Episode 62 - What It Takes to Be the First: Building a Ketamine Practice in a Resistant Healthcare System with Dr. Lowan Stewart
Dr. Lowan Stewart shares how he built ketamine clinics across two continents, navigated institutional resistance, and helped make Norway the first country to publicly reimburse ketamine therapy.
Dr. Lowan Stewart is not just someone who opened a ketamine clinic. He is someone who built the infrastructure for an entire country to access it.
In this conversation, Sam sits down with Dr. Stewart, an emergency physician who co-founded the first ketamine clinic in New Mexico in 2016, brought ketamine therapy to Norway two years later, established the first public ketamine treatment unit in Scandinavia, and played a central role in Norway becoming the first country in the world to approve national public reimbursement for off-label ketamine in treatment-resistant depression.
What makes Dr. Stewart's story particularly resonant for our audience is how familiar the starting point will feel. An EM physician who loved his work but felt the limits of what emergency medicine could do for the river of suffering flowing through the department. A side project that became a calling. An uphill battle against institutional skepticism that most providers in this space will recognize immediately.
He also brings a perspective on the future of psychedelic medicine that is worth hearing. His argument is straightforward: ketamine is not just a treatment. It is the infrastructure that will make everything else, psilocybin, MDMA, and what comes after, possible in clinical and public health settings. Getting ketamine right now is how the field prepares for what is coming next.
This is a wide-ranging conversation covering career pivots, pioneering in resistant systems, the mechanics of moving a national healthcare system, and the daily reality of doing work that genuinely transforms lives.
What You'll Learn in This Episode:
The full arc of Dr. Stewart's career pivot from emergency medicine to ketamine therapy, including what pushed him toward something with more systemic and sustainable impact than the ER could offer
A firsthand account of what it actually looks like to be the first mover in a resistant healthcare system, from opening the first ketamine clinic in New Mexico to fighting a formal complaint from the Norwegian Psychiatric Association
How Dr. Stewart built the first public ketamine treatment unit in Scandinavia and the strategy behind getting ten major Norwegian hospitals to implement ketamine therapy simultaneously through a multi-site clinical trial
What Norway's landmark decision to become the first country in the world to approve national public reimbursement for off-label ketamine in treatment-resistant depression means for the global field and what other countries can learn from it
Why Dr. Stewart believes ketamine is not just a treatment but the infrastructure that will determine how ready clinical and public health systems are when psilocybin, MDMA, and other psychedelic medicines arrive
His honest reflection on why this work is worth it, including what it feels like to shift from focusing on the quantity of life in the ER to focusing on the quality of life in ketamine therapy
Key Takeaways:
Being first is less about credentials and more about willingness. Dr. Stewart's core observation about Scandinavia applies everywhere: nobody wants to stick their head out. Ketamine is a legal, available, well-documented medicine that anyone trained properly can use. Most of the time, it simply takes someone who decides to do it.
Institutional resistance is navigable with data. When the Norwegian Psychiatric Association filed a formal complaint against Dr. Stewart's clinic, he responded with a 25-page document summarizing close to 100 clinical trials and meta-analyses. The medical board sided with him on every point. The lesson is that the evidence base for ketamine therapy is strong enough to defend, and knowing it well is one of the most important tools a provider in this space can have.
Systems change is possible from the inside. Rather than waiting for top-down approval, Dr. Stewart used a multi-site randomized controlled trial across ten major Norwegian hospitals to de facto implement ketamine therapy nationwide. The trial required each hospital to set up a treatment unit, train staff, and follow a standardized protocol, effectively building the infrastructure while the research was being done.
Ketamine is the infrastructure for everything coming next. Dr. Stewart makes a compelling case that the training, the clinical protocols, the treatment rooms, and the patient management systems that ketamine clinics are building right now are exactly what will be needed when psilocybin, MDMA, and other psychedelic medicines receive approval. Providers who get ketamine right now will be far better positioned to integrate new treatments smoothly.
The quality of the work is the real reason to do it. Dr. Stewart is candid that opening a clinic is hard, the learning curve is steep, and the business challenges are real. But his reflection on shifting from the quantity of life focus of emergency medicine to the quality of life focus of ketamine therapy captures why so many providers who make this pivot do not go back. Once you see someone whose life has been transformed, he says, you cannot not do it.
Listen to the episode on Apple Podcasts, Spotify, Overcast, or on your favorite podcast platform. Watch the discussion on YouTube here.
Episode 62 show notes:
00:00:00 Teaser: "Once somebody says, 'I'm alive today because of this treatment,' you can't not do it."
00:00:24 Episode Introduction
00:02:19 Sam Welcomes Dr. Lowan Stewart
00:02:53 Background Overview: Emergency Medicine, Norway, and the Journey to Ketamine
00:08:56 Why Neuroscience: Starting an MD-PhD and the Rat Brains Advice
00:10:09 From Space Medicine Dreams to Emergency Medicine Reality
00:12:14 The Decision Point: Going Away from EM or Toward Something New?
