New Ketamine Guidelines for Acute and Chronic Pain Published

Jun 6, 2018

Ketamine has captured headlines recently for its potential role in treating severe depression and post-traumatic stress syndrome. Now, a team of pain medicine physicians are calling attention to the use of ketamine to combat chronic and acute postoperative pain.

Over the past 10 years, the use of intravenous (IV) ketamine infusions to treat chronic pain has skyrocketed, notes lead author Steven Paul Cohen, MD, director of Medical Education, Pain Medicine Division, at Johns Hopkins Medicine in Baltimore, MD. Because ketamine is a generic drug that is not FDA-approved for chronic pain, its use in this context is characterized by wide variations in indications, dosing regimens, monitoring requirements, and billing. 

Guidelines published this week in Regional Anesthesia and Pain Medicine respond to calls for clarity from healthcare providers, payers, patients and their advocacy groups, and healthcare administrators regarding the use of ketamine in the chronic pain clinic setting.  Since the use of ketamine to treat chronic pain has not undergone the rigorous testing required by regulatory bodies for approved indications, the literature is characterized by small and methodologically flawed studies, note the authors of the guidelines. This makes the creation of guidelines challenging, but more imperative.  The guidelines contain recommendations on a variety of issues confronting clinicians including indications, monitoring requirements, dosing regimens, contraindications and recommended pre-infusion tests, and what constitutes a positive response.

Simultaneously published are guidelines for the use of IV ketamine for acute pain. These guidelines recommend that sub-anesthetic ketamine infusions “be considered for patients undergoing large painful procedures, patients who are opioid-dependent, opioid-tolerant patients with chronic pain that have an acute exacerbation, and patients at risk of side effects from high doses of opioids such as patients with obstructive sleep apnea,” writes James P. Rathmell, MD, professor of anesthesia at Harvard Medical School and Chair of the Department of Anesthesiology, Perioperative and Pain Medicine at Brigham and Women’s Health Care in Boston, MA, in an editorial accompanying the guidelines.

Both guidelines have been approved by the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists.

 

References:

Cohen SP, Bhatia A, Buvanendran A, Schwenk ES, Wasan A, Hurley R, et al. Consensus guidelines on the use of intravenous ketamine infusions for chronic pain from the American Society of Regional Anesthesia & Pain Medicine (ASRA), the American Academy of Pain Medicine (AAPM) and the American Society of Anesthesiologists (ASA). Reg Anesth Pain Med. 2018;43:ePub Ahead of Print.

Schwenk ES, Viscusi ER, Buvanendran A, Hurley RW, Wasan AD, Narouze S, et al. Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the American Society of Regional Anesthesia and Pain Medicine (ASRA), the American Academy of Pain Medicine (AAPM) and the American Society of Anesthesiologists (ASA). Reg Anesth Pain Med. 2018;43:ePub Ahead of Print.


See all ASRA guidelines and advisories.

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