Ketamine works. That’s the inconvenient part. For treatment-resistant depression and certain pain conditions, the evidence is genuinely promising, and for some patients it has been life-changing. The problem is not the molecule. The problem is the business model now built around it — telehealth scripts mailed to apartments, infusion clinics on strip-mall leases, and a regulatory posture that looks unsettlingly familiar to anyone who watched OxyContin get marketed in the 1990s.
The structural similarities are real
In the late ’90s, opioids were repositioned from end-of-life pain medication to a routine prescription for chronic conditions, backed by aggressive marketing, pliant pain-management clinics, and assurances that addiction risk was overstated. Ketamine is now being repositioned from a controlled anesthetic and short-term depression intervention to a long-running maintenance therapy, often delivered through clinics with minimal psychiatric integration and telehealth platforms that prescribe lozenges after a 30-minute video visit. The financial incentives push toward more sessions, longer courses, and looser screening. The drug has well-documented dissociative, cardiovascular, and bladder toxicity risks at chronic doses, and a meaningful abuse potential that the industry tends to soft-pedal in its marketing.
Where oversight is failing
The FDA has approved one nasal spray, esketamine, with a strict in-clinic monitoring requirement. Almost everything else operating under the “ketamine therapy” umbrella is off-label use of generic ketamine, which is legal for licensed prescribers but largely uncoordinated. The 2020 federal flexibilities that allowed controlled-substance prescribing via telehealth, originally a pandemic measure, opened a lane that ketamine startups drove a truck through. State medical boards are inconsistent. Death of actor Matthew Perry in 2023, with ketamine cited as the primary cause, briefly drew attention but didn’t change the regulatory architecture. Meanwhile patient volumes keep growing, and the long-term data on chronic at-home dosing barely exists.
What responsible use would look like
A defensible ketamine treatment model includes psychiatric evaluation by a clinician who isn’t financially tied to the dosing schedule, clear endpoints rather than indefinite maintenance, integration with talk therapy, in-person dosing for higher-risk patients, and honest informed-consent conversations about urinary tract damage, dependence, and tolerance. Some clinics do this. Many don’t. The ones cutting corners are competing on price and convenience with the ones doing it right, which is precisely the dynamic that turned pain clinics into pill mills two decades ago. Patients are not equipped to tell the difference from a website, and insurance coverage is patchy enough that the cash-pay model rewards volume over caution.
Bottom line
Calling ketamine the next opioid crisis is a warning, not a prediction. The drug has real therapeutic value that should not be lost to overreaction. But the combination of weak federal oversight, telehealth loopholes, chronic dosing without long-term safety data, and a venture-backed clinic boom is the same recipe that produced the last disaster. The honest move now — before the casualty count is large enough to force a crackdown — is tighter prescribing standards, mandatory integration with mental health care, and an end to mail-order dissociatives sold like vitamins.
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