Even if your insurance covers the "majority" you are still paying hand over pocket, most treatment centers give you a more convenient maintenance drug by now. If they try to give Nuedexta, punch them in the face or refuse. I tried it and was not impressed.
Last I checked, Ketamine Avocacy Network was "against" any form of Ketamine other than IV drip, because IV drip is the most potent. Well ****, I think Mercedes Benz (or whatever) is the best car, but most people don't walk on bare feet until they can afford one.
Who can prescribe? Any medial doctor. That doesn't mean they will. They have to understand the difference between. ACTIVE INGREDIENT and SAFETY.
Most psychiatrists under no circumstances are ever going to put an IV drip into your arm, ever. Ketamine in IV is absorbed rapidly which can make it have more dramatic effects, which gives them liability concerns. This is based mainly on liability concerns but also because they would have to buy equipment etc.
Ketamine sublingual is the same ACTIVE INCREDIENT but it does not have the same SAFETY profile because it absorbed much more slowly. Hence there doesn't need to be a Dr, a Nurse, an orderly, a Priest and a Rabbi on hand all waiting for you to have an accident. You just need to monitor blood pressure before and after taking the drug. If you have not had any dangerous reactions to Ketamine 40mg IV b(normal dose), you should start with 50 mg sublingual and titrate up to 100 mg, see how that affects you.
Here is a thought experiment: the first doctors that invented stimulants for ADD only used IV administration. This is a dangerous enough method that the ACTIVE INGREDIENT acquires a bad reputation and requires all sort of safety measure. IV amphetamines would rapidly spike blood pressure. Ketamine is the same, in that its history of use as an IV drug affects its perceived SAFETY profile.
Any doctor can prescribe, any compounding pharmacy can make the necessary formula of 100 mg / mL Ketamine Solution, accompanied with an oral syringe. Anaesthesiologists routinely Rx Ketamine. You have to choose which flavor you want.
Read the book Ketamine for Depression by (Steven, I think) Hyde. Sublingual is not new, it just is not in as widespread use. Unfortunately most doctors do not consider "reading" part of their job description, (or don't have the time), you might have success with a book report.
Bioavailability matters because if Ketamine hits your stomach it is rapidly metabolized into Norketamine, which gives inebriation side effects without therapeutic effect. IV bioavailability is close to 100%, so a 40mg dose IV is equivalent to 40mg total. Sublingual bioavailability is about 30%, so a 100 mg sublingual dose will give you only the equivalent of 30 mg IV.Increasing the dose (the amount of liquid in your mouth) rapidly hits diminishing returns. You only have a bit of sublingual tissue, once that is coated with Ketamine adding more into your mouth will just end up being oral (i.e. it is metabolized through your stomach) with a low bioavailability of about 10%. My doctor is going to ask about higher concentration Ketamine, like 200 mg / mL solution.
You may find the potency a bit lacking, 200 mg / 2x / week works for me and for my purposes of lowering my Parnate tolerance. Depends on the IV dose you were using. If you were at 100 mg for IV there is no way that sublingual can substitute. But you can also dose as frequently as you want.
IMO IV is ultimately more potent, but this is true of a lot of drugs and convenience almost always wins out over theoretical optimum setup. IV Ketamine is thousands of dollars, sublingual has cost me $80 for a month's supply of the drug. Sublingual is a good compromise.
Working dx Bipolar II
Medications: 225mg Lithium xl, 150 mg Lamotrigine, 20 mg Vyvanse, 150 mg Tranylcypromine, 75 mg Noritryptiline, 200 mg Buproprion SR, Agamantine 150 mg, Ketamine 200 mg (sublingual) twice a week. Trazodone 100 mg nightly + Sonata as needed for sleep.
I am NOT a doctor. Consult your physician on all medical decisions.