Ketamine has been used extensively in emergency departments, operating rooms, and in military conflicts with a very safe track record. Ketamine causes very little depression of a patient’s respiratory drive, which is why is has been attractive as an anesthetic agent in the military and in developing countries. Outpatient infusions at Klarisana are fundamentally different than the use of ketamine in an ER or operating room. The doses of ketamine are much lower than those used in a hospital setting. Patients are still conversant and very aware during the infusions. Additionally, there is no “bolus” of ketamine. We administer ketamine as a slow steady drip; usually over an hour but sometimes longer for certain pain conditions. Patients are monitored with continuous cardiac monitoring, pulse oxygen monitoring, and monitoring of the patient’s blood pressure at regular intervals. Patients are under continuous visual observation by clinic staff.
What To Expect
Most of the infusions at Klarisana centers are overseen by our nurse practitioners or physician assistants. We feel that Advanced Practice Practitioners (APP’s) are the ideal providers to administer ketamine infusions. Our goal at Klarisana is to make ketamine therapy accessible to the largest number of people possible in an economically feasible way. Our founder and Medical Director, Dr. Bonnett, has served on several combat tours in the Middle East. He developed a great respect and admiration for the APP’s who were the sole providers on Forward Operating Bases (FOB’s). The United States Military entrusts the care of it’s soldiers in forward deployed areas to APP’s and so does Klarisana. There is a rapidly growing trend nationwide to recognize the incredibly valuable role that APP’s play in many aspects of healthcare. Our Nurse Practitioners and Physician Assistants have many years of clinical…and just as importantly…life experience. We feel that Nurse Practitioners and Physician Assistants have a very important role to play in every aspect of American healthcare and will play a vital role in solving the problem of access to healthcare in the United States.
Running through the core of Klarisana is the concept of Crew Resource Management. This is an operational mindset that we have adopted from the aviation industry…and more specifically from Dr. Bonnett’s experience as a flight surgeon in Army Aviation. One of the main principles of CRM is that there is “no rank in the cockpit.” Any member of the Klarisana staff is empowered to call a halt to an infusion or the mixing of medications if they witness any unsafe act. All infusion bags are mixed with two staff members present and every single dose is confirmed by two people. Additionally, even though ketamine has a very reassuring safety profile, all patients are placed on cardiac monitoring and pulse oxygenation monitoring. Klarisana sets the standard for patient safety.
Many clinics try to save money by administering infusions to multiple people in the same room. They cut costs in this way because they can use less space and less staff. Another common strategy to save money is to have no one in the room…patients infuse by themselves. At Klarisana, each patient receives an infusion in a private room with one-to-one observation by Klarisana staff. We believe that the experience and the environment in which a patient receives their infusion plays a big part in how effective the treatment will be. Have a ketamine journey with several other patients in the same room would be very counterproductive. Having a ketamine infusion all by yourself with no one in the room can also be uncomfortable and counterproductive.
Generally not. Ketamine definitely elicits changes in perception of sights, sounds, time, and space. We find that carefully explaining what to expect ahead of time alleviates most of the anxiety that might otherwise occur. Also, by creating a private, safe, comfortable space with one-to one observation by clinic staff this also alleviates any anxiety about the experience. The vast majority of our patients actually report that it is a very positive, relaxing, and enlightening experience. Some of our patients have received infusions at other centers which do group infusions and report that this can be a very counterproductive experience.
Our rooms are decorated so that they are relaxing, tranquil, and peaceful. Patients receive their infusions in privacy with one of our Medics present during the whole infusion. The provider performs an initial evaluation and physical exam, he/she steps out of the room and the infusion is started. Most mental health infusions last for one hour. Some pain management infusions last two hours. Our rooms have TV’s where patients may watch videos of nature scenes, aquatic scapes, or they may bring in their own DVD or Google Chrome or Amazon Firestick. We strive to minimize distractions and interruptions during the infusion process. Our goal is to make the session a fluid and peaceful experience
One would think that “sounds of the rainforest” would be ideal. What we have found however is that it is a very personal choice and spans a wide range of musical genres. Our patients listen to all sorts of music..the genre is not as important as the meaning the music has for you. The important thing is that the music selection puts you in a good “headspace.” Our patients listen to everything from John Coltrane, to Nine Inch Nails.
You will not stop breathing. Ketamine has a very reassuring safety profile. There have been case reports of brief periods of apnea (no breathing) with a rapid push of a large amount of ketamine such as might be used to induce anesthesia in an operating room. With a low dose drip at Klarisana there is no respiratory depression. Our patients are responsive and able to talk throughout the infusion. The most common side effect is mild nausea in some patients. We do offer anti-nausea medication prior to infusions. We feel that the alterations in perception with ketamine should not be categorized as “side effects.” As we describe elsewhere in the FAQ, they are part of the therapy.
