91 Service evaluation reviewing the potential benefits of ketamine on mood when used in the management of complex pain in hospice inpatients

<h3>Background</h3> Evidence for the efficacy of ketamine for treating palliative inpatients experiencing complex pain is sparse and inconclusive.^1–4 It is well recognised that complex pain has multiple contributors (physical, psychological, social, spiritual).⁵ The benefits of ketamine for chronic pain syndromes and rapid acting anti-depressant are recognised,^6–8 though in the UK it is prescribed for mood almost exclusively within psychiatric services. For patients with a prognosis under 3-months, the benefits of standard anti-depressant drugs are limited. <h3>Aims</h3> Evaluate hospice ketamine use against local guidelines for pain⁹ and against recognised standards from other clinical settings for mood.¹⁰ Review how efficacy of ketamine is evaluated. <h3>Methods</h3> Electronic inpatient records mentioning ketamine were reviewed 2021–23. Outcomes reviewed included self-reported pain and mood; changes in visual analogue scale (VAS); IPOS for pain and mood; opiate use; reported side effects. <h3>Results</h3> 20 people received at least one day of ketamine; 5 received multiple courses. 60% female, mean age 55yrs, 75% had a documented mood disorder. All primary courses were given subcutaneously. All patients had pre-emptive opiate dose reductions. Most side effects were mild. Subjective perception of pain was frequently incongruent with opiate use and VAS. Repeat courses were rarely considered even when evidence of benefit. Most oral doses were significantly lower than local guideline recommendations. Outcome monitoring tools were often missing or uninterpretable. <h3>Conclusion</h3> This evaluation highlights the importance of accurate dosing and outcome monitoring without which it is difficult to understand ketamine’s role and potential benefits in the management of complex pain in hospice inpatients. We have developed a local ketamine treatment pathway reference tool and introduced a formal mood assessment score (PHQ9) to be used pre-, during and post-ketamine treatment with a plan to re-evaluate outcomes in the future. <h3>References</h3> Bell RF, Eccleston C, Kalso EA. Ketamine as an adjuvant to opioids for cancer pain. <i>Cochrane Database of Systematic Reviews</i> 2017;<b>6</b>(6). Art. No.: CD003351. DOI: 10.1002/14651858.CD003351.pub3 Balachandran A, Tassone VK, Adamsahib F, Di Passa AM, Kuburi S, Demchenko I, Ladha KS, Bhat V. Efficacy of ketamine for comorbid depression and acute or chronic pain: A systematic review. <i>Front Pain Res (Lausanne)</i> 2022;<b>3</b>:1022767. doi: 10.3389/fpain.2022.1022767. PMID: 36353699; PMCID: PMC9638121. Barbosa MG, Garcia GT, Sarin LM, Jackowski AP. Efficacy and safety of ketamine for the treatment of depressive symptoms in palliative care: A systematic review.<i> Braz J Psychiatry</i> 2023;<b>45</b>(2):182–195. doi: 10.47626/1516–4446-2022–2876. PMID: 36574497; PMCID: PMC10154013. Jiao Jiao, Jin Fan, Yonggang Zhang, Lingmin Chen. ‘Efficacy and Safety of Ketamine to Treat Cancer Pain in Adult Patients: A Systematic Review’. <i>Journal of Pain and Symptom Management</i> 2024;<b>67</b>Issue 3:185–210. ISSN 0885–3924. https://doi.org/10.1016/j.jpainsymman.2023.11.004. Palliative Care Clinical Practice Summary: Guidance on consensus approaches to managing palliative care symptoms. North West Coast Clinical Network: Consensus guidance for Cheshire &amp; Merseyside and Lancashire &amp; South Cumbria. 2nd Edition published November 2021. Accessed online 03.05.2024. https://www.england.nhs.uk/north-west/wp-content/uploads/sites/48/2022/11/20211124-NWC-LSC-and-CM-Palliative-Care-Clinical-Practice-Summary-2nd-Edition-V2.pdf?seq_no=5 Reif A, Bitter I, Buyze J, Cebulla K, Frey R, Fu DJ, Ito T, Kambarov Y, Llorca PM, Oliveira-Maia AJ, Messer T, Mulhern-Haughey S, Rive B, Von Holt C, Young AH, and Godinov Y. Esketamine Nasal Spray versus Quetiapine for Treatment-Resistant Depression. New England Journal of Medicine 2023;<b>389</b>(14):1298–1309. https://doi.org/10.1056/NEJMoa2304145 Anand A, Mathew SJ, Sanacora G, Murrough JW, Goes FS, Altinay M, Aloysi AS, Asghar-Ali AA, Barnett BS, Chang LC, Collins KA, Costi S, Iqbal S, Jha MK, Krishnan K, Malone DA, Nikayin S, Nissen SE, Ostroff RB, Reti IM, Wilkinson ST, Wolski K, Hu B. Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression. <i>N Engl J Med</i> 2023;<b>388</b>(25):2315–2325. doi: 10.1056/NEJMoa2302399. Epub 2023 May 24. PMID: 37224232. Singh I, Morgan C, Curran V, Nutt D, Schlag A, McShane R. Ketamine treatment for depression: opportunities for clinical innovation and ethical foresight. <i>Lancet Psychiatry</i> 2017;<b>4</b>(5):419–426. doi: 10.1016/S2215–0366(17)30102–5. Epub 2017 Apr 5. PMID: 28395988. P Shepherd, A Doyle, S Benson, J. Russell, A Dickman, S Doolan, M Lloyd-Williams, L Chapman. ‘Use of ketamine as an analgesic in palliative care’, Pallaborative North West, May 2022. Ketamine for treatment resistant depression, interventional psychiatry service, Oxford Health NHS Foundation Trust. https://www.oxfordhealth.nhs.uk/ips/ketamine-trd/