Opioids: A Case Study

Case reports and small studies demonstrated efficacy with ketamine use in patients non-responsive to treatment with opioids.1-3 The use of ketamine reduced the dose of opioids required and in some cases, enhanced quality of life at the end of care.1-3 A protocol for ketamine use in palliative care is available, however it was last revised in 2002.4 A lack of published evidence exists on large, randomized, controlled trials due to the patient population that requires IV ketamine for palliative care.

A case report of a 36 year old female with metastatic breast cancer demonstrated a 37% reduction in pain scores, as well as a 61.4% reduction in the amount of opioids required to manage her pain.1 The patient was initially taking oxycodone (sustained-release …show more content…
If pain is still uncontrolled, the dose can be increased by 1mg/hr until the dose reaches 4mg/hr.4 Another protocol recommended starting the dose at 1-2.5 mg/kg/day and eventually increasing in increments of 50-100mg/day. The maximum dose that has been reported for CSCI of ketamine is 3.6 grams/day.5 While the patient is receiving ketamine, opioid doses should be reduced depending on pain management and adverse effects.4 If adverse effects from the ketamine begin to occur, the dose of ketamine can be reduced by 50%, and then gradually increased to the lowest effective dose. Side effects that can potentially occur with ketamine are hallucinations, vivid dreams, hypertension, and respiratory depression. While the patient is receiving ketamine, close monitoring for unwanted side effects should be done. Prophylactic options for ketamine side effects include administration of haloperidol or benzodiazepines. Respiratory rate, heart rate, blood pressure, and sedation are all crucial monitoring parameters in a patient receiving IV ketamine for palliative care.4 The protocol serves as recommendations to guide clinicians when administering IV ketamine, but the doses required and side