Intravenous Ketamine for Rapid Opioid Dose Reduction, Reversal of Opioid-Induced Neurotoxicity, and Pain Control in Terminal Care: Case Report and Literature Review

Abstract

OIN should be considered as an etiology of CNS dysfunction occurring with prolonged, high-dose opioid therapy. This case highlights the opioid-sparing and analgesic properties of low-dose ketamine, allowing reversal of OIN in the home hospice setting.

The use of ketamine in a palliative-supportive care unit: a retrospective analysis

“…Adverse effects were limited and acceptable by using a combination of ketamine and midazolam at low doses, which were reduced only in minority of cases. Safety data confirm previous observations (11).…”

“…While most observational studies suggested that ketamine may be helpful in different clinical conditions, either decreasing pain intensity or opioid doses (10), in a recent well powered placebo-controlled study no advantages were found with the use ketamine that was also associated to toxicity (7). Similar findings were found in a smaller study, although 50% of patients seemed to have had major analgesic responses and no major adverse effects were reported (11). These findings contrast the benefits from ketamine observed in many open-label series (10,(12)(13)(14)(15)(16)(17)(18)(19)(20) even for prolonged periods of time (21,22).…”

Topical Ketamine with Other Adjuvants: Underutilized for Refractory Cancer Pain? A Case Series and Suggested Revision of the World Health Organization Stepladder for Cancer Pain

“…10 Although developed as an anesthetic, ketamine at subanesthetic doses can reverse pain crises in patients taking opioid medications 11 and also reverses opioid-induced neurotoxicity. 12 Through multiple routes, with and without other adjuvant pain medications, ketamine's varied actions have been exploited to optimize cancer pain control.…”

Ketamine Protocol for Palliative Care in Cancer Patients With Refractory Pain

“…Subanesthetic doses are more commonly associated with mild and transient impairments in attention, memory, and judgment (Quibell, Prommer, Mihalyo, Twycross, & Wilcock, 2011;Winegarden, Carr, & Bradshaw, 2015). If they occur, these effects can generally be controlled by concurrent administration of low doses of benzodiazepine or haloperidol, such as lorazepam 0.5 to 1 mg.…”

“…However, given the small number of patients and the clinical heterogeneity in these studies, the evidence was insufficient to assess the benefits and harms of ketamine for the treatment of cancer pain (Afsharimani, Kindl, Good, & Hardy, 2015). Most of the evidence supporting ketamine's efficacy as an analgesic for cancer pain is from case reports, retrospective surveys, or uncontrolled studies in patients with refractory neuropathic, bone, and mucositis-related pain (Quibell et al, 2011;Winegarden et al, 2015).…”