Medical Opinion about Ketamine Infusion Guidelines
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Summary: Question and Answer with Rita Rutland, APRN @ Restorative Health about ketamine infusion guidelines
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Question | How important is the frequency with ketamine infusions?
Rita: What I have noticed with my patients over the last three years is that the frequency, as well as how close the visits are, do not strongly affect whether the medication actually works. When it comes to depression what ketamine does long-term is re-grow neuro-connecting sites, as well as make new ones. In order to have a noticeable lasting effect, most people need about three treatments. Usually, after the first treatment patients will feel significant relief of symptoms or find that they feel more positive and hopeful for about two to three days, but then they notice that their mood tanks. This often is reported as feeling devastating because they actually felt good. It does not mean that patients drop lower than what their baseline was when they came in for a treatment. It's just that they really notice dropping back into that depressed state.
What I've observed after the third ketamine infusion is that patients using ketamine to improve their mental health feel a more lingering effect lasting several weeks, months, or longer for certain patients. For individuals dealing with nerve pain, the relief is more immediate. For mentally ill patients my hunch would be that it takes about three ketamine infusions before patients are able to integrate more of the infusion and the infusion experience into their day-to-day life. The first two treatments tend to be disorienting and lay a foundation of experience and understanding so that later infusions provide the mental clarify patients need to stabilize their mood in a positive direction.
Most of the existing clinical studies are based on 6 ketamine infusions performed over 10 to 14 days. Something worth noting is most of these clinical studies were done in-patient. I look forward to additional research done in an outpatient setting with variations on how quickly the infusions are done to explore if further improvements to patient's health outcomes can be accomplished.
Something I've noticed in my office is when patients do treatments too closely together, the patients self-report they don't have time to process what comes up during the treatment. Having more time spaced after a particularly intense, emotional, or enlightening treatment allows patients to access past trauma or the root cause of their mood disorder, find that they need some time to process and integrate that experience before continuing on with another treatment. This is why I do not require patients to do these treatments in a set period of time. Every patient responds differently to ketamine and each treatment elicits a different response. This is why our approach is individualized when it makes sense and is firmly based on existing protocols that show continued positive results.
Question | Which modes of administration work best?
Rita: On the psychiatric spectrum, both the intravenous drip and the intramuscular injection seem to elicit similar response rates. With pain, I have noticed based on patient self-reporting that the IV is superior. Patients who have had the injection report less pain relief than those who have done the IV infusion. The injection tends to be very therapeutic and effective when done in conjunction with talk therapy. The infusion done this way allows patients to enter a cathartic emotional state and access different emotional aspects of their psyche that need to be dealt with. It allows patients to detach from the emotional and physical response and be able to talk through it and come out on the other side knowing that they are okay as well as developing new thought patterns or processes that may prove helpful in coping with life.
The ketamine nasal spray is good for maintenance dosing, however, it doesn't elicit the same level of response that the injection or IV drip treatment provides. The ketamine nasal spray is more subtle. The exposure of the patient's neuro-connecting sites to ketamine through the infusion facilitates a faster rate of healing. The nasal spray is effective for maintenance dosing between IV treatments to extend the amount of time needed between those treatments. The ketamine nasal spray is very effective to utilize in a therapy session. The nasal spray works as a rescue treatment for moments of suicidal ideation, severe depression, anxiety, or panic states.
The ketamine troches tend to have a more physiological effect and are better for pain management, while the nasal spray is better for mood management. The troche can also be utilized as a gentle introduction to what ketamine feels like. It is a higher dose administered at one time, where the nasal spray is usually done a few sprays (1-2 sprays every 5 min up to 5 rounds or 10 sprays) total every few minutes over an hour. The troche is excellent, again, to combine with talk therapy, allowing you to sink into a deeper space and access areas that need to be adjusted within your mind and be able to process through. It's also an excellent alternative if there are severe financial concerns and the infusion or injection is not a viable option for some patients. We also use the troche as maintenance dosing, primarily for pain management or in combination for patients to utilize with their therapist.
The main difference between the injection and the IV drip infusion is the intensity of the experience. The drip allows for a gentle introduction and a slow sink into that deeper conscious state. It also allows for more control where we can speed up, slow down, or even stop the infusion if necessary. With the injection, the advantage is that you're not having to get IV access, you're not attached to any tubing and you don't have to worry about difficult veins. However, you are getting the entire dose of medication at one time and ultimately need to just work through that treatment experience, regardless of intensity. It does tend to be most intense at the beginning and lessened towards the end where the IV treatment tends to be the most intense towards the end.
