions

There are an estimated 500-750 clinics across the U.S. providing infusions of Ketamine for the treatment of a variety of medical conditions. This is big business, estimated to bring in $3.1 billion per year and projected to rise to 6.9 billion by 2030.  But is Ketamine safe and effective? 

Psychiatrist Kristina Kise, MD discusses the use of ketamine infusions in psychiatry, including the potential dangers to patients when physicians are not directly involved in drug oversight.  

PhysiciansForPatientProtection.org

Transcript

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​welcome to Patients at Risk, a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm Dr. Rebekah Bernard, your host and the co author of the book, patients at Risk, and the author of the follow up book, Imposter Doctors. In our last podcast, I reviewed the differences in training between psychiatrists and psychiatric mental health nurse practitioners, PMHNPs. Today I'm joined by psychiatrist, Dr. Christina Kise and she's here with us to continue this discussion, including the risks that patients with psychiatric conditions may face when they're receiving care by non physicians. Dr. Kise welcome to the show. Thank you so much for having me. I'm excited to talk about this topic today. Yeah, I think it's super important. why don't we start out by just having you tell our audience a little bit about yourself and your background. Sure. So I'm a child and adolescent psychiatrist. I've been practicing for the last 12 years in private practice. I opened my own private practice in Orlando about two years ago. I'm a cash based practice. And I do that so that I can spend more time with my patients. I really enjoy doing therapy. I treat a lot of OCD. I do exposure and response prevention and CBT for anxiety. I also teach at the University of Central Florida, their College of Medicine for their first year medical students. I really enjoy educating and teaching. Thank you for all the work that you're doing to, to help patients and to educate future physicians. It's just amazing. Let's talk about what the differences are in training between a psychiatrist and a nurse practitioner. And just to remind you, psychiatrists are physicians, MDs or DOs. They must complete four years of college, four years of medical school, and then psychiatry residency is Five years, is that right? Pretty close. So if you do adult psychiatry, you do four years. And then for me as a child and adolescent psychiatrist I did three years of adult psychiatry training and then two years of additional child and adolescent psychiatry training. So sometimes if you do child and adolescent, they'll let you do three years of adult, but some people will still do the full four years and then the additional two years for child. So minimum of four most many are going to be doing those five years. And then, of course, you have all sorts of additional fellowships and some people even train for longer, but I would, I guess the average psychiatrist, when you come out and you're practicing independently, you have about at least 20, 000 hours of patient care experience across the spectrum of so many different aspects of psychiatry. To compare that with a nurse practitioner, they will complete four years of college. They could also go a shorter route, but the average has a four year bachelor's degree in nursing and then a two year average nurse practitioner training program. And there's a minimum of 600 hours of clinical experience. And then in half the States of the country, a nurse practitioner can then care for patients with mental illness completely. Independently, including what they call across the lifespan, which means even caring for children, pregnant women and seniors. So with just 600 hours of training, again, compared to a psychiatrist with about 20, 000 hours. So Dr. Kise I'm guessing you have thoughts on that difference in training and what that looks like for patients. For sure. We do a lot of training in various settings, right? So, in my training, I worked inpatient, I worked in the ER, I worked at the VA, I worked at the college mental health, I worked in the community mental health centers, I worked in the FACT team, which is the assertive community treatment where you're working with severe mental illness going out into the community because the patients are ill, they really can't come in for appointments. So you get to see the whole spectrum and you get to see the really severe cases and then the more mild outpatient cases. You get to see all of the diagnoses. You know, I participated in ECT. So, you really get to see The whole variety. And I don't know how you can get that amount of training. And a nurse practitioner school with so limited hours. And you want to know what the rare things are, which you wouldn't get to see in a short amount of time. You also want to know what a normal presentation is for mental illness. And when something's not lining up to go, Hey, I think I need to refer, maybe there's something medical going on. You know, maybe I need to refer them to neurology. I think they're having seizures. That amount of training is so important. And in psychiatry, especially we get trained so much on boundaries and how to effectively interact with