Alcohol addiction is deadly, we know this.  It does not just punish the addict, it punishes their family and society.  For those who find sobriety alone or with help from a detox program, staying sober is a lifelong challenge. Relapse occurs when one resumes drinking and is a detrimental problem that deserves more attention. Understanding some basics of alcohol addiction and how to help prevent relapse can be a bit complicated.  The next section on “choice” will summarize an article on the neurobiology of addiction by Xavier Noel [i].  It simplifies some popular thoughts about how and why addiction works in the brain.  Then, we can see how to target effective treatment with ketamine to help prevent relapse.

Is alcoholism a choice?

The impulse/habit system:

How does the compulsion to drink develop?  A part of our brain, called the amygdala-striatum neural complex, motivates us to achieve rewards. This area is driven by dopamine, a naturally produced neurotransmitter in our bodies that has many effects, including feelings of pleasure, or reward. Alcohol, and other addictive drugs, increase overall dopamine levels in our brain. Therefore, a link forms between automatic, repetitive behaviors, such as pouring a drink, and increased dopamine. These actions are saved in our brain as rewarding. And the brain loves rewards.

Increasing dopamine activity also accelerates the change between the first steps of choosing to have a drink and later craving a drink.  New pathways in the brain form with repetitive behavior. Cues and memories in the environment to drink are noticed more quickly, like hearing glasses clink, or walking in the front door after work. These cues drive the compulsion to drink. The brain’s automatic response is to seek this reward, but can’t we control this behavior?

The control/decision making system:

The decision-making part of our brain is found in the prefrontal cortex. It is also known as the “reflective system”, or executive function system, where we can control impulses. This means we can trade short term rewards, like a drink, for possibly greater long-term goals, such as avoiding a DUI charge.  One explanation is that there is a balance between a “cool” and “hot” system that works out how we respond to triggers or cravings.  The “cool” refers to basic working memory and inhibition of impulses.  The “hot” involves numerous emotional responses that are possible. Damage to either of these systems may impair the ability to say “no” to situations, or drugs like alcohol, that can harm us. Either the impulse side or the emotional side wins when we lose a health balance.

When/How impulse overpowers control:

Poor decision making in alcoholics may also be explained by yet another system called the insular cortex. It responds to imbalance in our bodies from things like sleep deprivation, anxiety and stress. These stressors may hijack our impulse/habit system and increase cravings while promoting decisions to seek out alcohol. Repeated cycles of increased cravings can also essentially rewire brain circuits, reinforcing continued destructive behavior.

Addiction as a “Pathology of Choice”

Other studies support that “faulty brain connections related to decision-making can lead to addictive behaviors and relapse.” [ii]  There is a definite shift from blaming addiction on cravings to finding abnormalities in decision making areas of the brain. Thus, the brain is not able to make the right decisions to ignore the craving.

NMDA receptors are at fault too?

Family history of alcoholism is a risk factor for developing alcohol addiction. A study by Petrakis et al showed one answer may lie in the NMDA (N-Methyl-D-Aspartate) receptor, which is vital to the glutamate system in the brain.  Alcohol alters this receptor’s function, but if the receptor is not normal, that person may be more susceptible to alcohol abuse.[iii]

How can ketamine help?

Ketamine can play a key role in preventing relapse in those who have either completed a detoxification program or managed to stop themselves.

Over-write memories that drive addiction

It is possible a rewarding memory of taking a drink, for example, can be triggered repeatedly by seeing a glass of beer, going to a restaurant, or maybe returning home from work.  These triggers lead to the urge to drink.  Ravi Das from University College London explains why people often quit but return to drinking. “The main problem is the really high relapse rate after treatment,” said Das. “People can successfully quit using over the short term while they’re being monitored in the hospital … but when they return home they’re exposed to those environmental triggers again.”[iv] The good news, is that each time the brain accesses that rewarding memory, the neural connections that code the memory are destabilized.  It is at this moment that ketamine, which blocks the brain receptor required for the formation of memories (NDMA), can help weaken or even erase the memory. In other words, ketamine will help break the power of that trigger.

