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Bloomfield A, Chan N, Fryml L, Horace R, Pyati S. Ketamine for Chronic Pain and Mental Health: Regulations, Legalities, and the Growth of Infusion Clinics. Curr Pain Headache Rep 2023; 27:579-585. [PMID: 37572245 DOI: 10.1007/s11916-023-01150-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE OF REVIEW In this article, we will review evidence for ketamine's role in chronic pain and mental health conditions, its current legal status and abuse potential, and the regulations related to its administration in stand-alone infusion clinics, as well as future considerations. RECENT FINDINGS In the management of chronic pain, ketamine has shown potential to manage neuropathic pain and complex regional pain syndrome and has been used as a treatment for chronic pain management by clinics across the USA. Analogous to the historic rise of lidocaine clinics, ketamine clinics are demonstrating a similar pattern of unregulated growth. Ketamine is an anesthetic and analgesic agent commonly used in the perioperative setting and emergency department for sedation and pain management (Mo et al in West J Emerg Med 21(2):272-281, 2020). It was approved for use by the Federal Drug Administration in the USA in the 1970s as the sole anesthetic agent for short diagnostic and surgical procedures (Coppel et al. in Anaesthesia 28(3):293-296, 1973; Schwenk et al. in Reg Anesth Pain Med 43(5):456-466, 2018). Regarding its rising popularity as a treatment option in mental health, ketamine holds promise as a rapidly acting treatment for suicidal ideation and refractory depression.
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Affiliation(s)
- Andrew Bloomfield
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Norine Chan
- Duke University School of Medicine, Durham, NC, USA
| | - Leah Fryml
- Psychiatry Service, Durham VA Medical Center, Durham, NC, USA
| | - Reuben Horace
- Department of Emergency Medicine, Duke University Medical Center, Durham, NC, USA
| | - Srinivas Pyati
- Anesthesiology Service, Durham VA Medical Center, Durham, NC, USA.
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2
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Riccardi A, Guarino M, Serra S, Spampinato MD, Vanni S, Shiffer D, Voza A, Fabbri A, De Iaco F. Narrative Review: Low-Dose Ketamine for Pain Management. J Clin Med 2023; 12:jcm12093256. [PMID: 37176696 PMCID: PMC10179418 DOI: 10.3390/jcm12093256] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/14/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Pain is the leading cause of medical consultations and occurs in 50-70% of emergency department visits. To date, several drugs have been used to manage pain. The clinical use of ketamine began in the 1960s and it immediately emerged as a manageable and safe drug for sedation and anesthesia. The analgesic properties of this drug were first reported shortly after its use; however, its psychomimetic effects have limited its use in emergency departments. Owing to the misuse and abuse of opioids in some countries worldwide, ketamine has become a versatile tool for sedation and analgesia. In this narrative review, ketamine's role as an analgesic is discussed, with both known and new applications in various contexts (acute, chronic, and neuropathic pain), along with its strengths and weaknesses, especially in terms of psychomimetic, cardiovascular, and hepatic effects. Moreover, new scientific evidence has been reviewed on the use of additional drugs with ketamine, such as magnesium infusion for improving analgesia and clonidine for treating psychomimetic symptoms. Finally, this narrative review was refined by the experience of the Pain Group of the Italian Society of Emergency Medicine (SIMEU) in treating acute and chronic pain with acute manifestations in Italian Emergency Departments.
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Affiliation(s)
| | - Mario Guarino
- Emergency Department, Centro Traumatologico Ortopedico, Azienda Ospedaliera di Rilievo Nazionale dei Colli, 80131 Napoli, Italy
| | - Sossio Serra
- Emergency Department, Maurizio Bufalini Hospital, 47522 Cesena, Italy
| | | | - Simone Vanni
- Dipartimento Emergenza e Area Critica, Azienda USL Toscana Centro Struttura Complessa di Medicina d'Urgenza, 50053 Empoli, Italy
| | - Dana Shiffer
- Emergency Department, Humanitas University, Via Rita Levi Montalcini 4, 20089 Milan, Italy
| | - Antonio Voza
- Emergency Department, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, Italy
| | - Fabio De Iaco
- Emergency Department, Ospedale Maria Vittoria, 10144 Turin, Italy
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3
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Subramanian S, Haroutounian S, Palanca BJA, Lenze EJ. Ketamine as a therapeutic agent for depression and pain: mechanisms and evidence. J Neurol Sci 2022; 434:120152. [PMID: 35092901 DOI: 10.1016/j.jns.2022.120152] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 01/07/2022] [Accepted: 01/08/2022] [Indexed: 12/14/2022]
Abstract
Ketamine is an anesthetic drug which is now used to treat chronic pain conditions and psychiatric disorders, especially depression. It is an N-methyl-D-aspartate (NMDA) receptor antagonist with additional effects on α-Amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors, hyperpolarization-activated cyclic nucleotide-gated (HCN) channels, opioid receptors, and monoaminergic receptors. This article focuses on ketamine's role in treating depression and pain, two commonly comorbid challenging conditions with potentially shared neurobiologic circuitry. Many clinical trials have utilized intravenous or intranasal ketamine for treating depression and pain. Intravenous ketamine is more bioavailable than intranasal ketamine and both are effective for acute depressive episodes. Intravenous ketamine is advantageous for post-operative analgesia and is associated with a reduction in total opioid requirements. Few studies have treated chronic pain or concurrent depression and pain with ketamine. Larger, randomized control trials are needed to examine the safety and efficacy of intravenous vs. intranasal ketamine, ideal target populations, and optimal dosing to treat both depression and pain.
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Affiliation(s)
- Subha Subramanian
- Department of Psychiatry, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
| | - Simon Haroutounian
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Ben Julian A Palanca
- Department of Psychiatry, Washington University in St. Louis School of Medicine, St. Louis, MO, USA; Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA; Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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4
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Falk E, Schlieper D, van Caster P, Lutterbeck MJ, Schwartz J, Cordes J, Grau I, Kienbaum P, Neukirchen M. A rapid positive influence of S-ketamine on the anxiety of patients in palliative care: a retrospective pilot study. BMC Palliat Care 2020; 19:1. [PMID: 31900221 PMCID: PMC6942257 DOI: 10.1186/s12904-019-0499-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 12/04/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Patients in palliative care need rapid-acting pharmacological options for psychological distress. N-methyl-D-aspartate antagonist ketamine is known to have a fast onset of anti-depressant and anxiolytic action. Its S-enantiomer S-ketamine (or esketamine) is an analgesic used as a routine treatment for refractory pain as an intravenous infusion (0.25 mg/kg over 45 min). This study investigates whether S-ketamine pain therapy has a positive impact on psychological distress caused by anxiety and depression in palliative care. METHODS Patient routine data from a palliative care unit of a tertiary care hospital were used in a retrospective analysis after positive ethics approval. Eight patients, who received analgesic S-ketamine treatment, were compared to a control group matched by gender and age. The main analysis was conducted using three-way mixed MANOVA followed by two-way mixed ANOVA. Target variables were the values for anxiety and depression in the state-trait anxiety-depression inventory STADI. The predictor variables were the time of measurement before (T1) and after (T2) S-ketamine application and group membership. RESULTS Comparison of the S-ketamine group (n = 8; 4 male, 4 female; average age 52 years) with the control group (n = 8; 3 male, 5 female; average age 55 years) revealed a significant multivariate effect on anxiety and depression F(1, 14) = 4.78; p = 0.046; r = 0.50. The univariate comparisons showed a significant reduction of the anxiety scores from T1 to T2 in the S-ketamine group compared to the control group F(1, 14) = 10.14; p = 0.007; r = 0.65. With regard to depression, there was no significant reduction from T1 to T2 in the group comparison F(1, 14) = 1.60; p = 0.23; r = 0.32. No long-lasting effects on pain were found. CONCLUSIONS Our findings show that psychological distress of patients in palliative care may improve after a single administration of S-ketamine, which mainly alleviates anxiety in those patients. Limitations of this study arise from non-randomization, retrospective analysis and low sample size. Therefore, further prospective and ideally randomized studies are necessary.
