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People keep talking about ketamine. The drug has become a favorite of celebrities, billionaires and ordinary patients, many of whom view it as a potential miracle drug for depression and other mental health conditions.

Whether on Facebook or Instagram, patients and clinics alike are giddy about the possibilities. But it is a drug that can be abused and can be deadly. Thus, ketamine is the latest challenge for Meta, the social media platforms’ parent company, which for years has struggled to moderate posts and ads touting health-related products like weight loss supplements and dodgy COVID-19 cures.

Still, despite warnings about the drug’s dangers, Meta allows ads and posts about ketamine. Sometimes that chatter comes from sources that don’t meet the conglomerate’s voluminous standards, which, in theory, ensure posts are based on credible information.

Other internet ad networks are also trying to strike balances. Google says that because ketamine is a prescription drug, it can be advertised only if a provider is offering a prescription and is certified with a third-party oversight group; advertisers can’t promote “highs.” TikTok, which didn’t reply to a request for comment, broadly prohibits advertising from unauthorized pharmacies or dispensaries, or advertising that features prescription drug abuse.

Meta’s rules have created a conundrum for the company. Posts about ketamine, both a party drug and a possible mental health therapeutic, are governed by very different rules depending on the context, according to an investigation and report by the company’s outside Oversight Board, an organization dubbed Facebook’s “Supreme Court” for its role in refereeing the platform’s speech regulations. That balancing act was on public display after a post about the substance was inspected repeatedly by the company’s content review bureaucracy. When asked to comment for this article, Meta simply referred KFF Health News to the board’s report and the company’s reply to the report.

This back-and-forth dates to December 2022, when a paid influencer posted on Instagram how the drug eased the influencer’s “treatment-resistant depression and anxiety.” The post described a “magical entry into another dimension.”

After reviewing the paid post and Meta’s rules on drug promotion, the Oversight Board found that the post inappropriately hyped the high of the drug, while not placing it in a medical context — a problem, given the tension in the company’s rules allowing discussion of pharmaceutical products and disallowing references to illicit drug use. 

Ketamine, which is available in both liquid and powder form, emerged first as an anesthetic and became popular as a party drug because of its dissociative and hallucinogenic effects. It’s FDA-approved as an anesthetic and, in some formulations, as a prescription antidepressant, to be administered in medically supervised settings. Regulated as a Schedule 3, nonnarcotic substance under the Controlled Substances Act, the drug has been shown to cause dependence, especially for people with a history of addiction to other substances. But researchers are intrigued by another aspect of ketamine: its mind-altering properties, which have potential therapeutic benefits. 

These possibilities, aided by a boom in ketamine-focused medical startups and spas promoting the prescription drug as part of “holistic healing” or other wellness purposes, are fueling consumer interest, news coverage, and social media attention.

But there are indications of a dark side. According to an autopsy report from Los Angeles County’s medical examiner department, actor Matthew Perry died with ketamine in his system as he reportedly was undergoing infusion therapy meant to treat depression and anxiety. Poison center reports of exposures involving ketamine surged just over 80% from 2019 through 2021, a study showed.

The tug of war is leading to conflicts between social media giants and advertisers. While Meta and its peers sometimes allow posts on the drug, they also include warnings. For example, if you search Instagram for “ketamine,” you learn the term “may be associated with the sale of drugs” and are offered a button to “get help” for substance abuse treatment. (You can also opt to get the results anyway.)

In 2023, hoping to resolve the situation, Meta referred the controversy concerning the post to its Oversight Board. The group has received $280 million in irrevocable funding since 2019. Membership includes former heads of state, prominent journalists and human rights advocates. 

For the “magical entry” post, according to a Meta missive cited in the board’s report, the company expected the board would agree and open its platforms to more posting about mind-altering drugs with therapeutic potential. But the board instead offered pointed critiques and questions, threatening the status of other ketamine posts. The board argued that, based on the company’s policies, the post inappropriately made ketamine seem like a “high,” rather than a medical experience.

“This case indicates that Meta’s strong restrictions on branded content promoting drugs and attempts to buy, sell, or trade drugs may be inconsistently enforced,” the board concluded in its report.

