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Ketamine Could Soon Be Used to Treat Suicidal Ideation (bloomberg.com)
135 points by dankohn1 11 days ago | hide | past | web | favorite | 143 comments





A loved one went through a few rounds of Ketamine IV at a recently opened clinic. It was about $400 a treatment, not covered by insurance, but administered by credentialed professionals.

The experience was a bit like a dialysis clinic, where there are a bunch of beds in a room, tatami screens between the beds, and where a huge 2" diameter syringe dosing pump eases a tiny amount of Ket in the line over 15 minutes.

Aside from the expense, it didn't particularly help my loved one's condition. She said it felt more like it just got her high, and not the kind of high you want. Maybe if they used a stronger dose, but those cost more as I recall.

I feel there are at least three treatments one should try before Ketamine, for PTSD/Anxiety/Depression/Suicidal Ideation.

• EMDR. So successful it's amazing that it's not standard fare in counseling and therapy.

• Neurofeedback. The literature is equivocal at best, but the anecdata is very strong.

• LSD. As our nation struggles with medical marijuana still living on schedule I, LSD similarly inhabits schedule I (where the government knows better than your doctor about there being no possible medical benefit). Studies show LSD is over 10x as successful in curing alcoholism as AA.


> EMDR

I’ve been undergoing EMDR treatment for PTSD and it is quite amazing how well it works. You wouldn’t expect that just watching something move back and forth in front of your face (or having an electric pulse alternate between your hands) in between talking about a traumatic experience would do much, but for me it’s been the most effective thing so far after trying many different kinds of therapy and medication.

I think what a lot of people need when it comes to depression/anxiety/trauma is not simply to feel better in short bursts, but rather to reframe and reprocess thoughts, feelings, and memories in such a way that they become easier to “hold” even if they don’t go away. A lot of our treatments focus on elimination rather than acceptance and reprocessing.

I think of it like short-term dieting vs lifestyle changes. The former may provide a quick fix, but the latter will usually be longer lasting, healthier, and easier to sustain after the initial push.


> not simply to feel better in short bursts, but rather to reframe and reprocess thoughts, feelings, and memories in such a way that they become easier to “hold” even if they don’t go away

This is absolutely the gist of it. Anything that helps you do something along these lines is worth pursuing. It's about building up scaffolding around a disaster area-- not to cut off access, but to put up a useful, multipurpose firewall.


I find it curious that on sufficient doses of MDMA ones eyes can rapidly go back and forth, similar to the EMDR process.

It’s funny that you say that. I’ve taken MDMA once in my life, and I swear it was one of the only times my mind didn’t feel like it was trying to attack me. I felt totally calm and at ease rather than high or euphoric. I haven’t done it again because I’m paranoid about addiction, but I could absolutely see it being effective as a tool for facilitating longer-term treatments. I’d jump at an opportunity to participate in a MAPS study or something similar in a controlled environment.

MDMA is fascinatingly effective. You get some hours of pure bliss, all your fears gone and replaced by compassion.

It should absolutely be treated as something very special - it 'just works'. Using it too often would make it loose it's magic (on a physical level too)

Then again most additions seem to happen with more subtle substances. MDMA is a way too powerful experience to do it casually.


There is very limited evidence that the bilateral stimulation has _any_ impact on treatment outcomes [0].

EMDR is PE with a marketing machine behind it. To quote Robert Ursano, a prominent figure in trauma research and treatment at the VA, “I concur with the view that what's new about EMDR is not helpful and what's helpful is not new,"[1].

There is a disturbing trend of EMDR being billed as a panacea by commercial training institutes without educating clients about equally or more efficacious treatments (PE, CPT) that are studied primarily in academic centres.

0: Chemtob et al., (2000), Davidson and Parker (2001) 1: https://www.washingtonpost.com/archive/lifestyle/wellness/20...


You are correct, but I think you are overlooking a peripheral advantage: (relative) fidelity to the model.

I have sent countless patients to therapists purporting to do DBT, CBT, PE, and others - only to review those sessions with them and hear about poorly delivered supportive therapy with questionable boundaries.

EMDR seems to be delivered with something approximating the actual therapeutic model as studied somewhere around 50% of the time. Which, sadly, is pretty good.


Can you elaborate on what you've seen as far as "questionable boundaries" is concerned?

I went to a licensed therapist who insisted I call my GP to obtain antibiotics for a cold. I explained to her that antibiotics arent effective on viral illnesses, she insisted that yellow phlegm indicates "an infection" this antibiotics would be effective. I am also anaemic due to a genetic condition, and the anemia is mild but basically untreatable. She suggested I look into treating it with "herbs."

That sort of boundary crossing?

I stopped going to her, obviously. Pisses me off i actually paid her.


That's not what I had in mind, but that is also a problem. What I meant by "questionable boundaries" is being more of a hired friend than a therapist, and talking about themselves and their own lives more than they should. Poorly trained therapists tend to take the side of the patient without exception, and rarely challenge the behaviors that can cause them problems. Therapy should feel challenging, and feel like work, at least most of the time. If it's someone telling you that you can do no wrong, that's not useful.

Thanks, you've put into words my somewhat bad experience with therapy.

Do you have any experience with Schema Therapy practitioners?


> EMDR is PE with a marketing machine behind it

What is "PE" in this context?


Googling suggests Prolonged Exposure (PE), and Cognitive Processing Therapy (CPT): https://deploymentpsych.org/blog/staff-voices-pe-or-cpt%E2%8...

I have some experience with Ketamine ... the one I can share is when the hospital administered it via IV to put my dislocated shoulder back in place.

It was wild and would certainly NOT be my choice for a sedative in that situation. It hit fast and at first I felt high, doctors faces started to "melt", then a huge black abyss was in front of me and I felt like I was falling head first into it.

I started yelling "no, no!" because it was a very uncomfortable feeling.

Then as I was coming to the entire room was warped, with echoing voices and laughter.

I'll pass on that, not sure how that would help with depression. It would have to be a VERY small dose.


According to what I can find they were using a dosage of 0.5 mg per kg in this study, but dosages can be as high as 1 to 4.5 mg/kg when used as an anesthetic.

I had the same dose for the same reason, it was very disturbing. Apparently the doctor said it was normal for patients to scream that much.


