Frequently Asked Questions for Physicians
What is Ketamine?
Ketamine has been around for more than 50 years as an FDA-approved anesthetic agent and has a high safety profile. It is used on pediatric and adult patients as well as in veterinary medicine for a variety of acute medical conditions. Slow intravenous (IV) ketamine infusion therapy is an exciting intervention that has gained recent attention for its rapid-onset antidepressant effects. Additional research has also been done using IV ketamine infusions for other treatment-resistant conditions such as PTSD, Complex Regional Pain Syndrome and other chronic pain and mental health conditions.
How does Ketamine work?
Ketamine is considered a dissociative anesthetic. Depending on the dose administered, a person can have the sense of dissociating the mind from the body to varying degrees. The dosing range typically used for IV ketamine infusion is significantly less than the dose used to produce general anesthesia for surgery and minute compared to the dosages reported in recreational ketamine substance abuse/misuse. During the infusion process, patients remain aware of their surroundings and the people who are with them at all times. Some patients choose to listen to music and relax quietly, while others prefer to visit with a family member and have light conversation.
Ketamine works on different pathways compared to conventional antidepressants. Ketamine has a primary site of action as an NMDA- receptor antagonist, which affects neurotransmission of the excitatory neurotransmitter glutamate. Ketamine is believed to lead to neuroplasticity and affect new changes in the brain. Positive changes have been observed in areas of the brain involving memory, learning and executive functioning.
How soon after a ketamine infusion will I feel better? How long does it last?
Patients receiving IV ketamine infusions typically report “feeling better” during the infusion experience and can often sustain that feeling well after the drug has been metabolized and eliminated from the body. “Feeling better” can be a subtle change, and patients may notice an improvement in their day-to-day function before they notice an improvement in their mood or pain. This effect has been reported to last from a few hours to 18 days. When used in conjunction with other treatment modalities, behavioral health intervention in particular, the results can last up to several months or longer. For this reason, part of our initial evaluation includes psychological evaluation, patient education and planning. We provide additional support for the patient before, during and after the infusion process when ketamine infusion therapy is indicated for treatment-resistant chronic conditions.
How safe is ketamine infusion therapy if done in the outpatient/clinic setting?
Ketamine is considered a safe medication; however, how it is used and by whom determines how safely this medication can be used in the outpatient setting. We place a high degree of importance on the medical decision making of determining if a patient is an appropriate candidate for outpatient ketamine infusion therapy. Patients are screened for medical, psychological and social-emotional conditions that may prevent them from being an appropriate candidate for this intervention. In certain cases, a urine drug screen may be ordered in the initial consultation phase.
During the infusion process, patients are monitored by a board-certified anesthesiologist continuously for heart rate and oxygenation level. Blood pressure measurements are checked frequently. Patients are monitored until they meet the standard criteria for discharge into the care of a responsible adult.
How does ketamine infusion therapy get incorporated into a comprehensive treatment plan?
Anyone may call to inquire about ketamine infusion therapy. Before initiating treatment, a plan must be set in place to optimize the possibility of successful treatment. All patients first need to have an initial consultation to review their medical history, brief physical exam, previous treatments, baseline symptom severity, previous medical records, and pertinent self-reporting inventories to identify the most appropriate indication for ketamine infusion and to determine if the patient is an appropriate candidate. Informed consent is also discussed at this time. A supportive family member or advocate is also encouraged to participate in this process. Communication between the referring physician or practitioner is also established to help facilitate a smooth transition of care during and after the infusion process. Additional psychological services are a required part of our treatment model in order to provide patients with appropriate care and follow up. This process typically takes 1-2 weeks from the time of initial inquiry to the time of first infusion. We also facilitate and encourage patients to share information regarding the treatment they receive including psychological services, education and planning when they return to their primary treating physician after completing their ketamine infusion or infusion series.
What is the success rate of IV ketamine infusion therapy?
Most research studies and ketamine infusion centers report that approximately 70 % of patients treated will respond positively and begin to feel better after their first ketamine infusion. Most ketamine infusions are initially scheduled as a series of 6 infusions within a two-week period of time to in order to provide relief anywhere from weeks to months. A high degree of importance is placed on the initial patient evaluation and candidate selection for this intervention. Some conditions can be more challenging to treat and may require different dosages and length of infusion times to maximize the patient’s benefit. Some conditions such as refractory migraine may only require one ketamine infusion to provide complete relief.
