Diagnosing Ketamine Addiction

 

Stepwise clinical workflow aligned with DSM-5-TR

Step 1: Identify a Concerning Use Pattern

  • Frequency (daily? binge?)
  • Dose escalation (tolerance?)
  • Route (intranasal, oral, IM, IV)
  • Context (recreational vs prescribed infusions)
  • Loss of control?
Red flags:
  • Compulsive redosing
  • High seeking
  • Using alone
  • Using despite bladder pain or cognitive decline

Step 2: Apply DSM-5-TR Criteria

Diagnosis requires 2+ criteria from the list below within 12 months.

Impaired control

  1. Larger amounts or longer than intended
  2. Persistent desire or unsuccessful efforts to cut down
  3. Significant time spent obtaining/using/recovering
  4. Craving another hit

Social impairment

  1. Failure to fulfill major role obligations
  2. Continued use despite interpersonal problems
  3. Important activities given up

Risky use

  1. Recurrent use in hazardous situations
  2. Continued use despite physical/psychological harm

Pharmacologic criteria

  1. Increased tolerance
  2. Withdrawal (less defined for ketamine; may include mood disturbance, anxiety, insomnia)

Step 3: Determine Severity

  • Mild: 2–3 criteria in 12 months
  • Moderate: 4–5 criteria in 12 months
  • Severe: 6+ criteria in 12 months

Step 4: Rule Out Differentials

  • Primary psychotic disorder
  • Bipolar disorder (mania)
  • Major depressive disorder
  • Other substance use disorder (e.g., stimulants, opioids)
  • Medication-induced dissociation (therapeutic ketamine)

Step 5: Assess Physical Complications

  • Urinalysis --> hematuria / cystitis features
  • LFTs --> AST/ALT elevations
  • Renal function tests
  • Cognitive screening

Step 6: Evaluate Psychiatric Comorbidity

  • Depression
  • PTSD
  • Anxiety disorders
  • Polysubstance use
  • Personality disorders

Step 7: Distinguish Therapeutic Use vs Disorder

  • Using outside supervised treatment?
  • Seeking early refills?
  • Escalating dose without supervision?
  • Using illicit ketamine in addition?

Step 8: Toxicology Testing (if needed)

  • Urine drug screen may require specialized testing for ketamine
  • Not always necessary for diagnosis
  • Diagnosis is primarily clinical

Step 9: Functional Impact Assessment

  • Occupational impairment
  • Academic decline
  • Financial strain
  • Legal issues
  • Relationship deterioration

Step 10: Contact a Psychiatrist

  • Find a local psychiatrist
  • Avoid telemedicine if possible
  • Stick to the plan