Ketamine and CRPS
The drug Ketamine holds great promise for CRPS patients. Whether it is used in a low-dose "Awake" version, the "Coma technique", or as an out-patient. Doctors and patients around the world are curious about how this new medication interacts with the pain of CRPS. Studies are being conducted and many trial and error methods are being refined as we speak.
HOW DOES KETAMINE WORK ON CRPS?
In an article discussing Ketamine Infusion Therapy in PAIN MEDICINE, September 2004, it says, "Although Ketamine may have more than one mechanism of action, the basis for using it to treat CRPS/RSDS may reside in its strong ability to block NMDA receptors. Experimental evidence suggests that a sufficiently intense or prolonged painful stimulus causes an extraordinary release of glutamate from peripheral nociceptive afferents onto dorsal horn neurons within the spinal cord. The glutamate released, in turn, stimulates NMDA receptors on second-order neurons that produce the phenomena of windup and central sensitization. It is reasonable to consider that, by blocking NMDA receptors, one might also be able to block cellular mechanisms supporting windup and central sensitization [4–7,15]. Ketamine is the only potent NMDA-blocking drug currently available for clinical use. Our interpretation is that an appropriately prolonged infusion of Ketamine appears to maintain a level of Ketamine in the central nervous system long enough to reverse the effects of the sensitization process and associated pain."
You can read more of this article by going to JOURNAL OF PAIN MEDICINE ARTICLE ON KETAMINE AND CRPS
The three methods that hold the most hope are the LOW-DOSE AWAKE TECHNIQUE (which is typically a five-day inpatient program) and whose use was pioneered by Doctor Graeme Correll of Australia and Doctor Ronald Harbut of Arizona, the COMA TECHNIQUE, a more controversial treatment not currently allowed to be performed in the USA, and a third option, OUT-PATIENT TECHNIQUE, that as of yet has proven to provide only very temporary relief.
See the section below for the Neurology Today 2/07/06 article which compares/contrasts two of the methods!
In this section of the website you will find a large collection of information on CRPS/RSDS and Ketamine, especially concerning the low-dose method. Please read through the whole section to get a good handle on this if you are considering any version of Ketamine. It is a very powerful medication and not one to be taken lightly.
KETAMINE INFUSION - THREE TECHNIQUES
There are three main ketamine infusion techniques currently being performed on CRPS patients for the relief of their pain and allodynia symptoms.
LOW-DOSE KETAMINE INFUSION - IN-PATIENT ( AWAKE TECHNIQUE) Also called the "IN-HOSPITAL" TECHNIQUE.
This is the treatment pioneered by Doctor Correll, of Australia, and Doctor Ronald Harbut, of Little Rock, Arkansas. They were successfully treating CRPS/RSDS patients with this technique back in the 1990s'. In 2002 Doctor Harbut published the first study in a peer-reviewed journal of this procedure anywhere. Doctor Harbut worked with the FDA to establish the protocol being used by Doctors across the country currently. Today there are hospitals and clinics all over the country performing this procedure successfully. This treatment typically consists of five continuous days of infusion of a combination of Ketamine and clonidine while the patient is in a hospital.
When asked by Neurology Today magazine to describe why the low-dose Ketamine infusion works for many RSD patients, Doctor Ronald Harbut, while at Mission Pain Consultants in Hot Springs, Arkansas, had this to say;
"Dr. Harbut likened Ketamine therapy to the healing of a broken bone. If someone breaks a bone and you simply put the two pieces back together, they won't immediately heal. However, if you add a splint and hold the bones juxtaposed and steady for a period of time, and take away the splint later, the bone is healed. I think that the Ketamine treatment does something similar; it lends support and allows the abnormally sensitized nerve cells to heal themselves, so that when you finally take away the Ketamine, the pain is reduced or gone."