our patients. And that first, do no harm and evidence based treatments and being critical of the literature. Yeah. Again, there's just so much that we learn in training, and it's so important, and I, you know, I'm passionate about what I do, and I love my child and adolescent patients, and there are some of our most vulnerable patients, like children and adolescents with mental illness, and I, I want them to have the most educated person out there treating them and advocating for them. Yeah, there's a reason why you did all that training. It wasn't for nothing, and you can't take shortcuts to learn that information. Now, I could see where maybe you could train someone to assist maybe a psychiatrist, maybe to see the lower risk, or maybe follow ups, things like that. That could potentially make sense. But there are many states and, and in fact, Florida did not pass it this year, but there was a bill that was, they were, there was an attempt to allow nurse practitioners to autonomously, without physician supervision, see patients with mental illness in many states that already allows that. And so your opinion would be that that would be a pretty potentially dangerous thing for patients. Correct. I mean, kids are very complicated, especially when they have mental illness. And You know, especially for that first visit, you need a correct diagnosis because that's going to lead treatment. And so, I really feel like you need a psychiatrist, you know, making those diagnoses. Absolutely. Well, let's move into kind of maybe a little bit of a controversial topic in psychiatry, which is the use of the drug ketamine. And that's being used for some patients with mental illness, in particular depression. Can you explain to our audience what ketamine is and what it's used for? Yeah, and this is definitely a hot topic in psychiatry right now. So ketamine is a schedule three substance. It was it's been used for since the seventies as an anesthetic. It's used in pediatrics a lot for conscious sedation, for doing procedures like MRIs, if they can't stay still or if they need a lumbar puncture. So it's been used in that setting for a long time. But it, since about the two thousands, there's been studies in treatment resistant depression. And there actually is really pretty good evidence regarding the treatment of treatment resistant depression with IV ketamine. So it's an NMDA receptor antagonist. It increases glutamate. The idea behind it is it increases neuroplasticity. And the literature is really pretty good. It's not FDA approved though because it was already FDA approved as an anesthetic. So when it's being used, it's being used off label for IV ketamine. There is an FDA approved ketamine treatment that's called Spravato. It's a nasal spray. So that is FDA approved. But again, that's not the IV ketamine. It's an enantiomer, whereas the IV mixture. So it's not being used. You know, certainly not first line. It's for supposed to be for treatment resistant depression. And you mentioned that it is a bit of a hot topic. What is it that, people are concerned about or why do psychiatrists not take this drug lightly? What's great about IV ketamine is it works very quickly so for if you have somebody who's really disabled by their depression or has severe suicidal thoughts, we want to give something quickly to get them better. And so this is a great resource that we have now for that. However, the effects are very short lived. So, if you stop giving the treatment within a couple weeks, they are relapsing to their depression. And so, it really hasn't been figured out, what do we do long term with this so, this is really something that we haven't figured out yet. And I'm guessing that there are some alternatives that, of course, everybody gets a little freaked out, you know, anybody that's watched movies about, you know, psychiatry, especially old time movies, and they see things about ECT therapy, electroconvulsive therapy, everybody gets really scared, but actually that's considered a pretty good treatment for certain patients, isn't it? Yeah. ECT is really the gold standard. It's, you know, 80 percent effective and treatment resistant depression, which is huge, and that's even better for somebody with like psychotic depression. And so it's a very effective treatment. It's a relatively safe treatment. It really is sort of the tried and true. I always tell people, you know, if I ever got severely depressed, Sign me up for ECT. It is the treatment of choice. That's so interesting. I think it just, you know, immediately when you hear it, you start, you have these visions of like movies that you've seen. I can't think of what they are, but I, there are things in my head where somebody is getting shock and they're, you know, convulsing and it looks really scary, and that's probably one of the things that, that makes people shy away from it. But you're saying like, if you needed it, you would be like, absolutely. Absolutely. Yeah, it's just so effective. And, and yes, there's these scary scenes from old movies. But you know, the way that it's done now with modern medicine is you are under anesthesia. You don't actually experience any sort of convulsive movements. It's really just a seizure in your brain under anesthesia. It's a