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Katy Vine (voice-over): Hi, and welcome toTM Out Loud, exclusive audio storytelling forTexas Monthly Audio subscribers. I’m Katy Vine.

Many Texans who live with depression, anxiety, chronic pain, or PTSD have found some relief from treatment with the psychotropic drug ketamine.

But as ketamine therapy has become more popular, Texas regulators have also been raising concerns about its risks to patients. This debate over its safety could leave lots of Texans without access to the drug.

Texas Monthly staff writer Sasha von Oldershausen has been following the debate, talking to nurses, patients, and regulators about the future of the treatment in Texas. This week onTM Out Loud, Sasha joined me in the studio to talk about her reporting.

Katy Vine: Hey, Sasha.

Sasha von Oldershausen: Hey, Katy.

Katy Vine: Thanks for being here.

Sasha von Oldershausen: Yeah, thanks for having me.

Katy Vine: So today, we’re gonna talk about a couple of stories you’ve written about ketamine therapy in Texas. One where you interviewed a nurse out in West Texas, and then another one was a longer piece. So when did you start hearing about ketamine therapy, and what were your initial reactions to that use?

Sasha von Oldershausen: Honestly, I started hearing about ketamine therapy after I was aware of its existence, and, like, you know, when you’re out and partying. I think just maybe a handful of years ago, yeah—I’d started to hear about these clinics that were starting to crop up. I knew there were ones in New York, and they were using ketamine as—like, in a therapeutic setting. I’ve always been interested in psychedelics as a form of therapy. So it immediately piqued my interest, especially because I’d encountered the drug before in other settings. I think it was one of those things where, like, I heard about it and then all of a sudden it was everywhere. You know? And I think that was kind of the experience of ketamine clinics, just cropping up sort of all at once.

Katy Vine: It really did feel like all of a sudden you turned around and they were in every corner. 

Sasha von Oldershausen: Yeah, yeah. Absolutely.

Katy Vine: You you’ve written a lot about West Texas, because you lived for—how many?—a couple years in Presidio, right?

Sasha von Oldershausen: Three years.

Katy Vine: Three years in Presidio. Which, if you don’t know where that is, listeners, look it up. ’Cause it is remote. And you chatted with Tammy Vaught, a nurse [anesthetist] and psychiatric nurse, about her experiences running a clinic that runs ketamine-therapy treatment. What were her experiences in Midland with the treatment? And how are clinics like hers viewed by those kind of communities in West Texas?

Sasha von Oldershausen: I was—I mean, I was immediately drawn to Tammy because of the fact that her clinic resides in Midland, which, you know, typically a pretty conservative place. When I think of sort of psychedelic treatments, or things like ketamine therapy, I typically associate that with a sort of more progressive mindset. And so it was kind of surprising to me that this person was operating a clinic in this space, and I was immediately curious to know what that was like.

Katy Vine: How’s that work in Midland? Yeah.

Sasha von Oldershausen: I mean, she has tons of patients, and there’s, like, a real need for it. I was really interested by the sorts of people she was seeing and sort of what they said. I think a lot of people who enter the ketamine-therapy space are veterans. You know, a lot of people have PTSD. She told me that a lot of her patients, or clients, a lot of them were worried about taking other kinds of therapeutic drugs, like ones that we commonly prescribe for symptoms of depression and anxiety. Particularly with men, you know, when you take certain antidepressants, it really can reduce libido. There were a lot of concerns around that. A lot of the men that she had spoken to were also concerned that somehow taking these drugs would impede their ability to own firearms. So there was a really interesting cultural element to why they were drawn to this sort of more unconventional, but potentially slightly more aggressive, therapy that you do over the course of weeks, as opposed to taking a pill for the rest of your life.

Tammy Vaught:  Ketamine, specifically, is what’s called a dissociative anesthetic.

Sasha von Oldershausen: Here’s Tammy Vaught. 

Tammy Vaught: So it takes them into a dissociative state. And that’s allowing them to, like, look upon trauma, look upon their current situation, and go, “Why am I letting that affect me so much? Why am I letting that have such a negative impact? That was from this many years ago. And I’m safe. I survived. Like, it was a part of my story. But it’s not, doesn’t have to be controlling my future.”