The psychedelic experience

The benefits from the psychedelic experience while receiving a ketamine treatment may hold benefits.  Dr. Tobias Stevens, in his presentation on ketamine as a treatment for alcohol use disorder, postulates the hallucinations and altered mental state from ketamine may help change lifestyle choices.  He suggests the experience may alter perceptions and break routine behaviors.[v]  Therefore, a combination of psychotherapy with ketamine, (ketamine psychotherapy or KPT) may prove helpful for some folks. KPT allows the psychedelic effects from ketamine to enhance a psychotherapy session and is shown to be effective helping those with addiction, including heroin and alcohol by Dr. Evgeny Krupitsky.[vi]

Ketamine allows learning

Psychotherapy is a vital mainstay of alcoholism recovery treatment, but why are relapse rates so high?  Maybe, postulates McAndrew et al, the alcoholic brain simply can’t learn the new skills.[vii]  There is a proven decrease in neural growth factors in the brain, BDNF, with alcohol addiction.  With fewer connections between nerves, and less ability to make new connections, the brain cannot learn new skills.  With ketamine and synaptogenesis, which happens to peak 24 hrs after a treatment, well timed psychotherapy can have a greater impact.

What does ketamine for relapse prevention look like?

Ketamine is not a solitary treatment for alcohol relapse prevention.  To say so would oversimplify the disease.  Current studies include interesting combinations with ketamine.

KARE – Ketamine for reduction of Alcoholic Relapse

KARE is a multi-site project running in England that is a clinical trial seeking to explore psychotherapy combined with low dose ketamine as a possible treatment for alcoholism.[viii]  Participants who completed alcohol detoxification receive IV ketamine 3 times interspersed with 7 therapy sessions.  The psychotherapy model, developed by Dr.s Rob Hill and Jen Harris included 3 key areas:

• Risk reduction strategies: Identify high risk situations, cope with cravings, or restructure unhelpful thinking
• Wellness promotion: planning weeks, problem solving, relaxation, and mindfulness
• Education: what is addiction, biological effects of alcohol both acute and chronic, alcohol and sleep, and how alcohol interacts with the brain

Combining ketamine with other medications?

Combining ketamine with other prescription drugs is debatable as there is conflicting evidence.  For example, naltrexone is frequently used with alcohol dependence. It binds opioid receptors and is supposed to take away cravings for opioids and alcohol which can take away reward effects.[ix] In reality, it does reduce overall total alcohol consumption, but not necessarily abstinence. Nimodipine is a calcium channel blocker that is also studied for its’ ability to decrease alcohol-type effects from ketamine treatment.[x]  Additionally, some providers prescribe Baclofen to help suppress cravings.

But, isn’t ketamine addicting?

Are we just trading alcohol addiction for ketamine addiction? This is not true according to several studies.  A study by Krystal, et al in 1998 clearly showed ketamine did not increase cravings on recovering alcohol dependent patients.[xi]  Recently detoxified alcoholics given ketamine did not go on to abuse the drug. Keep in mind, ketamine for alcohol abuse is given by trained providers in a medical setting at doses far less than what one may find on the street. The body does not become physically dependent on ketamine, meaning there are no physical withdrawal symptoms when one stops. However, there is always a possibility of mental dependence on a treatment that is helping.  But, lets put this in perspective.  Many people are dependent, or “addicted”, to a variety of activities, like exercise, weight loss, meditation, because these things reward them, (ie their brain).

Conclusion

Reducing alcohol dependence and relapse has far reaching benefits from decreased personal injury from liver disease, to depression and anxiety, to family relationships, to work stability, or to alcohol related death from accidents.  Once detoxification is complete, ketamine can help people maintain sobriety when used in part with a comprehensive program.  Alcoholics Anonymous (AA), psychotherapy, adjuvant medications and physician oversight can all help cut cravings and save lives.

About The Author

Dr. Van Praag is the medical director of Spring Center of Hope, a ketamine center located in Houston, TX. She is a practicing anesthesiologist with 13+ years of experience caring for patients of all ages.

Visit: https://springcenterofhope.com/about-dr-van-praag/ for additional information.

[i] Noël X,Brevers D, et al. A neurocognitive approach to understanding the neurobiology of addiction Curr Opin Neurobiol . 2013 August ; 23(4): 632–638. doi:10.1016/j.conb.2013.01.018. link

[ii] Bergland C, The Neuroscience of Making a Decision: Various brain regions work together during the decision-making process. Psychology Today online, 05/06/2015. link

[iii] Petrakis I, Limoncelli D, et al Altered NMDA glutamate receptor antagonist response in individuals with a family vulnerability to alcoholism. The American Journal of Psychiatry Oct-2004 161 1776–1782 0002-953X link

[iv] Devlin H, Radical ketamine therapy could treat alcohol addiction. Theguardian.com, 01/24/2017. link

[v] Stevens T. Ketamine as a Treatment For Alcohol Use Disorder. Breaking Convention 2017, YouTube 09/13/2017. link

