Journal Logo

Breaking News

Read breaking news and articles published ahead of print. Tell us what you think and comment on your colleagues’ views about EMN articles.

Monday, January 3, 2022

​Starting a Ketamine Clinic: Another Option for EPs

Starting a Ketamine Clinic: Another Option for EPs

BY SAMUEL KO, MD, MBA

I have been working as an emergency physician for the past decade, but I took a leap four years ago into the world of side gigs by starting a ketamine infusion clinic in Palm Springs, CA.

The seed was planted years ago when I came across an early article about the off-label use of ketamine for depression. (Biol Psychiatry. 2000;47[4]:351.) I was curious and did a deep dive into the research and stayed on top of the latest studies and meta-analyses, which showed continued support for its efficacy in treatment-resistant depression. (J Affect Disord. 2020;277:831.)

I never imagined I would own my own clinic. Surprisingly, it’s one of the best decisions I have made in my career. I was able to transition out of night shifts and holidays. I now decide what time to start and end my clinic hours. Most importantly, my patients get rapid improvement compared with traditional antidepressants that can take months to take effect.

About Depression
Ketamine was invented in 1962 by Calvin Stevens, PhD, while consulting for Parke-Davis Research Laboratory. It was approved by the FDA in 1970 as a dissociative anesthetic agent, and is on the World Health Organization's list of essential medications.

Ketamine is used in the ED for procedural sedation, acute pain control, severe agitation, delayed sequence intubation, and even as a third-line agent for status epilepticus.

Interestingly, research is showing that sub-dissociative ketamine doses infused over 40 minutes can be effective for treatment-resistant depression. Improvement can last days to weeks after one infusion, but benefits seem to accumulate with multiple infusions (typically six infusions over two to three weeks).

It’s not ideal to give multiple treatments for depression in a busy ED, but that can be done in an outpatient clinic. Ketamine infusions are also not routinely covered by insurance, and out-of-pocket-costs can be significant for many patients. Janssen Pharmaceuticals, which is owned by Johnson & Johnson, released intranasal esketamine, which was approved by the FDA in 2019 for depression, and it is reimbursed by insurance companies.

A recently published systematic review and meta-analysis showed that intravenous racemic ketamine is more effective than esketamine for depression. (J Affect Disord. 2021;278:542.) Insurance companies will likely realize that it will save them money in the long run to cover IV ketamine treatments.

Current State of EM
Emergency physicians have always been on the cutting edge of medicine. We are trained in administering ketamine as well as vital sign monitoring and addressing potential side effects. We are also adept at handling any potential acute airway and cardiovascular issues as well as psychiatric emergencies.

I believe ketamine clinics can be an opportunity for emergency physicians who are curious about starting a side gig while taking more control over their future. By collaborating with psychiatrists and other mental health professionals, EPs are uniquely positioned to meet the increased demand from patients suffering from depression. That could also be a solution to the projection that emergency medicine will have an oversupply of 8000 physicians by 2030 (Ann Emerg Med. 2021;78[6]:726; https://bit.ly/3lVrGYu) and concerns about graduating residents being unable to find jobs because of COVID-19. (AAMC. Feb. 25, 2021; https://bit.ly/2P2M3Vz.)

The Downside
Starting a ketamine clinic has challenges. One of the benefits of emergency medicine is being able to clock in and out for shifts and be done. Owning your own medical practice will mean thinking about it all the time. This option is not for those who don’t want to devote extra time to their clinic.

You’ll likely also be criticized by your colleagues who may say that you are profiteering on the backs of suffering patients and peddling snake oil and that you are not a psychiatrist and only they should provide ketamine infusions. They may even accuse you of getting patients addicted to ketamine. And much more.

This venture is definitely not for you if you haven’t yet developed a thick skin in medicine. You’ll also have to get involved in the business aspects of medicine, such as marketing, accounting, and hiring. Some of this can be outsourced, but you’ll need to be willing to learn the basics.

Initial Steps
But a ketamine clinic just might be for you if you are entrepreneurial, proactive, and looking for a change. The first few steps will involve writing a business plan, finding a location, getting business licenses and malpractice insurance, and ordering medications and supplies. It took me about two years before physically opening to learn the nuts and bolts of starting a ketamine clinic. It then took two years after opening to establish a patient base. I continued working part time in the ED while the patient volumes grew at the clinic to keep my finances stable.

None of us is taught how to open up a private practice in medical school or residency, so I had to do a ton of research to launch the clinic. I made a free checklist you can download at www.ketaminestartup.com to get things started if you’re interested.

Dr. Ko is the CEO of a ketamine clinic (www.resetketamine.com) and a creator of an online course on how to start a ketamine clinic. (www.ketaminestartup.com.) Follow him on Twitter @drsamko.