Ketamine is extensively used in emergency medicine and, in fact, is the “go to” medication for procedural sedation in kids. It is routinely used in ER’s across America every day in young children who require sedation for painful procedures such as facial lacerations and reduction of broken bones. We have a number of patients with mental health conditions and chronic pain who are teenagers. That being said when we consider infusion therapy for patients under the age of 18 we require approval of and close cooperation with, the patient’s primary care and mental health provider.
I read an article where a university professor said that ketamine is promising but that it is not ready for prime time. If she is a professor she is not biased, right?
Whenever you hear anyone make a statement for or against the clinical use of ketamine it is very important to assess what their motivation for making that statement is. Ketamine is a real game changer but it is a generic medication. If a company could create a medication similar to ketamine and put it under patent that could make them a tremendous amount of money. Many universities will enter into agreements with private companies to share or sell patents that come out of their research. This can lead to significant revenue for universities. If someone from a university says that we need to hold off on using ketamine until a new version can be developed it is important to ask whether that individual and their institution might stand to gain financially through the development of the new version of ketamine.
Ketamine is approved by the US Food & Drug Administration for use in humans as an anesthetic agent and as an analgesic agent to supplement low-potency medications such as nitrous oxide. The use of ketamine for treatment resistant depression is considered “off-label” by the FDA. Once a drug is approved by the FDA for one indication, then clinicians may use that same medication for other indications if they feel that the evidence supports the practice. Ketamine is off-label because no one has invested the millions of dollars necessary to go through the multi-phase process of getting ketamine “approved” by the FDA for these indications. The fact that ketamine is a generic medication means that it is unlikely that any company or organization will EVER spend the money to get ketamine “FDA approved.” The issue of whether there is good evidence to support the use of ketamine for the indications for which Klarisana is using it is separate from the simple discussion of FDA approval. There are many medications that are prescribed and administered every day that are off-label. For example, Compazine (prochlorperazine) is indicated for nausea but frequently used to treat migraine headaches. A common misconception is that just because a medication is not “FDA Approved” for a certain indication that this means the FDA has prohibited its use for that indication. If the FDA wanted to prevent the use of a medication they would issue a “black box” warning; this is not the case for ketamine.
Like most things in life, there is linear relationship between the money spent and quality received. At Klarisana, we offer very personalized service and treatment in a private and fully monitored setting. In our experience, we believe that the setting and the experience are critical to success. After you contact us, you have a non-pressured discussion with our Patient Care Coordinator. If you are seeing us for a mental health condition, you will then have an intake session with one of our Licensed Professional Counselors (LPC) or Licensed Clinical Social Workers (LCSW). You then have an intake session either by phone or in clinic with one of our Advanced Practice Providers (NP or PA). Once you start your infusion therapy, you will receive your infusions in a private room with one of our Medics in attendance at all times. As one of our patients, we will develop a customized dosing protocol that works for you. If you are seeing us for chronic pain we will also create a custom regimen of adjunctive medications to target other receptors related to the pain pathway (e.g lidocaine, magnesium, etc.). It is not hard to find a center that is cheaper. Keep in mind however that the way in which many centers cut costs is to do two things. First, to put you in a communal room with several other patients where you all get infused together. Receiving an infusion sitting right next to several complete strangers is not only ineffective, we feel it is counterproductive to success with ketamine. Secondly, clinics that offer “discount ketamine” tend to follow a “one size fits all” model of ketamine therapy. Many of these are what we call “Oil Change Clinics” where they follow the (unvalidated) “NIH Protocol” of 0.5 mg of ketamine per kilogram of body weight and administer this over forty minutes. As described elsewhere on this website and FAQ, we feel that this only addresses the biochemical aspect of ketamine therapy but not the experiential. There is no effort on the part of “discount” clinics to maximize the experiential aspect of ketamine therapy.
Some critics on the internet will smugly refer to ketamine as a “horse tranquilizer.” Ketamine is, in fact, used extensively in both human and veterinary medicine. The reason that veterinarians use ketamine is because it generally does not suppress respirations. Said a different way, it does not make the patient stop breathing. This important quality of ketamine makes it not only desirable in veterinary medicine but it makes it very desirable in human medicine…particularly in pediatrics. Ketamine is the “go-to” medication for the sedation of children in emergency departments across the United States. In the same way, if a veterinarian has to do a procedure on a large animal like a horse, they would prefer to use a sedative agent that does not make the animal stop breathing. If a horse stops breathing, this poses some huge logistical challenges for the veterinarian. Horses and humans share a great deal of the same anatomy and physiology. The fact that a pharmaceutical agent can be useful in both the human and veterinary medicine does not represent any kind of earth-shattering revelation. Penicillin is also a medication used extensively in human and veterinary medicine. When critics try to label ketamine as a “horse tranquilizer” in social media outlets, one should recognize this as the uninformed and sophomorish comment that it is.
