The New York Times came out with a report a few days
ago describing potential problems that presidential advisor Elon Musk was
having with substances (1). The report
included concerns of other observers and his self-report of patterns of use of
stimulants, a sedative hypnotic (zolpidem), psychedelic mushrooms, an unknown
weight loss drug, and ketamine. He
described bladder complications of ketamine, that do not typically occur with
supervised medical use.
The NYT report also includes concerns about erratic behavior
by some high-profile individuals and some general concerns about drug use.
There are quotes where Musk acknowledges recreational drug use, using ketamine
at a frequency of every 2 weeks, and denouncing “traditional therapy” for
depression – but it is never clear whether the ketamine is prescribed and
supervised by any physician. He is described as having a history of “grandiose
statements and a mercurial personality” but some have observed further
changes. All of this occurs on a
backdrop of relationship conflicts and a recent goal of maximizing childbirths
in the US.
My previously stated adherence to the Goldwater Rule –
precludes me from making any armchair diagnoses based on a newspaper article. But I think it does provide an opportunity
for education and ties with some of my previous posts. On the ketamine issues –
I reviewed Rasmussen’s
book on ketamine and posted a review of it on Amazon.
In the book (p. 45-55) he describes 3
famous “ketamine celebrities” and likens them to modern “influencers”. All
three were interested in the altered states induced by the drug. All three were active from the 1970s to
1990s. One died by drowning while under
the influence of ketamine and another had several close calls with drowning. The third person may have taken a significant
amount of ketamine and wandered into the woods where she died of exposure
(although there is an alternate theory of homicide). In all three cases, these influencers
idealized the psychedelic effects of ketamine.
All three had uncontrolled use of ketamine, but only one acknowledged an
addiction and warned of that danger. One
of them injected ketamine every hour around the clock for 3 weeks or a total of
500 injections.
My professional experience with ketamine and the related compound
phencyclidine or PCP came at two points in my career. Initially during my tenure as an acute care
inpatient psychiatrist in the late 1980s and early 1990s – I would see people
who were acutely psychotic from the effects. The reason why they were
transferred to my unit rather than being detoxed in the emergency department was
severe agitation, psychosis, and in some cases self-injury. This represented an acute intoxication delirium
and it resolved with symptomatic care and detoxification. The second point was during my employment at
a large substance use treatment center. Toward
the latter half of that employment ketamine was heavily hyped in the press. There were typically stories about how club
drugs were now psychiatric drugs. I
would see people who were using excessive amounts of ketamine often rationalized
as a psychiatric treatment or a treatment for chronic pain. Some were using unusual
forms of the drug like tablets. Oral
ketamine has a very low bioavailability.
Others were using preparations formulated for sublingual use or the or
more typical use by insufflation or inhalation.
I got used to seeing people tell me that many of the substances they
were using were for a psychiatric treatment even though they had never been
seen or evaluated for a mental health problem.
Supervised medical use of ketamine is necessary because of
two risks – hypertension and the neuropsychiatric effects most notably the
K-Hole experience. During that episode
of extreme dissociation and delirium – a person has extreme detachment. Some people feel like it is a near death
experience and they are unable to respond to the environment. In a semi phenomenological study of infrequent,
frequent, and former users (3) – more specifically describe the disliked
effects as cognitive disorganization, paranoia, dissociation,
body/sensation distortion, auditory and visual hallucinations, loss of control,
depression, introversion, nausea, vomiting, and restlessness. The subjects who
like the experience basically endorsed similar experiences, but felt more relaxed,
social and sociable and did not have any of the physical side effects. Half of
the frequent users sought medical attention for stomach pain or “K-cramps (30%)
and bladder complications (20%). Half of
the frequent users also reported a decline in mental health. The authors also expressed a concern that
there was a signal for compulsive use in their survey question 80% reported
using whatever ketamine they had on hand until it was gone rather than saving
some for future administration.
As a clinical psychiatrist seeing people who may be using
multiple drugs and are often not using the drugs they think they are – the two
long term consequences I have seen are severe anxiety and panic attacks and
hallucinogen persisting perceptual disorder (HPPD). The HPPD is technically the result of taking
classical psychedelics, but many of these people will also be taking drugs that
they think may approximate those effects like ketamine. Many people compulsively take ketamine and/or
stimulants while taking other hallucinogens (Mushrooms or LSD).
I have included several references on the bladder complications
of ketamine (4-9). Most of them are
available online. In trying to determine
the bladder toxic dose of ketamine – the closest I could come was reference 9
at 3 grams/month to 3 grams per week. Estimates like this assume that the drug
ingested is pure pharmaceutical grade ketamine – a likely invalid assumption. I
have attended numerous conferences on ketamine infusions administered under
medical supervision and have never found any descriptions of bladder
complications even though they are listed in the FDA package inserts on
ketamine.
In terms of the self-reinforcing property of ketamine – the question
is the mechanism. Many authors write
that it causes psychological dependence and those properties may depend
on baseline psychological and personality characteristics. There is also the
intensity of the spiritual experience if there is a psychedelic experience. In some studies subjects are asked to rate
that experience in terms of similar experiences in their life and in the case
of psilocybin they rank it in the top 5 most meaningful (58%) or spiritual significant
experiences (67%) in their life (11). Although
ketamine is an N-methyl-D-aspartate receptor (NMDAR) antagonist it also
activates mu opioid receptors and has been suggested as a treatment for opioid
use disorder (12) suggesting another reinforcing mechanism.