The patient typically receives a dose of between 20 mg and 35 mg of Ketamine, (see the studies for exact dosages per hour, etc.). The dose depends on the patients weight, CRPS, health, and a variety of other factors. Costs vary depending on the hospital where it is performed. It can range from $10,000 to as much as $50,000 and up, depending on the Doctor, clinic, and/or hospital but typically average around $25,000. The costs are mostly due to the labor involved and the patients requirements to be closely monitored. When looking into the costs of the treatment at different clinics/hospitals be sure to get ALL of the costs upfront; including any pre/post treatment appointments, as well as any booster treatments if they are required (there are one or two Doctors out there who use post-treatment Ketamine boosters following the low-dose in-hospital treatment so these should be factored into the actual cost).
Besides Doctor Harbut's clinic in Arizona (2011) there are Doctors that have been performing this treatment in PA, NJ, GA, NY, and several other states for years now. Hundreds of treatments have been done since 2002 and a great deal of research data has been collected but more work still needs to be done. We are far behind countries such as Australia for instance.
The results of the "in-hospital" treatment have the highest success rate and highest relief retention rate. Many of the patients going through these procedures have reported going to zero pain and maintaining that zero pain level for months and even up to years afterward. The length of success depends on the patient and the Doctor performing the treatment as well as other factors. Every patient is different. It is continually being improved and the success rate is always increasing as well. It is not a cure and even in the most successful cases it is only considered putting the patient into remission, as are other ketamine treatments. But to be out of pain, or a large percentage of pain, for even a few years at a time is a wonderful thing!
KETAMINE INFUSION - OUT-PATIENT
The out-patient version usually entails repeated infusions done over a period of days, weeks, and months. It is, obviously, an out-patient procedure, lasting anywhere from 4 to 6 hours at a time generally. The cost varies but is typically $300 to $1000 per day, depending on the Doctor and the clinic.
In one example, the patient receiving a low level of Ketamine infusion every day for the first 2 weeks, for about 4-5 hours per day. The patient usually receives about 70-90 mg per day (note the difference in dosage from the low-dose). Then the treatments are stepped down to 2 treatments of 4 hours each every other week for 4 weeks, usually the same dosage. Then depending on the relief obtained, either stepped down again to 1 treatment of 4 hours every other week, or kept at that pace for another month, etc. The treatments can eventually be stepped down to once or twice every three months for 4 hours each.
Of course each patient is different and there will be variations. depending on the Doctor and hospita/clinic involved. The one listed above is simply a typical version. Unfortunately the relief obtained with this treatment seems to be far more fleeting. Some have suggested it is because the ketamine does not have a chance to re-set the sympathetic system in the same way as the low-dose because of the stop-start method.
HIGH-DOSE KETAMINE INFUSION - COMA TECHNIQUE
In this version, the patient is placed into a medically-induced coma and given an extremely high dosage of Ketamine; typically between 500-700 mg per hour for 5 to 7 days. (compare that to the low-dose version where the patient is given anywhere from 20-35 mg for 5 days).
This version, currenty not allowed in the United States, was being done in Germany but treatments are also taking place in Monterey, Mexico.
According to Dr Robert Schwartzman, a noted RSD specialist, "The theory is, the coma allows the constant throbbing pain connections from the body to the brain to reset, like a computer reboot. For seven days powerful drugs will surge (through the patient's) veins. (the patient) will need a ventilator to breathe. This treatment has been effective in some degree for 30 patients, giving a piece of their life back."
The costs for this treatment can vary widely depending on travel requirements, length of stay, etc. They range from $10,000 to $50,000 for the treatment plus travel, depending on whether you have it done in Germany or in Mexico.
There haven't been nearly as many patients treated with this version of Ketamine as with the low-dose. There is a long way to go as far as research is concerned before any long-term assessments can be made. But there are a number of patients who have gone into remission with this treatment as well as patients who have had severe repercussions from it.
We have added an article on the coma technique from January 2008.