In a clinic environment they wouldnt be putting ur arm back :) . U would be in a calm environment with nice music and blind folds

Some follow a low dose of around 30-35mg and some go up to 150mg which I found to be life changing


In a situation like that where you're in pain and anxious to start with, and are not prepared for what's going to happen, I can imagine it would be pretty horrible. I was in a comfortable situation and well-prepared when I got my first IV, and there were still a couple of brief, scary moments in the experience. And as someone else said, you probably got a much bigger dose, putting you deep into k-hole territory, if not actually knocking you out. When used for therapy, that kind of dose is usually reserved for those with chronic pain or other conditions, not depression or suicidal ideation.

I don't think they would have given you the same dose if it was to treat depression. By the sounds of your trip, you had way more than the standard dose (even by recreational standards).

Also transcranial magnetic stimulation which is FDA approved for treatment of depression. No drugs involved.

A treatment is either changing brain chemistry with the risk of side effects of some kind or it isn't and there is no potential benefit.

There are side effects with rTMI and they can be very serious, however, they are not typical. Side effects include: Headache, Scalp discomfort at the site of stimulation, Tingling, spasms or twitching of facial muscles, and Lightheadedness [0]. Serious side effects can include: Seizures, Mania, particularly in people with bipolar disorder, and Hearing loss if there is inadequate ear protection during treatment [1].

Particularly in the issues around PTSD that was induced alongside cranial trauma, rTMI is an unlikely treatment, though still viable. The issue is that PTSD and concussions share strong co-morbidities. If you have a concussion, your physician is more likely to suggest other treatments, as rTMI may cause other issues. In reading through the literature, I cannot find a case where an issue was seen, but I can understand the caution with such a new technology. That said, there may have been cases that I am unaware of. I'll be very clear here, I am not a medical doctor. If you are considering rTMI treatment, please see a physician.

[0] https://www.mayoclinic.org/tests-procedures/transcranial-mag...

[1] https://en.wikipedia.org/wiki/Transcranial_magnetic_stimulat...


My doctor prescribes ketamine for take home use. Unfortunately infusion clinics are taking advantages of patients by administering the most expensive ROA. Keep in mind that the IV ROA has not been proven more effective or safe than cheaper ROAs.

Ketamine's antidepressive effects are by far the most potent when ketamine is administered as an IV drip over a long period of time, like 40ish minutes. If you simply inject it all at once, you will definitely go to la la land, but the duration will be too short.

And if you're talking about starting an IV on yourself... without training, the risks of really bad health issues, including death, are pretty high. Almost no one outside of professional health care has that training. Even if they did, you still need to be monitored by someone else via pulse ox and sometimes blood pressure for safety reasons, and said person monitoring you needs to have the training to know how to help you if something goes wrong. Keep in mind that if ketamine is effective for you, you will end up needing to keep taking it for a long time, typically every 3-6 weeks, or the effects wear off. That frequency multiplies the risks.

In short, I see the ratio of risk to effectiveness for home use ketamine to be emphatically not worth it. Unless you have a partner / friend who has the necessary training.

I know from talking to my doctor that of the $375 I pay, his cost for the ketamine he uses for that one treatment is under 10 bucks. If you've got a medical license, you get access to buy legit pharma drugs very easily. I believe he told me that one vial of Ketamine is something like $20 and there's multiple doses in there.


> Ketamine's antidepressive effects are by far the most potent when ketamine is administered as an IV drip over a long period of time, like 40ish minutes. If you simply inject it all at once, you will definitely go to la la land, but the duration will be too short.

No one understands the exact mechanism of ketamine for depression even though there has been a lot of research and speculation on this topic. Therefore, you can't say which ROA is best for patients or if one works better than another.

Furthermore, all studies have been small and short in duration so there's no statistical significance to the fact that the IV ROA is used more in studies. If IV was the only route that worked it would be the first anti-depressant with that designation. Because of the cost of infusions patients are right to be skeptical about doctors that are running clinics.

> In short, I see the ratio of risk to effectiveness for home use ketamine to be emphatically not worth it. Unless you have a partner / friend who has the necessary training.

My doctor has clinical experience with ketamine and about 2+ years of prescribing patients with TRD with sublingual ketamine that is taken at home. Ketamine is an incredibly safe drug and nothing about his practice has changed. His insurance has even stayed the same. I know that’s a common justification for high prices from docs that run IV clinics.

The reason I’m not going anonymous on this is because I feel passionately that we need to stem the tide of shady ketamine doctors that don’t give a shit about patients. When I asked my doctor why he wouldn’t charge me a lot of money (he could!) for the treatment he asked me, “Would I charge you a lot for Lexapro because it works?” Good point.

See this book for background on Ketamine and the studies completed: Ketamine for Treatment-Resistant Depression: The First Decade of Progress (2016)

https://books.google.com/books/about/Ketamine_for_Treatment_...


I agree with you that what works best for some may not work the best for others. I disagree that doctors who charge a few hundred bucks for this "don't give a shit" about their patients. I also know that, from personal experience, sublingual ketamine did very little for me (tried that before IV). Doc then suggested IV use, and said most patients end up needing the IV route.

You don't need to start your own IV to do it at home. I've been getting IV ketamine occasionally for around 8 years. I've also been using a prescription ketamine nasal spray for most of that time. For me, the effects of the two are nearly the same. Intranasal only has about 20% of the bioavailability of IV, supposedly, although in my experience it's closer to 10%. It takes quite a few sprays to achieve the same level of the drug as the IV treatment provides, but it works.

$130 gets me 3000mg in a spray every month. That's enough for about 4 IV-equivalent treatments even with the low bioavailability. The biggest difference is that the intranasal (of course) absorbs more slowly than an IV, so some of the effects last for 2-3 hours after I stop administering the spray, whereas once the IV runs out, I'm ready to leave the clinic in about 15 minutes. (Taking an uber or the subway rather than driving, obviously.)

The therapeutic index for ketamine is ridiculous and I know I don't have adverse reactions to it, so I'm not at all concerned about harming myself with it accidentally. I wouldn't recommend it for anyone who hasn't had some IV treatments, partly because a small number of people do have strong negative reactions to it, and partly because it would be really difficult to know what kind of effect you need to achieve. It's pretty easy for me to tell how high the levels in my blood are because I'm so familiar with how it feels as the IV dose escalates.

While I wouldn't recommend it for an initial treatment, I would recommend it to anyone who has been successfully treated with ketamine. Unfortunately, I think that it's harder to get now. I know my doctor has stopped prescribing it to patients because too many people were selling or abusing it.


