Pain Treatment Requirements, Procedures and Expectations

When receiving ketamine infusions for treatment of pain, one may expect the following:

  • Prior to being scheduled for treatment all patients MUST provide a recent (within the previous 30 days) H&P (History and Physical) from their regular physician.
  • Lab work is required and consists of standard "pre-operative" screening labs, plus screening liver function tests. Your doctor will know what these are. No patient will be scheduled before review of these lab results.
  • A complete list of all medications and their dosages must be provided. You may need to taper off or stop some medications.
  • Patients should provide a pain summary from their pain management physician. This should include description of the pain syndrome, diagnoses, all previous procedures performed and results of these procedures.

The above are all required before a patient can be scheduled.

Once scheduled, the following will occur:

  • Patients will be brought to the treatment area where they will change from street clothes into a hospital gown. Underwear and stockings may be kept on. 
  • Patients will be allowed to ask any final questions, and after these are all answered to their satisfaction, they must sign a standard consent form for treatment and also to acknowledge that the treatment is purely elective and there are no guarantees of success.
  • An IV will be started and secured. Monitors will be placed for all vital signs. Oxygen will be provided via nasal cannula.
  • Sedation will begin using benzodiazepines and prophylactic anti-emetic drugs will be administered.
  • After appropriate sedation is achieved the agreed upon dose of ketamine will begin to be administered by infusion.
  • The infusion is administered over four hours. During this time the patient will be kept as comfortable as possible by, as required, additional sedatives and neuroleptic drugs, or in some cases with a concurrent infusion of Propofol. Propofol is only used in cases where a patient chooses to be sedated to the extent that there is no cognitive experience of the ketamine.
  • Note: there are some who say giving Propofol as sedation during a ketamine infusion interferes with ketamine's ability to achieve its pain blocking effect. There is no biochemical reasoning to support this, and I have a body of evidence proving this is not the case. I have treated many patients with Propofol sedation who got 100% pain relief that lasted for a prolonged time.
  • At the conclusion of the infusion period the patient will be allowed to rest until such time as normal cognitive function returns to a level which will allow discharge. This amount of time is impossible to predict and ranges from one to several hours.
  • Patients must be driven home or to their hotel by someone known to them, not by taxi or any other such publicly available transport, and someone must stay with the patient for the following 24 hours or, in cases of daily treatments, until presentation to the center the following day.
  • Patients are permitted to listen to music with headphones, and a family member or friend or support person may stay with the patient throughout the entire process. However, during the four hour infusion it it requested that the patient simply lie quietly with minimal external stimulation (conversation) to avoid negative experiences.
  • When deemed ready for discharge the IV will be removed, even if another treatment is scheduled for the following morning, and the patient will change back into street clothes. It is not expected that the patient will be as wide awake as upon arrival, but will remain in a relatively sedated state for the afternoon.
  • After the final infusion, regardless of total number, the patient will receive prescriptions for a very low dose of oral ketamine and for lorazepam, both two weeks supply. The ketamine is to be taken twice daily. This is to continue the NMDA blockade for maximum relief potential. If the patient cannot tolerate the dose, the ketamine may be cut in half, but continue to take it twice daily and not once, as it is desireable to keep as steady a blood level as possible. The lorazepam is to be taken at night before bed as benzodiazepines are shown to minimize or eliminate the potential for scary nightmares, which have been shown to occur only occasionally, but more so in females than males, and young than old.
  • Patients must have another physician who is in charge of their pain management, and should see this physician within the two week period following treatment to assess results and determine whether future infusions may be indicated.

I do not follow / treat patients chronically for their pain syndromes, I only provide the infusions and immediate post-infusion considerations.

  • If successful, pain relief is usually noted within a day or so of treatment.
  • It is usual for patients to be rather sedated for the two weeks following treatment due to the lingering effects of the high dose infusion and the continuing oral ketamine.
  • During the two weeks following treatment patients must not drive cars or operate machinery, should not sign important papers, should not be engaged in any activity which includes being responsible in any way for another individual. It is suggested that the patient expect to be rather a "couch potato" for that time period. This is for the safety and protection of others, and also for the patient. One may feel completely normal even while taking the oral ketamine. However, it remains important to avoid those listed activities as a patient not chronically taking ketamine may be blamed for any untoward consequence.
  • If successful pain relief is realized, it is impossible to predict for how long this will last. Once again I can only relate my years of experience, but in most cases relief lasts for nearly a year or longer. Individual results will vary.
  • If relief is achieved, but eventually pain returns and additional infusions are requested, all previous pre-scheduling requirements must be repeated.