Ketamine: Revolutionizing Pain Management and Psychedelic-Assisted Therapy with Dr. Nick Schiavoni
Ketamine is no longer just an anesthetic that is confined to the operating room. It’s a groundbreaking tool that is reshaping the way we approach pain management and mental health treatment. With growing research supporting its use for chronic pain, depression, and existential distress, ketamine is becoming a unique and beneficial agent in modern medicine. In our recent webinar, Dr. Nick Schiavoni, an anesthesiologist with expertise in pain management and psychedelic medicine, joined Dr. Houman Farzin to discuss ketamine’s potential, its complex mechanisms, and how it can be safely and effectively integrated into mental health treatments. Let's dive into some key takeaways.
A Brief History of Ketamine in Medicine
Ketamine was first synthesized in 1962 and gained FDA approval as a general anesthetic in 1970. It quickly became a critical tool, widely used in hospitals, emergency rooms, and even on the battlefield due to its ability to induce anesthesia without suppressing breathing or causing severe drops in blood pressure. This made it especially invaluable in resource-limited environments, such as during the Vietnam War, where it was used extensively as a battlefield anesthetic. Over time, ketamine’s applications expanded beyond anesthesia as doctors and researchers observed its potent pain-relieving and antidepressant effects. In recent years, its research and use in both acute and chronic pain management and mental health treatment have grown, leading to innovative approaches in Psychedelic-Assisted Therapy (PAT).
Ketamine as a Multidimensional Pain Management Tool
Beyond its conventional role in anesthesia, ketamine is a particularly valuable tool for addressing the multifaceted and multidisciplinary nature of pain, a concept known as ‘total pain’ . First introduced by Dame Cicely Sunders, total pain acknowledges that pain is not just a physical sensation; it’s a multidimensional experience comprising physical, psychological, social, and spiritual components. Each patient’s experience of pain has unique contributions from each of these dimensions. For many patients, especially those with chronic conditions or terminal illnesses, unaddressed emotional and existential suffering can amplify physical pain. “Ketamine has the unique ability to attack all four components of pain, ” Dr. Nick explained. “To me, this is the answer. By utilizing ketamine’s unique pharmacology, we can finally target the complex, interconnected nature of pain. It’s this ability to work on multiple levels that makes ketamine such a versatile tool in holistic pain management. ”
By effectively addressing physical and psychological pain, ketamine enables patients to reconnect with themselves and others, helping to heal social pain. For patients suffering with spiritual pain, especially those nearing the end of their life, ketamine’s psychedelic properties come into play, offering a unique opportunity for spiritual healing through deeper, transformative psychedelic experiences. This multi-level approach makes ketamine not just a pain reliever, but a tool for healing across all aspects of a person’s experience with pain.
Ketamine’s Complex Mechanism of Action
So how does ketamine actually work? Unlike traditional pain medications that focus primarily on opioid receptors, ketamine operates on multiple pathways in the brain and body. Dr. Nick explained why ketamine is a complex drug, describing it as “a different animal” , and how, “Ketamine works on multiple different receptors. ” He went on to break down its mechanism of action into three main components: “You have your pharmacological component, you have this element of neuroplasticity, and then you have this psychedelic experience. And those three things together contribute to ketamine’s therapeutic benefit. ”
NMDA Antagonism: “Ketamine's primary mechanism of action is this NMDA antagonism, ” Dr. Nick explains. But what does that really mean? The NMDA receptors are tied to glutamate, the brain’s primary excitatory neurotransmitter. An antagonist is a substance that blocks or interferes with the action of another substance. So, by blocking NMDA receptors, ketamine reduces the activity of certain excitatory neurons, leading to sedation and dissociation. At the same time, when ketamine binds to NMDA receptors on inhibitory neurons, it “releases the brakes” making these neurons fire faster and more frequently. This restriction of inhibitory neurons is essential for ketamine’s effects on neuroplasticity - enhancing the brain’s ability to adapt and strengthen certain pathways.
By creating this unique neurological state that is ripe for learning, the brain can rewire itself and strengthen certain pathways, similar to how muscles get stronger with exercise. This rewiring can lead to durable changes in thought processing and cognition. Dr. Nick concluded, “[Ketamine] doesn’t just numb the pain, it helps the brain and body rewire themselves in a way that can lead to long-term healing. ”
However, ketamine's effects extend beyond NMDA receptor blocking. It also interacts with opioid receptors, boosting dopamine and serotonin levels, and has anti-inflammatory properties, all of which contribute to pain relief and improved mood. “Ketamine is a pure agonist on both mu and kappa opioid receptors, ” Dr. Nick explained. Agonists are substances that activate receptors, producing effects similar to the body ’s natural chemicals, such as those involved in pain relief and mood regulation.
