“The dose makes the poison,” as any toxicology student knows, describes the dangerously disparate effects that therapeutic compounds can have on health depending on the amount.
With many drugs — whether fentanyl, Tylenol or over-the-counter laxatives — the line between healing and harm is sometimes measured in milligrams. This principle is especially important when it comes to ketamine, the powerful anesthetic and party drug that has become increasingly popular as a mental health treatment.
Depending on the dose, ketamine in its powdered form can make a person feel pleasantly introspective, uncomfortably immobilized — or sedated enough to undergo surgery and not remember a thing.
The drug has been implicated in the case of a former Cornell University student who claimed in a lawsuit that she was raped by seven fraternity brothers during an hourslong attack. The student, identified in the lawsuit as Jane Doe, said that she was already drunk when she arrived at the fraternity house and that the men pressured her to snort ketamine.
She told the police it was her first time trying the drug.
“Whenever the ketamine went down, I would say, is when things really start becoming a problem,” she later told university investigators.
The men have denied wrongdoing, and no criminal charges have been filed against any of them.
For many health care providers, the case has drawn unflattering attention to a pharmaceutical workhorse that is valued for its efficacy, safety and predictability — when administered in a medical setting.
“Ketamine is one of those really interesting unicorns with a huge range of experiences and effects depending on the dose, the route of administration, the genetics of the patient and prior exposure,” said Dr. Brigitte Gordon, the clinical director at Journey Clinical, a chain of ketamine clinics.
A short-acting anesthetic, ketamine can have hallucinogenic effects at certain doses, and it can make users feel detached from pain and their surroundings.
Although considered safe when given in clinical settings, with chronic use it can cause serious bladder damage, cognitive impairment and a strong psychological dependency.
Mixing ketamine with alcohol or other drugs is especially dangerous, experts say. Both alcohol and ketamine depress the central nervous system. Together they can dangerously slow breathing, and cause cardiac problems and impaired cognition and coordination.
It is not clear how much ketamine Jane Doe snorted over the course of the evening, but she told investigators she did so repeatedly, in part to numb the anguish she said she was experiencing.
“I had become extremely uncomfortable with how this night was turning out, so my thought was, if I do ketamine again, maybe I will pass out,” she told investigators. “My thought was that if I passed out and these men had sex with me, then they could be charged with rape.”
The recreational use of ketamine has exploded in recent years, fueled in part by its easy availability via prescription and the therapeutic veneer associated with its use as an antidepressant.
In clinical settings, the drug is typically delivered intravenously or through injection, with doses ranging from 30 to 150 milligrams depending on a patient’s weight and previous use.
When given intravenously, the drug is released slowly, over the course of 40 or 60 minutes, and the patient’s vital signs are monitored throughout the session.
A modest, so-called psycholytic dose can prompt a dreamlike state and a shift in self-awareness, but patients are still conscious and able to speak.
Recreational users prefer the powdered form, because “giving yourself injections at a party is not very sexy,” said Dr. Steven Radowitz, the chief medical officer at Nushama, a chain of ketamine clinics.
Compared with its liquid form, powdered ketamine is far more portable. It is also highly concentrated. The amounts consumed in recreational settings can vary wildly, in part because the drug is seldom measured out with precision.
Dr. Sandhya Prashad, president of the American Society of Ketamine Physicians, Psychotherapists and Practitioners, said that recreational users sometimes snort more than a 1,000 milligrams at once — 10 times more than the dose used to treat depression.
“For someone who has never used ketamine before, a fairly small dose could send them into a K-hole,” she said, referring to the state of disassociation that leaves users nearly catatonic — awake but disconnected.
A K-hole seldom lasts for more than 45 minutes, but it leaves users highly vulnerable to abuse.
Given its numbing effects, ketamine might not seem to be a drug of choice for sexual activity. But Dr. Dave Rabin, a psychiatrist in New York who specializes in ketamine-assisted therapy, compared the drug’s dissociative effects with those of to alcohol, which is often used to ease anxiety over intimacy.
Even then, he said, the dose matters. “Too much ketamine and a person’s judgment is impaired and they don’t have the agency to assert themselves,” he said.
Still, Dr. Rabin and other practitioners expressed concern that negative attention about ketamine could overshadow its therapeutic benefits. He said ketamine was unique as a fast-acting antidepressant that can interrupt suicidal thoughts and behavior with a single dose.
“Ketamine has tremendous utility when used and dosed properly,” he added. “As caregivers, the last thing we want is for powerful therapeutic tools like ketamine to to be classified as drugs of abuse.”
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