Individuals suffering from incapacitating and otherwise intractable chronic pain or pain syndromes, such as fibromyalgia, often explore diverse treatment options, encountering limited or no relief. Among chronic pain patients, ketamine therapy has proven remarkably effective, with some describing it as "the most helpful pain treatment I've ever tried." This statement comes from our patient who, after over 20 years of back pain, successfully discontinued long-term use of morphine and Oxycotin medications. At our ketamine infusion clinic in San Luis Obispo, California, we've observed that, for some, ketamine has led to a significant reduction in regular pain medication requirements. In certain cases, as mentioned, individuals have successfully discontinued pain medications entirely due to ketamine's notable efficacy in alleviating chronic pain.
Pain treatment is inherently complex, necessitating a multimodal approach that may includes pharmacological agents, psychotherapy, physical rehabilitation, and invasive procedures (such as nerve ablations, steroid injections, botox, and surgery). Specifically, many pain medications carry significant side effects, or, worse yet, may actually elevate pain levels with prolonged use.
While ketamine is not typically considered a first-line treatment option, it emerges as a potential lifeline, especially for individuals who have exhausted various medications such as opioids (e.g., morphine, Percocet, and Vicodin), nonsteroidal anti-inflammatory drugs (NSAIDs), amitriptyline, and gabapentinoids (e.g., Gabapentin). In this discussion, we will explore how ketamine serves as a safe and effective treatment option for pain. We will delve into its mechanisms, cite examples of use, and underscore the importance of initiating effective pain control early to prevent potential long-term consequences when left untreated.
It is estimated that 10-50% of post-operative patients experience persistent pain, while 2-10% of these patients endorse severe, often debilitating chronic pain that persists long after surgical intervention, sometimes for a lifetime (Kehlet 2006). Intravenous (IV) ketamine is commonly used during and after surgery to enhance postoperative pain control and reduce the need for opioids or other anesthetic medications. Additionally, epidural ketamine has been employed in this context. In other instances, ketamine has been administered as a prophylaxis or a measure to prevent the onset of chronic postoperative pain and or syndromes. Studies (Mercandante, 2000. Yang, 1996) indicate that the use of ketamine during surgery results in decreased postoperative pain scores, extended time before the first request for pain medication, lowered postoperative opioid requirements, and, additionally, reduced incidents of postoperative nausea and vomiting. Other review studies have demonstrated a significant reduction in the overall risk of developing chronic postoperative pain at 3 and 6 months with the use of IV ketamine.
Ketamine is frequently employed for cancer-related pain and for pain that doesn't respond to opioids or that is resistant, often in combination with other medications like NSAIDs. Clinical trials (Bell, 2017) studying the use of ketamine for cancer and resistant pain have shown that it effectively lowers pain intensity and reduces the need for morphine. Ketamine may be particularly beneficial for individuals facing challenges like opioid tolerance, a notable neuropathic pain component, inflammatory pain, depression, or any combination of these factors.
Ketamine is commonly used to manage refractory neuropathic pain, particularly when large opioid doses contribute to the development of severe hypersensitivity to pain (hyperalgesia). Reports on the use of ketamine infusions for neuropathic pain demonstrate a substantial reduction in hyperalgesia and a significant decrease in pain medication requirements. Ketamine may also be an option for chronic pain disorders and syndromes such a fibromyalgia, chronic migraines, complex regional pain syndrome (CRPS), temporomandibular joint disorder (TMJ), arthritic pain, chronic fatigue syndrome, inflammatory bowel syndrome, and endometriosis.
Randomized controlled trials (Sorensen, 1995. Graven-Nielsen, 2000) have investigated the use of ketamine in treating fibromyalgia, comparing its effects to morphine, lidocaine, naloxone, and a placebo. Patients who received ketamine experienced increased endurance and reduced pain intensity, along with improvements in tenderness at trigger points, referred pain, hyperalgesia, and muscle pain at rest. These findings suggest that tender points represent areas of hyperalgesia in individuals with fibromyalgia, and the relief of these symptoms can be achieved through the use of ketamine.
Untreated acute pain has the potential to evolve into chronic pain, persisting for months or even years and significantly impacting daily life. The physical toll of untreated pain includes limitations in mobility, as individuals may avoid certain activities to mitigate pain, leading to muscle atrophy and stiffness.
The psychological effects can be substantial, with untreated pain contributing to or exacerbating mental health issues such as anxiety and depression. Emotional distress, social isolation, and a diminished sense of well-being are common outcomes. Sleep disturbances often accompany chronic pain, further compounding the negative effects on cognitive functions, such as concentration and memory. The overall quality of life is compromised, affecting relationships, work, and the ability to derive satisfaction from life.
Additionally, untreated pain can result in an increased sensitivity to pain stimuli over time, a phenomenon known as central sensitization, which makes the pain experience more intense and enduring. Prolonged opioid use can amplify pain perception, diminishing the initial therapeutic effects and potentially leading to a cycle of escalating pain, higher opioid doses, and associated risks. From a medical perspective, underlying conditions causing pain may lead to further complications if left untreated. Timely and comprehensive pain management is essential to mitigate these long-term consequences, improving overall outcomes, and enhancing an individual's quality of life.
Some studies suggest that longer infusions may be required for the relief of chronic pain and syndromes such as fibromyalgia. However, in our experience, patients often endorse robust pain alleviation with protocols similar to those used for mood disorders such as depression. In accordance with the latest research, our protocol includes a starting dose of 0.5 mg/kg of body weight for 40-120 minutes, administered in six infusions over a course of 2-6 weeks. The duration of a pain infusion is determined by the diagnosis and severity of pain. We may titrate or increase the dose and duration based on the patients' response and tolerance.
Ketamine therapy emerges as a promising and innovative treatment option, offering a glimmer of hope for those navigating the often overwhelming landscape of chronic pain. As we seek alternative, safe, and effective treatment options for pain within the realm of holistic healing, it becomes evident that the potential benefits of ketamine extend far beyond its initial association with anesthesia. This transformative treatment not only addresses the physical aspects of pain but also delves into the intricate dimensions of mental and emotional well-being. With ketamine therapy, individuals may finally find relief from pain, and also a renewed sense of vitality with the possibility of reclaiming a life unburdened by the shackles of persistent suffering. Ketamine and other psychedelic medicines offer a new spectrum of hope for individuals with chronic pain.
About the Author
Dr. Ray Rivas, a former general and trauma surgeon with over a decade of experience utilizing ketamine, became a ketamine therapy specialist to treat mental health and pain after witnessing its profound impact on his hospital trauma patients and his own mental health. As the founder and medical director of Innerbloom Ketamine Therapy in San Luis Obispo, California, Dr. Rivas applies his extensive medical expertise to provide safe, evidence-based ketamine treatments for mood disorders, including depression, anxiety, PTSD, and chronic pain. His passion lies in helping patients find relief and rediscover hope through personalized, compassionate care.
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