The Debate on Ketamine and Cancer Pain

The Debate on Ketamine and Cancer Pain

When it comes to managing cancer pain, no one treatment plan looks alike. As reported in the Seminars in Oncology Nursing, Sandra Kurtin et al. wrote, “Pain remains a primary concern throughout the cancer trajectory across all age groups and diagnoses” (2019). They claim that communication is critical among health care professionals to address each patient’s individual needs (Kurtin, 2019). 

Often, ketamine is administered to “manage neuropathic pain” in those with cancer when other types of opioids or treatments fail. However, it occasionally causes side effects like “vivid dreams, nightmares, illusions, hallucinations, and altered body image” (Okamoto, 2013). To overcome this, Okamoto’s study found that “gradual dose titration of ketamine for management of neuropathic pain can prevent” those adverse psychological effects in patients with advanced cancer (2013). 

With that in mind, it is vital to account for the ongoing opioid crisis and ensure new patients do not fall victim to opioid addiction. 

Medical professionals have relied on ketamine for pain management for decades, but there is debate on its universal effectiveness for cancer patients. Numerous case studies have followed specific individuals through their cancer pain management journeys. 

In Baltimore, Maryland, professionals at the John Hopkins Hospital followed a 28-year-old man “with metastatic pancreatic neuroendocrine cancer with severe, intractable pain” despite high doses of methadone and other opioids (Waldfogel, 2016). When the patient was administered “short-course, low-dose ketamine, his opioid requirements decreased by 99% and pain ratings by 50%, with most of this decrease occurring in the first 48 hours” (Waldfodel, 2016). Essentially, in this case, ketamine “reduced opioid consumption by 99% and potentially ‘reset’ neuron hyperexcitability,” which decreased the patient’s pain signaling and “improved pain control” (Waldfogel, 2016). 

The Journal of Pain & Palliative Care Pharmacotherapy published Priya Amin et al.’s case study in 2014. A 36-year-old-female with breast cancer in her “bones, liver, lung, and pleura/chest wall” with severe back pain had been responding poorly to oxycodone and other opioids. Despite increased dosage, the pain did not dissipate. Then, she started on “weight-based ketamine protocol” for a 3-day rotation from intravenous to orally-administered ketamine. When “her dose was increased to 0.4mg/kg/h,” the nurse reported pain relief within 120 minutes. This transition decreased her opioid consumption by 61.4%. Amin et al. wrote, “The use of weight-based dosing of IV continuous infusion and transition to oral ketamine was effective and tolerable in managing opioid-refractory, neuropathic cancer pain” (2014). 

Mari Lloyd-Williams performed a case study published in the Journal of Pain & Symptom Management in February of 2000. A 20-year-old with Von Recklinghausen’s disease was in a motor vehicle accident one year ago and grew cancerous tumors in his right leg, causing severe pain. After being hospitalized with multiple attempts at pain management through other avenues, low doses of ketamine showed some success. The patient was discharged and administered higher doses of ketamine for home use. With the higher doses, the patient reported feeling almost pain-free. Williams wrote that the achieved outcome “suggests that ketamine in higher doses be helpful in alleviating severe pain and in restoring quality of life when more conservative measures fail” (2000). 

Lucinda Grande et al. recorded in the Anesthesia & Analgesia journal a circumstance of “opioid-refractory pain that responded to a low-dose IV infusion of ketamine in the inpatient setting” (2008). This patient was about to transition to “oral memantine for long-term outpatient management,” which was a new use for “this oral NMDA receptor agent” (Grande, 2008).

While opioids continue to be the main form of pain treatment, it is not always successful. Waldfogel et al. reported that “up to 20% of patients have persistent or refractory pain despite rapid and aggressive opioid titration, or develop refractory pain after long-term opioid use” (2016). 

It is important to note that everything listed above was case studies where one specific subject was sampled. That cannot be taken for sweeping results, as Kelly Jonkman et al. wrote for the Current Opinion in Supportive and Palliative Care. They said that ketamine is typically prescribed when an opioid therapy patient becomes opioid resistant or “when neuropathic pain symptoms dominat[e] the clinical picture” (Jonkman, 2017). 

