What Is a K-Hole? Symptoms, Signs of Overdose, & How to Get Help

What Is a K-Hole?

The slang term “k-hole” refers to an acute, dissociative state that results from ketamine intoxication. Low doses of ketamine induce dissociative effects that non-medical users refer to as “k-land,” however, very high doses – those leading to more pronounced immobilizing, dissociative, and hallucinatory effects – can take one down a “k-hole.” Contrary to a therapeutic or medical setting, illicit ketamine use can set one up for a bad trip.

K–Hole Physical Effects

Ketamine has diverse, dose-related effects on the brain and body. Its mechanism of action is complex and not fully understood, but it involves several interacting neurotransmitter systems.

It’s believed that ketamine’s psychotropic effects come from its antagonism of NMDA glutamate receptors and subsequent suppression of glutamatergic input onto GABA-ergic interneurons. This results in an overall disinhibition of this neuronal network, ultimately resulting in sedative, anesthetic, and analgesic effects in the central nervous system.^1,2 Associated increases in dopamine and serotonin may underlie ketamine’s antidepressant “feel good” effects but also may hold potential for ketamine addiction.³

The physical effects of a k-hole include:

• Inability to interact with surroundings
• Lack of balance/dizziness (12%)⁴
• Disassociation (66%)⁵
• Confusion (79% of k-hole experiencers)⁵
• Impaired consciousness (45%)⁴
• Disturbed speech (71%)⁵
• Nystagmus (rapid eye movements)
• Abdominal tenderness (18%) and pain (21%)⁴
• Urinary tract symptoms (12%)⁴
• High blood pressure (40%)⁴
• Elevated heart rate (39%)⁴
• Amnesia
• Reduced pain

What Does a K-Hole Feel Like?

The most common effects experienced in a k-hole include marked confusion (79% of k-hole experiencers), difficulty speaking (71%), unexplainable experiences (71%), floating sensations (71%), mind-body dissociation (66%), oneness (57%), sense of peace and love (57%). Less common k-hole phenomena include alien encounters (27%), near-death experiences (19%), and astral travel (17%).⁵

Many of the effects experienced in a k-hole can either be good or bad, depending on the person. For example, feeling “outside of one’s body” can be positive for someone needing to escape life stresses but be terrifying for someone with thanatophobia. “Floating” can be serene for one person and scary for another with a fear of heights. Interestingly, 45% of regular ketamine users fear falling into a k-hole.⁶

Signs and Symptoms of a K-Hole

Ketamine effects can vary greatly with dose. A person in a k-hole has likely ingested a very high dose for their body and will experience reduced motor function and dissociation. The individual will usually have their eyes open but be otherwise unresponsive and, at times, paralyzed. It induces a unique state somewhere between relaxed wakefulness and a coma.

Symptoms of being in a k-hole include:

• Sense of “melting into surrounding”
• Visual hallucinations
• Giggliness
• Sense of floating
• Sense of things being unexplainable
• Mind-body dissociation
• Oneness
• Sense of peace and love
• Alien encounter phenomena
• Near-death experience
• Astral travel

Positive & Negative K-Hole Experiences

K-hole experiences are highly individualistic and are influenced by both set and setting. Set refers to factors brought into the experience by the individual, like one’s drug sensitivity, previous experiences, expectations, and mental state. Setting refers to the physical and social environment in which the drug is taken (e.g., a serene retreat center or a loud dance club; music or spiritual imagery; presence of support staff).

As with any psychedelic, several factors can shade the experience as light and positive or dark and frightening. When ketamine is used recreationally, the setting is often less controlled than in a therapeutic setting, and thus, one is more susceptible to a bad trip.

What Are the Risks of Attempting a K-Hole?