short procedure. You go home that day. And, and again, it actually works pretty quickly as well. So you're usually doing it three days a week for six to 12 sessions. So in two to four weeks, you're done with the treatment. And, and again, 80 percent response in terms of depression. So, and that's much longer than what we're seeing with the ketamine. It sounds like, yeah, so it's two to four weeks. So the ketamine is, is also a. Again, depending on who's doing it, what academic institution, two to four weeks. So it's about the same amount of time. With ECT, it's more durable. It's a more lasting effect. I think that's so interesting. And as I'm listening to you talk, I'm realizing how much about this, I don't know, even as a family physician of 20 some years. And so I, that tells me that this is a very complex subject. That's why you train so long. And yet we are seeing people with minimal training offering these sorts of treatments like the ketamine. And in fact, we recently saw a post by a family nurse practitioner. Her name is Mindy Thomas, and she was sharing her protocols and what she's doing, treating patients with mental illness with ketamine. And I'm going to be talking about some of her publicly posted information, things from her website that I'll link to, and we'll actually show some screenshots on our YouTube video as well. Just so people can kind of see what the conversations are, are happening out there towards the public. But before we get into her protocols, I just want to review Nurse Thomas's credentials are to be treating patients with psychiatric conditions. So first, as I mentioned, she's a family nurse practitioner. She has a doctorate in nurse practice, and she actually refers to herself as Dr. Thomas on her website. Do you have any thoughts on, I'm guessing you do on people calling themselves doctor that are really not a physician. Yeah, I think it's really misleading. You know, patients really don't know the difference between a nurse practitioner and a physician. And so if you, you know, they don't even think to ask, like, what are your credentials? Are you, you know, an MD, a DO versus a nurse practitioner? And so I think that really confuses them. Yeah, it's, it's really, it's just about truth and transparency, I think, and patients understanding who, what the training is of the person that's caring for them. So, she is a nurse practitioner and she shares that she attended Johnson County Community College and then went to nursing school. School at Kentucky University, and then she worked at an emergency room and an intensive care unit. And I think it looks like she was a critical care nurse. And that is such important work and God bless our nurses, our bedside nurses, our critical care nurses. But when I read about that nursing background, it also makes me think, does that experience in nursing. Give a nurse the insight or the training or experience to then work with patients with psychiatric conditions. Yeah, I mean, obviously, yeah, they're not really learning therapy, they're not learning psychiatric treatment in those settings, so I, I don't see where that prepares them, and then, you know, in regards to what we're talking with the IV ketamine treatment, I mean, you really need to be prepared to manage an airway. You really need to know what to do in an emergency. If someone's, you know, has respiratory depression or if they go into a hypertensive emergency because it can increase blood pressure and heart rate. And so, you know, I agree my ICU nurses when I was training, they were wonderful and they are so good at what they do, but it's nursing training. It's not the same when you're the one in charge and responsible. Right. Well, she did get her nurse practitioner degree, the University of Missouri, Columbia, and it looks like she just went straight through and earned a doctorate, and then that was in 2020, and then she opened a cash based practice in 2021, and looking at her website, it says It seems like she focuses a lot on things like menopause and, and some other types of you know, niche practices. And then one of the niche practices that she does is to offer ketamine therapy. And so if you look at her website, hummingbird health, she has a section about ketamine. And then she says, quote, ketamine is a very safe medicine when used as prescribed from a trained practitioner. So do you agree with that assessment? I would, I wouldn't say very safe. I would say relatively safe, right? Again, they do use it for, you know, Procedures and pediatrics routinely, but you know, there are significant risks associated with it again. Respiratory depression being one of the main effects. I would be worried about is an anesthetic. Right? So again, it can the hypertensive emergency also. People can become quite agitated from ketamine or they can have a psychotic reaction from it. Do you have the training and the staff to manage a patient who's quite agitated as a reaction to the ketamine? So that is something that would really concern me. Or if somebody is really dissociated and really again agitated by that experience. Do you know how to manage that? So to me, it's relatively safe, but there are significant risks. Yeah. You know, it's so funny because when I read these websites and