Is this in the US?

Yes it is.

Anecdata is also all that supports TMS and Ketamine. There's not been sufficient time for longitudinal studies to be conducted or more efficacious protocols to be developed.

Had your loved one tried ECT prior to ketamine infusion? Though its reputation has been sullied by popular culture, it is bar none the most efficacious treatment we have for treating severe and persistent depression, and its efficacy is well supported by decades of research and outcome tracking.


The enthusiasm for ketamine and TMS undoubtedly outstrips the evidence and is driven by financial motivations. But to call it "anecdata" is a bit harsh. The available evidence certainly eclipses some of the other recommendations in the comments (CBD, lsd/psilocybin - before I get angry responses, these look promising but the data just aren't there yet).

Where I totally agree with you is ECT. It is, with a bullet, the best-supported intervention for treatment-resistant depression, and it's not even close. It is an absolute tragedy that it has such an unfairly terrible reputation. Even before anesthesia was a universal element of ECT, it was never as bad as usually portrayed in popular culture.


It is harsh, but where's the fun in the comment section of an HN post on psychology without a little hyperbole?

My disdain comes from seeing people I'm close to repeatedly pushed towards those treatments by practitioners who, when asked to provide references supporting their endorsement supply anecdotes about past or current patients rather than DOIs. There are specific TMS protocols that appear to have some growing amount of evidence behind them, but ketamine still seems to be a wildly variable cash grab that requires further data before anything can be said about its efficacy.


The negative side effects of ECT can be dramatic and life-changing. I've known people who lost significant chunks of their memory (and that's with modern ECT), and they said it was worth it for them... but I have zero interest in risking that. If the alternative is killing yourself, it might be worth it, but for TRD without attempted or planned suicide, I have never even considered ECT seriously.

That can be a side-effect, especially with bilateral lead placement. With unilateral placement, it's pretty occasional. I wonder if knowing two people with the same problem indicates a local psychiatrist using bilateral approaches more than usual?

I would like to add MDMA too to that list

Side note: I really like the photographic style of this article, particularly the man standing on a brick column as though on a building about to jump off, but perhaps instead standing strong having learned to cope with his negative emotions. The dark motif overall is a nice counterpoint to the ultimately uplifting, persevering tone of the article.

I guess the photo was shot on wet plate!? The large format lens DoF and the high contrast makes the scene scenery looks dramatic. Very well done.

I was intrigued and found out more about the photographer. He was a trained photographer (worked under Annie Leibovitz) and lectured photography in the 90s. Got his medical degree in 2004 and seems like he's coming back to photos. https://www.nationalgeographic.com/contributors/a/photograph... https://www.nationalgeographic.com/magazine/2019/01/max-agui...

I'm very much concerned that rather than traditional psychotherapy where a person has to confront the issues and trauma of their life we're moving towards the idea that if you drug someone enough they won't commit suicide. I should also point out that the anecdote given makes reference to Prozac, a prescription drug which some users have claimed has caused their suicidal ideation.

>I'm very much concerned that rather than traditional psychotherapy

Why on earth would you be concerned about a tool which allows clinically depressed individuals to see immediate, significant improvement in their condition with relatively few side effects? You should also not group ketamine therapy with prozac, they are completely different drugs with completely different mechanisms of action, grouping them under a broad "antidepressant!" umbrella is borderline negligent.

Psychotherapy is often a long, drawn out process which doesn't necessarily always guarantee results. Not to mention the large amount of variance between individual therapists.

Psychotherapy is useful as an adjunct to psychiatric drugs, and vice versa. They are both useful tools when fighting mental illness, and are even more efficacious when combined. Drawing a line between the two for ideological reasons, instead of purely evidence-based results, is a mistake.


Because I feel it may encourage existing harmful behaviours that are causing the ideation to persist and end up fueling a cycle of dependancy.

> fueling a cycle of dependancy.

Similar to how diabetics are dependent on insulin, or schizophrenics dependent on their anti-psychotic medication?

You're also implying that people with severe, clinical depression can assuredly be helped by psychotherapy. I'm sorry, but the literature is far more abysmal than that. Many patients don't even respond to psychotherapy, and need psychiatric intervention in the same way a schizophrenic does.


Sorry, but this bizarre. Psychotherapy is just one tool in the toolbox against treating mental illnesses. If there is evidence this drug helps treating mental illnesses, what's the reason not to use it? This is not some alternative medicine that is offered instead of or in addition to scientific practice. This is part of the usual treatment that involves psychotherapy, if it's useful. There is nothing inherently bad with drugs; you don't hesitate to use drugs when your liver chemistry breaks, why hesitate it when your brain chemistry breaks?

The problem is that the effect sizes for most anti-depressants is quite small and the role of pharmaceutical companies in advancing their use has been quite a bit larger. The difference between psychotherapy and medication and psychotherapy alone is small.

I would also point out that dialysis, chemotherapy, etc are also quite expensive, time consuming, and difficult to scale. We still consider them valid, life-saving treatments.


>The problem is that the effect sizes for most anti-depressants is quite small and the role of pharmaceutical companies in advancing their use has been quite a bit larger. The difference between psychotherapy and medication and psychotherapy alone is small.

Ketamine is not your traditional SSRI. You're making the same error as the other poster in grouping all "antidepressants" under the same umbrella, which is particularly egregious when discussing ketamine.


I am referring to traditional agents, not ketamine. There is insufficient evidence to draw conclusions about Ketamine's usefulness as a rapidly acting agent for treatment of depression.

I lack training in psychopharmacology or neuroscience and thus my interpretation of the research is that of a layperson, but my understanding from talking with psychiatrists on the matter is that it is unlikely that ketamine will become a frontline treatment but its mechanism of action will be explored and lead to the development of new drugs that activate the same pathways in the brain but lack or have lessened anesthetic effect.


You don't use a nuke if you only need to kill one guy. I'm not against it being used but we need to be careful, we don't want another opiod crisis.

I think opioids are in a very special spot. There are very few drugs that are as intensely addictive and as harmful as opioids and are used in medical profession. In particular, ketamine is nowhere near as addictive or harmful as opioids. Your point is valid, we should be careful, but we should also recognize the special status of opioids.

>I'm not against it being used but we need to be careful, we don't want another opiod crisis.

This is a horribly ignorant statement. Ketamine therapy is in no way comparable to widespread opioid prescription in risk. You are once again comparing drugs with entirely different mechanisms of action.