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Affiliation(s)
- Eduard Falk
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Daniel Schlieper
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Patrick van Caster
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Present Address: Klinik für Anästhesie, Operative Intensiv- und Palliativmedizin, Städtisches Klinikum Solingen, Solingen, Germany
| | - Matthias J. Lutterbeck
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jacqueline Schwartz
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Joachim Cordes
- Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ina Grau
- Department of Psychology, University Bonn, Bonn, Germany
| | - Peter Kienbaum
- Department of Anesthesiology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Martin Neukirchen
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Anesthesiology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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5
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Trujillo KA, Heller CY. Ketamine sensitization: Influence of dose, environment, social isolation and treatment interval. Behav Brain Res 2019; 378:112271. [PMID: 31593791 DOI: 10.1016/j.bbr.2019.112271] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/12/2019] [Accepted: 09/30/2019] [Indexed: 12/18/2022]
Abstract
Ketamine is a dissociative anesthetic first developed in the 1960s but is increasingly used at subanesthetic doses for both clinical and non-clinical purposes. There is evidence from human recreational users of compulsive use and addiction. Sensitization is an increase in an effect of a drug with repeated use that is thought to be important in the development of addiction. Research on psychomotor stimulants has shown the development of sensitization in laboratory animals to be modified by factors that influence addiction. In the current paper we describe four experiments on the development of sensitization in laboratory rats aimed at determining if ketamine sensitization is also influenced by factors thought to be important in addiction. Adult, male Sprague-Dawley rats received ketamine (5, 10, 20 or 50 mg/kg i.p.) for five or more days and the development of locomotor sensitization was followed. Experiment 1 examined the ability of low doses of ketamine to produce sensitization and found sensitization at 5, 10 and 20 mg/kg. Experiment 2 examined the influence of environmental context and found that ketamine sensitization (20 mg/kg) was greater when administration occurred in a novel environment (the experimental apparatus) than in home cages. Experiment 3 found that ketamine sensitization (20 mg/kg) did not occur when animals were housed in social isolation but occurred readily in pair-housed animals. Finally, Experiment 4 found that ketamine sensitization (20 or 50 mg/kg) was similar whether drug was administered daily or at 3-day intervals. Together, the results demonstrate that ketamine sensitization is robust and reliable, occurring under a variety of circumstances. Moreover, ketamine sensitization is influenced by factors that influence the development of addiction in humans. The current results may lead to a better understanding of ketamine abuse and addiction and may help inform clinical use of the drug.
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Affiliation(s)
- Keith A Trujillo
- Department of Psychology and Office for Training, Research, and Education in the Sciences, California State University San Marcos, 333 S. Twin Oaks Valley Road, San Marcos, CA 92096-0001, USA.
| | - Colleen Y Heller
- Department of Psychology and Office for Training, Research, and Education in the Sciences, California State University San Marcos, 333 S. Twin Oaks Valley Road, San Marcos, CA 92096-0001, USA
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6
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Pino CA. PAIN MANAGEMENT IN CANCER. Cancer 2019. [DOI: 10.1002/9781119645214.ch26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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7
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Nowacka A, Borczyk M. Ketamine applications beyond anesthesia - A literature review. Eur J Pharmacol 2019; 860:172547. [PMID: 31348905 DOI: 10.1016/j.ejphar.2019.172547] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/09/2019] [Accepted: 07/15/2019] [Indexed: 02/07/2023]
Abstract
Ketamine's clinical use began in the 1970s. Physicians benefited from its safety and ability to induce short-term anesthesia and analgesia. The psychodysleptic effects caused by the drug called its further clinical use into question. Despite these unpleasant effects, ketamine is still applied in veterinary medicine, field medicine, and specialist anesthesia. Recent intensive research brought into light new possible applications of this drug. It began to be used in acute, chronic and cancer pain management. Most interesting reports come from research on the antidepressive and antisuicidal properties of ketamine giving hope for the creation of an effective treatment for major depressive disorder. Other reports highlight the possible use of ketamine in treating addiction, asthma and preventing cancer growth. Besides clinical use, the drug is also applied to in animal model of schizophrenia. It seems that nowadays, with numerous possible applications, the use of ketamine has returned; to its former glory. Nevertheless, the drug must be used with caution because still the mechanisms by which it executes its functions and long-term effects of its use are not fully known. This review aims to discuss the well-known and new promising applications of ketamine.
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Affiliation(s)
- Agata Nowacka
- Laboratory of Molecular Basis of Behavior, Nencki Institute of Experimental Biology, Polish Academy of Sciences, Warsaw, Poland
| | - Malgorzata Borczyk
- Laboratory of Molecular Basis of Behavior, Nencki Institute of Experimental Biology, Polish Academy of Sciences, Warsaw, Poland.