Indeed, in a comment to the board, the National Association of Boards of Pharmacy suggested it’s easy to find sellers offering the drug for recreational use, citing two clear examples found “with only a cursory search.”

The company’s executives disagreed. When presenting the controversy to the board, they said they expected medical use of ketamine to increase, so it should allow the post. That led, in its response, to the company brushing off some of the board’s suggestions, which could directly impact ketamine clinics’ profits. After all, Facebook and Instagram audiences overlap with their clientele, and these ads are one of the main ways they promote their brands. Consider the money at stake. One recent academic review of ketamine clinics’ advertising online, which was published in JAMA Network Open, found prices ranging from $360 to $2,500 per infusion.

When a particularly influential influencer posts about his clinic, there’s “a sharp uptick” in interest “every single time,” Jacob Silverstone, the medical director of a ketamine infusion clinic outside Miami, told KFF Health News. That interest often drives patients to his clinic, he said.

Still, despite the social media buzz, evidence for ketamine as a mental health treatment is unsettled.

“Data from clinics strongly suggest that there’s a benefit” from the drug, said Boris Heifets, a Stanford University School of Medicine professor of anesthesiology studying ketamine and other psychiatric therapies like MDMA. Ketamine, some of these studies indicate, can work for depression — even for patients who don’t respond to conventional treatments like SSRIs, or selective serotonin reuptake inhibitors. 

But, Heifets said, pop culture oversells the potential. On social media, some clinics promote practices without scientific backing, he said. “It’s not clear that they have any mental health expertise,” he said.

Some clinic ads he has seen, Heifets said, dwell on the idea that the drugs act quickly and comprehensively — avoiding the lack of good data about long-term therapeutic use.

The review of ketamine clinics’ claims in ads on Google found the businesses rarely disclosed potential side effects, while aggressively marketing its benefits. Some ads falsely claimed the drug is nonaddictive, the review said.

Facebook and Instagram advertising can be similarly bullish about ketamine’s potential. A fall 2023 search of Meta’s ad library shows an armada of ketamine clinics with sunny claims, some promising “rapid relief” or telling viewers they can “say goodbye to a once-daily SSRI” or that “IV ketamine can be your light in the darkness.”

These types of claims, while downplaying risks like substance use disorders, create outsize expectations in patients, Heifets said. “You can create expectations for some of these kind of big interventions that if they’re not met — that can actually be disastrous for patients.”

The ads making such claims and minimizing or not mentioning the risks often appear to be slipping through a system with inconsistent regulations, and puzzling gaps, a review by KFF Health News suggests.

Meta’s policies require many advertisers who offer prescription drugs, and all advertisers offering drug and addiction treatment services, to undergo additional vetting by a group called LegitScript before they’re allowed to hawk their wares or services on Facebook and Instagram. (Google similarly requires certification from an outside body like LegitScript for online pharmacies, telemedicine and addiction services.) LegitScript reviews the advertisers’ operations, like their clinical leadership and partnerships with pharmacies.

But in practice, ketamine advertisers often don’t go through this process even if they fall into a category that should. KFF Health News reviewed 27 advertisers on Meta in October and November 2023. Of those, 10 advertisers, spread over both months, either offered ketamine for drug addiction or ketamine via telehealth, and were not registered with LegitScript.

The online ads promote services, generally via telehealth, that prescribe ketamine — often in a lozenge prepared by a compounding pharmacy. There’s much less evidence for the safety and effectiveness of oral ketamine, Heifets said, compared with that of intravenously administered ketamine, which is more often studied.

Enforcement is on Meta’s agenda. In its response to the Oversight Board on the ketamine case, Meta said it has improved its automated review tools for some advertisements promoting drugs, and pledged to consider auditing its policies in the first half of this year.

Federal regulators are showing signs of concern about ketamine, particularly when obtained online. Last year, the Drug Enforcement Administration shut down the telehealth practice of at least one physician who prescribed ketamine nationwide. In October 2023, the FDA issued a warning about compounded ketamine — which these telehealth startups tend to rely on, Silverstone said.

KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.