Ketamine has several properties outlined so far that
highlight its problems and potentials.
It is hyped as an antidepressant but also a general approach to “well-being.” The influencers of the 1970s emphasized the
spirituality and consciousness expanding potential for the drug and they
experienced uncontrolled use, medical complications, and deaths and near deaths
during periods of intoxication. Even
though many frequent users surveyed required medical help and were concerned about
their mental health – the downsides are never mentioned in the media.
This cultural profile is like drugs that people take as
performance enhancers believing that their subsyndromal symptoms of anxiety,
depression, insomnia, and appetite problems may improve. Beyond that there is an idea that certain drugs may enhance cognition, delay aging, and cause neurobiological changes consistent with both. As I reported earlier
on LSD these effects are unlikely to happen and it becomes a coin toss between
whether you are a person who will value any psychedelic experience you get from
the drug or not.
For the purposes of the NYT article – it is a fair question
to ask if a person making major changes to the federal government affecting millions of people is doing that while using intoxicants and whether that person was screened with the required
drug tests according to their policy.
George
Dawson, MD, DFAPA
1: Grind K, Twohey M,
On the campaign trail, Elon Musk juggled drugs and family drama. New York Times May 30, 2025.
2: Rasmussen KG. Ketamine: The Story of Modern Psychiatry's
Most Fascinating Molecule. Washington
DC. American Psychiatric
Publishing. 2024; 295 pp.
3: Muetzelfeldt L,
Kamboj SK, Rees H, Taylor J, Morgan CJ, Curran HV. Journey through the K-hole:
phenomenological aspects of ketamine use. Drug Alcohol Depend. 2008 Jun
1;95(3):219-29. doi: 10.1016/j.drugalcdep.2008.01.024. Epub 2008 Mar 19. PMID:
18355990.
4: Shahani R,
Streutker C, Dickson B, Stewart RJ. Ketamine-associated ulcerative cystitis: a
new clinical entity. Urology. 2007 May;69(5):810-2. doi:
10.1016/j.urology.2007.01.038. PMID: 17482909.
Original series of 9 daily ketamine users with severe
ulcerative cystitis.
5: Meng E, Wu ST, Cha
TL, Sun GH, Yu DS, Chang SY. A murderer of young bladders: Ketamine-associated
cystitis. Urological Science. 2013 Dec 1;24(4):113-6.
6: Jhang JF, Birder
LA, Kuo HC. Pathophysiology, clinical presentation, and management of
ketamine-induced cystitis. Tzu Chi Medical Journal. 2023 Jul 1;35(3):205-12.
This review suggests that conservative measures such as
medications may be successful if the patient is able to completely discontinue
ketamine. In refractory cases bladder
reconstruction is required. They
describe enterocystoplasty using the ileum to reconstruct the bladder.
7: Chen CL, Wu ST,
Cha TL, Sun GH, Meng E. Molecular pathophysiology and potential therapeutic
strategies of ketamine-related cystitis. Biology. 2022 Mar 24;11(4):502.
Authors suggest 19 possible pathophysiological mechanisms
leading to bladder damage from ketamine and reviewed available treatments
suggested by other case series.
8: Jhang JF, Hsu YH,
Kuo HC. Possible pathophysiology of ketamine‐related cystitis and associated
treatment strategies. International Journal of Urology. 2015 Sep;22(9):816-25.
Authors suggested 7 possible pathophysiological
mechanisms for bladder injury including a pathway to neoplastic change.
9: Chen CH, Lee MH, Chen
YC, Lin MF. Ketamine-snorting associated cystitis. Journal of the Formosan
Medical Association. 2011 Dec 1;110(12):787-91.
Case series of 4 patients using ketamine by insufflation
at a rate of 3 g/week (3 patients) to 3 g/month. All had severe hemorrhagic cystitis. Patients typically present with lower urinary
tract symptoms (LUTS) including urinary frequency, urinary urgency, straining
to urinate, weak stream, and post void leakage. Patients also have bladder pain
and may have gross hematuria. If they
are able to stop using ketamine the symptoms can persist for up to one
year. Urinalysis shows hematuria and
pyuria, with negative cultures for bacteria. Imaging of the bladder can show a
thickened bladder wall with smaller volume. Hydronephrosis and hydroureter can
also be present.
10: Morgan CJ, Curran
HV; Independent Scientific Committee on Drugs. Ketamine use: a review.
Addiction. 2012 Jan;107(1):27-38. doi: 10.1111/j.1360-0443.2011.03576.x. Epub
2011 Jul 22. PMID: 21777321.
11: Yaden DB, Newberg
AB. The Varieties of Spiritual
Experience: 2st Century Research and Perspectives. New York. Oxford University
Press. 2022; p. 353.
12: Levinstein MR,
Michaelides M. Exploring the role of mu opioid receptors in the therapeutic
potential and abuse liability of (S)-ketamine. Neuropsychopharmacology. 2024
Jan;49(1):315-316. doi: 10.1038/s41386-023-01652-x. PMID: 37438422; PMCID:
PMC10700302.
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