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8
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Shteamer JW, Harvey RD, Spektor B, Curseen K, Egan K, Chen Z, Gillespie TW, Sniecinski RM, Singh V. Safety of Intranasal Ketamine for Reducing Uncontrolled Cancer-Related Pain: Protocol of a Phase I/II Clinical Trial. JMIR Res Protoc 2019; 8:e12125. [PMID: 31038469 PMCID: PMC6658277 DOI: 10.2196/12125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 12/27/2018] [Accepted: 12/31/2018] [Indexed: 11/27/2022] Open
Abstract
Background Approximately 12 million Americans are affected with cancer. Of these, 53% experience pain at all stages of cancer. Pain may remain uncontrolled despite high-dose opioid therapy, and opioids have many well-documented harmful side effects. Intranasal ketamine has been shown to be effective in controlling breakthrough noncancer pain in a double-blind randomized control trial (DBRCT) by Carr et al in 2003 as well as to help with depression in a DBRCT by Lapidus et al in 2014. We seek to obtain preliminary data on the safety, feasibility, and utility of this novel technique for the treatment of uncontrolled cancer pain. Objective This study aimed to obtain preliminary data via a clinical trial addressing the safety, feasibility, pharmacokinetics, and pharmacodynamics of intranasal ketamine. These initial findings will be applied to a subsequent trial to determine the effectiveness and associated toxicities of ketamine in a larger sample of cancer patients and to address the compelling need to identify new, successful management therapies for cancer pain. Methods This is an institutional review board– and investigational new drug–approved, prospective phase I/II trial to investigate the safety and use of intranasal ketamine in patients with uncontrolled pain related to cancer or cancer treatment. Informed consent will be obtained prior to all study procedures. All patients will be assigned to the same investigational treatment arm. After patient selection via inclusion/exclusion criteria, patients will be seen over 5 visits, with each visit conducted 2-7 days apart. Patients will be administered ketamine on visits 1-4 and monitored for 240 minutes with continuous pulse oximetry and regular blood pressure checks. Blood samples as well as patient-reported outcomes will be collected at set time points at baseline and after drug delivery. Patients will receive 10 mg intranasal ketamine on visit 1, 10 mg intravenous ketamine on visit 2, 30 mg intranasal ketamine on visit 3, and 50 mg intranasal ketamine on visit 4. On visit 5, an addition blood sample will be drawn. Results As of March 2019, enrollment is in progress, and a total of 7 subjects have completed the study. Enrollment is expected to be completed by April 2019. Final data analysis will commence soon after, and the results are expected to be submitted for publication in 2019. Conclusions If intranasal ketamine can be utilized for pain control in cancer patients, it could provide superior analgesia and better quality of life, without the risk of significant respiratory depression and constipation associated with opioid medications. These findings will be an important initial step toward testing the effectiveness of intranasal ketamine as a nonopioid medication for cancer pain and as potential maintenance outpatient therapy. Trial Registration ClinicalTrials.gov NCT03146806; https://clinicaltrials.gov/ct2/show/NCT03146806. International Registered Report Identifier (IRRID) DERR1-10.2196/12125
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Affiliation(s)
- Jack W Shteamer
- Department of Anesthesiology, Emory University, Atlanta, GA, United States
| | - R Donald Harvey
- Department of Pharmacology, Emory University, Atlanta, GA, United States.,Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, United States
| | - Boris Spektor
- Department of Anesthesiology, Emory University, Atlanta, GA, United States
| | - Kimberly Curseen
- Department of Medicine, Emory University, Atlanta, GA, United States
| | - Katherine Egan
- Department of Anesthesiology, Emory University, Atlanta, GA, United States
| | - Zhengjia Chen
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, United States.,Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | | | - Roman M Sniecinski
- Department of Anesthesiology, Emory University, Atlanta, GA, United States
| | - Vinita Singh
- Department of Anesthesiology, Emory University, Atlanta, GA, United States
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9
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Jackson K, Ashby M, Howell D, Petersen J, Brumley D, Good P, Pisasale M, Wein S, Woodruff R. The Effectiveness and Adverse Effects profile of “Burst” Ketamine in Refractory Cancer Pain: The Vcog Pm 1-00 Study. J Palliat Care 2018. [DOI: 10.1177/082585971002600306] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This multi-centre study of adjuvant “burst” ketamine in palliative care in-patients documents its effectiveness, duration of pain relief, and adverse effects (AE) profile. Patients received a three-to-five day continuous subcutaneous infusion (CSCI) of ketamine escalated from 100 to 300 to 500 mg/24 hours if required. When the effective or maximum tolerated dose was attained, the infusion was continued for three days and each patient assessed as a responder or non-responder using strict criteria. The response rate was 22/44 (50 percent), with 4 (9 percent) becoming pain-free. Pain relief lasting two or more weeks was documented in 50 percent of responders. AEs were documented daily using the National Cancer Institute (NCI) Common Toxicity Criteria 0-4 scales. There were 11 grade 3 and 4 neurological AEs. However, no responders elected to cease treatment early due to neurological AEs. We concluded that this protocol in the controlled environment of an in-patient PC unit is relatively safe and simple with reasonable effectiveness.
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Affiliation(s)
- Kate Jackson
- K Jackson (corresponding author): Supportive and Palliative Care Unit, Southern Health and Monash University, and McCulloch House PCU, Monash Medical Centre, Locked Bag 29, Clayton South, Victoria 3169, Australia
| | - Michael Ashby
- M Ashby: McCulloch House PCU, Monash Medical Centre, Clayton South, Victoria, and Palliative Care, Department of Health and Human Services, Hobart, Tasmania, Australia
| | - Deb Howell
- D Howell, J Petersen: Cancer Council Victoria, Carlton, Victoria
| | | | - David Brumley
- P Good: McCulloch House PCU, Monash Medical Centre, Clayton, Victoria, and Newcastle Mater Misericordiae Hospital, Newcastle, New South Wales, Australia
| | - Phillip Good
- M Pisasale: Werribee Mercy PCU, Werribee, Victoria;, Heidelberg, Victoria, Australia
| | - Maria Pisasale
- S Wein: Peter MacCallum Cancer Centre, East Melbourne, Victoria;, Heidelberg, Victoria, Australia
| | - Simon Wein
- R Woodruff: Austin Hospital, Heidelberg, Victoria, Australia
| | - Roger Woodruff
- R Woodruff: Austin Hospital, Heidelberg, Victoria, Australia
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10
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Abstract
Increasing numbers of those living with and beyond cancer presents a clinical challenge for pain specialists. A large proportion of these patients experience pain secondary to their disease or its treatment, impeding rehabilitation and significantly impacting upon their quality of life. The successful management of this pain presents a considerable challenge. This review aims to outline current concepts and treatment options, while considering nuances within pain assessment and the use of large-scale data to help guide further advances.
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Affiliation(s)
- David Magee
- Department of Pain Medicine, The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK
| | - Sabina Bachtold
- Department of Pain Medicine, The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK
| | - Matthew Brown
- Department of Pain Medicine, The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK.,Targeted Approaches to Cancer Pain Group, The Institute of Cancer Research, 15 Cotswold Road, Sutton, Surrey, SM2 5NG, UK
| | - Paul Farquhar-Smith
- Department of Pain Medicine, The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK
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11
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Ettensohn MF, Markey SM, Levine SP. Considering Ketamine for Treatment of Comorbid Pain, Depression, and Substance Use Disorders. Psychiatr Ann 2018. [DOI: 10.3928/00485713-20180312-02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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Singh V, Gillespie TW, Harvey RD. Intranasal Ketamine and Its Potential Role in Cancer-Related Pain. Pharmacotherapy 2018; 38:390-401. [PMID: 29396996 DOI: 10.1002/phar.2090] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cancer-related pain continues to be a significant therapeutic challenge, made more difficult by contemporary opioid use and diversion concerns. Conventional treatment using a tiered approach of nonsteroidal antiinflammatory drugs (NSAIDs), opioids, and adjuvant agents is limited; and alternatives are needed for patients with rapidly progressing pain and those who develop hyperalgesia and tolerance to opioids. Ketamine, an N-methyl-d-aspartate (NMDA) selective antagonist, has historically been used for anesthesia in adult and pediatric populations but has also been investigated for depression, bipolar disorder, and general and postoperative pain management. As an analgesic, low-dose ketamine decreases morphine requirements and rates of nausea and vomiting, suggesting a potentially beneficial role in cancer-related pain. Ketamine is typically administered intravenously and has a rapid onset of action with a relatively short half-life (2-3 hours) but is inconvenient for use in an ambulatory setting. Oral bioavailability is low and erratic, limiting application of this route for chronic use. Intranasal administration has a number of potential advantages, including avoidance of first-pass hepatic metabolism, no need for venous access, ability to repeat doses quickly, and rapid absorption. Although early studies of intranasal ketamine are promising in a number of indications, information is more limited in its use as an adjunct in cancer-related pain. We review the background, rationale, pharmacokinetics, and clinical and safety data using intranasal ketamine as an adjunctive agent and its potential in cancer-related pain.
