What I Learned at the ASKP 2019 Conference in Denver, CO

The American Society of Ketamine Physicians (ASKP) formed in 2017 and had its second annual conference near Denver, Colorado in September 2019.  The gathering included over 300 people including: anesthesiologists, emergency physicians, family physicians, internists, nurse anesthetists, patients, pharmacists, psychiatrists, psychotherapists, registered nurses, and support staff.  

It was astounding to connect with others and learn a myriad of ways ketamine is being used therapeutically in outpatient clinics, homes, and hospitals. The learning not only came from the speakers’ presentations, who were experts in their fields, but also other ASKP members who are out in the trenches applying their unique perspective on ketamine. 

There was so much information at this conference that I didn’t get to attend every single lecture and presentation. So my intention in this post is to share with you as much information and insights that I learned, while acknowledging that the information provided are simply snippets, quotes, ideas, and points. It can, in no way, encapsulate the entirety of the conference, nor does it cover all speakers and topics presented at the conference. Accordingly, please do your own homework, research, and have active discussions with your ketamine provider. And if you are really interested, please plan on attending next year!  www.askp.org 

Now, let’s get to the information I’d like to share with you: 

• Ketamine is a safe medicine and has been used in humans for nearly 50 years. It was used in the battlefield of the Vietnam War, as well as operating rooms and emergency departments daily globally. Ketamine is one of the drugs in the World Health Organization's (WHO) List of Essential Medicines. -Steven Mandel, MD

• The number of ketamine clinics are dramatically increasing. Some are doing it right others really aren’t.  So ASKP will begin a certification process for clinics with certain standards to be determined in the upcoming year.  - Steven Mandel, MD.

• “Given the unacceptably high rates of suffering, disability, and premature death experienced by people with treatment-resistant depression and the surprisingly low rates of problems arising from the use of ketamine to treat the disorder, this is a therapy that all patients and doctors should be discussing.”  ~Dr. Stephen Hyde (quote from Dr. Mandel’s slide)

• The current FDA approved therapies in 2019 for treatment resistant depression (TRD) are: electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), vagal nerve stimulation (VNS), olanzapine/fluoxetine combination, aripiprazole, quetiapine (extended release), brexpiprazole, and esketamine nasal spray.  - Sanjay Mathew, MD

• D-cycloserine is an old drug (antibiotic) that is currently being studied for bipolar depression/suicidal ideation to maintain improvement after treatment with IV ketamine. -Sanjay Mathew, MD

• Suicide attempts and high suicide intent are associated with increases in inflammatory marker quinolinic acid. - Sanjay Mathew, MD

• Amantadine, dextromethorphan/quinidine, memantine, topiramate are medications that are being used by some doctors off-label to maintain symptomatic improvement after ketamine infusion. (But limited research) -Sanjay Mathew, MD

• Lamotrigine decreases dissociative effects of ketamine, but may actually increase the mood elevating effects from ketamine (this study was looking at ketamine given to healthy subjects - traditionally, those who are chronically on lamotrigine have a lower response to ketamine) - Amit Anand, MD

• There will be a study comparing ketamine vs ECT (electroconvulsive therapy) performed soon (ELEKT-D trial) and will cost $12 million to perform. This will be the largest study of ECT vs. ketamine. If the study shows ketamine is more effective or equally effective to ECT, this could help support insurance coverage of ketamine infusions (as ECT is already covered by insurance)!  - Amit Anand, MD

• 47,173 die annually by suicide in USA (2017). You cannot accurately predict suicide in the individual level. Suicide risk is not like a staircase model but more like a deterministic chaos model.  -David Sheehan, MD

• Toxoplasma gondii infection and lower cholesterol levels correlated with increased suicide levels. -David Sheehan, MD  (But remember correlation doesn't equal causation!) 