not just this, but tons of different ones where, especially when they're promoting cash based practices or alternative practices, it feels like there's always so many glowing things about, Oh, there's the benefits and the safety. And the same, when I talk to patients that have been to various clinics offering alternative therapies, they come back and they tell me all these pluses. And then I'll ask them, well, did they talk to you about any of the risks or any of the potential side effects? And. It always feels like they're kind of like, well, either they know or yeah, but they said it wouldn't probably wouldn't happen. And, you know, it really leads me to this bigger issue of informed consent. And have you noticed that to be the case that a lot of times people just aren't really getting the full picture? Yeah. I mean, again, I hear from my patients and I don't know who they saw when they. Yeah, but I'll ask them about various treatments that they've had and they often are like, Oh, I don't know. They didn't really talk to me about the risks. And, and so I'm one very much always talks about the risks. And so to me, I can't imagine not going over that with a patient. They need to have that informed consent. They need to know what to look out for and what they're signing up for. 100%. I really want to see a return to truth, transparency. And I mean, I don't know how we're going to get there. I mean, maybe educating patients to ask, but I think when you're desperate, when you're seriously depressed, when you're suffering, You know, you're looking, you're desperate for help and for answers. And you're going to latch on to whatever you see, anything that gives you hope. And I think that's part of the challenge that I have. When I see things like this, that I know these patients, especially if you're suffering with mental illness or your family, a family member of somebody, you're going to pay any money. You're going to do anything you need to do. And when you're told this is, oh, this is going to work, this is safe, you're just going to say, okay, sign me up. How much is it going to cost? And I think that's where I start getting really sad and frustrated with a lot of what seemed to be false promises, not necessarily about ketamine, but maybe, but also about all these other sort of alternate therapies that I'm seeing, from doctors, but more and more, I'm seeing it from non physicians. Yeah, no, I, I completely agree. I, you know, I feel for these patients. They are desperate and they're looking for anything. That could be that miracle cure like that gives them hope and there's so much hype right now that ketamine, you know, Michael Pollan had his book about change your mind. And so that really got people talking about ketamine. I guess Elon Musk recently has been talking about his ketamine use. So there's a buzz about it. And so you hear that and you're like, okay, oh, there's something new that will work for me. And they go in kind of not really knowing the facts, unfortunately. Right. Well, speaking of that if you go on to look at more information that is on this website it says, what do ketamine infusions treat? And she says, some examples of disorders that ketamine has been used to treat are resistant depression, which we talked about anxiety, OCD, bipolar, PTSD, complex regional pain syndrome, neuropathic pain, chronic pain from fibromyalgia, chronic pain from Lyme disease, and other Many others, it says. So what are your thoughts when you hear that list? I think those are far reaching claims that the science doesn't support at this point. I was talking to some colleagues about this the other day. You know, it's, it's sort of the new medical marijuana. It treats everything, right? Like, you know, everybody's coming and asking about it for every single possible thing. And it, it, The science just isn't there. Unfortunately, you know, they are starting to look at it for bipolar depression. There are only very small studies in OCD and anxiety that really need to be replicated and more structured and more randomized controlled trials. You know, the science. really isn't there yet. You know, for PTSD, there's some encouraging studies, but again, there's so much diversity in the studies right now. Is it ketamine assisted psychotherapy? So are you doing psychotherapy with it, or are you just doing the IV ketamine and at what frequency? These things really haven't been worked out, and And, you know, if you're interested in this, you know, I tell people sign up for a trial, do it at an academic institution that's doing a study that will really be on top of things in terms of monitoring your safety, making sure there is informed consent. If we're excited about it. Sign up for a trial, but don't just be doing it, you know, at some clinic that popped up in your neighborhood. I love that recommendation because not only for all those benefits that you said, but also because that's going to help progress the science and they can be actually part of making maybe the world a better place for, future patients by being involved in those kinds of trials. Science is you're actually supposed to Investigate whether the treatment you're giving is actually doing good, or is it doing harm? You're not just supposed to throw