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Affiliation(s)
- Vinita Singh
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Theresa W Gillespie
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Robert Donald Harvey
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia.,Department of Pharmacology, Emory University School of Medicine, Atlanta, Georgia
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13
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Lester PE, Shehata J, Fazzari M, Islam S. Impact of Hospital-Wide Comprehensive Pain Management Initiatives. Am J Med Qual 2017; 32:591-597. [DOI: 10.1177/1062860616686683] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This project aimed to improve pain management through clinician education, updated assessment tools, computer resources, and improved ordering and delivery systems. Clinicians were surveyed and results analyzed using Wilcoxon-Mann-Whitney testing and χ2 testing. Prescribing patterns were evaluated by comparing proportions of prescription orders and dose intervals. Cochran-Armitage Trend Test was used for linear trends in proportion of prescription orders over time. Knowledge scores improved significantly for nurses ( P = .004) and nurse practitioners/physician assistants ( P < .0001). Patient surveys showed a reduction in the percentage of patients dissatisfied with pain control. There was a decrease of 3.6% in intramuscular orders of opioids ( P < .0001). A significant reduction was found in the percentage of orders of potentially high initial doses of opioids of hydromorphone and morphine after implementing an electronic alert. This project demonstrates that a comprehensive educational strategy with improved assessment tools, clinical resources, and educational programming can have a significant impact on pain management.
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14
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Faisal W, Jacques J. Role of Ketamine and Methadone as Adjunctive Therapy in Complex Pain Management: A Case Report and Literature Review. Indian J Palliat Care 2017; 23:100-103. [PMID: 28216871 PMCID: PMC5294428 DOI: 10.4103/0973-1075.197956] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Assessment and management of complex cancer pain always remains a major challenge for any palliative care team, given its heterogeneity of underlying pathophysiology and limitations of any pharmacotherapy. Here, we present a case of complex pain management in a young patient with a life-limiting illness, highlighting the issues of organic and nonorganic contributors of pain and provide some insight into the role of ketamine and methadone as adjunctive therapy to opioid analgesics. A brief literature review is also done to provide the context of use of these adjunctive drugs in this setting.
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Affiliation(s)
- Wasek Faisal
- Department of Medical Oncology, Ballarat Regional Integrated Cancer Centre, Ballarat, Victoria, Australia
| | - Judith Jacques
- Department of Palliative Care, Central Coast Cancer Centre, Gosford, NSW, Australia
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15
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Abstract
The analgesic ladder guideline proposed by the World Health Organization has been shown to be effective in controlling cancer pain in about 80 percent of patients, but the remaining 20 percent still experience pain. Several strategies have been used to manage refractory cancer pain and opioid toxicity. Switching opioids, alternative routes of opioid administration, optimizing adjuvants, and invasive procedures are proposed treatments. Extensive medical literature corroborates each one of those treatments. Rotation from one opioid to another is a noninvasive strategy to overcome opioid side effects and refractory pain. Frequently, methadone is used during opioid rotation. However, there is a lack of consensus on how to proceed on rotation from morphine to methadone. In the current era of evidence-based medicine, the medical literature fails to answer some cancer pain-management issues. The purpose of this review is to clarify a process for transitioning from morphine to methadone.
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Mallick F, McCullumsmith CB. Ketamine for Treatment of Suicidal Ideation and Reduction of Risk for Suicidal Behavior. Curr Psychiatry Rep 2016; 18:61. [PMID: 27194043 DOI: 10.1007/s11920-016-0680-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Ketamine, an NMDA receptor antagonist with efficacy as a rapid anti-depressant, has early evidence for action to reduce suicidal ideation. This review will explore several important questions that arise from these studies. First, how do we measure reductions in suicidal ideation that occur over minutes to hours? Second, are the reductions in suicidal ideation after ketamine treatment solely a result of its rapid anti-depressant effect? Third, is ketamine only effective in reducing suicidal ideation in patients with mood disorders? Fourth, could ketamine's action lead us to a greater understanding of the neurobiology of suicidal processes? Last, do the reductions in depression and suicidal ideation after ketamine treatment translate into decreased risk for suicidal behavior? Our review concludes that ketamine treatment can be seen as a double-edged sword, clinically to help provide treatment for acutely suicidal patients and experimentally to explore the neurobiological nature of suicidal ideation and suicidal behavior.
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Affiliation(s)
- Faryal Mallick
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH, USA
| | - Cheryl B McCullumsmith
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH, USA.
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Abstract
Opioid analgesics continue to be the mainstay of pharmacologic treatment of moderate to severe pain. Many patients, particularly those suffering from chronic pain, require chronic high-dose analgesic therapy. Achieving clinical efficacy and tolerability of such treatment regimens is hampered by the appearance of opioid-induced side effects such as tolerance, hyperalgesia and withdrawal syndrome. Among the therapeutic options to improve the opioid effectiveness, this current review focuses on strategies combining opioids to other drugs that can modulate opioid-mediated effects. We will discuss about experimental evidences reported for several potential opioid adjuvants, including N-methyl-d-aspartate receptor antagonists, 5-HT7 agonists, sigma-1 antagonists, I2-R ligands, cholecystokinin antagonists, neuropeptide FF-R antagonists and toll-like receptor 4 antagonists.
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Busse J, Phillips L, Schechter W. Long-Term Intravenous Ketamine for Analgesia in a Child with Severe Chronic Intestinal Graft versus Host Disease. Case Rep Anesthesiol 2015; 2015:834168. [PMID: 26779350 PMCID: PMC4686632 DOI: 10.1155/2015/834168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 11/29/2015] [Indexed: 11/18/2022] Open
Abstract
Ketamine is reported to be an effective adjuvant to opioids in the treatment of refractory cancer pain; however, the use of high doses of ketamine for extended periods in pediatric patients has not been described. We present a five-year-old male with grade IV intestinal GVHD whose abdominal pain required both hydromorphone and ketamine for a period of over four months. There was no evidence of hepatotoxicity, hemorrhagic cystitis, or other adverse effects. Possible withdrawal symptoms were mild and were readily mitigated by gradually weaning ketamine.
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Affiliation(s)
- Jennifer Busse
- Anesthesiology, Morgan Stanley Children's Hospital at Columbia University, New York, NY 10032, USA
| | - Leroy Phillips
- Anesthesiology, New York University Langone Medical Center, New York, NY 10016, USA
| | - William Schechter
- Anesthesiology and Pediatrics, Morgan Stanley Children's Hospital at Columbia University, New York, NY 10032, USA
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Bhatia A. Ketamine as an adjunct to patient-controlled analgesia: why, for whom, and how much? Can J Anaesth 2015; 63:262-4. [PMID: 26607796 DOI: 10.1007/s12630-015-0552-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 10/19/2015] [Accepted: 11/19/2015] [Indexed: 01/17/2023] Open
Affiliation(s)
- Anuj Bhatia
- Department of Anesthesia and Pain Management and Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada. .,University Health Network-Toronto Western Hospital, Mount Sinai Hospital, and Women's College Hospital, Toronto, ON, Canada.
