Abstract
Ketamine is used to treat chronic refractory pain. However, there are no scientific guidelines for ketamine use in the Netherlands. The aim of this survey was to provide an overview of the use of ketamine for chronic pain in the Netherlands. All pain clinics in the Netherlands were contacted. A digital survey, available from June 2019 to January 2020, was sent to 68 pain clinics. The survey was completed by one pain physician as a representative of the entire pain department. The survey included questions about ketamine treatment indications, administration, dose, duration, treatment repetition and the inpatient or outpatient setting. The survey was completed by 51 pain clinics (75.0%). Thirty-one clinics used ketamine for chronic pain treatment. The most common indication was Complex Regional Pain Syndrome (83.9%). Pain clinics administered ketamine via intravenous infusions (96.8%), iontophoresis (61.3%), subcutaneous (3.2%) or oral administration (3.2%). Intravenous ketamine treatment was offered in an inpatient setting in 14 pain clinics, in both an inpatient and outpatient setting in 11 pain clinics and in six pain clinics in an outpatient setting. In the outpatient setting, the median starting dose was 5mg/h (IQR=17.5-5). The median maximum dose was 27.5mg/h (IQR=100-11.9). The median infusion duration was 6h (IQR=8-4). In the inpatient setting, the median starting dose was 5mg/h (IQR=5-1.5) and the median maximum dose was 25mg/h (IQR=25-14). Patients were admitted to hospital for a median of 4days (IQR=5-1). The results of this Dutch nationwide survey study show that there are heterogeneous treatment protocols with different indications, treatment setting and dosing regimen for the treatment of chronic pain with ketamine.This study encourages the formulation of a broader consensus and the development of evidence based guidelines for ketamine treatment.
Highlights
Chronic pain affects 20% of adults in Europe and burdens their daily lives with functional impairment, distress and demoralization [1, 2]
Intravenous ketamine treatment was offered in an inpatient setting in 14 pain clinics, in both an inpatient and outpatient setting in 11 pain clinics and in six pain clinics in an outpatient setting
The only guideline currently incorporating ketamine treatment in the Netherlands is the Dutch guideline for Complex Regional Pain Syndrome (CRPS) [25]: Ketamine is recommended in patients with treatment-resistant CRPS with pain scores of ≥7 on an 11-point Numeric Rating Scale (NRS) [25]
Summary
Chronic pain affects 20% of adults in Europe and burdens their daily lives with functional impairment, distress and demoralization [1, 2]. Untreated chronic pain is a major source of suffering for the individual, and creates a socioeconomic burden for health care systems and society in general [1, 3,4,5]. In addition to these concerns, chronic pain remains challenging to treat due to its variable clinical course and complex pathophysiology. The NMDA receptor plays an important role in the development of neuroplastic changes in chronic pain, such as wind-up and central sensitization [8, 15,16,17] These neuroplastic changes can result in spontaneous pain as well as allodynia or hyperalgesia to nociceptive stimuli
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