Klarisana is not a clinic…it’s an idea. It is the idea that we can help people who are in a dark season of life, realign themselves with the unique mission for which each of them was created. We believe that each person was created for a purpose and has an important mission in this life. Chronic pain, severe depression, post-traumatic stress disorder (PTSD), and other mental health conditions derail a person’s ability to carry out their mission. We offer ketamine infusion therapy, which represents a totally different paradigm in treatment. Klarisana was born out of a response to the alarming veteran suicide rate in the United States. Our founder, Dr. Carl J. Bonnett, MD is a twenty-year veteran of the Army National Guard with four overseas deployments to the Middle East. He has a great deal of experience with PTSD and the toll that it takes on veterans and their families. As the lives lost to suicide grew higher, he became more and more frustrated with the limited options available to give patients with severe PTSD and depression any meaningful relief. As more and more research articles demonstrating that ketamine could be a powerful treatment for depression, PTSD, and chronic pain were published, Dr. Bonnett recognized how important it was to make ketamine therapy available to patients. In response to this, he opened the first Klarisana center in San Antonio, Texas. Klarisana quickly expanded beyond this initial vision and now provides care to people from all walks of life and from all backgrounds. Our goal is to make ketamine therapy accessible to the largest number of people possible so that we can truly “rebuild lives.”
How did you come up with the idea that the experiential aspect of ketamine is an important part of the therapy?
We were heavily influenced by the work of Dr. Phil Wolfson and Dr. Terry Early. These gentlemen are psychiatrists who have been working clinically with ketamine for a very long time and are real pioneers in the field of outpatient ketamine therapy.
Yes and no. For a procedure to be paid for by insurance there needs to be a Current Procedural Terminology…or “CPT” code assigned to that procedure. When a clinician repairs a laceration with stitches, there is a CPT code assigned to this…”12002.” That CPT code is submitted to the insurance company and they pay the rate that has been determined for that code. When Klarisana administers ketamine for mental health conditions we consider this to be “Psychotropic Infusion Therapy.” When we administer ketamine for chronic pain we consider it to be “Analgesic Infusion Therapy.” The problem is that there is no CPT code for either PIT or AIT. What we have found is that patients can actually receive a higher reimbursement from many insurance companies if they submit for out of network claims than if we are in network. Please feel free to contact us for more information.
Other clinics have trademarked proprietary formulations of ketamine with catchy names. Do they know something that you guys don’t?
No they don’t. At Klarisana we embrace the concept of Evidence Based Medicine (EBM). The foundational principle of EBM is that the evidence for a given treatment and/or procedure is clearly laid out for scrutiny by the medical community. In that way, patients can have a reasonable assurance of safety and effectiveness. In certain circumstances the evidence for a treatment is either anecdotal or otherwise not very robust. In these cases, a patient can at least make an educated decision as to whether the potential benefits outweigh and potential risks. When certain clinicians say they have “special formulations” and “proprietary blends” of ketamine and other medications this is disingenuous and does not support the idea of true informed consent for the patient. At Klarisana, we will let you know our dosing protocols…we will let you know every medication we plan to administer…and we will share with you what the evidence is for everything we do. If the evidence is purely anecdotal, then we will be very transparent with this. We are currently engaged in research that has been approved by Integreview, an Institutional Review Board in Austin, Texas. We plan to publish our results for review by the medical community. For more information please see Dr. Bonnett’s video entitled “Ketamine Therapy – Is there a Secret Sauce?”
Patients eighteen years of age and older do not require a referral. Prospective patients will be scheduled with a psychological screening by one of our Licensed Professional Counselors (LPC) or Licensed Clinical Social Workers (LCSW). Subsequently, patients will have an intake session with one of our Advanced Practice Providers. For patients younger than 18 years of age, we do require communication with, and approval of, the patient’s primary care provider.