Question | What music works best for ketamine therapy?
Rita: Due to the way that ketamine works, it is sometimes distracting or difficult to process music with lyrics. Your tendency is to want to try and respond to verbalization or to the lyrics, but your brain is unable to integrate those words the way that it normally would and so for some people, that can be distracting. The other part of it is, those words in the music can provide guidance that isn't necessarily positive, as far as where it guides that journey. On the other side, if you pick music that is very positive and soothing and speaks to you, it can also help to make that treatment experience more positive. So again, with music, it is a very individualized treatment experience and we encourage patients to choose music that is soothing and speaks to them. It tends to be a bit of an experiment for individuals that will choose music that they feel will guide their experience in the manner that they wish, and then find that it is overwhelming or distracting from the actual treatment experience.
I am not against lyrics, however, just for people to be mindful of how that's going to affect them while their mind is in a very pliable and vulnerable state. Music without lyrics that is more quiet or soothing, tends to have a more calming effect. Music plays a very important role in your ketamine journey in that it can help to guide you and as the music shifts so will your thought processes, which can help keep you moving if you get stuck on a specific thought. Doing ketamine treatments with a sound therapist, skilled and guiding that mental state can be extremely healing. When managed appropriately, it can really help to shift and move through different thought processes to come out at the end with a conclusion that is helpful or a shift in perspective.
The main reason that I would caution people against lyrics is the level of distraction or potential irritation that they can cause because your brain can't fully comprehend what those lyrics mean. Music is also a fairly important because silence actually becomes very loud with ketamine and it helps to quiet the silence so that it doesn't feel like a roar. It's soothing when you're dropping into a deeper state, as well as when you are coming out. It provides a grounding or a lifeline back to your body should you wander far in your journey.
Question | Other common disagreements about ketamine?
Rita: The biggest discrepancy that I see is dosing. Dosing is very individualized and current recommendations are based on weight. However, there are numerous factors that play into how your body processes the medication. Some people are very small, have low body weight, and still process the medication very quickly, while other people can have a large muscle mass, be very tall, and need a lower dose. So while it's appropriate to stay within the recommendations of a milligram per kilogram, it remains an individualized process to find the appropriate dose for a patient. The most important part that I see is that patients get a dose that allows them to reach that sub-anesthesia state and mild dissociative state and maintain that state for about 15 minutes.
Without reaching that sub-anesthesia state, people tend not to experience the reset aspect that the medication provides and tend not to have as lasting effects at lower doses. The medication recommendation put out by the ketamine manufacturer and up-to-date protocol is 0.5 milligrams to 2.0 milligrams per kilogram. I do find that many clinics stay on the conservative side of that dosing and patients are not getting the appropriate results that they have the potential to reach. Another aspect that has a significant effect on the effectiveness, but mostly just the treatment experience itself is the setting. We've found that patients who have been treated in a very, very clinical setting have not had a positive experience or results as patients who are provided a more calming, soothing, and comfortable environment with minimal stimulation and very supportive staff.
Ketamine is a very intense medication and it's important to feel safe and supported through the infusion. We ensure that patients are always closely medically monitored and first-time patients are required to have a trained therapist or guide with them the entire time. Observational data from our clinic suggests that first-time patients who have never had an experience with ketamine feel more at ease, report greater satisfaction, and have a higher likelihood of self-reporting improved health in the long term with the presence of a trained therapist or guide.
Another aspect that can significantly affect the effectiveness of ketamine is the mindset into which the infusion is entered. Having someone available to talk with or arranging for integrative sessions with their therapist, post-treatment, plays a significant role in how fast patients are able to respond and heal, utilizing these treatments.
Question | Your opinion on daily ketamine infusions?
Rita: This isn't an area I have a lot of experience with, as again, going back to what was previously discussed as far as frequency of visit, I feel that patients need time to integrate. However, when someone is in a severe state of depression or suicidal ideation, or severe pain, doing back-to-back treatments can help shift out of that space faster. However, I think there's potential for fatigue, overstimulation, and decreased effectiveness when these treatments are done too close together, as it does not provide that reset effect once certain neuroreceptor sites have been stimulated. My recommendation is usually to have at least one to two days between treatments where possible. However, we do have patients that travel to see us and need to do several treatments in a row to accommodate their schedules. So, it is something that we've done. However, I believe having several days between will be more effective due to how the medication affects neuro-connecting sites.