In their study, Jonkman et al. tested four randomized controlled trials “examining the benefit of oral, subcutaneous or intravenous ketamine in opioid refractory cancer pain” (2017). What they found was that “none showed clinically relevant benefit in relieving pain or reducing opioid consumption,” which suggests a lack of evidence that ketamine works as an “adjuvant analgesic” with cancer pain (Jonkman, 2017). They argue that “there is still insufficient evidence to state with certainty that ketamine is not effective in cancer pain” (Jonkman, 2017). 

It is known that ketamine infusions show promising results for patients with chronic pain and mood disorders. Involved medical professionals aspire to change the reality of patients dealing with cancer pain; ketamine treatments, whether they be short-coursed or weight-based, offer hope regarding managing cancer pain. That being said, more research is needed before widespread ketamine prescriptions can occur. 

While cancer-related pain management is currently inconclusive, ketamine has been proven to help with noncancer pain treatment. Avesta Ketamine and Wellness strives to offer individualized treatment so everyone’s individual symptoms can be accounted for. We help patients optimize their mental and physical wellness with several high-end infusion options. To schedule a consultation, either call the office or go online to book a visit today. 









References

Amin P, Roeland E, Atayee R. Case report: efficacy and tolerability of ketamine in opioid-refractory cancer pain. Journal of Pain & Palliative Care Pharmacotherapy. 2014 Sep;28(3):233-42. doi: 10.3109/15360288.2014.938881. Epub 2014 Aug 7. PMID: 25102039.

https://pubmed.ncbi.nlm.nih.gov/25102039/

Grande LA, O'Donnell BR, Fitzgibbon DR, Terman GW. Ultra-low dose ketamine and memantine treatment for pain in an opioid-tolerant oncology patient. Anesthesia & Analgesia. 2008 Oct;107(4):1380-3. doi: 10.1213/ane.0b013e3181733ddd. PMID: 18806055. https://pubmed.ncbi.nlm.nih.gov/18806055/

Jonkman K, van de Donk T, Dahan A. Ketamine for cancer pain: what is the evidence? Current Opinion in Supportive and Palliative Care. 2017 Jun;11(2):88-92. doi: 10.1097/SPC.0000000000000262. PMID: 28306568.https://pubmed.ncbi.nlm.nih.gov/28306568/

Kurtin S, Fuoto A. Pain Management in the Cancer Survivor. Semin Oncol Nurs. 2019 Jun;35(3):284-290. doi: 10.1016/j.soncn.2019.04.010. Epub 2019 Apr 30. PMID: 31053398. https://pubmed.ncbi.nlm.nih.gov/31053398/

Lloyd-Williams M. Ketamine for cancer pain. Journal of Pain and Symptom Management. 2000 Feb;19(2):79-80. doi: 10.1016/s0885-3924(99)00142-6. PMID: 10766572. https://pubmed.ncbi.nlm.nih.gov/10766572/

Okamoto Y, Tsuneto S, Tanimukai H, Matsuda Y, Ohno Y, Tsugane M, Uejima E. Can gradual dose titration of ketamine for management of neuropathic pain prevent psychotomimetic effects in patients with advanced cancer? American Journal of Hospice & Palliative Medicine. 2013 Aug;30(5):450-4. doi: 10.1177/1049909112454325. Epub 2012 Jul 24. PMID: 22833552.

https://pubmed.ncbi.nlm.nih.gov/22833552/

Waldfogel JM, Nesbit S, Cohen SP, Dy SM. Successful Treatment of Opioid-Refractory Cancer Pain with Short-Course, Low-Dose Ketamine. Journal of Pain & Palliative Care Pharmacotheraphy. 2016 Dec;30(4):294-297. doi: 10.1080/15360288.2016.1231732. Epub 2016 Oct 18. PMID: 27754734.

https://pubmed.ncbi.nlm.nih.gov/27754734/

 

Author
Dr. Ladan Eshkevari, PhD, CRNA, FAAN Dr. Eshkevari is the lead clinician at Avesta, and is a long time researcher and educator in physiology, biophysics, and anesthesiology. She is passionate about assisting patients with retractable, difficult to treat mood disorders, and relies on the latest research to bring evidence to Avesta's practice to better understand and serve patients.

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