A drug that actually works is far preferable. Talk therapy is expensive, hard work, tough to scale, and it's difficult to find a qualified therapist who is right for you.

Ketamine treatments are pretty expensive at a clinic. If you wanted regular Ketamine doses for depression (maybe like 1 a month?), I would just buy some online and insufflate it. Safer than a needle and just as effective.

PS: Chronic Ketamine use destroys your urinary tract (I know people that wet the bed every night from too much of the stuff). Also, it might cause brain damage, but no one is really sure.


> I would just buy some online and insufflate it. Safer than a needle and just as effective.

You're advocating buying a black market substance online and then snorting it as the safer option?


That's what most do with ketamine to reduce chance of infection . U could also buy a reagent to test it before use .

Only issue I see with intranasal is that bioavailability is only 33%


Are you saying that buying a black market substance and injecting it would be the safer option?

No, I'd suggest using a clinic.

If you read my comment. I'm suggesting that you don't inject ketamine and instead you should snort it. I'm not suggesting that snorting black market ketamine is safer than a clinic.

Though, ketamine is pretty damn safe, and it's rarely adulterated on the black market. In powder form, it forms crystals so it's hard to fake.

A priori, you can always say that something regulated is more safe than something not. But if you're a savvy consumer, you can significantly mitigate or eliminate that risk.


Ketamine is heavily cut on the black market, both in crystal form and not.

What is harder to fake it vial ketamine. There is a significant cost to that.


Exactly. Street ketamine powder is often heavily cut. If I had to buy illegally for some reason, I would only consider buying sealed vials, and I'd probably still have them tested. My ketamine doctor has worked with patients who used to buy on the street, and they brought in "ketamine" that was the wrong color, had flecks of different colors in it, etc.

So in this case this has nothing to do with treating suicidal ideation and instead strictly for recreational consumption?

I'm not sure what point you are trying to make. I didn't say anything about doing it for recreational consumption.

I'm suggesting that if you can't afford a Ketamine clinic: a) Ketamine is generally unadulterated on the black market b) if it is adulterated you can often tell c) unless a professional is administering it, you probably want to snort it and finally d) snorting Ketamine should have roughly the same effects (anti-depressant or otherwise) as injecting it.


Are you arguing in good faith? The proposal is to buy ketamine online and snort it IF you cannot afford to do it in a clinic because (1) ketamine as a pure drug is pretty safe if you don't use it routinely (2) snorting is safer than IV. The topic is still to use ketamine against suicidal ideation. This has been repeated to you twice, please try reading better before arguing with people.

The chronic users are on very very high doses . It does happen on users who take low doses but much less compared to others . U need to flush ur system with liqueds according to harm reductions guides

Also egcg seems to completely block it's damaging effects https://www.sciencedirect.com/science/article/pii/S187952261...


> I would just buy some online and insufflate it. Safer than a needle and just as effective.

Insufflation is only "just as effective" if your goal is to get an intense psychedelic high.

If your goal is a strong antidepressant effect, insufflation is extremely less effective than IV-drip-over-40min. This isn't just my opinion, it's the consensus opinion of ketamine docs across the world.

Insufflation helps you for a few minutes to a few days, IV drip method works for 3-6 weeks.


What biological mechanism would make this the case? Are you saying it has to do with bio-availability? Half-life? Onset? Duration?

What about IM? What about rectal administration? How about sublingual? Are there any papers suggesting that IV is somehow quantitatively different from the aforementioned methods?

My personal experience is that IM, IV, and snorted all made me feel better for maybe a period of 2 weeks. I wasn't necessarily doing a "clinical" dose, whatever that means (maybe 25-75mg of IM or IV and 100-250mg snorted), but the anti-depressant effects all seemed comparable.

A drug crossing the blood-brain barrier is a drug crossing the blood-brain barrier. There should be no difference in administration if we are talking about weeks to months later.


The effectiveness of ketamine for depression is all about the state it puts your mind in. This is obvious because the drug itself has totally left your body shortly after administration, but the effects can last much longer. In this respect you can think of it as your mind actually healing itself, by being induced to by the ketamine, rather than the ketamine itself impacting your brain's structure. This is different from most conventional psychiatric medicine where the drugs need to build up and remain in your system over very long periods of time to be effective.

Optimizing the dose & duration to get your mind into that state, and for the right amount of time, makes a huge difference in how long the effects last. This is why I prefer using an actual doctor with ketamine depression treatment experience, because they have experience figuring out the right dose & duration for you.


Ketamine is an off label treatment. Many of the practitioners aren't even psychiatrists. There are nurses, anesthesiologists, and pain specialists that do this as a side gig to make money. Your statement reads like we should put a lot of trust in these people when it's actually the opposite. One of the biggest clinics just hired a CEO to expand their business.

The time that the effect lasts is variable. A patient may need an infusion every week. That's $26,000 a year in some cases.

I actually had a doctor tell me that the infusions last 6 months.


Yes, I am indeed saying you should trust the opinions of people with medical training and experience. Especially doctors that have been treating depression with ketamine for years. Whether or not they're an anesthesiologist or one of the handful of people in the entire world that are both an anesthesiologist and a psychiatrist. (All of my ketamine docs require you to also see a psychiatrist, so that profession is still completely involved for me.)

My previous doctor runs a monthly group meeting where patients get together to discuss their experiences. The vast majority of attendees had positive experiences. So even if you don't trust the doctor, you can trust the living proof of positive outcomes. Sure, you could say that the group self-selects for positive outcomes, but no one claims this treatment is 100% effective, either.


My doctor has been treating ketamine for years and he says that these doctors you are talking about are screwing patients. My doctor is more reputable: A) he has clinical research experience and B) he isn't making any more money than he would on other treatments for depression.

Yes, ketamine docs want you to see a psychiatrist because they don't want to deal with you. It's about the money and having as little responsibility as possible.

A support group to discuss experiences? That sounds like it would encourage a placebo effect.


Which doctors, exactly, are you referring to when you say "these doctors you are talking about"?

What makes you think both my doctors don't have clinical experience? (I never stated, you never asked. As it turns out, they both do.) You've turned this conversation into a pissing match about whose doctor is best, which is too petty for me, so this will be my last post in response to you.