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20
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Niesters M, Martini C, Dahan A. Ketamine for chronic pain: risks and benefits. Br J Clin Pharmacol 2014; 77:357-67. [PMID: 23432384 DOI: 10.1111/bcp.12094] [Citation(s) in RCA: 278] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 02/11/2013] [Indexed: 12/29/2022] Open
Abstract
The anaesthetic ketamine is used to treat various chronic pain syndromes, especially those that have a neuropathic component. Low dose ketamine produces strong analgesia in neuropathic pain states, presumably by inhibition of the N-methyl-D-aspartate receptor although other mechanisms are possibly involved, including enhancement of descending inhibition and anti-inflammatory effects at central sites. Current data on short term infusions indicate that ketamine produces potent analgesia during administration only, while three studies on the effect of prolonged infusion (4-14 days) show long-term analgesic effects up to 3 months following infusion. The side effects of ketamine noted in clinical studies include psychedelic symptoms (hallucinations, memory defects, panic attacks), nausea/vomiting, somnolence, cardiovascular stimulation and, in a minority of patients, hepatoxicity. The recreational use of ketamine is increasing and comes with a variety of additional risks ranging from bladder and renal complications to persistent psychotypical behaviour and memory defects. Blind extrapolation of these risks to clinical patients is difficult because of the variable, high and recurrent exposure to the drug in ketamine abusers and the high frequency of abuse of other illicit substances in this population. In clinical settings, ketamine is well tolerated, especially when benzodiazepines are used to tame the psychotropic side effects. Irrespective, close monitoring of patients receiving ketamine is mandatory, particularly aimed at CNS, haemodynamic, renal and hepatic symptoms as well as abuse. Further research is required to assess whether the benefits outweigh the risks and costs. Until definite proof is obtained ketamine administration should be restricted to patients with therapy-resistant severe neuropathic pain.
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Affiliation(s)
- Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, RC Leiden, the Netherlands
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21
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22
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Spruyt O, Le B, Philip J. Integrating new evidence about an old drug: growing pains as palliative medicine matures. J Pain Symptom Manage 2013; 46:e3-5. [PMID: 24176613 DOI: 10.1016/j.jpainsymman.2013.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 08/22/2013] [Indexed: 11/21/2022]
Affiliation(s)
- Odette Spruyt
- Pain and Palliative Care, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia
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Bredlau AL, Thakur R, Korones DN, Dworkin RH. Ketamine for pain in adults and children with cancer: a systematic review and synthesis of the literature. PAIN MEDICINE 2013; 14:1505-17. [PMID: 23915253 DOI: 10.1111/pme.12182] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Chronic cancer pain is often refractory and difficult to treat. Ketamine is a medication with evidence of efficacy in the treatment of chronic pain. DESIGN This article presents a synthesis of the data on ketamine for refractory cancer pain in adults and children. RESULTS There are five randomized, double-blind, controlled trials of ketamine use in cancer pain that demonstrate improvement in pain for some patients. There are six prospective, uncontrolled trials in cancer pain that also demonstrate improvement in pain scores for some patients. There are no randomized, controlled trials in children with cancer pain, although there are a few studies reflecting improved pain control with ketamine for children with cancer pain. Adverse events for adults on ketamine are most commonly somnolence, feelings of insobriety, nausea/vomiting, hallucinations, depersonalization/derealization, and drowsiness. However, when ketamine is combined with benzodiazepines, feelings of insobriety, hallucinations, and depersonalization/derealization are not reported. Children on ketamine have had few reported adverse effects, which include sedation, anorexia, urinary retention, and myoclonic movements. Recommended ketamine infusion dosages are from 0.05 to 0.5 mg/kg/h (intravenous or subcutaneous). Recommended oral dosages of ketamine are 0.2-0.5 mg/kg/dose two to three times daily with a maximum of 50 mg/dose three times daily. CONCLUSIONS Despite limitations in the breadth and depth of data available, there is evidence that ketamine may be a viable option for treatment-refractory cancer pain.
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Affiliation(s)
- Amy Lee Bredlau
- Departments of Pediatrics and Neurosciences, Medical University of South Carolina, Charleston, South Carolina
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Neri CM, Pestieau SR, Darbari DS. Low-dose ketamine as a potential adjuvant therapy for painful vaso-occlusive crises in sickle cell disease. Paediatr Anaesth 2013; 23:684-9. [PMID: 23565738 DOI: 10.1111/pan.12172] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2013] [Indexed: 11/29/2022]
Abstract
The hallmark of sickle cell disease (SCD) is the acute painful vaso-occlusive crisis (VOC). Among SCD patients, vaso-occlusive pain episodes vary in frequency and severity. Some patients rarely have painful crises, while others are admitted to the hospital multiple times in a year for parenteral analgesics. Opioids are the mainstay of therapy for SCD-related pain. However, a subset of patients report continued pain despite escalating doses of opioids. Tolerance and opioid-induced hyperalgesia (OIH) have been considered as possible explanations for this phenomenon. The activation of the N-methyl-d-aspartate (NMDA) receptor has been implicated in both tolerance and OIH. As a NMDA receptor agonist, ketamine has been shown to modulate opioid tolerance and OIH in animal models and clinical settings. Low-dose ketamine, by virtue of its NMDA receptor agonist activity, could be a useful adjuvant to opioid therapy in patients with refractory SCD-related pain. Based on limited studies of adjuvant ketamine use for pain management, low-dose ketamine continuous infusion appears safe. Further clinical investigations are warranted to fully support the use of low-dose ketamine infusion in patients with SCD-related pain.
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Affiliation(s)
- Caitlin M Neri
- Children's National Medical Center, Center for Cancer and Blood Disorders, Washington, DC 20010, USA.
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Yamaguchi T, Shima Y, Morita T, Hosoya M, Matoba M. Clinical Guideline for Pharmacological Management of Cancer Pain: The Japanese Society of Palliative Medicine Recommendations. Jpn J Clin Oncol 2013; 43:896-909. [DOI: 10.1093/jjco/hyt099] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Persson J. Ketamine in pain management. CNS Neurosci Ther 2013; 19:396-402. [PMID: 23663314 DOI: 10.1111/cns.12111] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Revised: 03/14/2013] [Accepted: 03/15/2013] [Indexed: 11/28/2022] Open
Abstract
For ketamine's fiftieth birthday, a narrative review of this unique drug in pain management is presented. Its history is traced from its conception, and its heritage, as a phencyclidine offspring, delineated. The earliest roots of the conceptions concerning the mechanisms of action are sought, and then followed in preclinical as well as clinical research. The major proposed mechanisms in the literature are commented on and evaluated. The growth of the clinical evidence for perioperative pain, acute pain, and chronic pain is followed from early attempts to systematic reviews. Finally, an attempt is made to foresee what the next 50 years might hold in store for our 50 years old.
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Affiliation(s)
- Jan Persson
- Department of Anesthesia and Intensive Care, Pain Clinic, Karolinska University Hospital, Stockholm, Sweden.
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Schneider PG, Rodríguez de Lores Arnaiz G. Ketamine prevents seizures and reverses changes in muscarinic receptor induced by bicuculline in rats. Neurochem Int 2012; 62:258-64. [PMID: 23279735 DOI: 10.1016/j.neuint.2012.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 11/27/2012] [Accepted: 12/12/2012] [Indexed: 11/17/2022]
Abstract
The cholinergic system has been implicated in several experimental epilepsy models. In a previous study bicuculline (BIC), known to antagonize GABA-A postsynaptic receptor subtype, was administered to rats at subconvulsant (1mg/kg) and convulsant (7.5mg/kg) doses and quinuclidinyl benzilate ([(3)H]-QNB) binding to CNS membranes was determined. It was observed that ligand binding to cerebellum increases while it decreases in the case of hippocampus. Saturation binding curves showed that changes were due to the modification of receptor affinity for the ligand without alteration of binding site number. The purpose of this study was to assay muscarinic receptors employing other BIC dose (5mg/kg), which induces seizures and allows the analysis of a postseizure stage as well. To study further muscarinic receptor involvement in BIC induced seizures, KET was also employed since it is a well known anticonvulsant in some experimental models. The administration of BIC at 5mg/kg to rats produced a similar pattern of changes in [(3)H]-QNB binding to those recorded with 1.0 and 7.5mg/kg doses. Here again, changes were observed in receptor binding affinity without alteration in binding site number for cerebellum or hippocampus membranes. Pretreatment with KET (40 mg/kg) prevented BIC seizures and reverted [(3)H]-QNB binding changes induced by BIC administration. The single administration of KET invariably resulted in [(3)H]-QNB binding decrease to either cerebellar or hippocampal membranes. KET added in vitro decreased ligand binding likewise. Results of combined treatment with KET plus BIC are hardly attributable to the single reversion of BIC effect since KET alone invariably decreased ligand binding. It is suggested that besides alteration of cholinergic muscarinic receptor other(s) neurotransmitter system(s) may well also be involved.
