84. A Look Inside Ketamine Clinics (and how to start your own)

An inside look at what it takes to launch a ketamine clinic including: first steps, navigating hurdles, potential pitfalls, which patients benefit from ketamine, and an exhortation about why you should (and shouldn’t) go into this type of business.

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Guest Bio: Dr. Samuel Ko is a Board Certified Emergency Physician and medical director of Reset Ketamine in Palm Springs, California. In addition to his medical practice, Dr. Ko is Co-Creator of an online course – Ketamine StartUp – which teaches other physicians how to start their own ketamine clinic. During his free time, he practices yoga, meditation, reads voraciously, and relaxes with his amazing wife, daughter, and four-legged son. Find Sam on the Insta and Facebook.

Here is the link mentioned in this episode with some ketamine clinic startup SWAG (the ultimate checklist and business plan template) from Sam Ko for Stimulus listeners.

We discuss:

Why Sam started a ketamine clinic [04:45];

Sam has a background in both emergency medicine and business, and he always anticipated a career in healthcare administration. But when it came to choosing a side gig to his clinical career, starting a ketamine clinic was the clear choice. This decision was purpose driven and happened because “the stars aligned”. It came down to his true passion about ketamine as a transformational medicine.

What patients report after awakening from a ketamine procedural sedation in the ED [09:30];

The mindset of the patient prior to receiving ketamine very much influences their experience while sedated. Sam shares the story of a patient who was given ketamine for a shoulder reduction. “He awoke crying, as he felt like he had died. But on awakening had an overwhelming sense of gratitude and love for his wife. It was just a profound experience for him.”

What it takes to open a ketamine clinic [11:45];

Ketamine therapy is very cutting edge and there are not a lot of regulations. Technically, anyone with a DEA and a medical license can start up a clinic, including psychiatrists, family physicians, etc. There are state regulations which determine whether a physician must open the clinic vs. a nurse practitioner.
The minimum space requirement is a room, but ideally you would also have a waiting room, bathroom, and storage area. It can be done inexpensively, or you can go big.
Depending on your geographic location, the initial investment is expected to be ~$50-75k to cover equipment (recliner, infusion pump, vital sign monitoring, other supplies), the build out of the space, malpractice insurance, and hiring staff.

It doesn’t take a lot of space. A waiting room, treatment room, storage, LAVATORY, good to go.

How ketamine is administered [17:30];

In Sam’s clinic, they start with intravenous ketamine. The dose is based upon body weight and most patients start with 6 sessions. The standard dose is 0.5 mg/kg which is slowly infused over a 40 minute period. With subsequent sessions, the dose may be titrated up as tolerated to 1.0-1.5 mg/kg as needed.
By giving ketamine slowly in a subdissociative dose, the goal is for the patient to have a gradual experience: ascend, plateau, and then slowly come back down to normal.
The advantage of giving ketamine IV is that it’s 100% bioavailable (so you can give the minimal effective dose), it can be stopped at any time (the effects will rapidly fade), and the IV line can be used as needed for ondansetron or other medications.
Some patients will transition to sublingual ketamine for home use, prescribed as infrequently as possible and as needed only. Sam is conservative and only prescribes for home use if the patient is responsible, trustworthy, and has had no adverse sequelae after 6 in-clinic sessions.

Adverse events during the infusion are rare [20:55];

Patients are carefully screened prior to infusion and have continuous cardiac monitoring during the session. Sam has administered ketamine ~1000 times and has had to call EMS around 5 times (for instances of a seizure, chest pain, atrial fibrillation, syncope).

What happens when the patient enters the clinic [23:05];

Sam practices measurement-based care, so all patients complete a survey related to their diagnosis which serves to numerically monitor how they’re doing over time.
Then the patient enters the infusion room to measure their weight for dosing calculation and to set their intention for the session. Ketamine creates neuroplasticity via an increase of the brain derived neurotrophic factor (BDNF) – having the patient focus on a goal guides the session.
Next, the patient sits in a comfortable chair that reclines into zero gravity mode. Electrodes, BP cuff, pulse oximeter, eye shades, headphones with appropriate calming playlist are applied and the session begins.
After the 40 min infusion, the patient awakens and recovers for 10-30 min before being asked to rate how strong the effect was from 0-10. The response helps determine the dose for the next session. Then they have a discussion to process what was experienced, create meaning, and to talk about integration. They find one small thing that the patient can do between the sessions, almost like homework (eg. meditate, talk to their therapist, start swimming again).
Patients aren’t sent home until they can walk, drink water, have normal vital signs, and have a safe ride.

