The primary aim of ketamine treatment for pain patients is to alleviate pain, although observed mental health benefits are secondary. Patients seeking treatment are managing a broad range of conditions that result in chronic pain, including Complex Regional Pain Syndrome (CRPS), fibromyalgia, neuropathic pain, spinal injury, migraine and other headache variants, and cancer. Patients with these disorders often seek ketamine clinics because they have not had much success with other pain medications.
The route of administration for pain management is always intravenous as the dosage can be considerably higher than used for mental health disorders (1-2 mg/kg/hr for 2-4 hours for pain management relative to 0.5 mg/kg over 40 minutes for mood disorders) and requires additional medications to allow patients to tolerate the treatment. Often patients are sedated through the process and require a higher level of monitoring. That said, some pain conditions can be treated with low dose protocol used for mood disorders, and patients should consult with their provider about the best dosage for their specific condition. Common treatment courses can vary from every other day to every day and range from 2 days up to 10 days for most outpatient clinics. Some hospitals also provide inpatient ketamine treatment over a series of several days. The frequency of follow up maintenance treatments will vary from patient to patient as well as on the onboarding protocol. Some patients require maintenance treatments every 1-3 months, while other patients might go up to a year before visiting a clinic again. Some clinics might supplement oral ketamine (typically sublingual) between treatments in effort to support ongoing treatment and potentially lengthen the periods between treatments.
Because the treatment is intensive and physically taxing, patients also need a lot of post-treatment care. Therefore, patients require someone able to care for them for at least 24 hours after each treatment.
The aim of ketamine treatment for mood disorders is to alleviate symptoms and, in some cases, enhance therapy. Patients seeking treatment are managing conditions such as treatment resistant depression (TRD), Post Traumatic Stress Disorder (PTSD), and suicidality. For most patients, ketamine is a last resort after many failed attempts with other medications to treat their conditions. For others, ketamine is an option when going through intensive therapy treatments, such as emersion therapy for PTSD. Esketamine is used along with an antidepressant taken by mouth to treat TRD and depressive symptoms in adults with major depressive disorder (MDD) with suicidal thoughts or actions.
The routes of administration vary more widely for treating mood disorders than in pain management. Intravenous, intramuscular, and intranasal are the most common routes of administration. Due to the relative low doses, patients are not sedated during treatment and experience some level of dissociation. Dissociation refers to a temporary mental state whereby a person’s mind becomes ‘detached’ from their surroundings and the person becomes less connected to their body. Dissociative symptoms can include feeling separated from reality, looking at things from outside one’s body, observing colors and sounds differently, time speeding up or slowing down, and loss of identity. The intensity and duration of the dissociation will vary by route of administration and dosage and can be anywhere from mild to intense. Some medications can be administered to make the treatment more tolerable, including anti-anxiety medications.
Duration of ketamine treatment typically lasts from 40-60 minutes and initial onboard protocols include a series of 6-8 treatments over a period of two to four weeks. Most patients treated for depression require maintenance treatments, which can range from every two weeks to every three months, with the average being once a month. Some clinics will supplement oral ketamine (sublingual troches) to support ongoing treatment and potentially lengthen the periods between treatment. Note, prescription and dosing of oral ketamine will vary by State and per clinical judgment based on each patient’s specific condition.
For patients administered esketamine through the nasal spray Spravato, the treatment protocol occurs twice a week for four weeks, once a week for four weeks and then maintenance is once a week or once every two weeks.
The biggest difference between clinics that treat for mood disorders will be in treatment approaches, specifically whether parallel therapy is involved (Ketamine Assisted Therapy – aka KAP). Many clinics will allow patients to sit with the medication alone without additional therapy, and it is recommended that patients working with a psychotherapist set up a therapy session soon after treatment to get the most benefit. An alternative KAP approach consists of therapy during the ketamine treatment, whereby a psychotherapist sits with the patient during treatment and an “integration” session occurs directly afterward to help the patient process any thoughts and feelings that emerged. This approach is particularly useful for PTSD patients. For clinics that do not offer KAP during treatment, there are often options for patients to have their own psychotherapist call in and conduct an integration session remotely. Patients are encouraged to discuss the details of their treatment options with their ketamine provider to ensure that the treatment is best tailored to them.
van Schalkwyk, G.I., Wilkinson, S. T., Davidson, L., Silverman, W.K., Sanacora, G. 2018. Acute psychoactive effects of intravenous ketamine treatment of mood disorders: analysis of the Clinician Administered Dissociative State Scale. Journal of Affective Disorders. 227. 11-16. https://doi.org/10.1016/j.jad.2017.09.023