While it’s uncommon for ketamine itself to cause fatality by overdose (only 6.5% of ketamine-related deaths are related purely to overdose), there are substantial risks for overdose and death when ketamine is: a) combined with other drugs; b) used by someone with medical contraindications, like heart disease or asthma; or c) used when engaging in circumstances where accidents can be fatal (e.g., driving, swimming, climbing, etc.).⁴

Beyond overdose and death, the risk for sexual assault is also substantial if one isn’t careful of their company and surroundings while high on ketamine. Also noteworthy is that most recreational ketamine use occurs alongside other drugs, and combined interaction effects can be unpredictable.⁷

Significant medical concerns around recreational ketamine use include:

Risk of Overdose

The risk of overdosing on ketamine alone is quite low. For reference, the surgical dose in clinical settings is typically five times the typical recreational dose. Most ketamine-related fatalities reported involve simultaneous use of other recreational drugs (e.g., alcohol, cocaine, opioids), medical contraindications (e.g., heart disease, asthma), or risky behavior while intoxicated (e.g., driving or bathing). Only 6.5% of ketamine-related fatalities are estimated to have resulted from ketamine exclusively.⁴

Risk of Physical Injury

Ketamine causes motor, perceptual, and cognitive effects that can impair one’s balance, coordination, and alertness. Accordingly, there is an increased risk of accidents from falling while walking or climbing, as well as driving and swimming, even at modest doses. A person in a k-hole has likely ingested a very high dose and is probably immobile or severely unbalanced and thus at a heightened risk of drowning or falling.

Ketamine also has an amnesic – memory-reducing – effect and has been used as a date rape drug.⁸ Sexual assault and trauma are a risk for unsuspecting victims slipped ketamine.

Persistent Disassociation

Hallucinogen-persisting perception disorder (HPPD) is a DSM-5 diagnosis for when perceptual disturbances, flashbacks, and dissociation continue, even intermittently, after the drug is no longer in the body.⁹ While HPPD is more common with other hallucinogens, like LSD, it can also be triggered by ketamine, especially at high doses.¹⁰

Emergent reaction is a medical term to describe a syndrome of delirium and bad dreams that sometimes results (in approximately 10-30% of people) when emerging from ketamine in a surgical setting.¹¹ K-hole experiencers may also have a similar reaction following detoxification.

Another ketamine after-effect involves amotivational syndrome characterized by not wanting to do anything, slowed thinking, feeling slowed down physically and emotionally, and memory and attention difficulties.⁵ This can last for days to months depending on misuse factors such as frequency and dose.

Side Effects

While low levels of ketamine are associated with feelings of relaxation, mood changes, and mild dissociation, high levels can induce more profound sensory, perceptual, cognitive, and motor effects. Like all other drugs – both illicit and pharmaceutical – ketamine use can yield short-term side effects (e.g., confusion, nausea, etc.) and long-term side effects (e.g., mood changes, memory problems).

Ketamine Abuse Symptoms

It is not clear the degree to which ketamine is addictive. Some studies have shown evidence of dependence (needing the drug to feel normal and experiencing withdrawal upon cessation) and addiction (craving or wanting the drug)¹² with repeated use, while others have argued that its complex action, though transiently reinforcing, does not lead to neural and behavioral changes typical of addiction.¹³

Despite this controversy, ketamine does not seem to be as addictive as other drugs of abuse like cocaine or heroin but does hold greater risk than other psychedelics, like psilocybin addiction. Anecdotally, some regular ketamine users reported experiencing it as “very addictive,” with 40%-60% of the interviewed sample expressing concern over their ketamine-seeking behavior.¹⁴ However, an estimated 75% of recreational ketamine use is alongside other drugs, making it difficult to disentangle cross-addictions.

Symptoms of ketamine misuse and addiction include:

• Mood changes
• Craving
• Drug-seeking behavior
• Nightmares
• Seizures
• Excessive salivation
• Bladder impairment (ulcerative cystitis)
• Urinary tract symptoms
• Gastritis
• Liver dysfunction
• Kidney dysfunction
• Memory problems
• Brain damage (e.g., deterioration of cortex)¹⁵

Signs of a Ketamine Overdose

A k-hole is one step away from overdose. Ketamine misusers seeking a k-hole experience are essentially trying to get as close to an anesthetized state or death as possible without crossing the line. However, the line between a k-hole experience and an overdose is a thin one.

