Obviously, most physicians have very litttle or no idea of the pharmacologic properties of sub-anesthetic doses of anesthetic agents like ketamine. This is not their fault, and many people are imbued with the political hype relating to misuse at 50-100fold (or greater doses) with stories of dissociation, psychosis, altered reality, rerealization, etc. At very subanesthetic doses, ketamine is a specific and potent blocker of NMDA-type glutamate receptors [one of a family of 5-6 glutamate blockers]. NMDA-type (and perhaps other subtypes of glutamate receptors] are considered potent activators, or promoters/amplifiers, of pain transmission in the spinal cord and central nerous systerm. At higher, and closer to anesthetic doses, ketamine can affect up to 10-15 different types of receptors, on the way to anesthesia. Bt even at those doses, it is considered safe in annimal and even in human use. I used it 33 years ago for animal surgeries that were complicated and long and where I needed a ZERO mortality rate. And I got it.
We have data on treatment of over 600 patients with 7-8 types of neuropathic pain and 6-7 types of migraines/headaches and variants. Some of the data has been presented and speaks to efficacy and safety, with appropriate monitoring. But, I agree, this is not for everyone, especially where there is no experience, fear predominates. Just as I would not attempt treatment of patients with chemotherapeutic agents, I can safely say that the use of ketamine will be in very small numbers of hands of people in pain management circles.
John Claude Krusz
Thank you for sharing your enlightening experience. Safety is in the hands of experience. However, experience should not eliminate the need to take preliminary steps in a treatment pathway. Thus, in my opinion, ketamine treatment should not be taken lightly or taken as a first step.
Dr. Christina Lasich, MD
Because this discussion has so many replies, I'm not sure where this fits best. However, I thought that a response from a patient could be useful in this conversation.
I'm quite certain that it would be in my best interest to go to a provider who has experience with ANY tool that they were going to use in a specialty practice, be it Ketamine for pain, or going to an orthopaedic surgeon who has done many wrist surgeries. I'm not going to go to a knee specialist for my wrist operation. For that same reason, I wouldn't use a provider who was unfamiliar with the use of ketamine in treating pain patients.
I'm curious as to how you came to the conclusion that using ketamine medicinally would come " with a high risk of death."
The other question that I have for you regarding this post is the blanket statement that " At this moment in time, ketamine infusion is not for the faint at heart." Is this meant to be "for the faint of heart in a provider role," or that of the patient? Infusion therapy isn't exactly fun for the patient, but if the agent used is going to make the patient feel better at the conclusion of the treatment?! Well, this girl would say "sign me up."
Oh wait. I did.
I use ketamine. I've had multiple ketamine infusions--- all in a setting where it was safe. Absolutely no problems. However, my provider knew what to do if something went wrong, and if I did develop complications.
In addition. I believe that this Sharepost may pose a disservice to the chronic pain community here on Health Central. The author was clearly not that comfortable with this agent, and instead of doing additional research on ongoing medicinal usage, just wrote a potentially misinformed article, using phrases which have little constructive purpose in this article... like "with a high risk of death." (?!) This has a potential of scaring individuals who would otherwise be willing to try another option that could change their lives in an extremely postive way.
Coincidentally, today I just spoke to a person who had a near death experience (very unstable vital signs) with a Ketamine infusion at a very reputable major medical center with a nationally known pain management expert and one of my mentors (of course I cannot mention names for privacy sake). That experience scared her and the medical professional. I appreciate your perspective as a patient, but not everyone has successful, positive experiences like yours. This particular patient wishes that she had been informed about the real risks associated with Ketamine before she was talked into it. Realistically, ketamine is a medication that is very potent and has the potential for great harm even in the right hands.
To those who are considering it. Even greater harm comes from being unaware of the potential harmful effects of any medical treatments. Read the potential serious adverse effects from Ketamine and decide for yourself whether or not the risk is worth it to you.
Dr. Christina Lasich, MD
Wow. What a coincidence. What an experience you had with your patient.
I would postulate that just about every patient who has tried medication of any sort has had a bad experience at one point. For your patient, (whom I wouldn't dream of asking you to name, by the way!) this was a bad medicinal experience.
No need to explain HIPAA rules for my understanding of why you can't name the patient. In fact, in this case, by even going down the path of using HIPAA makes me feel that you are trying to either show that you have an MD and I don't, thus marginalizing me, or that you are inventing a case which does not really exist. It is enough to say, "my patient" had a bad experience. Why would I care who this person is?
Back to the topic.
I've had reactions to other medications that have landed me in the ER with leads running from my chest, psychotic reactions to something as simple as Reglan, seizures from Wellbutrin, etc. When you take medicine, there are obvious risks. AND, for the record, the risks associated with Ketamine were fully explained to me when it was presented to me as ONE of my options.