things at people and then, you know, sort of anecdotally see how they do with it. And I hate to give people false hope because it doesn't work. They're disappointed. And also then you're doing a treatment maybe instead of another treatment that is evidence based and actually would be helpful. That's so true. And especially when we're talking about depression, because, you know, there is that very real risk of suicide when people are severely depressed. And if a person is delaying potentially good. quality, effective treatment, whether it's the right medication, because maybe they haven't seen a psychiatrist that made the correct diagnosis and tried the right treatment medication treatment talk therapy, maybe they are a candidate for ECT. If you're just doing all these other things, whatever they may be that aren't evidence based, you know, potentially you could have a very bad outcome because you didn't just get the right treatment to begin with Well, going through what this nurse practitioner lists on her website, as far as what's going to happen for her, for patients that sign up for this. she says here, we will start with an in depth assessment to fully understand your health history and make sure you are a good candidate for therapy. Now that sounds like something that would be. extensive, if you were assessing a patient for whether they needed ketamine, what would that look like? For me, not even just assessing for ketamine, if I am treating a new patient, I do a two hour intake with that person. So I can get a really good history of their symptoms as well as past treatments that have been tried. And then I'm also collaborating with any, Previous psychiatrists or therapists that they're currently seeing, so I really want to get a comprehensive evaluation to make sure that I understand, you know, their diagnoses and any past treatments to make a recommendation and and I find it so hard to imagine that after one evaluation, I could say you should go do ketamine to me. This should be I've been seeing a psychiatrist for a while. They know me. They know my history and we've had several discussions about what my options are and together we have decided that ketamine is the best option. And so to me, what concerns me is I think these ketamine clinics that open up, they don't require a referral from a psychiatrist. ketamine treatment and it may not be appropriate at all. And I, I don't know how you really assess that in one visit, which I'm sure is. Not the two hours that I do. I think you're probably absolutely correct about that. And certainly not from someone that has the depth of experience and training that you have. So after the nurse practitioner does this assessment that she talks about, she says, we will go over how to prepare for your infusion. You cannot drive after an infusion and we'll need to arrange a ride home. Everyone starts with a loading series of infusions, usually five to six infusions within three to four weeks. Does that sound about right so far? It does, yeah. That's pretty standard. Again, it varies somewhere in between two to three times a week, two to four weeks is kind of what people are doing in various studies and various institutions. And this is generally a cash based treatment. Do you have a ballpark idea of what it costs? So from what I've read, you know, for a single infusion because it because it's not FDA approved for depression, right? So that's why the cash based practice usually because insurance won't pay for it. It can range from anywhere from 600 and a session. 600 to 1, 000 a session. And that probably depends what, where you are with state, but yeah. And a session, it looks like there, she's saying it's five to six sessions over three to four weeks. So you're starting to look at a hefty amount of money I specialize in patients without health insurance and patients who are a little bit often lower income and sometimes patients are very sensitive to the cost of medical care and they'll say, well, I can't afford, let's say, to see a psychiatrist, but people often are surprised to find out that you can go and see and get proper care with a psychiatrist. And it does not necessarily break the bank. There are psychiatrists in my community, it's like maybe 200$220 for an initial visit and maybe a hundred,$150 for a follow-up visit. And even if you looked at that as seeing them. Every couple of weeks or every couple of months, you're still actually paying a heck of a lot less money than you are if you're doing one of these cash based practices, and you might actually be getting the right treatment and not needing to even go down this route. Correct. Yeah, I totally agree with that. I think people get this idea in their head that psychiatrists are so expensive. Again, maybe it goes back to like, Old time movies were like only super rich people and they go into analysis and they have to go every day. And do you think that's where this idea that psychiatrists are so expensive is coming? No, I don't really know where it comes from. I think honestly people are just so used to using their insurance And so anything that's more than their copay feels like a lot which I totally understand but again if you think about it as an investment and like In the short term, it feels