While high doses of ketamine are relatively safe in a controlled medical setting– where wild fluctuations in blood pressure and other vital signs can be easily managed – they can be quite dangerous in non-medical settings. For example, if a person is choking (e.g., on vomit), drowning, or experiencing a heart attack (possibly related to fluctuations in blood pressure from ketamine use), a k-hole’s paralyzing sedative effects can prevent them from seeking help.

Signs someone should seek immediate medical attention for a ketamine overdose are:

• Loss of consciousness
• Respiratory depression
• Apnea
• Chest pain
• Abnormal heart rate and blood pressure
• Hallucinations
• Paralysis
• Nystagmus (rapid eye movements)
• Seizure
• Stupor

Treatment for Ketamine Abuse & Addiction

When ketamine is misused, it is often used by individuals with other substance use disorders. While inpatient programs are best for detoxification and stabilization, ongoing psychotherapy and support groups are integral to long-term recovery. There are many therapy styles depending on the severity of the addiction, comorbidity with other mental health disorders, and factors that led to the addiction. Successful recovery often involves an integrative approach to individual, family, and group therapy.

If you or someone you care about is misusing ketamine, it is important to intervene as early as possible. In cases of acute intoxication or overdose, call 911 or go to the nearest emergency room. For less acute cases, contacting a mental healthcare provider or treatment facility can help get you on the right path. If you have trouble finding a provider near you, there are also online therapy options.

Therapy options for addressing ketamine abuse and addiction include:

• Cognitive Behavioral Therapy (CBT): A CBT therapist helps the individual identify maladaptive thought patterns and behaviors associated with ketamine and polydrug misuse, develop healthy skills and coping strategies to challenge maladaptive thinking and manage cravings or urge to misuse. Over time, these new ways of thinking and behaving are reinforced with the goal being long-term change and relapse prevention.
• Dialectical Behavior Therapy (DBT): DBT is similar to CBT but with more focus on emotional regulation, mindfulness and interpersonal skills to manage emotional distress that has previously led the person to misuse ketamine. A DBT therapist will help a struggling individual to accept current circumstances while also actively working towards change.
• Eye Movement Desensitization & Reprocessing (EMDR): EMDR for ketamine uses eye movement training while recalling traumatic or stressful memories in an attempt to create new associations and weaken existing neural connections involved with those memories. Paradoxically, ketamine is itself used as a therapeutic to overcome trauma and other addictions.
• Motivational Enhancement Therapy: As a short-term (4-6 weeks) form of therapy that is particularly effective for treating substance misuse, this approach utilizes motivational interviewing techniques to help the person develop their own awareness, understanding, and intrinsic motivation needed for change and improvement.
• Family therapy: Family therapy focuses less on the causes of substance misuse and more on the maladaptive ways in which an entire family system is currently maintaining (or enabling) it and how to break these patterns. Also discussed are ways for family members to help ease the symptoms that precipitate substance misuse (e.g., anxiety, stress, depression, etc.).¹⁶
• Psychodynamic Therapy: While not typically a first-line treatment for substance misuse, psychodynamic therapy can sometimes be helpful with patients who have good insight to recognize how their substance misuse may be related to past traumas – especially traumas involving sexual abuse – that haven’t been fully examined or acknowledged.

IOPs & PHPs for Ketamine Misuse

Intensive outpatient programs (IOPs) are for individuals who require a higher level of care than one weekly therapy session can provide but for whom residential programs are unfeasible. This integrative approach provides 9-20 hours of weekly intervention in the form of individual, group, and sometimes family therapy together with other related support.

IOPs allow the person to continue their daily activity outside the scheduled program/treatment time. However, it requires the individual to be stabilized and reliably attend sessions. In contrast to IOPs, partial hospitalization programs (PHPs) involve more intense day therapy than IOPs as they usually are 20 or more hours a week, but the individual lives at home.

Rehab for Ketamine Misuse

Rehabilitation programs (typically 28 days in duration) exist for several different levels of treatment, ranging from inpatient hospitalization to outpatient counseling. Cost, timeline, and treatment approach are just a few factors that may vary depending on the severity of addiction and the person’s insurance plan. An important part of rehabilitation is establishing a relapse prevention plan, as recovery is often dotted with relapse events, but with a plan in place, you can be more aligned with your long-term recovery goals.