Ketamine
KETAMINE
As we do need to be highly aware of the risk of abuse of medications and substances, we must do so in an objective manner and weigh the risks vs benefits. At this time we are living in a mental health crisis where external violence and suicides are noted at alarming rates. Current research is indicating if a “Breaking of the Cycle” is established by medications like ketamine (due to regeneration and central desensitization) then the likelihood of chronic medications and treatment may not be necessary.
With the consideration of all factors involved, below are newly included, necessary details added to a presented document by the Prevention Alliance of Tennessee. All added areas are noted in red.
Ketamine Clinics
Ketamine is an analgesic drug used as an anesthetic in surgery and was a popular club drug used to date rape women. All scheduled medications have this potential. Alcohol is the #1 date rape drug followed by benzodiazepines and most recently SSRIs (anti depressants). Currently there are new clinics opening up to treat Treatment Resistant Depression (TRD), which is not defined specifically Tennessee Assoication of Nurse Anesthetists have created a Ketamine Drug Task Force, and are working closely with the Board of Nursing, and chronic regional pain syndrome (CRPS).
Those being treated for TRD only had lasting effects for approximately 2 weeks and had to go back for more treatment.
Currently, the National Institutes of Mental Health recommend six infusions over a 2 week period with a goal of complete remission of symptoms. When combined with necessary discharge recommendations the rate of success is approximately 70% with many individuals never having to receive an additional maintenance infusion.
Those being treated for CRPS had prolonged results after a second infusion of upwards to 1-3 years of pain relief.
CRPS is much more involved and the rate of success is much lower. This treatment does help with pain for longer periods of time and greatly decreases narcotic use (many times eliminating them completely), but on average patients have to come back for maintenance infusions once every 3-4 months. Some patients (without anatomical injury) may have complete, long term pain relief but this is uncommon.
There are currently 7 ketamine clinics open and operating in Tennessee alone used to treat chronic depression and pain without regulations.
While these are not state regulated there are several national and international sources that have been released for clinics to abide by.
Oxford University Press recently released a 2019 reference guide titled
“Intravenous Ketamine Infusion for Complex Regional Pain Syndrome: Survey, Consensus, and a Reference Protocol | Pain Medicine | Oxford Academic”
The National Institutes of Mental Health have also released reference guides for mood disorders.
This is an “off-label” 20% of all medication use is considered “off label” use of ketamine and an alternative treatment people are using as a quick “cure” for their depression and pain. The patients receiving ketamine are those that have tried a minimum of two failed traditional therapies, medications, etc. Most individuals receiving ketamine have been on a plethora of failed medications, inpatient and outpatient treatments, residential treatments, failed ECT, TMS, EMDR, therapy, and more. These clients are not newly diagnosed individuals. The problem with this is that ketamine produces CNS disruption such as inebriation, hallucinations, dissociation from the body, and dizziness. It is labeled as a schedule III controlled substance due to its high potential for psychological dependence and low to moderate physical dependence.— Ketamine has a high potential for psychological dependence when used receptively (several times daily), or at dosages over 3000% higher than currently recommended to treat mood or pain conditions. Psychological dependence and physical dependence is of low potential with current recommendations of intravenous Ketamine or intranasal Esketamine due to its schedule regulation.
This graph shows the adverse effects reported from long term ketamine use based voluntary reporting and therefore, is not true to absolute population frequencies. There is no limit on the dosage each person gets when they go to the clinic nor the amount of times they can go get ketamine infusions. Since this “cure all” only lasts a short amount of time, people keep having to go back to sustain the benefits of this treatment. This makes the use dangerous since ketamine effects have not been studied long term. Due to the great safety index of ketamine, the World Health Organization has deemed it on their list of Essential Medications. Ketamine is a FDA approved anesthetic agent since 1970. Since then it has been used safely with pediatrics, obstetrics, adult, geriatrics, and in veterinarian medicine.
In 2009 a trial was approved for a CRPS client to receive ketamine weekly to note long term effects of repeated, 4 hour infusions. To date, there have been no reported adverse side effects.
Insurance will not cover this usage since it is not approved by the FDA so people must pay out of pocket. Most insurance companies are reimbursing patients for IV treatments at a rate of approximately 10%-65%.
Spravato (Esketamine) has been approved by insurance companies, Medicare, and the VA system. When they run low on cash, it is plausible that these people may turn to getting the drug illegally to sustain the benefits, causing a larger drug epidemic.
Both charts A and B are detailed charts of powdered ketamine (similar route of administration as cocaine). These are not documented adverse reactions to intravenous or intranasal ketamine. The recommended dose for mood is 0.5mg/kg over a period of 40 minutes. The recommended dose for pain is 0.5mg/kg-1mg/kg. The charts show the side effects of snorting, 1000mg-3000mg at one time period (typically 3-5 seconds).
Side effects of intravenous ketamine are nausea, headache, and a temporary increase of blood pressure 5-10% from baseline.
To further augment the policies in place that are limiting opioid administration and reduce substance abuse, The Prevention Alliance of Tennessee recommends the following actions:
Should there be regulation on the amount of ketamine administered to each person and the number of times ketamine may be administered in relation to time of each infusion?
Ketamine is an individualized, dose-based medication. Current research states a mild dissociative state is necessary in order to produce the necessary amount of glutamate
to stimulate the brain positive-growth; actually fixing damaged neurons.
Recommendations from NIMH state that 0.5mg/kg can achieve this effect, but due to a number of factors (age, medications, co-morbidities) the dose must be decreased or increased to achieve optimal effect.
Ketamine should not be regulated by dose or times of use. Of personal note, ketamine SHOULD NOT be sent home with patients as it has a known history of abuse. Current prescribed forms for home use include intranasal, oral, rectal, cutaneous. Ketamine is easily accessible in Japan, and has now surpassed Heroin with abuse.
Clinics giving ketamine should be REMS certified, and should function under each of their professional boards.
Should there be regulation of the types of medical practitioners that must be on staff and regularly at the clinic in order to maintain control over adverse reactions and assessing patients in their depression or chronic pain?
The American Society of Ketamine Physicians (a nationally regulated board of medical professionals) has providers of various specialties including Anesthesiology (CRNA, MD, and DO), Emergency Room Physicians, Internal Medicine Physicians, and Psychiatrists.
It is recommended that all practices have ACLS and PALS training, on-site emergency medications, cardiac monitors, and an AED.
This medication should be administered with a medical professional on-site that possesses a DEA license and ACLS capabilities.
Patients should have external providers that are informed of the care the patient received when seeking treatment at a ketamine clinic. This should be known information to the patient’s primary care provider, pain physician, mental health prescriber, and counselor. This would give patients more support in an outpatient environment decreasing the need for the patient to seek acute care in the hospital setting.