> Many of the practitioners aren't even psychiatrists

> ketamine docs want you to see a psychiatrist because they don't want to deal with you

So a ketamine doc that isn't a psychiatrist is bad, in your opinion. And also any ketamine doc who realizes that the situation he's treating requires psychiatry for optimum outcome, recognizes they lack said experience, and makes you go to someone with that experience, is also bad? I'm sorry, but your posts reek more of an anecdotal agenda rather than... science. So, I'm done.


I don't have an opinion on the subject in either direction, but I was struck by this sentence -

"ketamine doc who realizes that the situation he's treating requires psychiatry for optimum outcome, recognizes they lack said experience, and makes you go to someone with that experience, is also bad?"

The "ketamine doc" you're advocating people should see to treat their persistent psychological conditions such as PTSD or Depression, has no experience or background in treating any psychiatric/psychological conditions at all (and they get credit for recognizing that!).

Given the above, what service does the "ketamine doc" provide other than selling the ketamine? Like, what difference does it make that they are a doc? The access to an IV drip? The ability to google dosage? I can do renal function work ups with my family physician.

I'm genuinely confused on what value they add beyond a street dealer (assuming identical substance quality, home tests do exist).

Which is to say, a doctor is generally understood to be something beyond a prescription pad and should actually be involved in the treatment he's supposedly providing. Also, I feel like this "treatment" model is highly likely to incentivize profit-maximizing-pill-pushing clinics rather than compassionate therapists.


The value the ketamine doc (in my case, both docs have been anesthesiologists) provides, that a psychiatrist doesn't, are:

(1) Safely starting an IV on you

(2) Monitor your heart rate, O2, bp levels during the infusion - sometimes people have problems during infusions, I've never had one, but I feel safer having these treatments knowing my vitals are being monitored

(3) Training to know how to solve emergency health issues you may have during the treatment. I personally value this on-the-spot emergency medical knowledge very highly, but if you don't then I can understand why you might question the value. I am completely and utterly helpless during an infusion, if anything bad happens to me, I will be utterly unable to help myself, even a tiny bit.

(3) Access to pure/safe ketamine

I've never known, or heard of, a psychiatrist that will do all this. They very well may exist but not in my area.


If you want tighter control, I.M. ketamine using a micron filter is the way to go.

Is it possible to get some from your local veterinarian?

Absolutely. If you're friends, of course. Or maybe if you have enough money? But at that point, you might as well just go to the clinic.

This is not strictly true. Chronic ketamine ABuse can cause urinary tract problems. The doses and frequency used in a clinical session emphatically do not cause this problem. Ketamine has been in regular use since 1970 for a wide range of medical purposes. It's also been on the WHO Essential Medicines List since 1985.

tl;dr - don't need to worry about urinary tract issues unless you're using the drug (1) recreationally; (2) irresponsibly


I only know hearsay, but the issue effects those sniffing 2-3+ grams a day, every day for extending periods. The ketamine causes internal scarring of the bladder / urinary tract (not sure which or if either), that scarring stops the organ (maybe wrong word) from expanding and contracting.

So you feel like you need to piss regularly, but only a few drips come out. The damage can get so severe bladder gets removed.

At the lesser end of the damage is agonising stomach cramps, no idea what the cause of this is.

source: spent too long in the uk freeparty rave scene when ketamine was legal and people assumed it was completely safe due to lack of come down. Too many people ended up with severe ketamine addictions and many have to know piss through a bag


Though there hasn't been much research on it, I suspect that methoxetamine (MXE) might have the same anti-depressant effects as ketamine. Also, it doesn't have the urinary tract issues.

Also, it's much much cheaper on the black market than ketamine. We're talking around 1000 (recreational) doses for $20. Compared to say 10 (recreational) doses of ketamine for maybe $50?


>Also, it's much much cheaper on the black market than ketamine.

What is it like to still be living in 2014? MXE hasn't been manufactured in any significant quantity since China banned it years ago. The stockpiles that remained have been stretched out at high prices and have significantly degraded over the years, people are reporting needing 2-3x the previous dose.


I guess I don't know what I'm talking about anymore. Stopped all that stuff awhile ago. Probably shouldn't be giving advice on the internet about it anymore I suppose..

The last big batch was proven via test to be 30% caffeine by weight. I can't imagine people stopped cutting it.

MXE does. So does 2-Fluorodeschloroketamine, deschloroketamine, and several others. The issue is once you step off the PCM chain you have hider chance of a side effect of mania.

MXE does have the same bladder issues, but is taken as a smaller dose so it takes longer to happen.


2-3+ grams a day is crazy. Ketamine from a legit clinic is around 100mg give or take based on body weight, once per 3-6 weeks. If you increase the dose of any safe drug by that many orders of magnitude, yes, your body will be harmed!

(Pardon the throwaway; I try to keep my medical history private!)

I started monthly ketamine treatment about 3 years ago for treatment resistant depression. It has helped me immensely. It costs me $375 per infusion.

I tried 1-3 drugs from every class of antidepressant (and a few other types) before ketamine and had limited results. Ketamine, however, has been a godsend.

If anyone has any questions about the treatment, the drug, its effects on me, or anything else, feel free to ask.


Is the dose administered during these sessions high enough to cause hallucinogenic effects?

Could you describe what your depressive symptoms were like before/after treatment?

How many sessions did it take before you saw improvement?

Also, any personal insight on why it was so effective for you? Do you think it helped you view circumstances in your life in a different way (the way other hallucinogens like LSD might)?


> Is the dose administered during these sessions high enough to cause hallucinogenic effects?

Yes. It isn't effective unless you get well into a hallucinogenic state. The antidepressant effect seems to be maximized by setting the dose such that you are fairly "out there", but not so far out there that you get scared, or pass out. (Ketamine is used all the time as anesthesia for surgery, and they give you a much larger dose than is used in depression treatment, because past a certain dose, you just immediately zonk out 100%. Good ketamine therapy for depression is achieved by feathering the dose between the two extremes of zero effect and passing out.)

Hallucination means a lot of different things, but with ketamine it's pretty specific. It's not the kind of hallucination where you're looking around the room you're in and see things that don't exist. With ketamine you basically disconnect from the world you're in at the moment and go somewhere else entirely, in your own head. You will often not ingest input from your eyes, even if they're open. What goes on inside someone's head at this point varies wildly, I could tell you what it's like for me but not sure how much interest there is in that. I will say though that music has a profound impact on what goes on in my head during an infusion, and is a fun way of customizing the ketamine experience. I particularly love using my AirPods for this, because there are no wires and especially under ketamine, it feels like the sound is coming from inside your head, as opposed to feeling like you're wearing headphones.