Dr. Nick also noted that ketamine’s acute antidepressant effects are likely tied to its action on opioid receptors. “When you combine ketamine with naltrexone, which blocks the opioid receptors, the acute antidepressant effects disappear, ” he said. This suggests that activation of opioid receptors plays a key role in ketamine’s ability to quickly elevate mood and rapidly alleviate symptoms of depression and suicidality. In contrast, the durable antidepressant effects are likely due to positive lifestyle changes that occur during the neuroplastic state induced by ketamine treatment.
Ketamine’s Psychedelic Effects in Therapy
Ketamine is often recognized as a psychedelic, with its dissociative and hallucinogenic effects frequently highlighted in pop culture and media. While traditional anesthesia settings often aim to suppress these experiences, PAT embraces them. “In the hospital, we’re trained to minimize ketamine’s psychedelic effects because they can be disorienting, ” Dr. Nick shared. “But in a controlled therapeutic setting, those same effects can be profoundly healing.
Dr. Houman added, “In a psychotherapy setting, we use [ketamine] to unlock the gates to the subconscious, allowing repressed material to emerge and be explored in a controlled and safe manner. . ” This material, memories and emotions, has often been buried for years, even decades. Unlocking these memories provides a unique window into trauma, grief, or other emotional wounds, offering the opportunity for deep therapeutic breakthroughs.
Dr. Nick describes how a ketamine journey can transform patients, “It [the ketamine experience] has, a lot of the components of a mystical experience. It brings about these feelings of pure love, joy, happiness. It induces a state of ego dissolution, fostering connectedness to self, to others, to the universe. And often there’s these interactions with the divine and deeply spiritual or religious components. ” He pointed out that ketamine can help patients process the deep existential questions that often arise near the end of life such as, “Why me? What comes next?” , offering relief from fear, emotional suffering, and unresolved trauma.
Despite its similarities to classical psychedelics, ketamine has not been widely studied in this context. “We’re seeing incredible results with psilocybin for existential distress and emotional healing, but ketamine isn’t receiving the same level of attention, even though it reliably induces similar states. ” Unlike other psychedelics, ketamine offers a somewhat controlled and predictable experience. “We can safely guide patients into a non-ordinary state of consciousness, ” Dr. Nick said. He emphasized that many patients who may be hesitant about traditional psychedelics can benefit from ketamine in a structured, controlled setting.
Dr. Houman then stressed the importance of a patient-centered approach. “Some patients are really into the more psychedelic oriented outlook, while others prefer it medical. And I think, wherever anyone sits on that spectrum, we should respect that. ” He continued, “We can facilitate healing experiences regardless of how it's done, as long as we're respecting set and setting and developing the right sort of therapeutic alliance by maintaining awareness of our responsibility in that power dynamic when patients are in these vulnerable states. ” Ultimately, the responsibility of clinicians is to create a safe, supportive space where each patient can heal in a way that feels right for them.
Ketamine Therapy Integration and Risks
As promising as ketamine assisted therapy is, both doctors emphasized the importance of careful integration and responsible use. “Most of the work takes place in the integration phase, ” Dr. Houman stressed. He continued, “This altered state experience reveals what work needs to be done, and then you actually have to do the work. ” Therapy is ultimately just as crucial as the medicine itself. Ketamine can open the door to healing, but it’s through the integration process, with the assistance of skilled practitioners, that patients can navigate and fully embrace their experiences. This is what makes a ketamine such a powerful tool for creating lasting transformation.
There are also important risks to consider. Ketamine can temporarily raise blood pressure and heart rate, making it unsuitable for some patients with cardiovascular issues. Additionally, concerns about dependency and misuse highlight the need for careful oversight. “One of the things that we're seeing more now is ketamine being offered at home with minimal oversight, ” Dr. Houman cautioned. Ketamine went from being a substance that was always administered by an anesthesiologist in a very medicalized setting, to now being used more remotely without direct supervision. ”
Ketamine is an exciting and versatile tool that holds promise for pain management and mental health treatment. Nevertheless, as with any powerful medicine, it must be used responsibly. Dr. Nick and Dr. Houman believe that when administered with proper support and integration, ketamine has the potential to transform lives, offering relief for chronic pain, easing psychological suffering, and even helping patients find meaning in life’s most difficult moments. This is just the beginning, we’re only scratching the surface of what ketamine, and psychedelic medicine as a whole, can do.
FAQs
1. Am I eligible for ketamine therapy?
2. Does insurance cover the cost of ketamine therapy?
3. How many ketamine treatments will I need?
We recommend two initial treatments to determine suitability and adjust dosage. After these sessions, additional treatments are available based on your progress and specific requirements.