All three techniques have their proponents and opponents, those who think they are the answer and those who feel patients need to stay very far away from them, maybe the answer is somewhere in between. Enough patients have been helped, some for a short time and some for a long time, with the various methods that it certainly warrants the investment into all three techniques.
HOW DOES KETAMINE WORK ON CRPS?
In an article discussing Ketamine Infusion Therapy in PAIN MEDICINE, September 2004, it says, "Although Ketamine may have more than one mechanism of action, the basis for using it to treat CRPS/RSDS may reside in its strong ability to block NMDA receptors. Experimental evidence suggests that a sufficiently intense or prolonged painful stimulus causes an extraordinary release of glutamate from peripheral nociceptive afferents onto dorsal horn neurons within the spinal cord. The glutamate released, in turn, stimulates NMDA receptors on second-order neurons that produce the phenomena of windup and central sensitization. It is reasonable to consider that, by blocking NMDA receptors, one might also be able to block cellular mechanisms supporting windup and central sensitization [4–7,15]. Ketamine is the only potent NMDA-blocking drug currently available for clinical use. Our interpretation is that an appropriately prolonged infusion of Ketamine appears to maintain a level of Ketamine in the central nervous system long enough to reverse the effects of the sensitization process and associated pain."
You can read more of this article by going to JOURNAL OF PAIN MEDICINE ARTICLE ON KETAMINE AND CRPS
The three methods that hold the most hope are the LOW-DOSE AWAKE TECHNIQUE (which is typically a five-day inpatient program) and whose use was pioneered by Doctor Graeme Correll of Australia and Doctor Ronald Harbut of Arizona, the COMA TECHNIQUE, a more controversial treatment not currently allowed to be performed in the USA, and a third option, OUT-PATIENT TECHNIQUE, that as of yet has proven to provide only very temporary relief.
See the section below for the Neurology Today 2/07/06 article which compares/contrasts two of the methods!
In this section of the website you will find a large collection of information on CRPS/RSDS and Ketamine, especially concerning the low-dose method. Please read through the whole section to get a good handle on this if you are considering any version of Ketamine. It is a very powerful medication and not one to be taken lightly.
KETAMINE INFUSION - THREE TECHNIQUES
There are three main ketamine infusion techniques currently being performed on CRPS patients for the relief of their pain and allodynia symptoms.
LOW-DOSE KETAMINE INFUSION - IN-PATIENT ( AWAKE TECHNIQUE) Also called the "IN-HOSPITAL" TECHNIQUE.
This is the treatment pioneered by Doctor Correll, of Australia, and Doctor Ronald Harbut, of Little Rock, Arkansas. They were successfully treating CRPS/RSDS patients with this technique back in the 1990s'. In 2002 Doctor Harbut published the first study in a peer-reviewed journal of this procedure anywhere. Doctor Harbut worked with the FDA to establish the protocol being used by Doctors across the country currently. Today there are hospitals and clinics all over the country performing this procedure successfully. This treatment typically consists of five continuous days of infusion of a combination of Ketamine and clonidine while the patient is in a hospital.
When asked by Neurology Today magazine to describe why the low-dose Ketamine infusion works for many RSD patients, Doctor Ronald Harbut, while at Mission Pain Consultants in Hot Springs, Arkansas, had this to say;
"Dr. Harbut likened Ketamine therapy to the healing of a broken bone. If someone breaks a bone and you simply put the two pieces back together, they won't immediately heal. However, if you add a splint and hold the bones juxtaposed and steady for a period of time, and take away the splint later, the bone is healed. I think that the Ketamine treatment does something similar; it lends support and allows the abnormally sensitized nerve cells to heal themselves, so that when you finally take away the Ketamine, the pain is reduced or gone."