> Could you describe what your depressive symptoms were like before/after treatment?

My depression manifest itself in extreme anhedonia, and after my 3rd infusion, I played, and enjoyed playing, a video game again, for the first time in over a year. Also, at that point in my life (3 years ago) I was going through a lot of difficult personal life problems, and dealing with those problems went from "completely insurmountable" before, to "this is shitty but I can figure it out" after.

In other words, it helped me deal with my life and enjoy things again, but it didn't turn me into someone who will never experience sadness again. It doesn't mean you'll never have a bad day again, but it does mean you'll be able to handle those bad days a lot better.

> How many sessions did it take before you saw improvement?

The way my doctor recommended starting ketamine treatment was to have 6 doses over the course of 2 weeks (m/w/f, m/w/f), and then after that "as needed", which for me turned out to be every 4 weeks. It was after the 3rd dose in my initial course of 6 that I noticed a significant effect.

> Also, any personal insight on why it was so effective for you? Do you think it helped you view circumstances in your life in a different way (the way other hallucinogens like LSD might)?

I can answer this in two parts.

First, one reason it is effective for me is because I don't take any other drugs that conflict with ketamine. Regular benzodiazepine use, or opiate use, or lamictal (this list is not exhaustive) significantly impact the effectiveness of the treatment. Lamictal completely kills the effectiveness. I had just started on lamictal treatment a month prior to discovering ketamine treatment, and had to come off it for 10 days before starting. Same with benzos.

Second, and this is just my personal theory about my own experience, I think one thing ketamine does that helps me is to get my mind out of ruts. The experience of ego death, or near ego death, that I get with ketamine feels like a complete reset for the problems my brain was relentlessly focusing on before. Afterwards, I still care about those problems, but obsessing over the negative parts of my life abates significantly. I would say that before, my focus on the negative vs positive was quite lopsided to the negative, to the point that I rarely noticed / felt the positives. Whereas now, the two are much more balanced. I still lean a bit towards the negative, but just a bit.

One more personal anecdote: Before ketamine, I was dating a lot, but almost out of desperation because of how extremely lonely I felt, rather than because I was being thoughtful/intentional/patient about finding a great partner. The ladies I dated picked up on this quite easily, and it lead to a lot of negative outcomes. And each negative outcome felt like the world ending, which made things worse. A few months after starting ketamine I tried dating again, and it went so much better. I wasn't as desperate, and I took the time to figure out who I was and what I really wanted, and what I offered. It still took a while before I found the right partner for me, about one year after starting ketamine treatments, but we're happily married!


One more thing I'd like to add, my mother has a very similar kind of depression as I do, and ketamine was not effective for her at all. She was on a fairly high, regular dose of opiate medication, and also she's in her mid 50s. Doc said that it doesn't work as well sometimes, for older people. But we couldn't say for sure if it was her age or the opiates, and getting her off the opiates wasn't an option for her unfortunately.

Thank you for your comment. I can't really relate, but it does sound very interesting and potentially useful to many others.

Thanks for the thorough response.

FYI - Kaiser Permanente is running some ketamine in clinics in California. If your insurance is Kaiser, this might be a low-cost option.

I've never used ketamine, but I did take hallucinogenic doses of dextromethorphan (DXM, a dissociative hallucinogen, the same class of drugs as ketamine) a few times in college. I have mild depression, and for several days to a week after each DXM trip, I felt very energized and creative, with all of my depressive symptoms gone. I'm not surprised that ketamine helps depression in some people. I sometimes consider microdosing DXM for depression and also general productivity.

Of course, don't take any medical advice from anonymous online posts.


IV ketamine is already being used to treat depression. Its about $500 per treatment.

Yes and I believe that nasal administration is either under FDA review or active development.

Edit: For anyone suffering from suicidal ideation, I recommend trying lithium (in close consultation with your doctor).


Lithium was the only drug that helped me. Two weeks on it and the ideations were gone. Of course it also requires monthly blood tests, and for me being nauseous every morning but the positive effects did stay after I discontinued.

At least in my case, I didn't need to continue with the monthly blood work once my optimum level was found. Also I fortunately never experienced the nausea you mention but did experience tremors occasionally at the beginning, when trying to find the right level. Too high and they would begin to manifest.

if you read the article you would note that that is true but its use for depression is off-label and without well defined procedures

I pay $375. And at a different doctor, before I found my current one, I was paying $750.

> I pay $375. And at a different doctor, before I found my current one, I was paying $750.

Most of them are charging more than $375. This is not regional pricing. There is no reason why an infusion in Albuquerque should cost half as much as an infusion in Chicago. In another comment you suggested these experts should be respected.

> This isn't just my opinion, it's the consensus opinion of ketamine docs across the world.

When doctors are robbing patients that may just be the beginning of impropriety...


So is intranasal ketamine.

200 Euro in Germany

Is the incidence of suicide lower among regular ketamine users?

There is a gigantic difference in patient outcome between clinical ketamine use and recreational ketamine use. For a variety of reasons: careful dose control, having an actual doctor involved, etc. But the biggest one is the antidepressant effects of ketamine only really happen when it's administered via IV drip over a course of 45 minutes. The most common use of recreational ketamine is inhaling it, the effects come up too fast and go away too fast for the antidepressive effects to occur.

Insufflation is the word you're looking for.

That's also untrue. IM, and IV are most faster come offs then insufflation or eating it. Though eating ketamine sucks for the amount you need.

What is true about IV is you can control the amount that actually gets taken in much better.


> What is true about IV is you can control the amount that actually gets taken in much better.

I agree 100% with this. Furthermore, being able to carefully control the dose and duration is paramount in getting the effects to last as long as possible.


I've spoken with a few . Once u start getting high tollerances the anti depressive effects go away permanently .

You do not build up a tolerance to ketamine if you follow the treatment protocol, which dictates a lower dose (around 100mg, give or take for body weight), and one infusion every 3-6 weeks.

Source: Been having regular infusions every 3-6 months for 3 years, and it still works for me.

I can't say this enough: experience & anecdotes based on recreational ketamine use /do not apply at all/ to clinical use.