Sasha von Oldershausen: When I spoke with Tammy, I was curious because, again, she’s in the middle of the Permian Basin. You have this huge industry there. She talked a lot about, you know, the sorts of pressures that people who work in oil and gas deal with. There are a lot of accidents. Death.

Katy Vine: At all levels. It’s pressure.

Sasha von Oldershausen: Absolutely, yeah. If you’ve seenLandman, there are tons of accidents happening at all times. It can be a traumatic place. If you’ve ever been out to Midland-Odessa, it’s, like, a harsh climate. You know? It’s tough.

She said that a lot of the people who move there are moving for work, and then they do these, like, intense two-week-on, two-week-off kind of schedules, and they don’t see their families as much. So there’s a depressive element to that. And then a lot of them are kind of resorting to alcohol or other kinds of drugs to cope. And so, I think this has been a real balm for people who don’t really have anywhere else to turn. And there’s still a lot of stigmas around mental health in Texas, I think particularly in sort of rural spaces. I think ketamine therapy—because it has this sort of alternative vibe to it—is maybe more appealing to people than your sort of typical, you know, therapy, antidepressants. So I think it’s been hugely helpful for that kind of population. 

Katy Vine: What is the importance of these clinics for safe injections? Ketamine usage is largely unmonitored, according Tammy, right? So—

Sasha von Oldershausen: Yeah. So ketamine—which is a dissociative drug—has been around since the 1970s. It was approved by the FDA as a surgical anesthetic. People started to document that after patients woke up from surgery, having used ketamine during their surgery, that they reported increased, better mood. Now that people are starting to use it within a mental health space, the complication is that the FDA hasn’t approved it for that use. So these ketamine clinics are actually using ketamine in an off-label-use kind of way. And because of that, there are very few regulations. And that’s what has been a challenge for these clinics. 

Katy Vine: And you wrote about this in November, about a month before the Texas Medical Board was meeting to reconsider its rules around low-dose ketamine. You mentioned there’d been a wrongful death lawsuit brought against a telehealth company related to ketamine overdose. What objections were state regulators raising? 

Sasha von Oldershausen: Well, Katy, I want to distinguish between—so, the wrongful death case was under a company called Mindbloom, which is telehealth. And there’s been this kind of controversy between ketamine clinics on the ground in Texas and the Texas Medical Board, which has been sort of cracking down on regulations.

Proponents of ketamine therapy in Texas say that it’s a much safer avenue to be in a clinical space, with paramedics or nurse practitioners or nurses administering the ketamine, than it is to purchase, basically, ketamine off of these telehealth providers that basically emerged during the pandemic. Because there’s nobody on-site administering the drug. You’re basically administering it yourself. 

But what’s been happening in the clinic space in Texas is that the Texas Medical Board, because of concerns around the safety of the drug, have been have decided to implement what they call “office-based anesthesia” rules, which means that an actual physician has to be on-site at all times.

A lot of these clinics don’t operate that way. They have a remote physician associated with the clinic, but then they actually operate day-to-day with just nurses and nurse practitioners. And many of these clinics say that it would be financially unviable for them to actually hire and have a physician on-site at all times, forcing some to shutter.

One clinic recently closed in Lubbock. And Tammy, whose clinic is in Midland, said that she’s been seeing tons of patients from that Lubbock clinic. Which, you know, they’re driving hundreds of miles to reach her for this treatment. So, it’s really putting people who rely on these forms of therapy in a difficult situation, and they might then resort to telemedicine providers, where they have no one, you know, monitoring them on-site.

Katy Vine: What would happen if you had, say, schizophrenia, or you had bipolar, and went onto a telemed site and got the drugs? I would imagine that you could have major problems. You could have a psychotic break, right? I mean, if you are undiagnosed with some serious mental health issues before getting ketamine, that can end very poorly, right?

Sasha von Oldershausen: Absolutely.

Katy Vine: So that’s why it’s important to make sure that there are some kind of regulations in this space.

