No Longer Just a Horse Drug, Ketamine Increasingly Used for Military Pain Management

Annette M. Boyle

ROCKVILLE, MD — Morphine has met its match — and then some. After 200 years as the gold standard in battlefield analgesia, morphine is increasingly giving way to ketamine, a phencyclidine (PCP) derivative initially used in veterinary medicine.

Ketamine’s status has changed so rapidly that Army Col. Chester C. Buckenmaier III, MD, director, Defense and Veterans Center for Integrative Pain Management, has encountered some stiff resistance when using the drug. “I’ve twice had a nurse say, ‘You aren’t going to use that horse drug on my patient, are you?’”

Army Col. Chester C. Buckenmaier III, MD, Director, Defense and Veterans Center for Integrative Pain Management, with a patient in Afghanistan in 2009.

“That ‘horse drug’” is now one of the most effective tools available. Combat medics rate ketamine as more effective than morphine or fentanyl in providing rapid relief of severe pain, according to an ongoing survey conducted by the Naval Operational Medical Lessons Learned Center, Pensacola, FL.

Unlike morphine, ketamine does not cause hypotension or respiratory depression. It is “unique among anesthetics, because pharyngeal-laryngeal reflexes are maintained and cardiac function is stimulated rather than depressed,” said Air Force Lt. Col. John V. Gandy, MD, (ret.) in a Defense Health Board Decision Briefing.

In a March 8, 2012, memo to Jonathan Woodson, MD, assistant secretary of Defense (Health Affairs), the Defense Health Board (DHB) recommended adding ketamine to the Tactical Combat Casualty Care (TCCC) Guidelines as a battlefield analgesic. The memo noted that ketamine’s “clinical effects present within one minute of administration when given intravenously and within five minutes when given intramuscularly.”

“Four or five years ago, we would have had one or two patients on ketamine at Walter Reed; now about half are on ketamine on any given day. The use of ketamine in battlefield trauma has led the way to using it on wards — and even in civilian emergency departments,” Buckenmaier told U.S. Medicine.

Inhibits NMDA Receptors

Ketamine inhibits the action of the N-methyl d-aspartate (NMDA) receptors throughout the body and, at low doses, acts as a powerful analgesic and mild sedative and produces a sense of euphoria. At higher levels, it works as a dissociative anesthesia and provides moderate to deep sedation.

Ketamine also can cause hallucinations at higher doses, a problem seen particularly in its use in nonclinical settings as the street drug “angel dust” or “special K.” When used in surgical settings, especially for patients who have previously experienced hallucinations with ketamine, the International Committee of the Red Cross recommends using 10 mg of diazepam intravenously five minutes before and again at the conclusion of a procedure to minimize their incidence.

By blocking NMDA glutamate receptors, ketamine minimizes acute pain and decreases the wind-up pain caused by continual bombardment of the central nervous system. Wind-up amplifies incoming pain signals at the level of second-degree neurons in the spinal cord. Blocking these receptors also decreases tolerance to opioid medications.

“Inhibition of NMDA receptors in the acute phase is one of the few therapies that prevent development of chronic pain,” said Buckenmaier. Ketamine’s ability to reduce acute pain and short-circuit the development of chronic pain pathways makes it effective in any perioperative situation or trauma and can reduce post-operative and phantom-limb pain.

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  1. mark clyce says:

    I suffered a very serious injury to my neck and after being on methadone now used in pain management which works better and its therapeutic effects last much longer than the typical hydrocodone used so widely in the U.S.This new [I suppose it is fairly new ] K2K topical is a wonderful treatment for post surgical treatment and muscular pain associated with degenerative arthritis after very serious surgeries.i have sampled it and will ask my Dr. for a prescription for it even though I have to pay for it as ins. will not pay for it.I have reduced my doses of methadone now to 5mg.2x.This would get me off opioids COMPLETELY !

  2. PGroeger says:

    Ketamin is not a new drug. It was frist used during the Vietnam war. Later it was used to induce short anesthesia when intubation was not required for example dressing change in burn patients in the late 1980s. I am a physician and I am also a patient who received ketamin several times. Like in the olden days esketamin induces “horror trips” or K- Holes as called by drug addicts, which is not a rare side effect! And while in the late 1980s the physician was warned to administer it with a benzodiazepine, this is not mentioned anymore. Interestingly articles from 4 years ago and before that mentioned this in detail, are not available anymore. This worries me. I think Ketamin in Kombination with a benzodiazepine is a gtreat help for short anesthesia, it may be an alternative to ECT in major depression but everything else???

  3. HMP says:

    PGroeger, they mention administering diazepam with it in certain situations in the 3rd to last paragraph of this article.

  4. Jerry cox says:

    I was administered ketamine during a botched surgical procedure in the Army in 1976. The Army anesthesiologist gave me spinal block. the second failed. He came in and was completing the third when a nurse ran in and got into an animated conversation with the him and the surgeon. I was in severe pain from the pressure of the fluids in my back as they had tried to cinch me to the table face down with a leather strap. The anesthetist came in quickly and said PFC Cox, we know you are in pain and we are gonna give you something different but you’re gonna go on a little trip. Just go with it and you’ll be fine. When the surgery was complete they talked to me about all the hallucinations I had during my surgery and all of my antics including singing at the top of my voice in the surgical suite, trying to bite the anesthetist like a snake, and asking all the nurses for dates. I remember no further pain following the surgery and have vivid recollections of the hallucinations. Nothing further until a couple of years ago, when I had several nights of repetitive dreams that mimicked those hallucinations of 1976…Found out after the surgery that there had been a recall on the spinal tap units and the Army had not been notified. Seems the best drug for surgery to me (2 major procedures last year) is Versed. That was a godsend…

    • James says:

      Jerry – the strange thing about Ketamine is that all cognitive functions are preserved. It just connects all the normally limited-access of your brain, and everybody gets to talk in there. First infusion was hell because no one warned me of this. 2-6, a nice pleasant 40 minutes of space music in the ipad and I floated to places no words can describe. Could have done calculus at the same time if needed – hence why you remember everything. All cognitive and hippocampus memory processes remain preserved. Science man! Hope you continue to do well. You are in my thoughts buddy. Don’t give up the option to try infusions under controlled situations later. They saved my life.

  5. James says:

    Injury to my left calf in my 5th deployment led to 3 years of ECES which damaged the sympothetic nerve endings. Finally, scar tissue entrapped a nerve so bad, after it was surgically released, I met Mr. CRPS. Together, I have a little imaginary Joe Pesci who stabs me in the calf about 1500 times a day with an ice pick, followed by what feels like a tire iron squeezing the nerves from my ankle to my spinal cord (CRPS). There are maybe 6 specialists in the US who can treat this, and of course none will talk to a non-millionare like me. But then I tried Ketamine infusion. Expensive, but for the first time since 2010 I have full relief. It killed both the neuropathic stabs and the CRPS for at least a few days at a time. I forgot what it felt like to be normal again – at least for a month. Of course the VA’s position on this remains it is a dangerous, illegal drug. PLEASE keep pushing to change this mentality. It pretty much saved my life, sanity, and marriage.

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