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Affiliation(s)
- Patricia Graciela Schneider
- Instituto de Biología Celular y Neurociencia "Prof. E. De Robertis", CONICET-UBA, Facultad de Medicina, Universidad de Buenos Aires, Paraguay 2155, 1121 Buenos Aires, Argentina.
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Hardy J, Quinn S, Fazekas B, Plummer J, Eckermann S, Agar M, Spruyt O, Rowett D, Currow DC. Randomized, double-blind, placebo-controlled study to assess the efficacy and toxicity of subcutaneous ketamine in the management of cancer pain. J Clin Oncol 2012; 30:3611-7. [PMID: 22965960 DOI: 10.1200/jco.2012.42.1081] [Citation(s) in RCA: 144] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The anesthetic ketamine is widely used for pain related to cancer, but the evidence to support its use in this setting is weak. This study aimed to determine whether ketamine is more effective than placebo when used in conjunction with opioids and standard adjuvant therapy in the management of chronic uncontrolled cancer pain. Ketamine would be considered of net benefit if it provided clinically relevant improvement in pain with limited breakthrough analgesia and acceptable toxicity. PATIENTS AND METHODS In this multisite, dose-escalation, double-blind, randomized, placebo-controlled phase III trial, ketamine or placebo was delivered subcutaneously over 3 to 5 days. RESULTS In all, 185 participants were included in the primary analysis. There was no significant difference between the proportion of positive outcomes (0.04; 95% CI, -0.10 to 0.18; P = .55) in the placebo and intervention arms (response rates, 27% [25 of 92] and 31% [29 of 93]). Pain type (nociceptive v neuropathic) was not a predictor of response. There was almost twice the incidence of adverse events worse than baseline in the ketamine group after day 1 (incidence rate ratio, 1.95; 95% CI, 1.46 to 2.61; P < .001) and throughout the study. Those receiving ketamine were more likely to experience a more severe grade of adverse event per day (odds ratio, 1.09; 95% CI, 1.00 to 1.18; P = .039). The number of patients needed to treat for one additional patient to have a positive outcome from ketamine was 25 (95% CI, six to ∞). The number needed to harm, because of toxicity-related withdrawal, was six (95% CI, four to 13). CONCLUSION Ketamine does not have net clinical benefit when used as an adjunct to opioids and standard coanalgesics in cancer pain.
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Affiliation(s)
- Janet Hardy
- Dept Palliative Care, Mater Adult Hospital, Raymond Terrace, South Brisbane, Queensland, Australia 4101.
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30
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Salas S, Frasca M, Planchet-Barraud B, Burucoa B, Pascal M, Lapiana JM, Hermet R, Castany C, Ravallec F, Loundou A, Auquier P, Duffaud F, Baumstarck K. Ketamine Analgesic Effect by Continuous Intravenous Infusion in Refractory Cancer Pain: Considerations about the Clinical Research in Palliative Care. J Palliat Med 2012; 15:287-93. [DOI: 10.1089/jpm.2011.0353] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sébastien Salas
- Service d'Oncologie Médicale Adulte et de Soins Palliatifs, CHU Timone, APHM, Université de la méditerranée, Marseille, France
| | - Matthieu Frasca
- Service d'Accompagnement et de Soins Palliatifs, CHU St André, Bordeaux, France
| | | | - Benoît Burucoa
- Service d'Accompagnement et de Soins Palliatifs, CHU St André, Bordeaux, France
| | - Monique Pascal
- Centre de Lutte Contre la Douleur, Centre Hospitalier Général, Aix-en-Provence, France
| | | | - Raymond Hermet
- Equipe Mobile de Soins Palliatifs, CHU Clermont-Ferrand, France
| | - Claudine Castany
- Unité de Soins Palliatifs, Centre Hospitalier de Salon-de-Provence, France
| | - Frédéric Ravallec
- Unité de Soins Palliatifs, Hôpital Saint Thomas de Villeneuve, Aix-en-Provence, France
| | - Anderson Loundou
- Unité d'Aide Méthodologique à la Recherche Clinique, APHM, Marseille, France
| | - Pascal Auquier
- Research Equip 3279 Evaluation de la santé perçue, Université de la méditerranée, Marseille, France
| | - Florence Duffaud
- Service d'Oncologie Médicale Adulte et de Soins Palliatifs, CHU Timone, APHM, Université de la méditerranée, Marseille, France
| | - Karine Baumstarck
- Unité d'Aide Méthodologique à la Recherche Clinique, APHM, Marseille, France
- Research Equip 3279 Evaluation de la santé perçue, Université de la méditerranée, Marseille, France
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S-ketamine concentrations are greatly increased by grapefruit juice. Eur J Clin Pharmacol 2012; 68:979-86. [DOI: 10.1007/s00228-012-1214-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 01/04/2012] [Indexed: 01/01/2023]
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Caraceni A, Martini C, Zecca E, Fagnoni E. Cancer pain management and palliative care. HANDBOOK OF CLINICAL NEUROLOGY 2012; 104:391-415. [PMID: 22230457 DOI: 10.1016/b978-0-444-52138-5.00027-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Augusto Caraceni
- Palliative Care Department, Fondazione IRCCS National Cancer Institute of Milan, Milan, Italy.
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34
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Mercadante S. Emerging drugs for cancer-related pain. Support Care Cancer 2011; 19:1887-93. [DOI: 10.1007/s00520-011-1281-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 09/13/2011] [Indexed: 02/07/2023]
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Peltoniemi MA, Saari TI, Hagelberg NM, Laine K, Neuvonen PJ, Olkkola KT. St John’s wort greatly decreases the plasma concentrations of oral S-ketamine. Fundam Clin Pharmacol 2011; 26:743-50. [DOI: 10.1111/j.1472-8206.2011.00954.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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James PJ, Howard RF, Williams DG. The addition of ketamine to a morphine nurse- or patient-controlled analgesia infusion (PCA/NCA) increases analgesic efficacy in children with mucositis pain. Paediatr Anaesth 2010; 20:805-11. [PMID: 20716072 DOI: 10.1111/j.1460-9592.2010.03358.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM To assess the efficacy of adding ketamine to morphine nurse- or patient-controlled analgesia (NCA/PCA) infusions in treating mucositis pain in children. BACKGROUND Mucositis pain can be very difficult to control in some patients despite the use of parenteral opioids. In our institution, we have started adding low-dose ketamine to the morphine NCA/PCA in these children in an effort to improve analgesic efficacy. METHODS/MATERIALS The records of all children receiving a morphine/ketamine PCA or NCA for mucositis pain in our institution from 1999 to 2007 were reviewed. At the time of treatment, details of the analgesic management and consumption, pain scores and side effects were prospectively recorded and then entered on to an electronic database. Ketamine was added at a concentration of 20 or 40 microg x kg(-1) per ml with our standard morphine NCA/PCA infusions and protocols being used. RESULTS In 28 patients, there was no difference between average morphine consumption in the 24 h pre and post the addition of ketamine (33.1 (+/-10.7) vs 35.2 (+/-14.3) microg x kg(-1) per hour, P = 0.45) but in those with recorded pain scores (n = 16), the median percentage of pain scores > or =4 was 48% (13-100%) preketamine versus 33% (0-82%) postketamine (P = 0.01). In all patients, there was no change in the rates of nausea and vomiting and pruritus pre and post the addition of ketamine and no other significant side effects were reported. No difference was seen between those who had 20 or 40 microg x kg(-1) per ml of ketamine added. CONCLUSION The addition of ketamine to a morphine NCA/PCA improves analgesic efficacy in children with mucositis pain with no increase in the incidence of side effects.