Sasha von Oldershausen: Yeah, yeah. And the people who are running these clinics also want more regulations around the space. I mean, a concern too is that even though ketamine that is being administered within a mental health space is a much lower dose than you would see in, like, a surgical space . . . So, whereas when you’re in surgery, you’re unconscious, with ketamine therapy, you’re fully conscious. You’re just kind of in a dissociative state of mind. But the people who have expressed concern around this therapy say, you know, like, if you have your classic veteran dealing, struggling with PTSD, they might be taking, like, fentanyl patches for pain, or any number of different kinds of drugs. And when you add ketamine to that equation, it could potentially, like, tip them over the edge, and then suddenly they’re not breathing anymore.

So there are very real risks to this kind of drug. I think, ultimately, what everybody wants is some kind of regulatory framework for making sure that people are safe. The people, the folks who are running these clinics, are saying that what the TMB—the Texas Medical Board—has proposed, of having this “office-based anesthesia” with physicians in the office, just doesn’t make sense.

Katy Vine: Just for people who aren’t familiar, when we’re talking about these therapies, it’s not like they go into a room and are just given the drug and the person walks away, right? 

Sasha von Oldershausen: Yeah. So, in my experience of walking into Tammy Vaught’s space, for example, you walk into this room, and it’s, like, very well-appointed, very comfortable. There’s a lounge chair, there’s a stereo for music. It’s just a very calm, peaceful space. Ketamine will be administered either by IV or an intramuscular shot. There’s a nurse, typically, that’s sitting with you at all times, just monitoring if you’re having any sort of, like, anxiety symptoms, or . . . one of the common side effects is nausea. You know, they’re there to to assist and support you. It’s a very, like, kind of controlled space. I think people have this idea that there’s, like, sort of this Wild West of ketamine therapy, but it feels very much like walking into a therapist’s office.

Katy Vine: I wrote a little bit about the ketamine-therapy centers in 2021, when I started noticing them everywhere. There were all these new ketamine clinics opening in Texas, but folks I talked to also expected other drugs to get FDA-approved soon after that. I heard predictions that MDMA, or ecstasy, would be approved as a PTSD treatment, maybe as soon as 2023, and that by 2025 psilocybin—also known as psychedelic mushrooms—would be approved to treat depression. What I was hearing then was that these ketamine centers were just kind of placeholders. They were sort of staking out the space, so that when those drugs were approved, they could kind of switch over to some other kind of drugs, not ketamine.

But instead, in 2024 the FDA rejected MDMA, at least for now. The year before, they issued a warning about some ketamine products. It’s 2026, and psilocybin still isn’t approved—though a drugmaker has applied and hopes to get approval later this year. It looks like things are moving a little slower than folks predicted five years ago. It feels like someone kinda hit the brakes. Is there still momentum behind expanding the medical use of psychedelics in Texas?

Sasha von Oldershausen: I think there is, but the attention is, like, focused to other drugs, specifically ibogaine, I would say. Rick Perry has been a huge advocate for ibogaine. And a lot of the veterans I spoke to actually saw ketamine therapy as a placeholder for this very powerful drug that they say has had, like, huge, huge impacts on the veteran community. I have this stat in my story, which was mind-blowing to me, that the number of military personnel who’ve died by suicide since the wars after 9/11 is something like 140,000, compared to 5,800 who died in combat. That is mind-blowing to me.

Katy Vine: It’s unbelievable. It’s so shocking, and I think anybody who feels like hitting the brakes hard needs to take a good look at those numbers. It’s like, this is what—this is what they’re up against, is desperation.

Sasha von Oldershausen: Absolutely. We need standards; we need regulations. But is having a physician on-site the most imperative thing here?

Katy Vine: When you’re looking at those numbers. That suicide number.

Sasha von Oldershausen: Right.

 Katy Vine: Yeah. Okay. Thanks for sitting with me, Sasha.

Sasha von Oldershausen: My pleasure.

Katy Vine (voice-over): That was my conversation with Sasha von Oldershausen.You can read her coverage of ketamine therapy in Texas—and the politics around it—at texasmonthly.com. . . . We’ll be back with more from the pages ofTexas Monthly next week.

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