The “Ketamine Queen” is headed to prison. On April 8, Jasveen Sangha was sentenced to 15 years in prison in connection with Matthew Perry’s 2023 overdose death. She sold Perry the vial of ketamine that killed him. 

But Sangha’s sentencing isn’t the only ketamine story right now. There have also been reports of deaths allegedly linked to telehealth clinics prescribing ketamine for depression and any other number of ailments. But just a few years ago, the story around ketamine seemed radically different. It was called a “breakthrough” in mental health treatment, reported to show “promise” in reducing PTSD symptoms, and has been said to give people their life back after severe depression. Telehealth services offering ketamine straight to your doorstep cropped up in response, some promising depression treatment, but others claiming that ketamine can treat a variety of ailments from alcoholism to restless leg syndrome. It’s also reported to be among Elon Musk’s favorite drugs, allegedly the campaign trail fuel that produced some of Musk’s weirdest moments (he denies this).

So, which is it? Is ketamine a dangerous and deadly club drug, a mental escape favored by the ultra-rich, or a wonderdrug with the potential to radically change people’s lives for the better?

Caleb Alexander, MD, MS, professor of epidemiology and medicine at the Johns Hopkins Bloomberg School of Public Health, thinks ketamine’s good press got way ahead of the evidence. 

“I am hesitant to be the skunk at the picnic, but [ketamine] is a fundamentally dangerous drug,” he said. “Keep in mind all drugs have risks, but ketamine is really a much, much more dangerous drug than most that we prescribe.”

Developed in the 1960s as a battlefield anesthetic, ketamine continues to be used in clinical settings for its sedative power. According to the Drug Enforcement Agency (DEA), ketamine “distorts the perception of sight and sound and makes the user feel disconnected and not in control. It is referred to as a ‘dissociative anesthetic hallucinogen’ because it makes patients feel detached from their pain and environment.” In 2019, the FDA approved esketamine, a “chemical cousin” of ketamine, for treatment-resistant depression in nasal spray form. 

Since then, ketamine has gone from a substance administered in highly controlled environments to something prescribed off-label that you can legally access from your couch. Dr. Alexander is concerned. 

“The primary effect of ketamine is to produce an altered state of consciousness. The magnitude of its effect varies by individuals,” he said. “It produces changes in perception, mood, behavior, and cognition. These changes aren’t always immediate or short lived. It’s not predictable.”

The evidence supporting that migration, Alexander says, is “tenuous at best” — limited to short-term studies, and compromised by a basic problem: it’s hard to run a blinded trial when one group is getting “high as a kite” and the other isn’t. As for the wilder claims made by telehealth clinics, he rates them on a spectrum from “questionable to pants on fire, outright lies.”

“There’s nothing not to like about the idea that a product may be able to produce a significant change in the trajectory of one’s depression and life,” Dr. Alexander said. “The question is, what’s the evidence? And unfortunately the evidence isn’t there.” 

Other researchers push back. “It’s a drug that I’m convinced has saved people’s lives, undoubtedly,” Dr. Gerard Sanacora, the director of the Yale Depression Research Program, told the New York Times last year. Robert Meisner, MD, medical director of the Ketamine Service in the Psychiatric Neurotherapeutics Program at McLean Hospital said he believes “strongly in the utility of ketamine for the right patient in an appropriate setting” in a statement about his own research that found ketamine to be an effective depression treatment. But both experts share the same caveat: outside a clinical setting, ketamine is a different animal entirely.

The risks are real. Ketamine can knock you out. It can produce euphoria or suicidality, sedation or violence. These effects aren’t always immediate or short-lived. In overdose, it causes unconsciousness and dangerously slow breathing. It interacts badly with a long list of common substances: alcohol, cocaine, marijuana, Xanax, Adderall.  

Dr. Alexander isn’t convinced there’s a safe way to use ketamine at home. And, many of the pop-up ketamine clinics that offer the drug in an out-patient setting might get that same warning. Peter Grinspoon, MD, a primary care physician and a board-certified addiction specialist at Massachusetts General Hospital, wrote for Harvard Health Publishing that there are no definitive answers on how to find a safe or reputable ketamine clinic. Posing as a potential patient, Dr. Grinspoon called multiple clinics and found few barriers to access if he was willing to pay for the drug. Only a few clinics asked for a diagnosis from a psychiatrist. 

Perry was receiving ketamine infusion therapy, according to NBC News. His last infusion was reportedly a week before his death. Reports indicate that Perry developed a dependence on the drug, and began using it recreationally, without supervision.

Still, some research has pointed to telehealth ketamine being “largely safe.” For people with serious, treatment-resistant depression, ketamine may genuinely be lifesaving. But for everyone else, Alexander has simpler advice: 

“Just have a martini.”