Ketamine May Offer Rapid Relief from Persistent Pelvic Pain

In Pelvic Floor Physical Therapy by Allison Wells4 Comments


By Allison Wells, MD


Chronic pelvic pain is at a difficult intersection of anatomical pain generators and mood disorders like depression and anxiety that are coincident with or caused by the pain itself. To effectively relieve chronic pelvic pain you need a treatment that addresses the pain and the mood disorder issues. Ketamine infusions do both.


Ketamine has been used safely for anesthesia since the 1960s when it was first created. It has been a first choice for battlefield medicine and for the most critically ill patients in the operating room. Since the 1980s ketamine’s effect on chronic pain and on depression and other mood disorders has been studied and thousands of patients have obtained relief around the world through programs at academic medical centers and private ketamine infusion clinics alike. Ketamine possibly works on chronic pain through down regulating GABA-A or NMDA receptors that have been up regulated and become self-sustaining in the pain syndrome. This is in contrast to the opioid narcotics, like Oxycontin, which work on the mu receptors.


Ketamine works to calm the overexcited pathways that cause neuropathic pain. It stops the feedback loop from the revved up peripheral neurons and allows the peripheral pain nerves to return to a normal resting state. Ketamine is good for acute pain, but it really shines with chronic pain. It doesn’t just cover the pain, like opioids. It actually changes the neural pathways to get them to stop sending faulty signals.


Europe and Australia have ketamine as a standardized part of their chronic pain and depression guidelines that are written by the national health systems of both countries. In America, ketamine is not FDA approved for the treatment of pain and depression because there have been no large randomized controlled trials, although there have been many small trials with positive results. Since ketamine is an old, generic drug with FDA approval already for other uses, specific indications for depression and pain have not been sought.


It is really hard to randomize patients in a ketamine trial – they know immediately whether they were given the control or the active medication. Also, who is going to pay for such a trial when there is no readily apparent way to profit off a generic drug that can’t be patented? For this reason ketamine is considered “off-label”. However, some reports indicate that in America more than 80% of all doctors prescribe off-label medications and more than 21% of adult medications and up to 78.9% of children discharged from hospitals were on at least one off-label medication. We are beginning to see insurance companies recognize the depth and breadth of positive studies and they are beginning to cover ketamine treatments. BCBS and UHC are the insurers that we have begun to see routinely cover this care and Aetna and Humana have been slower to provide coverage, but each patient’s plan may be different.


Ketamine is typically used as an infusion in most treatment protocols. There are a few programs that administer the infusion as a continuous drip over up to 10 days in the ICU at levels that render the patient comatose. This is not a standard practice because of the huge cost and also because of the risks and side effects of being in an immobile, general anesthesia, intubated state for 10 days, namely: pneumonia, blood clots, and muscle wasting. The majority of ketamine infusion programs perform the infusion as an outpatient procedure over the course of a few hours each day of treatment and as deep sedation, where the patient is still able to talk and breathe on their own.


Other delivery methods, such as oral delivery, are generally less favorable for ketamine pain treatments. Ketamine is unpredictable when taken by mouth as it is first metabolized and broken down by the liver after absorption from the intestinal tract before it can have its effect on the nerves it’s meant to treat. Only about 16% of the active compound is available after oral administration to have an effect with the rest being metabolized into inactive or underactive metabolites. Also, most studies appear to indicate that ketamine concentrations need to reach a certain threshold and stay steadily above that threshold for a few hours to accomplish the resetting of the pain receptors.


I practice at Lone Star Infusion in Houston, Tx. A patient here receives a low-dose infusion of ketamine for up to 4 hours at a time in a quiet, relaxed setting. The patient then recovers for up to 2 hours before being released to go home. Infusions are administered by a board-certified anesthesiologist experienced with using ketamine and adjusting medications for safety and patient comfort, including the use of adjunct medicines as appropriate.


Most side effects of the ketamine are well-tolerated and last only as long as the infusion. Hallucinations and feelings of dissociation are generally mild and may be treated. Sleepiness is common. Nausea is common without pretreatment but rare if patients are given oral ondansetron first.


The beneficial effects of ketamine can last for weeks or months depending on the severity and chronicity of the pain and follow-up treatments with single infusions of ketamine can help maintain the effects over many years. Clinics around the world have now been working with pain and depression patients and have 10 years’ worth of data on ketamine’s safety and long-term efficacy.


In short, ketamine infusions may be an excellent option for patients with severe, intractable neuropathic pain. There are websites like Ketamine Advocacy Network ( that list ketamine providers by state and also by talking with local medical schools and pain fellowship programs patients can find information on a ketamine infusion center near them. Treatments can cost anywhere from just a co-pay to $1,450 per 4 hour infusion depending on insurance coverage.


Allison Wells, MD
Board Certified Anesthesiologist
Trained at Harvard and  Baylor College Of Medicine
Lone Star Infusion, PLLC




Ketamine Advocacy Network


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  1. I just had ketamine infusion for three days Dx of CRPS from pudendal neuropathy. My insurance, Blue Cross, denied coverage, so BCBS does not always pay. It was $750 per infusion, which is pretty “cheap” in a clinical setting. It had minimal effects, however the treatment itself was very pleasant due to listening to my favorite tunes. I highly recommend listening to beautiful music to make the experience that much more pleasant. I had NO PAIN during the infusion. It is sad that only those with $$ can afford it. The cost was a big hardship. I wish I could have been in a trial.

  2. We have United healthcare which is one of the insurance companies mentioned that will pay for ketamine infusion so I’m going to check it out. This is very exciting to me as I have suffered severe chronic pain for nine years.

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