Mental preparation prior to the ketamine session [25:50];

For 5 days before each session, the patient prepares with journaling, meditating, exercising, avoiding social media/news, reducing caffeine use, reducing alcohol and marijuana use. The goal is to enter the session with a positive mindset.

The 4 stages of ketamine therapy [28:10];

The preparation
The intention
The experience (letting whatever comes to the surface come up)
The integration

Monitoring the patient during the experience [28:50];

There is quite a bit of variability in the degree of monitoring. Some, like Sam, have continuous monitoring of rhythm and oxygen saturation during the entire session. Others do not.
Sam or his medical assistant are in the room the entire time the patient is sedated.

Liability, price, insurance coverage, and intranasal ketamine [30:10];

5 years ago, when Sam started his clinic, his application for medical malpractice insurance was denied by 7 companies. After speaking for 45 min with a senior underwriter of one company, he was able to advocate for himself and get approval. In addition to malpractice insurance, you need business owner’s insurance and workers’ compensation insurance.
The price per session ranges from $500-$1000, varying by clinic. While ketamine itself is relatively inexpensive, the cost of providing the therapy and running the clinic are costly.
Health insurance companies consider intravenous ketamine to be off-label/experimental use and most are not covering the therapy. But it’s changing. Johnson & Johnson created Esketamine, the S(+) enantiomer of ketamine, which is an intranasal formulation. This became FDA approved in 2019 and insurance companies for the most part cover the $1000/spray cost.
A recent systematic review showed that the IV ketamine is more robust and effective compared to intranasal, so the insurance industry is starting to reconsider coverage. Massachusetts Blue Cross/Blue Shield now covers IV ketamine as well as Esketamine.

Online telemedicine ketamine prescribing and therapy [35:30];

Several companies are offering ketamine therapy (orally). Patients have a virtual appointment with a provider, the medication is mailed to them, and the sessions are monitored virtually.
While Sam believes this is a viable option, he argues that the patient selection has to be rigorous and strict to ensure safety. Oral ketamine has a 20-30% bioavailability, so large doses must be given to have an effect. With no monitoring for complications, there is some risk involved.

What people get wrong when they start a ketamine clinic [40:40];

“For those who are strictly driven by the profits and the cash component, it’s probably not worth it. It’s a lot of work.” Like anything, you have to be mission-driven and be strong on the “why” of what you’re doing.

Indications for ketamine therapy [43:20];

On-label: ketamine was FDA-approved in 1970 for specific use in the operating room for diagnostic procedures and sedation.
Off-label: depression, PTSD, anxiety, OCD, pain syndromes (eg. trigeminal neuralgia, fibromyalgia, complex regional pain syndrome, post herpetic neuralgia)
“Super off-label”: psychospiritual exploration, creativity, tinnitus, Parkinson’s disease
Once something becomes FDA approved for a certain indication, we have the freedom to use it for any purpose felt to be medically necessary. That being said, Sam limits ketamine therapy to indications supported by evidence based medicine and does not accept patients who fall into the “super off-label” category.

Ketamine for neuropathic pain [44:50];

Ketamine is an NMDA receptor antagonist, so for patients with complex neuropathic pain it seems to reset hypersensitized pain receptors by blocking activity of glutamate.
Patients with pain disorders (vs. those with mood disorders) require a higher dose and longer sessions to achieve positive results. For complex regional pains in, the studies are showing the need to do ~4 hour infusions daily for 5 days.

Ketamine vs. antidepressants for mood disorders [49:15];

The STAR*D trial looked at the effectiveness for SSRIs and showed that the rates of depression remission with antidepressants was ~33%.
Ketamine studies (1, 2, 3) have shown effectiveness rates of 60-80%.
The success rate at Sam’s clinic is ~83%, with success defined as ≥50% score reduction on the PTSD score, anxiety score or PHQ-9 score for depression.
Durability after the 6 ketamine initiation sessions is variable. Some need no further treatment, some are non-responders and therefore don’t seek further sessions, and some need maintenance infusions monthly.