Panel Discussion -
Cohen, Hermes, Kogan, O’Brian, Poole, Prashad
O’Brian “We’ve done a lot of research, but have a long way to go, more research needed** (how many studies have been cited?) - Dose Response Curve, Maintenance Treatment “ - follow up study showed majority of providers starting .5 mg/kg then titrating up throughout course of treatment to optimize patient response - no trials that are testing repeating doses that are titrating above .5 yet community clinics are going above this. No RCT trials — large gap remains between studies and real-world use.
Psychedelic-assisted psychotherapy - hopeful more studies integrating psychotherapy in ketamine treatment to enhance effects and extend benefits, more important to focus on maintenance doses.
Poole “ Revisit evidence and update the guidelines - Certified Nurse Anesth. — Need for alternative treatment paths for psychiatric and pain disorders, but no foundation or language in regulations or statutes that would guide.
Pennsylvania guidelines on safe practices focus on appropriate multidisciplinary members available, address prescribing, diagnosis, appropriate patient selection.
Prashad “American Society of Ketamine Physicians” (rebranded as ASKP3) — with oral antidepressants, only a 3rd will be treated. Why ketamine? Focus on TRD in private practice
**Kogan - we have seen ketamine due to the failure of standard of care for at least a half dozen conditions - pain, depression, long covid, chronic lymes, POTS, Parkinsons - some signal of benefit. We only used the word psychedelic once - that’s not right. We have to be open, yes, it’s scare to say, but it is a classic psychedelic, best with IM/IV, weakest with oral and nasal, but youc an get there, afrter thousands of treatments, the psychedelic effect is where the magic happens here. COming out of tripm patients have “ah ha” “I se eit differently now”. Gifted THERAPIST will flush it out so you know where you’re going next with therapeutic journey”. Report on long covid (30% cure — research coming) —
Are we studying psychedelic experiences like Hopkins did with psilocybin? Where are we with that?**
Cohen - for all psychiatric treatments, the psychiatric doses are always higher, and it takes longer — for ketamine, people use higher doses for higher pain than for psychiatric indications. Everything that works for depression works for pain. Are we underdosing for psychiatric and overdosing for pain? Anesthesiologists give 4.5 mg/kg no problem giving boluses.
Hermes— Dose- VA .5 mg/kg — most facilities staying with that dose, Maintenance Treatment - Single most important factor - Not a lot of data
Psychedelics- VA is moving forward in sponsoring psychedelic research and psychedelic medicine. Developed workgroup for clinical implementation of psychedelic medicine if approved in future
Prashad- “depression" is many different things, there is an art to dosing - sweet spot, nuanced - some patients do better with different doses
Settings-
Kogan - 90% will not peak with nasal, bias towards iv/im
Coach - yoga therapist 2000 hours of psychedelic training / sitting - not a therapist officially ,, also ketamine-assisted psychotherapy doing counseling (with a therapist) - ketamine administered without that would have no benefit - the benefit is in the counseling, not in the actual drug., The drug induces the state that aids counseling”
Evidence- use a lot of counseling - psychologist, social worker there as a therapist - followed by multiple after-session continuous counseling
Fertile ground to continue counseling “Like 10 years of psychotherapy in 2 hours” we hear this repetively. If it’s not guided, the effect is fractionally as good. Dramatically enhanced by having a therapist
O’Brian - Psychologist / psychotherapist - evidence speaks for itself, plenty of trials with no psychotherapy component and patients are getting better. Cites ASKP3 conference where private practice provider presents data compared with and without therapy - outcomes were identical. Having psychotherapy support can take a bad experience and produce a good outcome. No one sized fits all approach. There are different settings. Screening patients for best setting.
Cohen - in pain clinics- iv works better, doses are higher, often 100’s of mg, 2 patients 1 nurse, sometimes 1 nurse 1 patient,
Tolerance possible, but not like opiods - behavioral tolerance, changes of sensitization, lots of ways for tolerance — there should be some flexibility. At Johns Hopkins, ketamine infusions don’t have CPT codes for ketamine
Neuropathic itch vs nociplastic itch or nociplastic pain — some signal that it helps
Kogan- - chronic pain IM shots, 2 shots 20-30 minutes apart, sitter there to observe. Several patients at once. Physician available, theoretically a billable model if physician on staff
Home setting administration -
Speaker notes a clinic “in a strip mall” linking home use with “stip mall”
Home use - O’Brian — CPT codes for home visit, how to bill for sitter? From patient’s perspective, really good- patients in home environment. Practitioner goes to patient’s home.
Psychologist - unsupervised at home - as safe as it is, it still is a medicine that requires some supervision. Doing that at home makes it more complicated. Safety & Efficacy in home use
Prashad- no home use in her clinic. ASKP3 thoughts are- few situations where it may be appropriate. Strong provider alliance required. Increased likelihood of misuse.
O'Brian - almost always it’s only after it’s been done in office and safety has been established.
Cohen - other medicines in pain medicine are used at home. There is a contradiction with ketamine — there should be some consistency.
Hermes- how to provide maintenance treatment -
Pool - goal in guidelines - clinics opening with no guidance from the State — safety protocols emphasized, but no guidelines on prescribing — side effects and adverse effects - quite minimal, but can still occur. Recommend ACLS certified, other advanced medical practitioner if medical complications — what types of providers physically present— how many patients safe to treat at one time? At least 2 providers required to monitor throughout infusion.
Prashad- data for longer term safety - what is the safety for repeat dosing? I don’t know that we have enough data.
O’Brian - developing a registry would be helpful. Trials lasting more than 5 years - hard to do. Partnering with real-world practices to critically evaluate the data.
Prashad - what do we need to be tracking?
Cohen - I do clinical trials. The placebo effect is higher than the intrinsic effect for almost everything. Some psychiatric conditions have even higher placebo effect. Placebo effect in pain in a procedural intervention is greater than the medication. Ethical question - you can’t blind these studies for pain. Registries are important, but limitations at looking at this data. People on opioids fail at everything. If you’re on opiods, you fail on everything. Registries needed, but also high-quality randomized trials.