An effective alternative to opioids for acute pain?

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Intranasal (IN) ketamine may be a safe and effective alternative to intravenous opioids for acute pain in adult patients, new research suggests.

In a systematic review of the literature of 15 studies involving 2218 adult patients, ketamine IN was associated with improved pain scores.

“While covering acute pain service, me and my co – author, Dr. Nadkarni [Anisha Nadkarni, MD] I realized the efficacy of intravenous ketamine in the treatment of acute postoperative pain, even in adult patients with chronic pain who were not naive in opioids, ”study researcher Anne Hermon, MD, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, said Medscape Medical News.

“We knew that ketamine has several routes of administration and we wanted to identify whether intranasal ketamine could prove to be a safe and effective alternative to opioids. We did a basic literature search and found that ketamine IN has been used to treat pain. acute in various patient settings and populations and we wanted to do a more extensive review, ”he added.

The results were presented at the 2021 annual meeting of the American American Academy of Pain Medicine (AAPM) virtual.

Early promise

Using “ketamine” and “acute pain” as keywords, the researchers conducted a literature search of three popular medical databases for studies published through June 2020.

Studies were included in the review if they detailed the primary outcomes related to ketamine IN for the treatment of acute pain. Exclusion criteria include the main results related to procedural sedation, intraoperative analgesia, neuropathic pain, chronic pain, depression, or other psychiatric problems.

Of the 15 articles that met the inclusion criteria, 12 were prospective randomized controlled trials and three were observational studies. The studies included a total of 2218 adolescent and adult patients aged 15 years and older. Ketamine doses ranged from 0.4 mg / kg to 84 mg / kg.

The most common methods for assessing pain were the visual analog scale, which was used in 12 studies, and the numerical rating scale, which was used in three studies.

Intravenous ketamine was used in the following parameters:

  • paramedical administration (1)

  • emergency service (11)

  • wound clothing changes (1)

  • post-dental surgery (1)

  • post spine surgery (1)

In all reviewed studies, pain scores improved significantly with the use of ketamine IN.

Five studies compared IN ketamine with IV opioids. None showed that ketamine IN was significantly more effective, but 75% showed similar efficacy.

“Due to a limited number of articles and heterogeneity in study types and methods, we were unable to perform a meta-analysis,” Hermon said.

“We look forward to seeing prospective randomized controlled trials comparing ketamine IN with opioids in the postoperative and post-discharge period,” he said.

If this research indicates that ketamine IN effectively reduces pain, there would be reasons to explore it as a supplement or substitute for opioids to control pain after discharge, he added.

“In the context of an ongoing opioid epidemic, it is important to identify strategies to mitigate the damage that opioids can cause. Through the postoperative period, when many people are exposed to opioids for the first time, it is possible to limit the number of opioids. patients who become opioid dependent, ”he said.

Commenting on the study for Medscape Medical News, W. Michael Hooten, MD, professor of anesthesiology, Mayo Clinic, Rochester, Minnesota, and president-elect of the AAPM, noted that only one of the included studies used ketamine IN for acute postoperative pain, indicating that ” unrecognized knowledge there is a gap in this important area of ​​clinical practice. “

Hooten agreed that randomized controlled trials are needed to further investigate the efficacy, appropriate dose, and appropriate duration of ketamine IN treatment for acute postoperative pain.

Hermon and Hooten do not report any relevant financial relationship.

2021 Annual Meeting of the American Academy of Pain Medicine (AAPM).

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