Of course . I wasn't talking about people on AD treatments but multigram addicts

I have been to a clinic and even weekly doses don't build up tollerance at all which I find very interesting


This is J&J's S-ketamime NOT racemic ketamin

Racmic is better


This has been my experience too. None of the ketamine-based drugs have been as effective as regular ketamine. That said, drug companies will not seek to get regular ketamine FDA approved because they can't patent it. So this is the only way they will go through the process of FDA approval. I hope it leads to regular ketamine being FDA approved for treating depression because only then will it be covered by insurance.

The literature points to R-ketamine, on it's own, appearing to have stronger antidepressant effect, with less of the disassociative effects.

AFAICT, it's not patentable, so nobody would pay for the trials.


This is very true . R-ketamine holds most of the benefit but some of the metabolites of s-ketamine also do contribute to the positive effects .

Regarding patents . It is possible to patent an ROA method just like what j&j did with s-ket


[flagged]


It is the natural state of fire to burn. It is the natural state of life to live. Humans are programmed genetically to do so, and to go to (and suffer) extremes to continue to do so. While there might be situations where suicide is (judged to be) the best bad alternative, it is literally the most unnatural thing a human can do to themselves. And poverty (vs. scarcity) is not a natural concept; is a wild rabbit with enough to eat "poor" (only if their neighbor rabbits have a larger burrow!)? This is the projection of human concepts about how the universe should be arranged (right/wrong, wealth/poverty, culturally-oriented logic) onto a physical universe which has no such concepts built into it.

Your argument strongly depends on a narrow view of the word "natural". Could you explain why your definition of natural is useful in this context?

Suicide isn't new or specific to humans, so calling it "unnatural" seems unnecessarily silly to me.


By "natural", I mean according to the laws of physics, and all higher-order laws or principles which arise from them (basically, everything else). So, yes, narrow, but no, not. What we call "nature" is largely a fiction, a story that we impose on the universe (the "natural world") to help us navigate our place in it and understand it in abstract ways. Humans occupy a strange place, in that we are manifestations of "natural laws" (physics, chemistry, biology, psychology), but at the same time, able to understand and rationalize about our own existence and place in that world in ways that most (all?) other animals are not. I think suicide (vs. self-sacrifice, which is an entirely different thing) is a very human (or human-like) phenomenon, and can only arise from a high-level consciousness which can rationally/emotionally think in terms of "Is living my life worth the cost I am paying (in emotional or physical terms)?". No "less conscious" living thing would ever make that kind of calculation, because they will always follow their instincts to survive as a default (again, differentiating between sacrificing oneself for a goal vs. ending ones' own suffering on purpose). Not saying that it's impossible that "nature" has enabled such a mechanism in a species (though it would violate the "selfish gene" principle), but I don't see it.

> Suicide isn't new or specific to humans

Self-destruction is found in non-humans, but mostly as a reaction to acute circumstances. I'm assume you are widening the scope of what is suicide to include these examples, but they seem different than relieve of existential suffering that is human suicide.


Most people don't like having suicidal urges, and given the choice of ending life vs making life more enjoyable (without the urge to die), would probably pick the latter.

The natural state of living organisms is to remain alive and reproduce (or help their progeny), this is such a basic concept of life that I have no idea what else I could say to support it... Life's natural state is to remain alive and make more life

A philosophical conversation on the meaning of life is good.

People attempting suicide due to suffering caused by (treatable) mental illness is an entirely different thing.


While an impartial outs view may be able to say that living is the less optimal path, the desire to keep living is the basic principal of life as we know it. Culture views these ideations as something that needs to be treated as they are either a sign that some part of you is malfunctioning, or an evolutionary relic that now does more harm to society than good.

> Culture views these ideations as something that needs to be treated as they are either a sign that some part of you is malfunctioning, or an evolutionary relic that now does more harm to society than good.

Culture might want to look at itself for the answer to the question of why severe mental illness is on the rise.


But that's a separate problem. Figuring out how to prevent mental illness is obviously important, but figuring out how to help cure it when it does happen is important, too.

Suicidal ideation is by definition not healthy. You can argue the ethics of suicide (particularly assisted suicide, which I'm opposed to), but there is no situation where it's a good outcome. It can only ever be seen as the least worst outcome, and if we ever change our collective opinions on that I think we are far down a dark path to great evil.

There's a huge difference between considering suicide if you're terminally ill and in a lot of pain, vs. considering suicide because your life is not going well and you're really depressed, which is something that may be treatable, and I expect the vast majority of suicides are the latter and not the former. I personally know one such example.

As someone whose life has been affected by suicide, and almost affected much more seriously by a close call, I see suicide as the ultimate failure, and think we should be doing everything we can to help people escape from these ideas (and yes, I've done hard work to help someone who had these problems, and that person is definitely doing better, and enriching his own life and the lives of others because of it).

Our world is making us crazy and sick more than it should, so attack the problem at both ends. Figure out the causes and the cures and try to stop the first and accomplish the second.


You're saying suicidal ideation is "the natural state"?

I think he's saying non-existence is the natural state and the decision to live and expend energy gathering resources just to survive needs to be justified, rather than be expected to justify your wish to stop existing.

I think the counter to that is the idea that human life is inherently valuable and doesn't need to be justified.

You shouldn't make this argument without supporting it in any way. Why does it have inherent value? Life doesn't have inherent value to us as a collective society. Look at livestock. We've had countless pointless wars where people die horrible deaths. Abortion is legal in many parts of the world. Humans have made tons of negative impacts on our planet like tossing literal tons of plastic in the ocean.

I agree that human life is valuable, but you have to support your claim in some way. If you can't find a way to support it, then maybe the claim is wrong.


[flagged]


Because people start off with nothing essentially. And the statement on abundance is the same exact fallacy as Marx. Although to be fair it predated him in far /worse/ forms like many "thinkers" in Ancient Greece thinking conquest was the only way to obtain more wealth. They thought that if someone managed to conquer and enslave the entire world they wouldn't build any more wealth over time. Medieval economic philosophy had a denialism that merchants could be generating value without fraud because they presumed universal values of good. While exploitation may be real presuming that management and capital contribute nothing is just plain not anchored in reality.

Hunter gatherers have little social stratification but no real wealth inequality because they are limited to what they can carry personally and cooperative health is what keeps them alive. It takes a /lot/ of skill and knowledge to live on one's own in the wilderness without advanced tools like say a steel knife.

Productivity is what creates wealth in a meaningful sense. It can improve and boost living standards per person without a specialized pyramid scheme of labor. Proof? The fact that industrialized societies aren't over 90% farmers and haven't starved to death!