like a lot of money, but in the long term, you're probably saving money, like you're saying, because you got the appropriate treatment instead of continuing to visit somewhere over and over and over again without getting benefit. So in the long term, you end up paying more. Well, it's just like, you know, fruits and vegetables are more expensive than a dollar menu at a, at a drive through fast food joint. But what is actually fueling your body and giving you what you need? Even though, yes, there are some people that really truly can't make it work, you know, there are a minority of people, but I would say there are a lot of people that could, if they knew where to go, knew what resources, and they made that decision to invest in their health. For sure. But I understand it's, it's, the health care system is hard for people to navigate and to know where to go. To get that information. It is hard. Yeah. That's one of the things that I love about DPC, about direct primary care, because I have my network, especially like I have my community psychiatrist or a few of them that I know what their cash prices are. And I know how to get patients there and the same for other specialists. And how do we, how do we work the system? Because you're right. Especially if you don't have. You know, amazing insurance, even though I don't even know that there is such a thing anymore. So just navigating the system is, it takes help. So, going on to what she talks about with what people will experience with their ketamine infusion, it says here, The goal of a ketamine infusion is to have the feeling of dissociation from the body. This may sound scary at first, but many people report a feeling of contentment and peace during infusions. Is that, is that the goal of ketamine infusion? No. And so I'm not quite sure what she's talking about. You know, it's common to have that dissociative effect from the ketamine. But that's not the goal. It's not required. A lot of the studies and, you know, most of the people really doing this research will tell you it's not this dissociation the cause of the improvement or the benefit. So yeah, the dissociation we don't think really matters. It's a common thing that will happen from ketamine, but that's not the important part. So, so clearly this is a person that maybe doesn't have that full thorough understanding. So she's Kind of simplifying it, I guess. And she talks about how they've created a healing space in the office and there's eye masks and blankets and music. It sounds quite peaceful and kind of, kind of sounds like a spa or like a massage. But she says here that patients, they might feel tired and slightly disoriented after the infusion and need more sleep than usual. Some patients may have a ketamine flare after the first few infusions, which means that their symptoms of anxiety or pain get worse. And she says, this can feel discouraging at the time, but it is seen as a sign that the infusions are working. And many times after the first two to three infusions, a person starts to feel the relief they are looking for what's right. And what's not quite right about that. Anything. Yeah, I I'm very confused by that statement. So I've never heard the term ketamine flare in, in all of my readings and. Conferences that I've attended on ketamine. So I'm not sure what she's referencing in that. So to me, that doesn't make sense. And then in terms of the relief, I mean, again, most of the studies show, like, that day you're having a response again, doesn't last if you just do one treatment, but usually within a day, you're noticing a response. Well, I'm not surprised that you're confused because Nurse Thomas is a little confused, too, because she made a post on a nurse practitioner Facebook page, I guess, where they talk and get advice from each other, and so she, this is one of the things that brought this to our attention because it was kind of an odd question. First of all, There's the big question about whether or not it's a great to like crowdsource patient care advice on social media, which is something that even nurse practitioner, the president in the past urged nurse practitioners not to do because, you know, it's, it's not a great way to take care of patients, but it's still very common. So in this post nurse Thomas wrote. Has anyone doing ketamine ever had a patient have no response to the infusion? I did the first infusion for a new client today. She has tried other psychedelics to help with severe and chronic depression and had no response. We had discussed this during her pre infusion assessment and she was nervous. She may not respond to ketamine. I started her off at a higher dose than I usually do and ran it a little faster. But she still didn't get a response. She also has some genetic mutations and I'm going to increase the dosage for the next infusion. But I didn't know if others had experienced this or had ideas to help her feel the disassociation needed to get the therapeutic benefit. So what were your thoughts when you saw that post? Yeah. So, I mean, again, the dissociation is not what's needed. I just, there's so much that confused me, to be honest. So one, you know, the history of psychedelics, I'm like, well, what else has this patient done? Is this somebody who has