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Banks ML, Folk JE, Rice KC, Negus SS. Selective enhancement of fentanyl-induced antinociception by the delta agonist SNC162 but not by ketamine in rhesus monkeys: Further evidence supportive of delta agonists as candidate adjuncts to mu opioid analgesics. Pharmacol Biochem Behav 2010; 97:205-12. [PMID: 20678514 DOI: 10.1016/j.pbb.2010.07.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 07/19/2010] [Accepted: 07/25/2010] [Indexed: 11/17/2022]
Abstract
Mu-opioid receptor agonists such as fentanyl are effective analgesics, but their clinical use is limited by untoward effects. Adjunct medications may improve the effectiveness and/or safety of opioid analgesics. This study compared interactions between fentanyl and either the noncompetitive N-methyl-D-aspartate (NMDA) glutamate receptor antagonist ketamine or the delta-opioid receptor agonist SNC162 [(+)-4-[(alphaR)-alpha-[(2S,5R)-2,5-dimethyl-4-(2-propenyl)-1-piperazinyl]-(3-phenyl)methyl]-N,N-diethylbenzamide] in two behavioral assays in rhesus monkeys. An assay of thermal nociception evaluated tail-withdrawal latencies from water heated to 50 and 54°C. An assay of schedule-controlled responding evaluated response rates maintained under a fixed-ratio 30 schedule of food presentation. Effects of each drug alone and of three mixtures of ketamine+fentanyl (22:1, 65:1, 195:1 ketamine/fentanyl) or SNC162+fentanyl (59:1, 176:1, 528:1 SNC162/fentanyl) were evaluated in each assay. All drugs and mixtures dose-dependently decreased rates of food-maintained responding, and drug proportions in the mixtures were based on relative potencies in this assay. Ketamine and SNC162 were inactive in the assay of thermal antinociception, but fentanyl and all mixtures produced dose-dependent antinociception. Drug interactions were evaluated using dose-addition and dose-ratio analysis. Dose-addition analysis revealed that interactions for all ketamine/fentanyl mixtures were additive in both assays. SNC162/fentanyl interactions were usually additive, but one mixture (176:1) produced synergistic antinociception at 50°C. Dose-ratio analysis indicated that ketamine failed to improve the relative potency of fentanyl to produce antinociception vs. rate suppression, whereas two SNC162/fentanyl mixtures (59:1 and 176:1) increased the relative potency of fentanyl to produce antinociception. These results suggest that delta agonists may produce more selective enhancement than ketamine of mu agonist-induced antinociception.
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Affiliation(s)
- Matthew L Banks
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA 23298, USA
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Elsewaisy O, Slon B, Monagle J. Analgesic Effect of Subanesthetic Intravenous Ketamine in Refractory Neuropathic Pain: A Case Report. PAIN MEDICINE 2010; 11:946-50. [DOI: 10.1111/j.1526-4637.2010.00863.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Adolph MD, Stretanski MF, McGregor JM, Rawn BL, Ross PM, Benedetti C. Intracerebroventricular Morphine for Refractory Cancer Pain: Transitioning to the Home Setting. Am J Hosp Palliat Care 2010; 27:326-32. [DOI: 10.1177/1049909109355150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Refractory cancer pain may be effectively controlled by titrating intracerebroventricular (ICV) preservative-free opioid. In this case report, a continuous infusion of ICV morphine permitted our patient with lung cancer and painful spinal metastases to be discharged to home hospice with family. The approach exploits the high potency of morphine injected into cerebrospinal fluid (CSF). Sterile, injectable, preservative-free morphine is directly infused into CSF through a subcutaneous Ommaya reservoir placed under the scalp by a neurosurgeon, with an attached catheter passed through a burr hole in the skull with its tip in a cerebral ventricle. Although investigators have described home care of patients receiving intraspinal analgesics, no report describes the process of transitioning the patient receiving continuous ICV morphine infusion to the home setting.
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Affiliation(s)
- Michael D. Adolph
- Medicine and Surgery, James Cancer Hospital and Solove Research Institute, Ohio State University Medical Center, Columbus, Ohio,
| | - Michael F. Stretanski
- MedCentral Hospice; Interventional Spine & Pain Rehabilitation Center, Ltd, Mansfield, Ohio
| | - John M. McGregor
- Neurological Surgery, Ohio State University Medical Center, Columbus, Ohio
| | - Bonnie L. Rawn
- James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Patrick M. Ross
- Department of Surgery, Division of Thoracic Surgery, Ohio State University Medical Center, Columbus, Ohio
| | - Costantino Benedetti
- Department of Anesthesiology, James Cancer Hospital and Solove Research Institute, Ohio State University Medical Center, Columbus, Ohio
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Hagelberg NM, Peltoniemi MA, Saari TI, Kurkinen KJ, Laine K, Neuvonen PJ, Olkkola KT. Clarithromycin, a potent inhibitor of CYP3A, greatly increases exposure to oral S-ketamine. Eur J Pain 2009; 14:625-9. [PMID: 19897389 DOI: 10.1016/j.ejpain.2009.10.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 09/03/2009] [Accepted: 10/05/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Oral ketamine is used as an adjuvant in the treatment of refractory neuropathic and cancer-related pain. Drug interactions may alter the analgesic or other effects of ketamine. AIM AND METHODS The aim of the study was to investigate the effect of cytochrome P450 3A enzyme inhibition with clarithromycin on the pharmacokinetics and pharmacodynamics of oral S-ketamine in a randomized controlled cross-over study with two phases. Ten healthy subjects were pre-treated with oral clarithromycin or placebo for 4 days. On day 4, they ingested an oral dose of 0.2mg/kg of S-ketamine syrup. Plasma concentrations of ketamine and norketamine were measured for 24h. Analgesic effects were evaluated in a cold pressor test and psychomotor effects were followed for 12h. RESULTS Clarithromycin increased the mean C(max) of ketamine by 3.6-fold (p<0.001) and the mean AUC(0-infinity) of ketamine by 2.6-fold (p=0.001). The relative amount of the CYP3A dependent metabolite norketamine was decreased by 54% by clarithromycin (p=0.004). Self-rated drug effect of S-ketamine was enhanced by clarithromycin (p<0.05) but other behavioral effects or cold pain scores were not affected. CONCLUSIONS Clarithromycin strongly increases plasma concentrations of oral S-ketamine probably by inhibiting its CYP3A-mediated N-demethylation. This increase is reflected as modest changes in behavioral effects of oral S-ketamine.
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Affiliation(s)
- Nora M Hagelberg
- Department of Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine, University of Turku, Turku, Finland.
