Telehealth Ketamine for Substance Use Disorders

The use of ketamine to treat addiction and substance use disorders represents one of the most exciting—and most controversial—frontiers in ketamine research. Emerging data suggests ketamine may meaningfully affect alcohol use disorder, cocaine dependence, opioid use disorder, and nicotine dependence. But this application also carries unique safety considerations that make the telehealth delivery model complex.

The Science Behind Ketamine for Addiction

Why Addiction?

Substance use disorders share neurobiological features with depression—impaired reward circuitry, reduced neuroplasticity, and dysregulation of the glutamate system. The same NMDA receptor blockade and BDNF release that underpins ketamine's antidepressant effects may address mechanisms underlying addiction.

Specific proposed mechanisms include:

• Disruption of maladaptive memory consolidation: Addiction involves strong learned associations (cues triggering craving). Ketamine given during cue exposure may interfere with the reconsolidation of these memories
• Neuroplasticity for new learning: The BDNF surge may facilitate the formation of new, healthy behavioral associations to replace addiction-maintaining ones
• Acute reduction in craving: Some studies show acute anti-craving effects in the hours to days following ketamine administration
• Antidepressant effects: Addressing co-occurring depression reduces a major driver of relapse (see telehealth ketamine for depression)

The Evidence

Alcohol Use Disorder (AUD): The best evidence base for ketamine in SUD is for AUD. A landmark 2019 randomized controlled trial by Dakwar et al. demonstrated that a single IV ketamine infusion combined with mindfulness-based therapy produced significantly higher abstinence rates than midazolam plus mindfulness. A UK KARE trial also showed ketamine plus psychological therapy was superior to standard treatment.

Cocaine Use Disorder: Smaller studies and case series suggest ketamine may reduce cocaine craving and use, though the evidence is less robust than for AUD.

Opioid Use Disorder (OUD): Using ketamine in patients with opioid use disorder requires special care because of pharmacological interactions and shared dissociative mechanisms. Some research suggests benefit, particularly for patients with co-occurring depression. This application is being explored at academic centers.

Nicotine Dependence: Very preliminary evidence from a small trial suggests ketamine may enhance smoking cessation attempts.

The Telehealth Model for SUD: Special Cautions

The Fundamental Tension

Ketamine is itself a substance with misuse potential. Using a drug with addictive properties to treat addiction creates an obvious tension that requires careful management. In an in-person clinical setting, this tension is managed through close monitoring, limited supply, and direct clinical observation. In the at-home telehealth model, these safeguards are substantially reduced. For more on how programs handle this, see our article on preventing misuse.

Who Is NOT Appropriate for Telehealth Ketamine for SUD

• Active alcohol use disorder: Combining alcohol and ketamine is dangerous (anesthetic interaction, CNS depression). Patients with active heavy drinking are not appropriate for at-home ketamine. Some platforms require documented sobriety periods before considering enrollment.
• Active stimulant use disorder: Stimulants and ketamine have cardiovascular interactions that are difficult to monitor remotely.
• Active ketamine or dissociative misuse history: This is an absolute contraindication for virtually all telehealth platforms. Prescribing ketamine to someone with a history of ketamine misuse is fundamentally contraindicated.
• Active opioid use disorder without medical treatment: Patients with unmanaged OUD are not appropriate for at-home ketamine without extensive safeguards.

Who Might Be Appropriate

• Patients with alcohol use disorder currently in recovery (significant sobriety period, stable in treatment) with comorbid depression
• Patients with nicotine or cannabis use disorder with comorbid depression where ketamine's primary indication is psychiatric
• Patients whose substance use is in sustained remission and whose primary current diagnosis is a depressive or anxiety disorder

What Responsible Programs Require

If a telehealth platform is willing to evaluate patients with SUD history, it should require:

• Documentation of sobriety period or current substance use status
• PDMP review specifically for opioid and benzodiazepine history
• Random urine drug testing (some programs can coordinate this via mail-in test kits)
• Mandatory coordination with a SUD treatment provider or addiction medicine specialist
• Smaller initial dispensing quantities with more frequent refill evaluations

Emerging Specialized Programs

A small number of addiction medicine specialists and specialized clinics have begun integrating ketamine into structured SUD treatment programs. These are primarily in-person programs but some have telehealth components for follow-up:

• Academic medical centers running IRB-approved ketamine for AUD studies (clinical trial participation may be available)
• Addiction psychiatry practices that include ketamine as an adjunct to MAT (medication-assisted treatment) for appropriate patients
• Integration-focused programs that combine ketamine with intensive motivational interviewing and relapse prevention counseling

These programs are not available at scale through consumer telehealth platforms as of 2025. This remains an emerging area.

The Ethical Dimension

The use of ketamine for addiction raises ethical questions worth considering: Is using a dissociative substance to treat addiction appropriate? What are the dependency risks if ketamine itself is used regularly in an addiction context? How do we ensure that harm reduction goals are met and not undermined?

Most practitioners in this space approach ketamine for SUD with: structured, time-limited protocols (not indefinite ongoing prescribing), mandatory therapy integration, strict exclusion of patients with ketamine misuse history, and regular reassessment of the benefit-to-risk ratio. These safeguards matter enormously in this population.

References

• StatPearls: Ketamine — Comprehensive clinical reference on ketamine pharmacology, mechanisms of action, and therapeutic applications
• PubChem: Ketamine Compound Summary — NCBI chemical database entry with ketamine molecular data, pharmacokinetics, and bioactivity profiles
• MedlinePlus: Ketamine — National Library of Medicine consumer drug information on ketamine including uses, proper administration, and precautions
• NIMH: Depression — National Institute of Mental Health overview of depressive disorders, treatment-resistant forms, and emerging therapies
• WHO: Depression Fact Sheet — World Health Organization global data on depression prevalence, burden, and treatment approaches