Ketamine may be a viable alternative to opioids in the ER.
Opioids, such as morphine, are an effective and relatively safe way to treat acute pain.
However, with the seemingly unstoppable opioid epidemic, alternatives must be explored and rated against opioids.
Alongside the potential for addiction, there are a number of other reasons to use alternative analgesics for acute pain in the emergency room (ER).
For instance, in older patients, opioids can cause respiratory depression, which can be dangerous. And, if an individual has a substance use disorder, a seizure disorder, or certain cardiovascular problems, opioids are not always an ideal choice.
Although replacing opioids entirely is not necessary, having other options available is useful and will help reduce their overall usage.
Ketamine's new dawn
Although ketamine has become infamous for its use as a recreational drug, it is an effective anesthetic; ketamine has been used in a medical setting since its approval by the Food and Drug Administration (FDA) in 1970.
Despite the drug's image problem, ketamine is effective, relatively safe, and well-tolerated. It is worth mentioning, however, that its dissociative psychological effects can be disturbing for some patients.
Importantly, in stark contrast to opioids, ketamine is not particularly addictive and does not cause respiratory depression.
Perhaps surprisingly, there has been little research into whether ketamine might be a viable replacement for opioids when managing acute pain. Although regularly used to bolster the effects of opioids, it is used on its own much less often. This could be due to clinicians' lack of confidence in its effectiveness.
Recently, a group of researchers from the Washington University School of Medicine in St. Louis, MO, conducted a meta-analysis to get a better understanding of how well ketamine performs when it is provided alone to treat acute pain in an ER setting. The team wanted to understand whether it is at least as effective as opioids.
After searching for relevant trials to analyze, just three met their stringent criteria. In all, the studies involved 261 patients. The researchers contacted the authors of the three studies, who provided them with access to more detailed, patient-level information.
Their findings were published in the journal Academic Emergency Medicine.
Confident ketamine use
The authors concluded that ketamine was not inferior to morphine. Importantly, "no severe adverse events were reported in any study." However, there were higher rates of nonsevere adverse events with ketamine use.
"Ketamine appears to be a legitimate and safe alternative to opioids for treating acute pain in the emergency department. Emergency physicians can feel comfortable using it instead of opioids."
Senior study author Dr. Evan Schwarz
Although the authors are certainly not calling for opioids to be removed from ERs, they hope that clinicians will feel confident using ketamine in its place when appropriate.
Although, as the authors acknowledge, the analysis was carried out on a relatively small sample, it adds to the evidence in favor of ketamine use in the ER. More work is sure to follow.