Ketamine therapy is a rather unique entity because it represents a fundamentally different use of a time-tested medication. Ketamine has traditionally been used as an anesthetic by emergency physicians and anesthesiologists. The way in which ketamine is currently being offered at centers like Klarisana represents an entirely different paradigm. At Klarisana, we feel that ketamine for mental health and chronic pain conditions should be more accurately described as Ketamine for Non-Anesthetic Indications (KNAI). In light of this, one will see clinics that come from several different specialties. There are many clinics that are operated by either emergency physicians or anesthesiologists; which makes sense given the historical familiarity with ketamine by these disciplines. One will also see clinics that are operated by psychiatrists, which is understandable given the important role that ketamine can play in the treatment of mental health disorders. We feel that the important thing is not so much the specialty of the clinician’s who opened the clinic but rather the way in which they have structured their practice and the intent behind it. Ketamine is a relatively safe medication but still needs to be treated with respect. The important thing is that the clinicians who operate the clinic have ensured that they place a top priority on safety and have taken the time to undergo any additional training as necessary to administer ketamine infusion therapy. The founder of Klarisana is Dr. Carl J. Bonnett, MD who is Board Certified by the American Board of Emergency Medicine and has extensive clinical experience with ketamine.
This issue can be very challenging for patients because the field of ketamine infusion therapy is relatively new and has not been well defined. Many interested parties have recognized that ketamine represents a potential “game changer” for mental health and for the management of chronic pain. Some clinicians see this as an amazing opportunity to change the lives of countless people. Some, unfortunately, see this as a way to make more money. A quick search of the internet will show that some groups offer training programs to teach clinicians how to set up ketamine clinics in order to make extra money from this “amazing revenue stream.” Against this backdrop Dr. Bonnett was one of the founding members of the American Society of Ketamine Physicians (ASKP.org) which is the first professional society of ketamine providers. ASKP was formed by the leaders in the field of ketamine therapy to try and establish some basic standards and best practices for ketamine therapy. We would recommend you chose a center that is a member of ASKP.
No. When we opened in 2015, Dr. Bonnett made the conscious decision to not register for OBA because he felt strongly that what Klarisana offers is not OBA…it is Ketamine for Non-Anesthetic Indications (KNAI); a fundamentally different clinical entity. In 2017 a one of our competitors filed a complaint with the Texas Medical Board against Klarisana and several other clinics in Texas that offer ketamine infusion therapy and haven’t obtained an OBA certificate. Klarisana and the other clinicians in Texas presented their argument to the TMB as to why this clinical use of ketamine should be considered KNAI and not OBA. The TMB agreed with us and the complaint was quickly dismissed. We applaud the forward thinking of the TMB and are pleased that their decision set an important precedent for the clinical use of outpatient ketamine in the United States.
We are a healthcare organization that works very hard to perfect the art of administering ketamine for mental health conditions and chronic pain. We are not a primary provider of psychiatric services nor do we wish to be. Instead we work closely with psychiatrists and psychologists in our communities to partner with them to offer a valuable treatment option to their patients. If a patient presents to Klarisana who doesn’t have a psychiatrist or psychologist, we work hard to set them up with one who has an understanding of ketamine therapy. The environment in which ketamine is administered and the experience that a patient has is absolutely vital to increasing a patient’s chance of success. This is not the kind of therapy that lends itself to just being an “add-on” revenue stream for a clinic has an “extra office.” We do it right and we do it effectively. We feel that the role of the psychiatrist in a patient’s care is vital but there is nothing to be gained from having them present at the actual infusion. Far from trying to replace or compete with local psychiatrists, we strive to be an effective resource that they can have at their disposal to treat their patients.
No. We focus on providing outstanding clinical care. Most of our “secrets” are laid out on this document, our web page, or on our YouTube channel. We view ketamine as an incredibly valuable treatment option that should be performed at centers who are very serious about its use and have a mission to serve humanity. If you are looking for some place to teach you how to “get rich quick,” add another revenue stream, or find a way to “quit your J.O.B.” we have nothing to offer you in this regard.
I read some articles that marijuana and LSD can be helpful for treating depression. Would it be a good idea for me to do one or both of these before my infusion and not tell you about it?
No, this would not be a good idea. While there is literature out there suggesting that marijuana, LSD, and psilocybin (“Magic Mushrooms”) may have a role to play in the treatment of depression and/or PTSD, combining them with ketamine…especially if you do not tell our clinical staff…can lead to a very unpredictable reaction. This will most likely be a very counterproductive experience for you.
My boyfriend is an ER nurse and he has administered ketamine many times. Would it be helpful if I brought him along to give you some suggestions regarding dosing?
No. The use of ketamine in this setting is very different from the way it is traditionally used in emergency departments and operating rooms. For our mental health patients, we are trying to achieve what we call the Psychotropic Therapeutic Response (PTR). This is a very different end state than what is being used in traditional settings. We have a great deal of experience at dialing in on the correct dose through careful interviewing of the patient. We are happy to explain the process to your loved one who may work in the medical field but we would respectfully request that they refrain from demanding a particular dose or rate of delivery as this can be counterproductive to your treatment.