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Effects of low-dose intranasal (S)-ketamine in patients with neuropathic pain. Eur J Pain 2009; 14:387-94. [PMID: 19733106 DOI: 10.1016/j.ejpain.2009.08.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Revised: 07/28/2009] [Accepted: 08/06/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND NMDA receptors are involved in the development and maintenance of neuropathic pain. We evaluated the efficacy and safety of intranasal (S)-ketamine, one of the most potent clinically available NMDA receptor antagonists. METHODS Sixteen patients with neuropathic pain of various origins were randomized into two treatment groups: (S)-ketamine 0.2mg/kg (group 1); (S)-ketamine 0.4mg/kg (group 2). Plasma concentrations of (S)-ketamine and (S)-norketamine were measured over 6h by High Performance Liquid Chromatography combined with mass spectrometry. Quantitative sensory testing (QST) was conducted before, during and after treatment. Side effects and amount of pain reduction were recorded. RESULTS Intranasal (S)-ketamine administration lead to peak plasma concentrations of 27.7+/-5.9ng/ml at 10+/-6.3min (group 1) and 34.3+/-22.2ng/ml at 13.8+/-4.8min after application (group 2). Maximal plasma concentrations of (S)-norketamine were 18.3+/-14.9ng/ml at 81+/-59min (group 1) and 34.3+/-5.5ng/ml at 75+/-40min (group 2). Pain scores decreased significantly in both groups with minimal pain at 60min after drug administration (70+/-10% and 61+/-13% of initial pain in groups 1 and 2). The time course of pain decrease was significantly correlated with plasma concentrations of (S)-ketamine and (S)-norketamine (partial correlations: (S)-norketamine: -0.90 and -0.86; (S)-ketamine: -0.72 and -0.71 for group 1 and group 2, respectively). Higher dosing elicited significantly more side effects. Intranasal (S)-ketamine had no significant impact on thermal or mechanical detection and pain thresholds in normal or symptomatic skin areas. CONCLUSIONS Intranasal administration of low dose (S)-ketamine rapidly induces adequate plasma concentrations of (S)-ketamine and subsequently of its metabolite (S)-norketamine. The time course of analgesia correlated with plasma concentrations.
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Vella-Brincat J, MacLeod AD. Adverse Effects of Opioids on the Central Nervous Systems of Palliative Care Patients. J Pain Palliat Care Pharmacother 2009. [DOI: 10.1080/j354v21n01_05] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ben-Ari A, Lewis MC, Davidson E. Chronic Administration of Ketamine for Analgesia. J Pain Palliat Care Pharmacother 2009. [DOI: 10.1080/j354v21n01_04] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Legge J, Ball N, Elliott DP. The Potential Role of Ketamine in Hospice Analgesia: A Literature Review. ACTA ACUST UNITED AC 2009; 21:51-7. [PMID: 16524352 DOI: 10.4140/tcp.n.2006.51] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of this review is to examine the role of ketamine as an analgesic for palliative treatment in the hospice care setting. DATA SOURCES The sources referenced in this review were found September 22, 2005, via an Internet search of the MEDLINE database and Cochrane Database of Systematic Reviews. Search terms included analgesia, cancer pain, dextromethorphan, hospice, ketamine, opioids, palliative care, neuropathic pain, and morphine. Articles and case reports were included that relate to ketamine use as an analgesic agent and not as an anesthetic. DATA EXTRACTION Because of patient variability with ketamine use and dosing, focus was placed on analgesic benefit versus no analgesic benefit. Because of the lack of controlled trials, application of all analgesic data related to ketamine use was relevant to this review. The strength of evidence is currently moderate, but the available trials and reports reviewed in this paper describe compelling results. DATA SYNTHESIS Ketamine has been effective in producing analgesia in patients receiving palliative care, especially when used in combination with opioids. CONCLUSION When opioid therapy is no longer sufficient to improve quality of life in the hospice setting, the addition of ketamine may be considered as adjunctive therapy.
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Affiliation(s)
- Justin Legge
- Veterans Affairs Medical Center, Huntington, West Virginia, USA
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Potvin S, Grignon S, Marchand S. Human evidence of a supra-spinal modulating role of dopamine on pain perception. Synapse 2009; 63:390-402. [DOI: 10.1002/syn.20616] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
Methadone is generally believed to be devoid of neuroexcitatory properties, and its use is increasing. This paper reports two cases of myoclonus with high-dose parenteral methadone in patients with cancer under hospice care. This side effect may be dose related and/or due to the parenteral route of administration. Reduction of the dose and change of route was sufficient to eliminate the myoclonus while maintaining an adequate pain control. Possible mechanisms for methadone causing myoclonus include a redistribution of receptor saturation in the N-methyl-D-aspartate (NMDA) and delta receptors. Ketamine may be an option for patients with intractable pain who develop methadone-induced myoclonus.
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Affiliation(s)
- Shiho Ito
- VITAS Innovative Hospice Care, Orange County, Orange, California, USA
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Abstract
Managing acute pain in opioid tolerant patients can be a significant challenge. This article will provide an overview of the terminology used when managing acute pain in these patients. This understanding is essential to ensure adequate pain relief while avoiding opioid withdrawal. It is also crucial that these patients are identified and that sufficient peri- and postoperative pain management plans are formulated. This article will present an overview of the terms tolerance, physical dependence and addiction. The literature on the management of acute pain in opioid tolerant patients will be considered. Finally an audit that explores and compares the practises of a group of London hospitals, with regard to managing postsurgical pain in opioid-dependent patients will be discussed.
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Kalso E, Paice J. Global year on cancer pain. Pain 2008; 140:247-248. [PMID: 18950939 DOI: 10.1016/j.pain.2008.09.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 09/15/2008] [Accepted: 09/15/2008] [Indexed: 10/21/2022]
Affiliation(s)
- Eija Kalso
- University of Helsinki, Helsinki University Central Hospital, Pain Clinic, Department of Anaesthesia and Intensive Care Medicine, Pain Clinic, P.O. Box 140 (Haartmaninkatu 2A), 00029 HUS, Finland. Tel.: +358 9 47175885
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Kalia LV, Kalia SK, Salter MW. NMDA receptors in clinical neurology: excitatory times ahead. Lancet Neurol 2008; 7:742-55. [PMID: 18635022 DOI: 10.1016/s1474-4422(08)70165-0] [Citation(s) in RCA: 304] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Since the N-methyl-D-aspartate receptor (NMDAR) subunits were cloned less than two decades ago, a substantial amount of research has been invested into understanding their physiological function in the healthy CNS. Research has also been directed at their pathological roles in various neurological diseases, including disorders resulting from acute excitotoxic insults (eg, ischaemic stroke, traumatic brain injury), diseases due to chronic neurodegeneration (eg, Alzheimer's, Parkinson's, and Huntington's diseases and amyotrophic lateral sclerosis), disorders arising from sensitisation of neurons (eg, epilepsy, neuropathic pain), and neurodevelopmental disorders associated with NMDAR hypofunction (eg, schizophrenia). Selective NMDAR antagonists have not produced positive results in clinical trials. However, there are other NMDAR-targeted therapies used in current practice that are effective for treating some neurological disorders. In this Review, we describe the evidence for the use of these therapies and provide an overview of drugs being investigated in clinical trials. We also discuss new NMDAR-targeted strategies in clinical neurology.
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Affiliation(s)
- Lorraine V Kalia
- Division of Neurology, Department of Medicine, University of Toronto, ON, Canada.
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