[vi] Krupitsky E, Ketamine psychotherapy for heroin addiction: immediate effects and two-year follow-up. Journal of S/ubstance Abuse Treatment 23 (2002) 273–283.link

[vii] McAndrew A, Lawn W, et al. A proof-of-concept investigation into ketamine as a pharmacological treatment for alcohol dependence: study protocol for a randomised controlled trial. Trials (2017) 18:159 DOI 10.1186/s13063-017-1895-6. link

[viii] KARE: Ketamine for reduction of Alcoholic Relapse. University of Exeter, England. link

[ix] Krystal J, Madonick S, et al. Potentiation of Low Dose Ketamine Effects by Naltrexone: Potential Implications for the Pharmacotherapy of Alcoholism. Neuropsychopharmacology (2006) 31, 1793–1800 link

[x] Krupitsky E, Burokov A, et al. Attenuation of Ketamine Effects by Nimodipine Pretreatment in Recovering Ethanol Dependent Men: Psychopharmacologic Implications of the Interaction of NMDA and L-Type Calcium Channel Antagonists. [Neuropsychopharmacology 25:936-947, 2001  link

[xi] Krystal J, Petrakis I et al.  Dose Related Ethanol-like Effects of the NMDA Antagonist, Ketamine, in Recently Detoxified Alcoholics. Arch Gen Psychiatry Vol 55, April 1998, 354-360  link

Disclaimer: This article represents an informed opinion of the author and/or the opinion of others. It does not constitute medical advice and should not be relied upon to make decisions about medical care. Please consult your physician for questions regarding your specific conditions and possible treatments

Photo Credits:
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Ketamine therapy is not just a passing fad in the treatment of depression, suicidal thoughts, PTSD and other mental health issues.  Each week continues to bring more studies to support the breakthrough use of this time-honored drug.  Ketamine has been in use over 50 years in emergency rooms, operating rooms and the battlefield.  It has the powerful ability to relieve pain and in larger doses, induce anesthesia. In very recent years scientists have discovered it has profound neuroregenerative effects on the brain.  Chronic trauma, anxiety and depression can change the brain by destroying nerve cells. Ketamine helps form new connections to rebuild and alleviate the symptoms of these mood disorders.^[1]  While it is easy to find a front-page article or a long list on Google search to support these facts, there is a key component of healing that is often missing in these articles: psychotherapy.

It may seem logical to some that psychotherapy should accompany a medication to treat depression. However, many have viewed ketamine as a quick fix, magic drug that will alone reverse suicidal thoughts or depression. Let us think about high blood pressure treatment as a comparison. Yes, taking a pill can reduce the pressure, but losing weight, changing diet and adding exercise may have a more profound effect for many. Ketamine therapy is essentially the same idea.  True, some will do great with just the drug and no other changes in their life, but for many adding in the necessary psychotherapy will reveal more substantial results.  And, here is the key, the results will last longer with possibly less ketamine needed over time.

Working Together

Ketamine is a legal medication out of a handful of psychedelic drugs that have found a niche in psychotherapy. And, within this niche there are big differences in how these drugs are used.  While some may use ketamine to experience personal growth through a psychedelic journey with their therapist, many are using ketamine plus psychotherapy to assist with healing depression, PTSD, suicidal thoughts and so forth. This is achieved in two ways:

1. KAP, or ketamine assisted psychotherapy, is a guided psychotherapy session under a low dose of ketamine which induces a mild trance-like state where the patient can interact with the therapist and gain physiological anti-depressant effects of ketamine.^[2]
2. Psychotherapy provided before and after the ketamine treatment may allow for higher dosing to increase physiological change. The patient does not have to interact while under the effects of ketamine. Discussion and interpretation of events under treatment may occur immediately after a treatment and in the following days to weeks.

This synergy between psychedelics and psychotherapy is formally studied by many respected groups such as KRIYA (Ketamine Research Institute) link, Ketamine Research Foundation link, and MAPS (Multidisciplinary Association for Psychedelic Studies) link. With MAPS, the drug MDMA is currently used in an FDA approved trial with psychotherapy to treat PTSD.  The purpose of the MDMA is to decrease fear and allow the patient to experience emotions and visit the trauma without heightened anxiety.^[3]

What About the Side Effects?

