Opinion | Why Are Ketamine Ads Following Me Around the Internet?

A few months ago I started noticing that I couldn’t open Instagram or TikTok without getting an ad for ketamine. I had previously only known ketamine as an illegal drug that could cause dissociation, taken by acquaintances in the dank basements of my misspent youth, or as the sedative given to my older daughter when her broken arm needed to be reset in the hospital.

These ads promised incredible, groundbreaking mental health outcomes through ketamine tablets offered via telemedicine, with the vast majority of patients purportedly finding relief from their depression and anxiety. Some experts have cautioned that ketamine, which is a Schedule III controlled substance, is not ready for general use, citing a “lack of long-term data, potential for troubling side effects and possibility for abuse,” as one researcher noted.

I didn’t hear about any of these concerns on TikTok. I only heard about the miraculous benefits of ketamine. Few of the social posts served to me disclosed the fact that promoting ketamine tablets in this way was an off-label use of the medication.

Ketamine wasn’t the only mental health treatment I would be offered on social media. I was also frequently getting ads that tried to convince me that I had undiagnosed A.D.H.D., listing symptoms like “fidgeting” (which I do constantly, and always have) as a behavioral red flag. While fidgeting could be a symptom of A.D.H.D., it could also be a symptom of restless leg syndrome or a common response to stress, boredom and anxiety that doesn’t require treatment. I’m certainly not equipped to tell after just seeing a few Instagram reels.

Other posts warned that “overthinking” and “overanalyzing” could be other signs of A.D.H.D. (Or they could just be signs of being an opinion journalist.)

The bombardment only got worse when I decided to take a brief quiz offered by one of the ketamine purveyors to see if I was an appropriate candidate for this treatment. I answered these questions honestly: I wasn’t pregnant. I haven’t ever been suicidal or diagnosed with a primary psychotic disorder. I do have a history of clinical depression and anxiety, though I haven’t had a significant episode since 2012. These days I do feel depressed and anxious — probably as often as any sentient human in the 21st century.

In about five minutes I was told I was a fit for telehealth services, which could include a few consultations with a clinician and several ketamine tablets sent directly to my home, with zoom guidance offered before and after ingesting the drug for the first few sessions.

When I didn’t go through with buying the package, which would have set me back a few hundred dollars and wasn’t likely to be covered by any insurance, the marketing became even more aggressive. I received follow-up emails and texts, with offers of $100 off my introductory program. In fact, I just got one as I was writing this paragraph, which touted the incredible, “science-backed” benefits of ketamine but did not list a single risk of the drug. I had to click through the ad and then click about five more times on the website to find a list of the side effects, which include slurred speech, anxiety (which the drug claims to ameliorate) and, in rare cases and with heavy use, urinary incontinence.

Last week, my Times colleague Chris Hamby published a big investigation into the telehealth providers connecting patients with ketamine. He explained that a pandemic-related loosening of telehealth laws in 2020 allowed for the prescribing of controlled substances remotely and this led to an increase in the availability of ketamine. “The shift away from clinics has led many patients to take the drug more frequently and for longer periods of time — multiple times a week, even daily in some cases, and for months or years — despite scant research on safety,” Hamby wrote. Before the telehealth rules were relaxed, “patients needed to first meet in person with a doctor and treatment was mostly limited to infusions in clinics,” he added.

Hamby spoke to “more than 40 patients who said their access to the drug was expanded through telehealth” and found that while some said they were helped by taking ketamine, others admitted to abusing their prescriptions and concealing resulting health issues from their providers. Two people Hamby spoke to felt embarrassed about potentially permanent bladder issues (as Hamby reported, “when taken chronically in high doses, ketamine can cause severe bladder damage”).

As The Wall Street Journal reported in 2022, some of the companies selling direct-to-consumer A.D.H.D. medications since the loosening of telehealth regulations have already run into legal trouble. The Journal reported that some clinicians for the online mental health start-up Cerebral, which offered Adderall for A.D.H.D. via telemedicine, did not have the proper credentials in psychiatric care.

“When customers signed up, Cerebral asked them if they were interested in being prescribed a controlled substance so they could be routed to a nurse practitioner with a license to prescribe such medication. This isn’t a question typically asked on intake forms in a psychiatry office and was designed to give clients the drugs they wanted, said people familiar with the intake process,” The Journal found. (Subsequently, major pharmacies have refused to fill prescriptions for controlled substances issued by the telehealth companies Cerebral and Done, which also prescribed Adderall. Cerebral told The Journal that only a “single digit percentage” of its patients were given a controlled substance to treat A.D.H.D. and it has now stopped prescribing Adderall to treat the disorder in new patients.)

On Feb. 24, the Drug Enforcement Administration announced that it was planning to tighten the rules around prescribing or refilling controlled substances via telemedicine, which would include ketamine, and put a damper on the free-flowing prescription of the drug.

I believe these changes would be more effective if they were paired with enhanced regulation of online pharmaceutical advertising. It’s one thing to be followed around the internet by a pair of designer boots you covet that are out of your price range. It’s quite another to be stalked by prescription drug advertisements for potentially addictive medications, some of which are violating even the very lax online guidance around prescription pharmaceutical advertising that currently exists in the United States.

The United States and New Zealand are the only two developed countries where it is legal to advertise prescription pharmaceuticals direct to consumers (D.T.C.). Though the American Medical Association has called for a ban on D.T.C. pharmaceutical advertising, it’s highly unlikely that these ads will go away, as Vox’s Emily Stewart argued in a recent article. A law professor told Stewart that these ads are here to stay because of the way “courts have interpreted the First Amendment to protect commercial speech.”

In 2020, The Washington Post’s Nitasha Tiku reported that drug companies were “growing bolder” about advertising on social media, and that the increased number of ads exposed “loopholes around the way data can be used to show consumers relevant ads about their personal health, even as both social networks and pharmaceutical manufacturers disavow targeting ads to people based on their medical conditions.” In the intervening three years, there have been no updates to ad regulation: The last time the F.D.A. issued non-binding guidance about social media D.T.C. advertising was 2014, which is approximately 10,000 years ago in social media time.

According to an email from an F.D.A. spokesperson, prescription pharmaceutical advertising is supposed to “present both benefit and risk information to best serve the public health.” Though some telehealth companies, depending on how they are structured, may fall outside the F.D.A.’s regulatory purview, the spokesperson said.

In STAT, Thomas J. Moore and G. Caleb Alexander argue for closing that telehealth advertising loophole. But the issue is bigger than that. In December, The Wall Street Journal’s Khadeeja Safdar and Andrea Fuller published an investigation into whether D.T.C. social media ads on Meta platforms were adequately balancing the benefits and risks of the drugs they were touting. Safdar and Fuller wrote:

In a four-week period spanning October and November, about 20 companies ran more than 2,100 ads on Facebook and Instagram that described benefits of prescription drugs without citing risks, promoted drugs for unapproved uses or featured testimonials without disclosing whether they came from actors or company employees.

Their article doesn’t cover the dark social marketing I received from the ketamine purveyor over text and email, which felt more personal and invasive. In the aftermath of The Journal’s investigation, lawmakers have called for more regulation of social media advertising, though there were few details about what that might look like.

At the bare minimum, there should be a binding requirement — not just suggested guidance — that the risks of a medication be given equal weight and presentation to the benefits, even when there are character limits. The F.D.A.’s own researchers have found that some online advertisements seen on mobile phones write the risks in smaller font, present them after the benefits or link to a landing page that includes only benefits and no risks at all.

A so-called miracle drug may not seem so miraculous if it’s understudied or poses a known risk for addiction. We should all be well-informed before making that choice.

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