A prolific prescriber of sublingual ketamine telemedicine, Scott William Smith, MD, closed his practice as of Wednesday after losing his ability to prescribe controlled substances. The closure has prompted a wave of frustration from patients being cut sharply, as well as questions about the long-term viability of online access to controlled substances.
According to an email to patients from Smith that was posted on Reddit and verified by the Washington Postthe Drug Enforcement Administration (DEA) suspended Smith’s controlled substances license and ordered him to close his practice.
“My privileges to prescribe controlled substances have been suspended until further notice,” Smith wrote in the email. “I’m quite shocked about this.”
His website now reads, “Contact us via the Patient Portal for record transfer and referral assistance to providers in your area due to our practice closing.” The reason for the suspension and closure is still unclear, and Smith has not responded to multiple requests for comment from MedPage Today in time for publication.
Smith has been licensed in at least 45 states, according to a precedent Washington Post story and had built an active patient pool of over 3,000, largely on Reddit where he posted as u/KetamineDrSmith in a subreddit where patients exchanged information about ketamine treatment. He was based in South Carolina.
He told the Washington Post that access to the drug was critical for his patients: “I’m like a medic running to the battlefield tending to the wounded, and ketamine helps the people I care for.”
According to information from his website and gleaned from online accounts, the treatment model was similar to other telehealth platforms: Patients would see Smith for an initial video and have follow-up appointments with his staff, which included therapists. licensed, nurses, and “ketamine coaches.” The patients took the sublingual troches themselves at home, without medical supervision. The treatment cost $250 a month, not counting the ketamine.
The easing of restrictions during the COVID-19 public health emergency (PHE) in the United States allowed Smith and others to see patients and prescribe controlled substances via video visit, and gave rise to the success of a number of online platforms such as Mind Bloom and Nue Life. The demise of PHE has led to a number of proposed changes to the DEA’s rules, including a return to requiring an in-person visit to prescribe controlled substances. The deadline for the start of the standard, however, was recently extended to November 11, 2023, with an extra year for those with pre-existing telemedicine relationships.
A nasal spray derivative of ketamine known as esketamine (Spravato) is approved by the FDA for the treatment of treatment-resistant depression and related symptoms. Other forms of ketamine, a sedative that has traditionally been used during operations as a pain reliever or anesthetic, are increasingly being prescribed off-label. These include pills, tablets and infusions. According to Smith’s website, patients were getting their monthly prescriptions of ketamine sublingual tropes through local pharmacies.
Ketamine’s reputation as a party drug, plus its side effects, and lack of randomized controlled trials to establish its safety and efficacy for long-term use have attracted skepticism, even from physicians concerned about the widespread off-label prescribing for home use, without supervision, has exceeded available research.
“There is very minimal data to support the use of ketamine at home,” said Gerard Sanacora, PhD, MD, a professor of psychiatry and director of the depression research program at Yale in New Haven, Connecticut, who has treated patients with ketamine and wrote about its role in treating mood disorders. “The downside is that it’s incredibly expensive to get quality data. So it’s difficult.”
But ketamine’s potential for side effects and abuse has been well established. Sanacora emphasized the risk of bladder injury, bladder disease, potential neurotoxic effects, and addiction. “It’s not risk-free by any means, so how to balance the potential benefits of access versus the potential harms is really difficult,” she said.
Members of the subreddit for medical professionals, r/medicine, put their criticisms of prescribers like Smith in the strongest terms. “These sketchy ketamine clinics will ruin a promising treatment,” wrote one commentator who identified himself as a hospitaller.
Another identified emergency medicine doctor wrote, “If you market yourself by prescribing only one thing (ketamine, testosterone, Adderall, etc.), then you’re not a doctor, you’re a drug dealer.”
But patients who say they depend on it for life-saving treatment think otherwise. Immediately following the news of Smith’s practice closing, panicked patients flocked to Reddit to voice their grievances, voice their support for Smith, and seek advice.
“Dr. Smith and his team saved me from suicide. I don’t know what I’ll do without him and his team,” wrote one Reddit user in the r/TherapeuticKetamine subreddit, a sentiment that appeared on the thread many times. Another wrote, “The DEA has blood on their hands. No warning. Wish we could report them.”
Another wrote, “Absolutely heartbreaking. My routine seems like the only thing keeping me going these days after losing both my parents in the past 6 months; I’m definitely beside myself.” Yet another argued that “beyond the obvious therapeutic value, services like Smith’s provide a safe supply. No matter why you use drugs, the harm is greatly reduced when purity is assured by a doctor.”
The DEA did not respond in time for publication to a request for comment on the reason for suspending Smith’s statute of limitations privilege. For now, patients are turning to other online providers.
“There are some unscrupulous people who do things that are clearly not in the best interest of the patient,” Sanacora said. “But I think there are a lot of providers out there who really think they’re doing what’s in the patient’s best interest, but are likely to act on very limited data.”
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