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Ketamine: Advancing the Treatment of Chronic Pain Conditions

Ketamine has emerged as a transformative agent in the management of chronic pain conditions such as Complex Regional Pain Syndrome (CRPS), pelvic pain, and pudendal neuralgia. In some cases, ketamine therapies can provide relief from pain when no other treatments have worked.

Transition from Anesthetic to Analgesic

Ketamine was first developed in the 1960s and was originally developed as an anesthetic and it has a long history of safe and reliable use in operating rooms and emergency rooms, and it found use in battlefield medicine and in underdeveloped countries – largely due to its effectiveness and safety profile. It remains in wide use in many settings including inpatient and outpatient surgeries, emergency medicine, and veterinary medicine.

Over time the therapeutic potential of ketamine was recognized and studied. Ketamine has demonstrated efficacy in treating depression, anxiety, PTSD and other mood disorders and some pain conditions. Its ability to alleviate neuropathic pain, which is often resistant to other treatments, has made it a valuable asset in pain management protocols.

How Ketamine works

As with many drugs, the exact mechanisms of ketamine in treating pain – how it works at a molecular level – are not totally understood. There is substantial and growing research in this area, however. Ketamine largely works at the level of neurons and appears to improve the function of neural pathways and transmission. Ketamine appears to re-calibrate pain pathways – effectively reducing symptoms of pain and allowing for more normalized neural function.

Targeting CRPS with Ketamine

CRPS is a chronic and excruciating condition that typically affects a limb after an injury, surgery, stroke, or heart attack. The disproportionate pain experienced by CRPS sufferers is often resistant to standard pain medications and treatments. Studies, and my own clinical experience, has shown that ketamine infusions can often significantly reduce CRPS flares and make pain more manageable.

Addressing Pelvic Pain and Pudendal Neuralgia

Pelvic pain and pudendal neuralgia, which impact the regions serviced by the pudendal nerve, including the genitalia and anus, can be debilitating. These syndromes often stem from nerve inflammation or dysfunction – which is where ketamine excels at providing benefits. Ketamine treatments can provide relief of pain in these cases.

Modalities of Ketamine Administration for Pain Management

There are multiple methods or pathways to administer ketamine treatments – with benefits and drawbacks to each:

  • IV Infusions: This is the most common form of administration, offering quick and controlled relief – which can be especially fine-tuned when combined with a controllable pump for precise and adjustable dosing. IV infusions should only be administered by appropriate professionals.
  • Sublingual, Oral and Intranasal Delivery: These methods are often used for administration where more sophisticated delivery options may not be available. These methods should be approached with greater caution because of the potential for more uneven dosing, and even the potential to ingest a very large dose if, for instance, sublingual ketamine is accidentally swallowed.
  • Suppositories, Lotions and Topical Creams: These are alternatives for those who might prefer not to have IV infusions or are looking for localized treatment options to manage symptoms more directly associated with pelvic pain, for instance.
 

Safety and Efficacy Considerations

Most side effects of ketamine are transient, including dissociative experiences and nausea. There are other, more serious concerns such as changes in blood pressure, potential distress at moderate and high doses, and some other rare but possible negative outcomes from use – especially prolonged use at high doses. It is imperative that treatment be overseen by healthcare professionals with expertise in pain management, preferably anesthesiologists, who can effectively manage dosing and monitor for adverse effects.

Choosing an experienced and qualified provider is crucial when considering ketamine for pain management. The provider should be well-versed in ketamine’s pharmacodynamics and adept at handling its complex effects toward a safe and beneficial outcome.

An Important Treatment Option

Ketamine’s promise in treating refractory cases of chronic pain such as CRPS, pelvic pain, and pudendal neuralgia represents a notable advancement in pain management. By addressing the function of neurons directly ketamine appears to uniquely help conditions where other treatment options have failed. I have seen ketamine infusion therapy significantly reduce suffering and enhances the overall quality of life for many patients. It may not be a cure, but it can be an important method of managing pain and getting back to your life.

– Allison Wells, MD

 

About Dr Allison Wells

 

Dr Wells is an anesthesiologist and an experience-leader in ketamine treatments for mood disorders and pain conditions. She founded one of the first focused clinics in the country, has helped many patients with many thousand infusions, and actively contributes to the field with research and advocacy. Wells Medicine wellsmedicine.com, in Houston, TX, provides interventional procedures and a focus on comprehensive mental health toward excellence in evidence-based care.

Dr. Wells holds degrees from Swarthmore College and Baylor College of Medicine. She trained at Baylor College of Medicine and Harvard Medical School. She is a member of the American Society of Anesthesiologists, The Texas Society of Anesthesiologists and the Texas Medical Association. 