The nature of ketamine is a dissociative medication that causes an out of body experience, and with higher doses can induce hallucinations. Drug companies are actively searching for a new drug that works like ketamine, but without the “side effect” of dissociation. Alternatively, many argue the journey under ketamine is precisely what helps one heal from past trauma and ongoing anxiety or depression. There are three ways to view the effects of ketamine according to Raquel Bennett, a psychologist and founder of KRIYA Institute in California.^[4]

1. Ketamine is a purely medical treatment where we give the drug to patients and try to eliminate annoying dissociation by giving counteracting drugs.
2. It is a “shamanic” approach and what the patient experiences under treatment is important to healing.
3. Combining both above, ketamine is correcting neurochemical pathways while a mental health professional helps guide the patient through the experience, gaining insight.

How the Therapist Aids the Healing Process

Preparation: Any ketamine treatment program should include a time for education. The patient learns about the method of delivery, how to prepare themselves, what to expect, what to avoid, time for questions and answers and how to take care of themselves afterward.  A mental health professional adds to this by ensuring a trusting relationship, setting goals, and teaching relaxation, breathing or other techniques to manage anxiety.

Manage challenges: While most ketamine experiences are interesting, calming or fascinating, some include revisiting past or current stressors. According to a recent article by Gold and Sienknecht, “The healing process is not about avoiding challenges but rather engaging them in new ways…Challenging experiences can be incredibly valuable and important, sometimes even essential, to the journey towards wholeness.”^[5]

Integration: The healing process continues beyond the day of treatment. Gold and Sienknecht also explain the integration process that follows the psychedelic experience will allow one to explain their experience, collect insights and implement new changes. The therapist can help with this process and maintain positive ground.

Long Term Benefits

One small study by Dr. Wilkinson, et al, out of Yale School of Medicine explored the strategy of combining cognitive behavioral therapy (CBT) with ketamine treatments to extend the anti-depressant effects.^[6]  They found a strong connection between ongoing CBT and depression relief.  Given ketamine causes new connections to form between neurons in the brain, Dr. Wilkinson states “It may be possible to exploit this critical period of induced plasticity to initiate attempts at modifying cognitions and behaviors that require synaptic plasticity.” In other words, CBT and ketamine working together boosts relief.

A second benefit of long-term effects discussed in this Yale study, is the possibility to limit ketamine exposure over time when combined with psychotherapy. This makes sense.  If one feels better with combined therapy and ketamine, the need for ketamine boosters may decrease in frequency over time.  This is important considering long term studies are not available concerning the effects of repeated ketamine exposure over years in an individual.  Dr. Wilkinson refers to mixed studies about long term cognitive effects.  We just don’t have the answers yet.

Final Thoughts

Ketamine plays one part in the whole treatment plan for depression, PTSD, suicidal thoughts OCD, etc. It has a powerful physiological effect to relieve depression.  Now, we also need to focus on the psychological component by incorporating a trained mental health professional in the treatment plan.  A therapist will prepare the individual, manage challenges during ketamine therapy, and integrate positive changes into daily life.  Taking advantage of this synergy may allow greater success and possibly less ketamine overall.

Disclaimer: This article represents my informed opinion and/or the opinion of others. This does not constitute medical advice and should not be relied upon to make decisions about medical care. Please consult your physician for questions regarding your specific conditions and possible treatments.

About The Author

Dr. Van Praag is the medical director of Spring Center of Hope, a ketamine center located in Houston, TX. She is a practicing anesthesiologist with 13+ years of experience caring for patients of all ages.

Visit: https://springcenterofhope.com/about-dr-van-praag/ for additional information.

^[1] Nanxin L, Boyoung L, et al. mTOR-Dependent Synapse Formation Underlies the Rapid Antidepressant Effects of NMDA Antagonists.Science 2010;Vol. 329 Issue 5994: 959-964 link

^[2] Wolfson M.D., Phil.(2016) Opportunities and Strategies for a Ketamine Psychotherapeutics (KAP). The Ketamine Papers. (p339-359) Santa Cruz, CA: MAPS

^[3] Mithoefer, M.C. (2016). MDMA-assisted psychotherapy treatment manual (Version 8.1). Santa Cruz, CA: Multidisciplinary Association for Psychedelic Studies. link

^[4] Velasquez-Manoff, M. (05/08/2018) Ketamine Stirs Up Hope – and Controversy – As a Depression Drug. WIRED. link

^[5] Gold, V., Sienknecht, E.(12/13/2018) Ambassadors to Hidden Territories: Set and Setting in Psychedelic-Assisted Psychotherapy. Chacruna.net link

^[6] Wilkinson, S T, Wright DS, et al. Cognitive Behavior Therapy May Sustain Antidepressant Effects of Intravenous Ketamine in Treatment-Resistant Depression. Psychother Psychosom 2017; 86:162-167.

The post Ketamine and Psychotherapy: Working Together first appeared on Optimum Ketamine Center.