an addiction? Who's like using other substances. So, or have they done spr, the FDA approved and didn't have a response and you think the IV ketamine's gonna be different? I, to me that was just very confusing. And why you would start at a higher dose or faster, to me that didn't make sense either. I mean, yeah, I, I mean there's a lot of that that I have a lot of questions about. And again. When they say they had no response again, give it a day. Most will get a response within an hour, but they say up to a day for the response. But are they not getting a response? Because they've been abusing oral ketamine. Okay. I don't I just have so many questions about that. Yeah. And I mean, you can just tell when you read this post that this is a person that really, just kind of like just winging it, it almost feels like. Yeah, yeah. And that's scary to me. I agree. And I think, you know, one of my big concerns, there's many with nurse practitioners doing these IV ketamine treatments is it is really new science and you really have to stay on top of the literature as it's evolving. And I don't know that that's the culture that's created and nurse practitioner training about really staying on top of the evidence and reading the literature. Yeah, and that we don't just make it up as we go along. I mean, that's really, really not something that we're, we're, that's something we're very much discouraged from doing. You know, we're supposed to practice evidence based medicine. And I would think especially nurse practitioners being trained to follow protocols and algorithms, this is really far outside of their scope of training. It definitely is. Yeah. And what's probably the saddest thing is that this is a person that's seriously unwell, certainly needs care from a psychiatrist. And now, instead of getting that proper care, they're basically just trying random things that may or probably may not actually make any difference to the patient and may delay proper care. Agreed. And like someone who's seeking out ketamine treatment probably does have very complex mental health needs, right? And again, if it's a nurse practitioner assessing that who doesn't have the amount of education and training that a psychiatrist has, You know, I just, it's a mismatch. You know, these are probably your most complicated mental health patients. So they really deserve a psychiatrist that's assessing them and making treatment recommendations. And I, I worry too, you know, because we don't know We know some of the long term effects, but we really don't know the long term effects. And again, what ends up happening is the ketamine treatments are only effective for a couple weeks after you stop taking them. And so, you know, nurse practitioners, I think, having not done, you know, learned boundaries and really understood, like, we have to sometimes say no to our patients. If our, if that patient keeps coming back and saying, I want long term maintenance ketamine. I don't know that they're ever going to say no or say, you know what, I think you need to try another treatment, or you know what, it's time to do therapy. I, I really worry that they're not going to be able to say no to the patient for those who keeps wanting more and more treatments. Yeah, I feel like if we were involved, not that anyone is asking us to be involved in oversight because it just seems like the states are letting people do whatever they want. California is one state that actually did get this somewhat right when they allowed some autonomous NP practice, which is that they actually have a list that's like, if your patient isn't responding or getting better, they should be referred to a physician. So if there even were some way to just ensure that, you know, Okay, maybe for low risk things and, but some kind of guide rails to keep these patients from just continuing down pathways where they're, they're not going to get better. And they're potentially going to get worse. I wish that we could figure out some way to work together to be able to make sure patients get the right care. Yeah, absolutely. And, I don't want to pick on the, the nurse we've been talking about because I'll point out, there's an article that I'll link to that was published from KFF Health News, Kaiser Foundation just this January, 2024. For is called the ketamine economy. New mental health clinics are a wild West with few rules. And they point out that there are between 500 to 750 ketamine clinics across the U S and that they're bringing in 3 billion per year estimated that that's going to rise to almost 7 billion by 2030. And I do think that they don't say in here, but I suspect that there are a lot more non physicians running these clinics than there are physicians. Yeah, I mean, I would agree. I think it is from what I've seen. It's the Wild West when it comes to the ketamine clinics. And because it's complicated, like you really do need both a psychiatrist and either an anesthesiologist or an emergency medicine physician collaborating in these clinics, you know, someone who has that psychiatric training to really evaluate and evaluate. Determine if they truly are a good candidate and to assess benefit and again, when to stop doing treatments, but you also need either someone who's very familiar