Are there side effects with ketamine infusion therapy?
The presence of side effects depends on the dose of ketamine given and the frequency of use. In general, the side effects of ketamine infusion therapy are mild and not every patient experiences them. Some side effects are anticipated, and can be easily treated at the time of infusion such as anxiety or nausea. Other side effects that can occur during an infusion include increased heart rate and blood pressure, or a deeper level of dissociation than intended. Although all patients are pre-screened to assess the likelihood of these side effects from occurring, on the rare occasion they do occur. By either stopping the infusion or treating them with IV medications, these side effects usually resolve within 5-15 minutes. The most common side effect following a ketamine infusion is feeling tired for a few hours.
Long-term side effects of ketamine have been reported in chronic, daily users who consume much larger doses of ketamine; 100-1000x the dose of a typical ketamine infusion. Recreational use of ketamine is not only illegal, but it is also very dangerous as it is uncontrolled for purity, dosing and monitoring. Serious long-term side effects such as bladder cystitis, addiction and cognitive impairment have all been reported in ketamine misuse and abuse. These side effects have not been reported by experienced ketamine infusion providers, and it is important to choose a ketamine infusion provider who is maintaining a high standard of care. Professional judgement and careful follow up with patients are an essential part of our patient safety protocols as well as maintaining a responsible contribution to establishing good practice guidelines.
Can ketamine be administered in other forms?
Although ketamine can be administered in many forms (pills, creams, sprays, sublingual tablets, suppositories, intramuscular/intravenous injections, and as infusions), IV ketamine infusion therapy is the most common and most researched route of administration for treatment-resistant depression and other chronic mental health and pain conditions.
What are the mental health and medical conditions currently being treated with IV ketamine infusion?
IV ketamine infusion has been used as an intervention for several chronic “treatment-resistant” conditions. Treatment-resistant depression is currently the most studied condition and has received the most media attention and public awareness in recent years. Other treatment-resistant conditions that have been responsive to IV ketamine infusion therapy include but are not limited to:
- Bipolar disorder
- Anxiety disorder
- Various neuropathic pain syndromes
- Posttraumatic Stress Disorder (PTSD)
- Obsessive Compulsive Disorder (OCD)
- Complex Regional Pain Syndrome (CRPS)
IV ketamine infusion has also been used successfully to treat refractory migraine headache. In the acute inpatient setting, IV ketamine infusion has been reported to rapidly reverse acute suicidality. Research for IV ketamine infusion therapy for other mental health conditions and chronic pain is still emerging and demonstrating positive outcomes. Nevertheless, IV ketamine infusion therapy for any condition is currently considered an “off-label” treatment by the FDA. Do insurance companies cover IV ketamine infusion therapy? IV ketamine infusion is considered an “off-label” intervention, and therefore, most insurance companies do not cover the cost of this service yet. The additional services we provide with this intervention including initial consultation and psychological screening and follow up are possible services that patients may seek reimbursement for by their insurance companies. We will do our best to provide prompt and adequate documentation to facilitate reimbursement to the patient.
How much does ketamine infusion therapy usually cost?
The range for ketamine infusion therapy across the United States averages between $400-800 per infusion. Our cost per infusion at our facility starts at $500 for a 40 to 60-minute infusion. The cost per infusion may be more depending on the patient’s indication for ketamine infusion therapy, as some medical conditions require longer infusion times (3-4 hours) to achieve maximum benefit.
Why did Dr. Wolfsohn start offering ketamine infusion therapy to patients?
As an anesthesia resident, Dr. Wolfsohn had an excellent mentor who taught her how to use ketamine in different clinical situations. She continued to apply this knowledge as an anesthesiologist in private practice for more than 10 years. During that time, she worked closely with a very busy interventional pain practice, caring for complex and often treatment-resistant chronic pain patients. Over the years, Dr. Wolfsohn has administered ketamine to thousands of patients as part of their anesthetic plan. If used appropriately in anesthesia, sedation regimens become safer, doses of opiate pain medications can be reduced, and patients generally feel significantly happier when they have received even a very small dose of ketamine. The transition from administering ketamine as part of an anesthetic to administering ketamine infusion therapy for treatment-resistant mental health and chronic pain conditions was an easy one in terms of experience and interest.