Oral and Intranasal Ketamine

[Aaron Hartman]

I have a group of EDS patients and similar neuroinflammated chronic pain patients I work with on a routine basis. I was using topical pain compounds including 10% ketamine (100mg/g) and when I considered increasing to 20% (200mg/g) the compounding pharmacist recommended oral ketamine 25-50mg dosing. I am reviewing the Dallas Brain summit notes and saw the discussion that talked about psychosis. Has anyone in the group seen this in oral usage or intranasal usage?

I have no hesitation with topical, even though the dosage is high just wondering what the experience in the group is.

 

Thanks

Aaron Hartman

[Kristelle Reyes]

Hello @byurthgmail-com and @drhusaininterlinkedmd-com, would love to have your insights here. Thank you 🙂

[Abid Husain]

Hello Aaron,  I don’t have much experience with Ketamine.  The extent of my usage is limited to what was discussed at the Dallas Brain Summit.

[Cynthia Keller]

The experiences I have had with ketamine therapy in my patients have been profound and remarkably life changing for  most of them.

Having said that, I only use it in patients in whom I feel confident that a reset of their Neuro-Psych system/circuitry is what the next best step is.

And, I only feel comfortable with my patients having it administered by an experienced anesthesiologist in IV form.
The normal course that I have seen effective is somewhere around 6 sessions, with clear effectiveness seen by 3 sessions in.

I worry quite a bit with people compounding this treatment for home use (oral and nasal) and all these pop up online clinics using ketamine that I even see being advertised on Instagram.  It is a powerfully effective treatment and I feel strongly that it should be used with the respect that it deserves (IV by experienced anesthesiologists).

I worry about someone with chronic pain being offered another pain treatment at home for self administering that has the potential for emotional “escape”. My teens (not “my” personal teens, but lots of teens I know and care about/for) reach for this as a street drug.  We need to be careful about who we give this to use even “medically” at home.

So my advice would be to find a good local anesthesiologist who specializes in real cures for patients with chronic pain syndromes and partner with them on this patient if you feel like systemic ketamine would be a wise next step.

I welcome differing opinions, of course as always here…but I feel pretty strongly about my concerns above.
As one example, I currently have an 18 y/o teen with Asperger’s syndrome and chronic Lyme who was doing really, really well after years of being on and off suicidal and even violent to others.  He saw a new psychiatrist for his moods who Rx compounded nasal ketamine at home. He is now abusing it, combining it with alcohol, stopped taking his other meds and is raging again, calling me panicked saying “something is wrong with me, I think half of my brain is gone”.   I am saddened for his family, and for him, and frustrated that a MD wouldn’t have thought this through. The progressive psychiatrists that I know who use ketamine successfully for their patients with medication-resistant-depression also only recommend it being used by the anesthesiologists that I use. I am sure that sometimes it can be used safely at home….. but, I worry seriously about the risk.

[Kristelle Reyes]

Thank you so much Dr. Husain and Dr. Keller! 🙂

Hello @hartmanangmail-com just making sure you got these responses. Thank you!

[Aaron Hartman]

Thanks for the detailed thoughtful responses.

[Kristelle Reyes]

Claim your CME here: https://earnc.me/Il4c8y

[tim blend]

I agree with dr Keller. my wife and I utilize IV ketamine for selected patients and it has had a profound life changing experience for most. (she is the therapist (ARNP/PSYCH) I administer (with my EM experience). the intranasal seems to have a minimal effect although we do not utilize it. I think its very important that the patient be comfortable, and unfortunately most anesthesiologists know very little about psychology yet they are administering a drug that may require some intervention during that administration. For that reason my wife’s use of ketamine is more than 90% effective since she has an opportunity to do therapy during ketamine administration.

[sjzman@gmail.com]

I routinely use ketamine troches and injectable ketamine with patients. The mechanism is similar, but how far it gets pushed is drastically different. If individuals have trauma they need to process or more significant changes needed then you need a higher dose and injectable is the best for it.

If you are only looking for small changes in stress response or changes in mood then troches are usually sufficient.

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