Yet, we as a society don't scare people from trying medications- even the NSAIDS- which have major GI implications. We teach. Inform. Educate.
Can you imagine if the tone of your Sharepost was used amongst the Depression community? No one would ever try additional medications if they had a previous scary reaction to a previous one.
I hope that we can agree that tone is as important as content sometimes when writing (in general), and especially if you're a trusted figure from whom educational content is being provided.
Medical writing for laypersons should be done carefully, and with a great deal of thought as to how you'll affect the psyches of already potentially fragile and questioning individuals. This was not an opinion piece. If it had been, then there would have been nothing wrong with how you worded this Ketamine article- it was based on YOUR opinion, and YOUR knowledge.
We, as pain patients, seek to be treated like any other patient.... but unfortunately, we're often not treated with that respect. Many of us have been already talked down to, or looked at with suspicion, and this is a place where we should feel safe, and know that the Experts are giving us the best information possible for us to stand up for ourselves.This article didn't fit with the idea or ideal of such a Chronic Pain site.
When it comes to counseling patients about treatments, informed consents need to be based on all the possible outcomes, even the worst outcomes. The simple foot surgery can cause RSD/CRPS. Daily use of NSAIDs can cause cause life-threatening GI bleeds. And ketamine infusions can lead to near-death adverse reactions. Deciding what is acceptable risk is a personal decision and should be based on all possible end points.
Yes, I am alarmed that people seem to take the risks of medical treatments lightly in the face of desparation. Desparation should not always lead desparate measures because the possible risks can result in worse situations. No one ever knows who is going to get worse which makes what most of what we do as doctors a calculated gamble and an art.
Dr. Christina Lasich, MD
I'm appreciating this whole discussion. The use of infusion therapy is one I certainly do not take lightly, and in my case has in no way been a first-line treatment. It has been the result of exhausting all other options. It is inconvenient and takes a lot of time... not only time to get to the outpatient clinic (hospital) but the time it takes out of functionability. I believe it is very difficult to "abuse" any infusion unless I'm tethered to the IV.
My treatment options are extremely limited due to other risk factors like TIA/CVA's, but I would ask any one of my physicians what are the pros/cons of any of the infusion treatments and then it's my responsibility to assess the risk and if I'm willing to take it. This does not matter whether it's magnesium or ketamine and everything in between. If my physician is not comfortable with the treatment, I would hope s/he would refer me to someone who is (i.e., anesthesiologist) should the treatment continue to be pursued.
I can see the doctor's POV that there may be some ethical issues should something go wrong with the treatment. As a responsible, educated patient, ultimately the decision to go ahead is mine.
Personally, if my migraines continue to debilitate me, I may choose a more aggressive treatment.
Great. I am glad you have had a positive experience with Ketamine and weighed all your options carefully. You obviously did not take your decision to give informed consent lightly. There are many instances when a medication (and not just ketamine, Prozac for example) has caused a death and what is worst is that no one knew that the possibility existed. No drug should be taken without knowing all the possible adverse events, especially when those events could be life-threatening.
Ketamine can be a very helpful treatment for those willing to accept the risk with a healthy fear.
Dr. Chrisitina Lasich, MD
As I read through all the postings, I am amazed at the responses. Unfortunately, at times words get misinterpreted. Through my experiences, I read Dr. Lasich's article as one that reflects uninformed patients at times.
I believe it is common for people who suffer from chronic pain conditions to listen with ears half closed...I know, I have been there! I have been around the block a few times when it comes to pain. Throughout the last 10 yrs I have undergone 2 back surgeries (one being a global fusion) and 3 foot surguries, which resulted in RSD/CRPS. I underwent many treatment options: Physical Therapy, drug trials (too many to name), at least 30 sympathetic nerve blocks, epidurals, botox injections, Chemo infusions, and yes...Ketamine. At one point I requested amputation of my foot...I figured a good prosthetic would be better then the constant burning and stabbing. RSD/CRPS is nerve pain in it's own class...even sitting under a ceiling fan poses a huge challenge for me as I tell myself "it is just air..there are no knives piercing my skin" Crazy!!!
I am the "person" Dr. L is speaking of in one of her posts and I am not a patient of hers. Just someone that happened to be in the same place at the same time. In fact, I am not even sure how Ketamine came up in our converstion...however, she had no idea my view on treatments. After I shared a little about my experience she asked that I take a look at this blog.
I would call myself a highly informed patient and one who seeks the BEST care. I sought opinions from world recognized doctors in PM...and found myself in several University settings. The doctors did differ in their treatment plans... some went straight to the "big guns" while other were more conservative in approach. However, after my Ketamine experience my opinion has changed on PM care.