 

Wells Medicine, Houston, TX

 

wellsmedicine.com

 

 

Some additional information and helpful references

 

Health Organization for Pudendal Education. (2018). Chronic pelvic pain. Retrieved May 12, 2024, from https://www.pelvicpain.org.au/wp-content/uploads/2018/12/HealthOrganisationforPudendChronicPainBro1_0.pdf

 

Pudendal neuralgia. Global Library of Women’s Medicine. Retrieved May 12, 2024, from https://www.glowm.com/womens-medicine-amp.html?item=691&name=pudendal-neuralgia

 

Leslie SW, Antolak S, Feloney MP, et al. Pudendal Neuralgia. [Updated 2022 Nov 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562246/


Gargori NMB, Alahwal H, Vacheron CH, Alam FMA. Predictive factors of success and failure for intravenous ketamine therapy in patients suffering from chronic neuropathic pain. Saudi J Anaesth. 2023 Jul-Sep;17(3):340-348. doi: 10.4103/sja.sja_737_22. Epub 2023 Jun 22. PMID: 37601528; PMCID: PMC10435804.  https://pubmed.ncbi.nlm.nih.gov/37601528/

9 Comments

  1. Anonymous on May 21, 2016 at 1:27 am

    Is there any Dockets it jhb soutg Africa that know about pedendul nurelga the 3 that i have seen now nother bunch of idiats is there anyone in ptas

  2. Adele Casden on May 29, 2016 at 2:40 am

    I am completely incapacitated by rectal pain. But I would want more information on possible problems, before I’d try it. If it’s being given at some hospital, Stanford, etc, where are the records of the outcome. There need to be some statistics.

  3. HMC on December 4, 2016 at 7:29 am

    Is ketamine more effective that lidocaine in an infusion?

    • Pelvic Guru on December 4, 2016 at 7:53 am

      I believe the mechanism is much stronger and more effective with Ketamine. We can see if the physician can answer that.

  4. Mickey Nilsen on February 21, 2017 at 10:55 pm

    I am ready to return to Phoenix to discuss this option with Dr. Hibner again. This Thursday is my 2-year anniversary of my PNE decompression surgery and I am 7 months in on a medical trial back to work – my pain level is as high as it was prior to surgery and then some. We’ve talked on the phone and he understands I am likely re-entrapped, and more surgery is not recommended. Ketamine infusions seem like a logical option for me since I have tried every other thing asked aside from an interstim and Botox (which he didn’t feel would work for me). Ketamine infusions were recommended prior and were too costly to consider at the time, but my home can now go, as pain relief is the top priority for the remainder of my life. I’m into 6 years of PNE and something must work soon to improve quality of life over length of life.

  5. Ronald on February 24, 2017 at 12:49 am

    Hi Tracy

    Nothing has helped me this far except Botox injections into pelvic muscles, effective for about six months on average. Would a low dose of oral ketamine (30mg/day) eventually counter PN induced central sensatization if taken for a prolong period? I have a cardiac condition so cannot consider infusion.

    Regards

    Ronald

    • Pelvic Guru on February 24, 2017 at 7:20 am

      Hi Ronald. Sorry to say, but no one knows that answer. There’s no specific drug that can prevent central sensitization per se. The good news is that it can be reversed. The most important things that help – moving/exercising in ways that don’t aggravate the pain (if possible), not having catastrophic thoughts “I’ll never be normal again.” And working with a physical therapist or other health professional who really understands how to deal with persistent pain.

  6. phyllis Rentie on March 5, 2017 at 5:17 pm

    I wonder would I be good candidate for ketamine the outpatient type if my prudential nerve block did not elevated any of my vulva pain.

  7. Sarah on June 12, 2018 at 2:24 am

    Hi there, just a quick question. I see that you claim those with crps are twice as likely to have a mood disorder. Unfortunately that quote is not cited. I would like to read that. I’ve had crps for six years and I am always looking for new updated information. I’m not sure I believe it, but I’d like to check it out. With crps and serious chronic pain anxiety, grief, and depression are secondary issues to your life changing in ways you probably didn’t see coming. Especially with crps, it is a unexpectedly crazy making diagnosis.
    As for ketamine I have had a four day low dose infusion and it was amazing. I was “pain free” for about six weeks and it seems to have halted and even reduced the spread of crps to just the original area. Unfortunately at that time I had to travel from Oregon to Utah to do it.
    Anyway thank you for the pelvic physical therapy information it has been very helpful.

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