00:15:37 Opening the First Ketamine Clinic in New Mexico: What the Ketamine World Looked Like in 2016
00:17:55 Bringing Ketamine to Norway: Opening Axon Clinic in 2018
00:20:06 Approaching the Norwegian Psychiatric Association and Health Department with the Data
00:26:40 Psychiatrist Skepticism: "I Don't Know What to Do with These Patients If They're Fine"
00:28:29 The Formal Complaint from the Norwegian Psychiatric Association
00:31:23 Establishing the First Public Ketamine Treatment Unit in Scandinavia
00:34:34 Axon Clinic's Acquisition by Awaken Life Sciences and the Ukraine War Impact
00:40:18 Norway's Landmark Approval: National Public Reimbursement for Off-Label Ketamine
00:44:20 The Multi-Site RCT Strategy: Implementing Ketamine Across Ten Major Norwegian Hospitals
00:50:17 Why Ketamine Gets Overlooked at Psychedelic Conferences and Why That Needs to Change
00:55:14 One Piece of Advice for Any EM Physician or Clinician Considering This Pivot
00:58:34 Rapid-Fire Questions
00:59:07 How Dr. Stewart De-Stresses: Cold Ocean Swims and Sauna in Norway
01:02:17 How to Connect with Dr. Lowan Stewart
01:04:03 Episode Ending
Thanks for Listening
Connect with Dr. Steward
Clinic Website - Axonklinikken http://axon.no/
Email: lowan@axon.no
Linkedin: https://www.linkedin.com/in/lowan-stewart-27349616/
Selected Links From the Episode:
World Happiness Index: https://data.worldhappiness.report/table
Professional Education Disclaimer: This content is intended exclusively for licensed healthcare professionals and should not be used by patients for self-treatment or self-education. The information presented reflects individual provider experiences and should not replace clinical judgment, professional training, or comprehensive research. Healthcare providers must conduct their own due diligence, consult current literature, and evaluate treatment approaches within their specific practice context and regulatory environment. This educational content does not constitute medical advice for specific patients or clinical situations - treatment decisions should always be based on individual patient assessment and adherence to professional medical standards.
Frequently Asked Questions
How did Dr. Lowan Stewart navigate institutional resistance when opening a ketamine clinic in Norway?
When Dr. Stewart opened Axon Clinic in Norway in 2018, the Norwegian Psychiatric Association filed a formal complaint with the medical board arguing that off-label ketamine was not academically defensible. Rather than backing down, Dr. Stewart responded with a 25-page document summarizing close to 100 clinical trials and meta-analyses supporting the use of ketamine therapy. The medical board reviewed the submission and sided with him on every point, confirming that the treatment was being administered with proper informed consent and was entirely defensible. The experience underscores a broader principle he shares in the episode: the evidence base for ketamine therapy is strong enough to defend, and knowing it thoroughly is one of the most important tools a provider in this space can have.
What does Norway's national public reimbursement approval for ketamine mean for the global field?
In 2025, Norway became the first country in the world to approve national public reimbursement for off-label generic racemic ketamine when administered in the public health system for treatment-resistant depression. This followed a four-year review by the Norwegian medicines agency that concluded ketamine is as effective as, if not more effective than, ECT, costs approximately half as much, and is better tolerated and preferred by patients. Unlike sporadic state-level or insurer-level programs in the US, this approval operates on a national level, meaning ketamine therapy is now accessible to any Norwegian patient who qualifies regardless of their ability to pay. Dr. Stewart views this as a template other countries can follow and is actively working to help additional European countries pursue similar approvals.
How did Dr. Stewart use a clinical trial to implement ketamine therapy across Norway's public hospital system?
Rather than waiting for top-down policy change, Dr. Stewart designed a multi-site randomized controlled trial involving ten of Norway's major hospitals. Because participating in the trial required each hospital to establish a ketamine treatment unit, train staff, and follow a standardized protocol, the research process itself became the mechanism for nationwide implementation. The protocol included evidence-informed extras such as eye shades, music, a mindfulness induction, and a requirement for concurrent psychotherapy. A national registry is now collecting outcomes data across all sites, with each hospital using slightly different therapeutic approaches such as acceptance and commitment therapy or CBT, which will generate meaningful comparative data for the field.
What is Dr. Stewart's argument for why ketamine is the infrastructure for psychedelic medicine?
Dr. Stewart makes the case that the training, clinical protocols, treatment rooms, and patient management systems that ketamine clinics are building now are exactly what will be needed when psilocybin, MDMA, and other psychedelic medicines receive regulatory approval. He observes that most psychedelic conferences give ketamine minimal attention despite it being the only legally available psychedelic-assisted treatment currently in widespread clinical use. His view is that providers and systems that get ketamine right now will be far better positioned to integrate new treatments smoothly, while those who wait will face the much harder task of building that infrastructure from scratch at the same time they are trying to adopt a new and less familiar medicine.
What does the prevalence of mental health disorders in Norway tell us about the global picture?
Despite Norway consistently ranking among the happiest countries in the world, Dr. Stewart notes that the prevalence and incidence of mental health disorders in Norway is, as he puts it, the exact same throughout Northern Europe as it is in the US, plus or minus a couple percent. Approximately 30 percent of Norwegians will struggle with clinical depression, anxiety, or addiction at some point in their lives. His point is that social infrastructure, low crime, free education, and strong safety nets can improve overall quality of life and life satisfaction without meaningfully reducing the underlying burden of mental health conditions. The need for effective treatments like ketamine therapy is therefore just as real in high-functioning societies as it is anywhere else.
What advice does Dr. Stewart give to emergency physicians or clinicians considering opening a ketamine clinic?
Dr. Stewart acknowledges that opening a clinic involves real challenges, including a learning curve on both the clinical and business sides, especially for providers transitioning from a specialty outside psychiatry. His single piece of advice is that it is worth it. He draws a distinction between the focus of emergency medicine, which he describes as largely oriented toward the quantity of life, and the focus of ketamine therapy, which centers on the quality of life, giving patients back meaning, hope, joy, and connection. He describes the experience of seeing a patient move from a place of profound suffering to genuine recovery as the most rewarding work he has done in his career, and says that once you witness that kind of transformation, you cannot not do it.