The patient typically receives a dose of between 20 mg and 35 mg of Ketamine, (see the studies for exact dosages per hour, etc.). The dose depends on the patients weight, CRPS, health, and a variety of other factors. Costs vary depending on the hospital where it is performed. It can range from $10,000 to as much as $50,000 and up, depending on the Doctor, clinic, and/or hospital but typically average around $25,000. The costs are mostly due to the labor involved and the patients requirements to be closely monitored. When looking into the costs of the treatment at different clinics/hospitals be sure to get ALL of the costs upfront; including any pre/post treatment appointments, as well as any booster treatments if they are required (there are one or two Doctors out there who use post-treatment Ketamine boosters following the low-dose in-hospital treatment so these should be factored into the actual cost).
Besides Doctor Harbut's clinic in Arizona (2011) there are Doctors that have been performing this treatment in PA, NJ, GA, NY, and several other states for years now. Hundreds of treatments have been done since 2002 and a great deal of research data has been collected but more work still needs to be done. We are far behind countries such as Australia for instance.
The results of the "in-hospital" treatment have the highest success rate and highest relief retention rate. Many of the patients going through these procedures have reported going to zero pain and maintaining that zero pain level for months and even up to years afterward. The length of success depends on the patient and the Doctor performing the treatment as well as other factors. Every patient is different. It is continually being improved and the success rate is always increasing as well. It is not a cure and even in the most successful cases it is only considered putting the patient into remission, as are other ketamine treatments. But to be out of pain, or a large percentage of pain, for even a few years at a time is a wonderful thing!
KETAMINE INFUSION - OUT-PATIENT
The out-patient version usually entails repeated infusions done over a period of days, weeks, and months. It is, obviously, an out-patient procedure, lasting anywhere from 4 to 6 hours at a time generally. The cost varies but is typically $300 to $1000 per day, depending on the Doctor and the clinic.
In one example, the patient receiving a low level of Ketamine infusion every day for the first 2 weeks, for about 4-5 hours per day. The patient usually receives about 70-90 mg per day (note the difference in dosage from the low-dose). Then the treatments are stepped down to 2 treatments of 4 hours each every other week for 4 weeks, usually the same dosage. Then depending on the relief obtained, either stepped down again to 1 treatment of 4 hours every other week, or kept at that pace for another month, etc. The treatments can eventually be stepped down to once or twice every three months for 4 hours each.
Of course each patient is different and there will be variations. depending on the Doctor and hospita/clinic involved. The one listed above is simply a typical version. Unfortunately the relief obtained with this treatment seems to be far more fleeting. Some have suggested it is because the ketamine does not have a chance to re-set the sympathetic system in the same way as the low-dose because of the stop-start method.
HIGH-DOSE KETAMINE INFUSION - COMA TECHNIQUE
In this version, the patient is placed into a medically-induced coma and given an extremely high dosage of Ketamine; typically between 500-700 mg per hour for 5 to 7 days. (compare that to the low-dose version where the patient is given anywhere from 20-35 mg for 5 days).
This version, currenty not allowed in the United States, was being done in Germany but treatments are also taking place in Monterey, Mexico.
According to Dr Robert Schwartzman, a noted RSD specialist, "The theory is, the coma allows the constant throbbing pain connections from the body to the brain to reset, like a computer reboot. For seven days powerful drugs will surge (through the patient's) veins. (the patient) will need a ventilator to breathe. This treatment has been effective in some degree for 30 patients, giving a piece of their life back."
The costs for this treatment can vary widely depending on travel requirements, length of stay, etc. They range from $10,000 to $50,000 for the treatment plus travel, depending on whether you have it done in Germany or in Mexico.
There haven't been nearly as many patients treated with this version of Ketamine as with the low-dose. There is a long way to go as far as research is concerned before any long-term assessments can be made. But there are a number of patients who have gone into remission with this treatment as well as patients who have had severe repercussions from it.
We have added an article on the coma technique from January 2008.
All three techniques have their proponents and opponents, those who think they are the answer and those who feel patients need to stay very far away from them, maybe the answer is somewhere in between. Enough patients have been helped, some for a short time and some for a long time, with the various methods that it certainly warrants the investment into all three techniques.
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