CTP Kap at Home Lozenge Method
CLICK HERE to download a .docx file of the letter below
We pioneered the lozenge method some 4 years ago and have been performing supervised at-home trance sessions with hundreds of patients and thousands of sessions with no adversity. Our Ketamine Training Center has trained now some 310 practitioners in Canada and across the US and we would have continued in Europe and the US in April save for this awful interruption. In this time of quarantine, we present our work to you for your potential use with patients who cannot come to the office for your and their safety.
As per our ‘Letter to Patients’, we will continue to provide in-office sessions to those in crisis who are already under our care, including IM sessions if so determined to be necessary. This requires our utilizing stringent methods to prevent contagion. We would rather see our patients then send them to ERs and expose them to corona plague.
We provide here the essence of preparing patients for at-home sessions and their conduct. We are available for consultation if you wish. Our Ketamine Psychotherapy Associates is also a resource with about 50 members now across the US in KAP practices.
- We began with troches and then pioneered the development of rapid dissolving lozenges in association with Peter Koshland and his Koshland Pharmacy. He has been generous in sharing his formulation to enable other formulating pharmacies to duplicate this method—formula attached at the conclusion of this note.
- We developed the RDTs to enable rapid dissolution and presentation of the full dose of ketamine to the buccal mucosa in one to two minutes versus the five or more minutes needed for the troche’s dissolution. This enables more rapid onset and greater absorption in the time patients are holding the saliva contents—the most unpleasant and difficult part of the sublingual experience.
- We use 50 and 100mg RDTs. The general dosage range is 100-400mg and this depends on the patient’s sensitivity, and factors relating to absorption. Weight is not a significant variable. Occasionally, a single 100mg lozenge in a sensitive individual will generate a profound experience. The most common range is 150-300mg. Absorption is variable and difficult to estimate as a percentage, perhaps 15-30% of the dose.
- We prescribe only 20 RDTs at a time with a refill request needing to be made to our practitioners. There has been no abuse as the RDTs are difficult and unpleasant to use in bulk, an occasional patient checking out the effect of 5 at once. We control the frequency of refills.
- Our patients begin their experience in-office with a full KAP experience in a dosage escalation format, generally beginning with a 100mg RDT. The holding of the contents in the mouth is at first unpleasant–and patients do get used to it with repetition. We provide an Invocation which is personal in nature, directed at core conflicts, and relaxing patients into the experience. We follow this with ambient music and meditative suggestions. We remind patients to ‘swish’ contents about so as to make maximal contact with the mucosal surfaces.
- Holding—not swallowing—is key: 12-15 minutes. After swallowing we do guided breath meditation. At home, patients tend to keep contents present even longer to extract more ketamine. Sitting forward helps to avoid swallowing. If swallowing is premature, we add an additional RDT.
- Onset tends to begin at 9 minutes with most patients achieving full trance effect at 20 minutes. At that time, we assess depth of trance and make a decision to stay with the first RDT, or add one or two more. Timing is designed to maximize duration and effect in accord with ketamine’s rapid metabolism. Adding RDTs requires another hold of 12-15 minutes. In subsequent office or at home sessions, the dose we have determined is given at one time: 1, 2, or 3 lozenges held for 12-15 minutes. The schema above is a dosage determination guide–and what is reflected to the patient and to us is their sensitivity to ketamine.
- The principle side effect is nausea –with about 5% of patients vomiting. For some this means ketamine is not an option because of the severity of the nausea. The sublingual method adds a gastric nausea effect to what is generally a CNS induced nausea. We urge patients who are sensitive to spit out the contents after the absorption period is concluded rather than swallow. The higher the dosage, the greater the probability of nausea on swallowing.
- We use ondansetron 8mg RDTs either in advance if we know nausea is an issue, or as a rescue—often ineffective. We will use up to 3 ondansetron RDTs—and this without SEs. We may start ondansetron the night before or in the morning the day of a session. Injectable ondansetron has no advantage in our experience. We have used scopolamine patches with no greater benefit. We have on hand olanzapine 5 mg RDTs but have not used this to date—though it is widely used in ERs. Overall, our effort is to maximize the ketamine experience and sedation does not help.
- Therapist presence during sessions as we train our patients in our method is a necessity; as is contact when patients do at home sessions. Integration is a catchword with various meanings and interpretations and will not be presented here due to the volume of considerations and possibilities.
- We have patients journal and email us. We provide playlists—now available on our websites: Ketamine Research Foundation, etc. We give an instruction sheet for at-home use; and recommend eyeshades—Mindfolds to be specific—and headphones. We suggest having another person present nearby certainly for first at-home sessions.
- There is more, much more. But this is the basic and the rest is available with consultation.
- With established patients, with known ketamine sensitivity—IV, IM, Spravato-switching to at-home sessions following this method in your own way could be easy and satisfying as a therapeutic strategy to both you and your patients. Communication is of the essence and zoom and other aps are essential for this.
- Conducting the dosage escalation strategy described herein is more difficult and time-consuming and requires a thorough Intake and relationship building with your clients prior to initiating KAP. A KAP Trance session will take 2-3 hours and that is a lot of zooming. Having a therapy team on-line may be very beneficial to both you and your patients. In this time, we may well need to resort to this.
- We—and you—need to attend to the full spectrum of emotional and spiritual suffering. Ketamine is not a stand-alone medicine. We urge a full psychiatric review including contact with collaterals. KAP is a psychedelic psychotherapy practice using all of our available skills that are culled from all of our available training and experience. There are no ‘garden variety’ depressions and no ‘garden variety’ humans. Complexity is constant and most interesting and our humility in all of this is essential. As is our relying on each other as therapists and people workers.
- Consider support to those actually suffering with the illness and to their caregivers. These are truly anxious and difficult times and community building, friendships and collaborations are essential to getting through it. We have the KAP potential for helping many people and I hope we shall take advantage of its possibilities.
–respectfully submitted by Phil Wolfson MD 3/25/20