What are the treatment options for ketamine (Ketamine) withdrawal?

From the Guidelines

Ketamine withdrawal treatment typically involves supportive care and medications to address specific symptoms, with no specific FDA-approved medication exclusively for ketamine withdrawal. The most recent and highest quality study on the topic is not directly related to ketamine withdrawal, but rather focuses on the use of ketamine as a potential rapid-acting antisuicidal agent 1. However, based on the available evidence, treatment for ketamine withdrawal may involve medications such as:

• Benzodiazepines like diazepam (5-10mg every 6-8 hours as needed) or clonazepam (0.5-1mg twice daily) for anxiety and agitation
• Clonidine (0.1-0.2mg every 6 hours) to manage autonomic symptoms like increased heart rate and blood pressure
• Trazodone (50-100mg at bedtime) or mirtazapine (15-30mg at bedtime) for sleep disturbances
• SSRIs like sertraline (50-200mg daily) or fluoxetine (20-40mg daily) for depression Psychological support is crucial alongside medication management, and treatment should be individualized based on symptom severity and patient history. It's worth noting that ketamine withdrawal is generally less severe than withdrawal from other substances, with symptoms including cravings, anxiety, insomnia, and mood disturbances that typically peak within 24-72 hours and resolve within 1-2 weeks.

Some key points to consider when treating ketamine withdrawal include:

• The importance of a supportive environment, as recommended by the WHO guidelines for managing drug withdrawal 1
• The potential benefits of psychological support, such as cognitive behavioral therapy (CBT), in reducing suicidal ideation and behavior 1
• The need for individualized treatment plans, taking into account the patient's specific symptoms and medical history
• The importance of monitoring for potential complications, such as depression or psychosis, and seeking specialist advice if necessary.

From the FDA Drug Label

DRUG ABUSE AND DEPENDENCE Ketamine has been reported being used as a drug of abuse. Reports suggest that ketamine produces a variety of symptoms including, but not limited to anxiety, dysphoria, disorientation, insomnia, flashbacks, hallucinations, and psychotic episodes. Ketamine dependence and tolerance are possible following prolonged administration. A withdrawal syndrome with psychotic features has been described following discontinuation of long-term ketamine use. The treatment options for ketamine withdrawal are not explicitly stated in the drug label.

• The label describes the symptoms of withdrawal and the potential for dependence and tolerance, but it does not provide guidance on how to manage or treat these symptoms. 2

From the Research

Treatment Options for Ketamine Withdrawal

• Abstinence from ketamine is considered the mainstay of treatment for ketamine withdrawal, as it may reduce the adverse effects of chronic use 3
• Screening and management of depression are recommended for patients with ketamine dependence, as there is a high prevalence of depression in this population, particularly those with higher cravings 4
• Ketamine infusion has been shown to be effective in treating severe ethanol withdrawal, and may also be useful in treating benzodiazepine withdrawal, suggesting its potential as an adjunct medication in the treatment of substance withdrawal 5, 6
• Spontaneous remission of ketamine withdrawal-related depression has been reported, with mood symptoms remitting without medication after 1 month 7
• Patients with greater cravings and severer depression may require a longer duration of withdrawal treatment 4

Considerations for Treatment

• The relationship between craving and negative affect, such as depression and anxiety, should be considered when treating patients with ketamine dependence 4
• The use of ketamine as an adjunct medication in the treatment of substance withdrawal may be associated with reduced gamma-aminobutyric acid agonist requirements, shorter ICU length of stay, and lower likelihood of intubation 6
• Specialized urine drug testing may be required to detect ketamine use, as not all point of care urine drug screens include ketamine 3