Ketamine Assisted Treatment 

When a Slow Taper Isn't the Path

A slow, medically supervised taper is my preferred approach to withdrawal management. There are situations in which that path isn’t viable — patient preference, medical or psychiatric conditions that make a prolonged taper inadvisable, or circumstances that make it unlikely to succeed. There are also people who have already been through a rapid taper and are still managing significant symptoms — sometimes long afterward — and who are not looking to restart the substance and taper slowly. Ketamine is one option that can be useful in either situation.

What Ketamine Is and How It Works

Ketamine is a dissociative anesthetic that acts primarily as an NMDA receptor antagonist, blocking glutamatergic excitatory transmission in the brain. It also has rapid antidepressant and anti-anxiety properties whose precise mechanisms are still being worked out. These properties make it a useful clinical tool in certain situations that arise during the treatment of substance dependence.

Why It Has a Role in Addiction Treatment

Withdrawal from alcohol, benzodiazepines, and many other substances involves a state of glutamatergic hyperexcitability — the excitatory nervous system, no longer held in check by the substance, becomes profoundly overactive. This is the mechanism behind seizures, severe anxiety, and the constellation of symptoms that make withdrawal medically dangerous and subjectively unbearable.

The standard clinical response to this has been benzodiazepines, which work by boosting inhibitory GABA signaling. This is well-founded when the substance being withdrawn from acts directly on GABA receptors — as alcohol and benzodiazepines do. For withdrawal from other substances, the rationale is less clear, since the hyperexcitability is present but the GABA mechanism isn’t the primary issue.

Ketamine addresses the hyperexcitability directly, at the NMDA receptor, regardless of which substance caused it. This makes it applicable across a broader range of withdrawal states than benzodiazepines — not as a fallback when other approaches fail, but as a more precise fit for the underlying mechanism. The practical reason it isn’t a first choice is that it is more involved to administer. When a slow taper isn’t possible, that consideration is outweighed by what ketamine can do that other agents cannot.

Beyond acute withdrawal, ketamine’s antidepressant and anti-anxiety properties can be valuable for symptoms that emerge during treatment and prove resistant to conventional approaches — severe depression, anxiety, or the profound dysphoria that can accompany protracted withdrawal or Post-Acute Withdrawal Syndrome (PAWS) from multiple substance classes. In these situations, carefully administered ketamine can stabilize a person’s clinical picture enough to allow the broader therapeutic work to continue.

How I Use It

I use ketamine selectively, as one tool among several, in situations where the clinical picture calls for it. It is not a standard part of every treatment plan. The decision to use it is made individually, based on the specific withdrawal syndrome, what has and hasn’t responded to other approaches, and the person’s overall situation.

When ketamine is indicated, it is administered under close medical supervision, at carefully controlled doses, and integrated into the broader treatment. It is not a standalone intervention. It creates the conditions for the therapeutic work to proceed — stabilization is a necessary part of treatment, but it is not sufficient on its own. That includes situations where mood symptoms arising during treatment — severe depression or anxiety that hasn’t responded to other approaches — are what’s blocking progress.

Frequently Asked Questions

Q: What does a ketamine session involve?

A: Sessions take place in my office, with me present throughout. They typically run about two hours, sometimes longer. Patients are awake and conversant for the duration — this is not general anesthesia or an unconscious state.

Q: How many sessions are needed?

A: There is no fixed number. Frequency and duration are determined by ongoing clinical assessment — by what the symptoms are doing and how they’re responding. This is worked out as part of the treatment, not decided in advance.

Q: Does ketamine replace the taper, or is it used alongside it?

A: It depends on the clinical situation. In cases where a slow taper isn’t viable or wasn’t taken, ketamine addresses what the nervous system is left with in those circumstances. Where mood symptoms are interfering with an ongoing taper, it may be used alongside it. It is not a substitute for the larger work in either case, and it is not a standalone offering. It is one tool within a larger clinical relationship.

Q: Can ketamine itself become a problem?

A: Ketamine has potential for dependence, particularly with recreational use or outside careful medical supervision. In a supervised clinical context, this is rare — the doses and patterns of use are fundamentally different from those associated with recreational dependence, and it is monitored throughout.

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