To refresh readers and from one who experienced it....I was presented with Ketamine, a procedure that would be infused into my lower leg/foot to minimize the systemic involvement. This doctor is Chief of PM. I was admitted to the Outpatient surgery center and waited a few hours before my procedure when they realized they had ordered the wrong procedure. So at bedside, he said "why don't we try a low dose infusion of ketamine since you are here and see what relief you get". I said I was nervous about it because of things I had seen on the internet. He assured me I would be "fine"....in fact he said "he would start low and titrate up every 5 mins." I was told I would not feel anything until about 15 or 20 mins...at that time he would ask if I want to con't to go up or hold it there. He said every patient he had given ketamine in this manner liked it...felt a warm, good feeling. So with that information, I said ok. The Resident pushed in the 1st dose and within 10 seconds I felt myself spinning and thought I was going to "pass out". I remember my legs thrashing in the bed, my head rocking side to side, I could not open my eyes. I instantly thought "why is this happening? Am I going to die? The doc said I wouldn't feel anything...yet I feel like I am going into dark hole". As the thrashing con't, I began to sweat uncontrollably and I couldn't talk. My mom had driven me for the procedure and they allowed her to be bedside. She asked, "what is happening?" The doc quickly turned the monitors and said my blood pressure and heart rate is going way too high. He keep asking me to open my eyes, of which I couldn't. The Resident said "it's 5mins, do we go up?" He said no, "her blood pressure can't handle it...get the reversal drug now". Soon after I was given it I came around...soaking wet! I asked what happened...the doc had no reason for the respose and said he had never seen that before.
My concern is what happens in his office moving forward. Is he better explaining the risks? I don't know what choice I would have made given all the possibilities... but I can rest assure that no longer do I live in "desperate measures"! I assess every procedure by weighing the risks.
I have to applaud Dr. Lasich for her concern that patients need to be WELL informed! Nothing should be taken lightly in Pain Management...
Dana
I totally agree with you, Dana. Thank you for sharing your experience. Wow! So scary.
I am very careful w/all drugs because I have a lot of drug allergies, and my doctor is aware of this. We thoroughy discuss the potential benefits and risks of any drug she is considering for me. Then, we decide together, but I have the final say, of course.
I am one of those pain in the butt patients who wants to know everything about any drug I am taking. LOL My GP is great. She doesn't mind. She is very careful with drugs generally.
Best Wishes, V
When/if this becomes available as a treatment - I want to be there - first in line!
After 2 failed shoulder surgeries, 2 failed back surgeries AND fibromyalgia - I have been on every drug available and yet on a high dose of slow release morphine, 2 muscle relaxants and Lyrica I still experience pain ranging around the 7 - 8 mark (on average) daily - sometimes higher.
Resetting pain receptors sounds like a jolly good idea to me...lets hope the powers that be agree - think of the money it would save governments in lost work days, worker's compensation etc etc.
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Dr. Lasich,
Not all doctors consider Ketamine a "last resort" treatment. In lower doses than used for anesthesia, Ketamine is being used in IM injections for Migraine and neuropathic pain. It's also being used in IV infusions for intractable Migraine. There's more information on this on Dr. John Claude Krusz's web site, on the research page. There's also some information on it on MyMigraineConnection in IV Treatment of Refrachtory Migraines.
I'm not sure why you say Ketamine has "a high risk of death." Used properly by a well trained physician, the drug doesn't carry that high a risk. Your statement seems to be to be a bit out of perspective.
Teri
Thank you for your comments. For those of us who are not properly trained with Ketamine (which is a majority of doctors), we find Ketamine to be a bit scary because we all understand its potency and potential for harm. Sure, in the right hands, Ketamine does have great potential for good which is what I was eluding to at the end of this article, but not as a first line treatment. Anyone who is considering this treatment should find the professional with the most experience and error on the side of caution.
IM and oral ketamine will become more available and safer options in the future as more research is done and more doctors become trained.
Dr. Christina Lasich, MD
Thanks for your reply, Dr. Lasich.
Still, I wish you had worded your last paragraph differently. Your statement, "Possibly, but with a high risk of death and at a high cost. At this moment in time, ketamine infusion is not for the faint at heart and only as a last option at the end of the line when one is at the end of his/her rope," is so broad that it has already caused concerns among some Migraine and headache patients who have been receiving Ketamine treatment or are considering it. Such a broad statement in most any context is bound to cause such responses. Better to speak to your own experience than to paint all doctors with the same brush. You could be frightening people away from treatment that could do them a great deal of good.