While raw inputs may come from land processing it is where the bulk of value actually comes from. If I gave you a claim to all of the gold in Antarctica it would be of very little value because of the extraction expenses.


"Because people start off with nothing essentially"

I do not believe this. In a world without private property, everyone is entitled to the world's land. Everyone has everything available to them. People survive off the land. Eventually these people don't want to just survive, so they begin to do a single thing all day (hunting, gathering, eventually farming) They trade the output of their labor (their wages of berries, food) for other peoples output.

The introduction of private property allows for some people to collect rent on productivity, without actually being productive. Private property is a tax on productivity and rent will always consume any excess production value.

Progress drives poverty, as well as any inequality in wealth only increasing as time goes on in a positive feedback loop.

"While exploitation may be real presuming that management and capital contribute nothing is just plain not anchored in reality."

I don't believe this either. I believe any rent-seeking is adverse to progress towards eliminating poverty. I see it as a failure of society to allow for the upper class to enjoy greater pleasures as time goes on at the expense of those born poor.

We are all guests on a floating spaceship rocketing through space. The idea of inheritance has no place in a free market in my opinion, it should be taxed as income for the recipient. Inheritance is the vessel through which wage equality is growing larger, in my opinion.


>Because people start off with nothing essentially.

This is disputed by figures as diverse as Aristotle, Spinoza, Hegel and Rousseau. It is not fact at least as presented here without discussion.

>While exploitation may be real presuming that management and capital contribute nothing is just plain not anchored in reality.

The theory of exploitation in Marx or post-Marx (even without the LTV) does not depend on the assumption that capitalists cannot add value. I'd suggest looking at the work of John Roemer and his work on PECP and CECP.

>It can improve and boost living standards per person without a specialized pyramid scheme of labor.

Was this ever cast in doubt? I'd also caution the application of a historical example to the society of today, since the applicability of the principle has not been proven.

>While raw inputs may come from land processing it is where the bulk of value actually comes from.

This is textbook Marx.


Without private property, you'd be subsistence farming and fighting off anyone stronger than you that wanted your land (since it wouldn't be privately owned).

How is labor being misappropriated if it's creating productivity?

"Humans have never made a single new thing, at least as far as I know. "

You're typing this on a phone or computer connected to the internet.

"The purchasing of people for labor has long been out of style"

What is the alternative to this that you think is in style?


The phone I (could) be typing this on, was made out of the earth, not from anything humans created. Anything with value is land that had labor applied to it.

The alternative to purchasing people for labor has been wages, which is giving back to a laborer the portion of their labor which is not stolen from them.

cubano 10 days ago [flagged]

Marx of course came up with these ideas, and much of the 20th century was filled with the unimaginable horror that the people of the world suffered as leaders such as Stalin, Mao, and Pol-Pot, to name of few, implemented them on a national scale.

I am totally unconvinced that any leader seduced by Marx would ever be someone I would care to live under.


Please keep generic ideological tangents off HN. They're predictable, therefore uninteresting, therefore off topic here.

https://news.ycombinator.com/newsguidelines.html


He didn't come up with it on his own - it was based on previous fallacies which also caused millennia of suffering. Bad economics taken seriously does that in general - many wars were fought under the gold standard to boost the effective economic cap imposed by deflation.

Falling for a model of thinking is certainly a sign of a poor leader.


I'm totally convinced that any leader seduced by Marx would be someone I would not care to live under.

Marx's ideas, aside from being wholly unrealistic, inevitably result in tyranny and misery because man cannot be perfected. If your worldview cannot survive the fact that a lot of people are assholes, it will always fail when you try to put it in practice.

If you look at the Acts of the Apostles, how they are describing the early Christian community sounds an awful lot like what communists are trying to achieve. And it worked, for a time, but this was a small group of zealous believers banding together because of both their beliefs and persecution from without. While this may be the ideal of Christian life, you have not seen any large-scale Christian societies working this way, outside of places like monasteries, where life is very strongly regulated, or other similar small groups (and those often go poorly as well), because it simply doesn't scale.

So we have to create a society that accounts for the fact that a lot of people are greedy and won't work for the common good. We counter that by first teaching that they should, but also allowing for something like capitalism where people's energies can be focused on something that at least has the potential to make others' lives better along with their own (the mythical "enlightened self-interest", which is possible).

The only other alternative is absolute totalitarianism, which is the worst condition humans can inflict on each other.


"because it simply doesn't scale."

How do you decide to believe that it is because of lack of scaling and not another factor? I believe wage inequality exists because private property is allowed to be held by citizens and rent taken for the lands productive use.

I think people should be able to own buildings, but the land should all be the governments. A Land Value Tax would be something I would be ecstatic to see. There should be no incentive to hold land and wait for it's value to rise. To do so is unproductive to society and incredibly productive for a single person's return on investment. But their investment is stolen from society at large. (of course theft is a matter of opinion, I don't mean to misconstrue what I believe is fact vs belief)


I thought Ketamine was considered a rape-drug and thus prohibited.

Not even remotely. You're thinking of GHB.

It is a common misconception though, perhaps bolstered by anecdotal experiences where the two drugs were confused. Larger doses of K can incapacitate you, so it's not totally off base to think it could be used in that way, but it's certainly not why it's banned by the DEA. It's banned bc of the drug war military-industrial complex.

Which, incidentally, also has perfectly legitimate medical uses - treatment of narcolepsy, anesthesia, etc.

As do cocaine, MDMA, shrooms, ...

Science might be finally gaining the upper hand in the drug war against political forces which won the public opinion battle back in the 70s. It's much harder to convince the public drugs r bad if 95% of the "hard" drugs have medical uses.


As well as recreational uses, for which purpose it is actually a rather benign substance when dosed correctly [1].

[1] https://hilaryagro.wordpress.com/2017/04/12/alright-lets-tal...



Virtually any sedative can be a "date rape drug". As that page notes, very-much-legal alcohol "is the drug most commonly used to help commit sexual assault".

Ketamine has substantial legitimate medical uses, and is thus legal in those situations.


Its a disassociative, and at high enough doses can make you loose grip of reality.

It also has a very distinct bitter taste, which would make it quite obvious if someone put it in your drink or similar.

Drugging someone else (wether that be with legal drugs or illegal ones) is allready prohibited, no matter the intent.


The first thing I associate it with outside of recreational human usage is horse tranquilizers.



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