RSD/CRPS is a very painful condition and initially patients may not full understand the long term financial implications of their condition.
Ketamine Infusion Therapy is only administred on patients, who have full-body RSD/CRPS long term and have tried a wide variety of alternative approaches to relieve thier pain like: Bier blocks, spinal blocks, intrathecal pump and other treatments, but still experience high levels of pain. The program can be done on both an inpatient and outpatient basis, but prior to beginning either therapy, extensive laboratory, cardiac, and psychological evaluations are completed to determine the current medical status of the patient. While there have been NO significant adverse events, clinics have been extremely cautious in screening patients with concurrent medical problems. The two most common reasons a patient would be eliminated are a psychiatric history of note (apart from the depression due to chronic pain) and cardiopulmonary disease.
The hospital-based infusions require a five-day in-patient stay when an intravenous (IV) line is inserted and the patient is started on a dose of 20mg of ketamine per hour, which is increased by 5mg increments to a maximum of 40mg per hour. As an adjunct, clonidine, 0.1 mg (per FDA) is administered with small doses of lorazepam (Ativan®), 1-to-2 mg, utilized for any dysphoria or hallucinations. Other medications may be required to treat such problems as nausea and vomiting, headache etc. The most common adverse event is fatigue, although there have been some instances of short-term hallucinations related to dosage, but these have disappeared within an hour of lowering the dosage. Dr. Schwartzman and Philip Getson, DO have treated more than 100 patients over three years with no significant lasting adverse events
Following discharge from the hospital, patients enroll in an outpatient infusion program of varying degrees and lengths. Initially, they are treated 1-to-2 times a week for a 4-hour IV infusion of 100 mg to 200 mg of ketamine. The frequency of outpatient treatments is weaned over time. Currently, the protocol being used consists of two outpatient treatments a week every other week for one month, then one treatment every other week for a month then monthly for three months then every three months. This protocol is merely a general guideline however and varies at times. Then one outpatient treatment the following month, after which the patientis reassessed. Outpatient visits are then monthly, or at 3-month intervals, depending on the patient.
Alternatively, the patients are given therapy only on an outpatient basis. They are given 10 daily treatments initially in two consecutive weeks in an outpatient infusion suite. They are administered from 70 mg-to-200 mg of ketamine per day in titrating doses over the 10-day timeframe and then they are placed in the outpatient program as described above. Again, there have been few adverse events and most of them have been dosage related. As before, the most common is fatigue on the day of the infusion. There have been NO long term side effects. Most patients are given 2 mg of midazolam and sleep through the procedure. Other medications are given as needed for side effects such as nausea and headache.
The results obtained so far have been very promising with outcomes measured using pain scales, physical exams, psychologic profiles, and activity increase. Rough estimates show approximately 85% of those undergoing the hospital stay protocol have improvement measured by increased activity, reduction of medication, and improved lifestyles. For example, some have discarded wheelchairs, walkers, and canes, and others have increased activities or have returned to work. Those beginning with outpatient therapy have similarly improved, but to a lesser degree (approximately 60% to 70%). All patients receive the follow-up outpatient boosters.
The one major problem with ketamine infusion therapy is the inability to “hold” the improvement achieved by the five-day inpatient or 10-day outpatient regimen. Without the infusion boosters, the patients almost universally return to their pre-treatment state. It is therefore necessary to combine the initial start-up therapy on an inpatient or outpatient basis with follow-up boosters in order to maintain the level of pain relief. Virtually all participants in the program have continued the out-patient ketamine infusions with no patient treated having discontinued due to side effects.
Treatment of Ketamine Infusion Therapy is very labor intense due to the continual techincal and clinical interface required during the entire treatment process and the need to ensure the patient is constantly monitored with medication adjustments being administered when indicated. The range of fees for outpatient protocol – hospital based nornally runs between $10,000 – $50,000 and highlights the need for RSD/CRSP patients to seek legal advice on how to best financially prepare themselves to access ongoing needed treatments in the future.
For additional information on Ketamine Infusion Therapy: RSDSA