Teri
I would hope that people do think twice before resorting to Ketamine. Speaking from my experience, when folks are considering treatment options whether it be surgical or chemical, the first treatment option should always be the safest and the one that has the most potential to improve health. This first line defense against any painful condition should include eliminating potential pain triggers like nightshade plants, eliminating unhealthy habits like smoking,and improving health by eating a low glycemic load diet and exercising more. Call me a traditionalist or a dinosaur, but health is the first treatment option to try before trying chemical warfare.
This over-medicated society has lost touch with the importance of health. And have become comfortably numb to the risks of chemicals and surgery. But that is just speaking from my experience.
Dr. Christina Lasich, MD
Of course people should think twice before using Katamine or ANY medication, Dr. Lasich.
Looking to your reply to Dr. Krusz, I'll point out that neither of us said it should be a first-line treatment. Your responses are as if we'd said things we did not. Neither of us need a lecture about health or the risks of medications.
I'll stand by my comment that your last paragraph was far too broad. I'd call you neither a traditionalist nor a dinosaur, but that last paragraph borders on sensationalistic and alarmist.
Teri
If my doctor discouraged the use of a medication, because of the possibility of death associated with it's MISUSE without telling me of it's benefits associated with it's PROPER use, I'd fire his/her sorry butt.
No one has said anything about misuse of Ketamine here. Even when used properly in a properly monitored setting by an expert, significant cardiorespiratory responses can occur with Ketamine; however rare, the possiblity still exists. If one is willing to accept that risk, then yes the benefits can be great.
Please note, the medical evidence for the use of Ketamine is weak. The safety and efficacy has not been well established for long-term use of Ketamine. And risk is always relative to other available treatments. That is why Ketamine should be considered a last resort when other treatments with proven safety records have been tried as first, second, and even third line treatments in a clinical pathway.
Like all treatment decisions, the decision to use Ketamine is a personal decision based on acceptable risks and potential benefits.
Dr. Chrisitina Lasich, MD
No, no one has said anything about misuse of Ketamine here, but you should have. This "high risk of death" you discuss does not occur in the PROPER use of Ketamine. It occurs in the IMPROPER use of Ketamine. I'm not a doctor, but I'm smart enough to know if there was a "high risk of death" with this medication it wouldn't be used as an anesthetic in CHILDREN.
Just because people die when MISUSING this drug does not mean they are going to die when used PROPER LY. Yet, you were the one who made the blanket statement that Ketamine use comes with "a high risk of death and at a high cost.". You didn't say "the possibility of a high risk of death". rxlist.com, drugs.com, the DEA, and CESAR (University of Maryland Center for Substance Abuse Research) do not say anything about the "high risk of death" however, drugs.com does say death is a side-effect in CATS and CESAR mentions death from overdose in severe instances.
Four people have questioned you about this "high risk of death". You have not addressed this once in any of your responses.
When I read an article by a HealthCentral Expert, I expect an unbiased, well-informed and knowledgeable article about the topic, not an opinion that says "don't use this drug because there's a "high risk of death" associated with it. You're not talking to people who are considering this drug for recreational use here. You're talking to people that need all sides of the issue; the benefits, the risks, the short and long term side-effects, etc.
Pam
(Paragraphs broken up this way for easier readability)
The serious reactions listed under Ketamine include: respiratory depression, severe hypotension, severe bradycardia and arrhythmias. Typically and traditionally, this drug is administered in the operating room, emergency room and intensive care unit because in the event that one of these life-threatening adverse reactions does occur then the effects can be reversed. "A high risk of death" means that relative to other drugs, ketamine has a higher potential to cause severe, life-threatening adverse reactions. These reactions have been experienced by some, so we all need a healthy fear and respect for these types of powerful chemicals, especially when the chemical is used in a non-traditional, poorly studied fashion.
Dr. Christina Lasich, MD
Thats is fine Dr, But myself, i have been on Ketamine for aprox two yrs for chronic back&leg pain, i was at the end of the road with my pain i thought my life was over due to this horrible constant pain, now with controled Katimine my pain is under control which gives me my life back, im not over weight i get excersise, i never smoked, eat a good diet, this had no effect on my chronic horrible daily pain.
That's great that Ketamine has worked well for you when you were at the end of your road. This "reset button" is a viable option for those who are at the end of the road, the end of the rope, and have exhausted other treatment options. Sounds like it was a good resort for you.
Dr. Christina Lasich, MD
I had ketamine infusion at HSS. I developed diabetes insipidous and poly uria as a result. I has nor subsided and now have kidney stone disease. My MD only told me it was "a batch batch of ketamine and has closed down the unit" I wonder if any one else for peace of mind had these symptons