with managing an airway and using ketamine, which psychiatrists are not and so, you know, that's, and I, you know, I've gotten to again, several talks by like Mayo, and that's really what they recommend is you need that collaboration. And so, you know, You know, ketamine clinics are great in like hospital settings because you, it's very easy to have that collaboration, but these just standalone ketamine clinics, that's often not what's happening. So what it sounds like you're saying is that you as a psychiatrist would not probably feel super comfortable with just bringing a patient into your office and putting an IV in and giving them ketamine yourself. No, I would not. Because what, what would you be afraid of? We were never trained to manage airways. You know, if there was a hypertensive emergency, that's not in my scope of practice. I can't even imagine what my malpractice would think about me doing that. So That's so interesting because you're, you know, you're a physician. You went to, you did the whole scope of training and yet you are You are nervous, rightfully so, because you know that potentially there could be life threatening emergencies during this infusion, and you wouldn't have the ability to manage that necessarily. No. You know, most psychiatrists feel that way. And so, you know, there are A few fellowships that are popping up and called interventional psychiatry where people are learning about ketamine and ECT and TMS and getting trained, but, you know, that shows because the psychiatrist recognize that they need more training to sufficiently do these things. I think it's when you don't know the things that can go wrong. You've never seen anything really scary and you can't even begin to imagine it that maybe that's when people have the hubris to think that they can offer these types of treatments because those of us like you who know the things that can go wrong are rightfully not going to do that. Right. Exactly. Wow. Well, thank you so much for sharing your insights. Is there anything else that you'd like to share with our audience? Yeah, I mean, one thing we just didn't touch on, you know, with the ketamine is, the risk of addiction, which is significant. And so, what my concern is, and I think there's studies that are real life examples that are showing this is when people get IV ketamine. Again, they know that. The long term effects aren't there. And who wants to keep going in to get IV ketamine? So they turn to oral ketamine. And, and that is where then people really have that risk of abuse and addiction. And, in October of 2023, the FDA put out a warning saying, stop doing oral compounded ketamine. There's lots of risks associated with this. And so, to me, that's another concern is if you're just providing anybody IV ketamine, are we increasing the risk that they're going to, at some point, then use oral ketamine and have an increased risk of abuse and addiction, which has significant effects, when someone gets addicted to ketamine. They can have bladder toxicity, meaning like, you know, there's reports on Reddit of people who are addicted to ketamine, who in their 30s have to use a catheter now or adult diapers or have painful hematuria. Then there was also a report where, many people are going to this particular clinic and they asked the doctor, do you think there's a huge risk of addiction in your patients with this? No, no, no. It's very, very rare. Well, then they investigated and talked to the patient and there were several patients who had addiction issues who had not disclosed that to their doctor. And we're having these bladder toxicity issues and wouldn't tell the doctor because they didn't want their ketamine taken away. So I worry a lot if we're just providing IV ketamine to anybody who wants it, that then that's a segue to. Transitioning to oral ketamine and having addiction and abuse issues. Wow. I didn't even know or think about that, but that's really important. And of course, all we've probably all heard news about Matthew Perry. We don't know all the details, but we do know that ketamine may have been involved in his death and no one's quite sure where he was getting. And I'm sure we'll learn more in the future. Exactly. Yeah. Yeah. I know they saw they were going to press charges against whoever's supplying their oral ketamine. It can be a significant problem. Wow. That is something that I didn't know about. So thank you so much for sharing that. Yeah. Well, thank you so much, Dr. Kise, I really enjoyed talking with you. Thanks so much for listening. I hope you have enjoyed this episode. And if you'd like to learn more, then I encourage you to get the books. Patients at risk, the rise of the nurse practitioner and physician assistant in healthcare and the follow-up book, imposter doctors, patients at risk, you can get those at Amazon or at barnesandnoble.com. If you're a physician and you'd like to learn more about getting involved in our mission, which is advocating for physician led care for all patients. And truth and transparency among healthcare practitioners. Please join our group. It's called physicians for patient protection. You can learn more at our website physiciansforpatientprotection.org. Thanks again, and we'll see you on the next podcast.