Relapse on ketamine followed by severe and prolonged withdrawal: A cautionary case and review of potential medical therapies

Ketamine is a non-competitive N-methyl-D-aspartate receptor antagonist used medically as a dissociative anesthetic. It has been used recreationally since the 1970s. In recent years, ketamine has been investigated in the treatment of depression and chronic pain. Given ketamine’s addictive potential, increasing medical use poses the risk of misuse or addictive use following medical exposure. This risk may be higher in patients with co-occurring substance use disorders (SUD). We present the case of a patient with opioid use disorder well-controlled on buprenorphine who was exposed to ketamine in the emergency department (ED), then relapsed by misusing ketamine. He procured it from the darknet to “self-medicate his depression.” After using heavily for 15 days, he experienced debilitating withdrawal syndrome requiring intensive care unit admission. Ketamine use should be in the differential of any young patient who presents to the ED with agitation and visual hallucinations or nystagmus. Moreover, the benefits of therapeutic ketamine use should be weighed carefully against the risk of misuse or addictive use. In cases where ketamine use is absolutely necessary for high-risk patients, we recommend that dosing be limited to the sub-dissociative range (0.2-0.5 mg/kg). We also recommend the use of a slow infusion rather than bolus. For patients with ketamine withdrawal, benzodiazepines and/or anti-glutamatergic anticonvulsants may be helpful to alleviate symptoms. Journal of Nature and Science (JNSCI), 3(10):e450, 2017