• Clozapine, lithium* and magnesium* may help decrease depression and suicidal thoughts in some patients.  - David Sheehan, MD (*not FDA approved for suicidality)

• Esketamine (Spravato) was not significantly (statistically) better than placebo in phase 2 and phase 3 trials in reducing treatment-resistant depression symptoms. - Gerard Sanacora, MD, PhD

• There is reduced prefrontal connectivity metrics found in PTSD and depression. This hypoconnectivity could result in blunted prefrontal top-down control over the limbic system leading to an enhanced amygdala activation and negative bias. Ketamine seems to fix these networks. - Rachel Dalthorp, MD

• The amygdala is like the watchdog of the brain. - Rachel Dalthorp, MD

• Estrogen and ketamine work synergistically. Estrogen and BDNF both help promote neuroplasticity. - Rachel Dalthorp, MD

• Depression is most frequent when estrogen drops, i.e. menopause, PMS. - Rachel Dalthorp, MD

• For women, schedule booster infusions at 14 day of the menstrual cycle for atypical depression. For anxious depression, schedule the booster on day 16-23? of cycle to increase the anti-depressant effect of ketamine. - Rachel Dalthorp, MD

• Ketamine coma (5 days of continuous ketamine in ICU setting with patient intubated, sedated, foley, etc.) is an option for CRPS (chronic regional pain syndrome) treatment and has been very effective for some who have tried it. However, currently it is done only in Germany and Mexico, and there are risks of complications such as bed ulcers, pneumonia, blood clots, and UTIs. - Daniel Richman, MD

• Ketamine not effective during the “hot phase” of CRPS.  High dose steroids may be better for this phase. -Daniel Richman, MD

• NMDA receptor effects of ketamine may help in opioid-induced hyperalgesia.  Ketamine suppresses nitric oxide synthase and endotoxin effect and may have anti-inflammatory effect in sepsis. Ketamine inhibits TNF and IL-6 in macrophages. -Daniel Richman, MD

• Intravenous ketamine is effective for a wide array of chronic pain syndromes with maximum effect 48 hours - 2 weeks and some studies showed persistent effect at 12 weeks. -Daniel Richman, MD

• Intramuscular (IM) ketamine may potentially worsen CRPS (via the repeated trauma of injections) and could potentially trigger another part of the body to go into severe pain. -Daniel Richman

• During training, our goal in mental health was to help people get stable, but with no expectation of recovery. - Omid J. Naim, MD

• The Dominant Forces of Modern Mental Health Care:

Late 1800s: Psychoanalytic revolution 

1950s: Behavioral revolution 

1980s: Biological/Genetic Revolution 

All are top down models of intervention. Could the psychedelic revolution be different?

- Omid J. Naim, MD

• Resilience research on what is protective: time in nature, exercise, community, faith and spirituality, gratitude, purpose, meaning. - Omid J. Naim, MD

• The idea of a nuclear family is a modern idea. For many years, kids had many caregivers. What if an entire tribe was run by 2 people? - Omid J. Naim, MD

• We are narrowing our direct & felt experience with technology and becoming more socially isolated.  - Omid J. Naim, MD

• There is an epidemic of suicide in Aspen, CO. Which may be surprising because it’s very wealthy. And actually the extremes of wealth (very poor/rich) is where we see the most mental disease. - Omid J. Naim, MD

• Is trauma the root cause of later behaviors and health outcomes? The Adverse Childhood (ACE) Study examined this relationship and found that more trauma early on had a tremendous negative impact on health. - Omid J. Naim, MD

• Animals in the wild do not get mental illness. But in the zoo, they mimic signs of mental illness. - Omid J. Naim, MD

• Symptoms are expressions of not completing emotions in our bodies. Trauma can be healed, e.g. a broken bone has the innate capacity to heal under proper conditions.  -Omid J. Naim, MD

• Salutogenesis: What if disease is the norm? And what if health is actually a triumph? -Omid J. Naim, MD

• Ecological model: when you buy a plant, it has a card that tells you optimal conditions for health (water, sun, soil, etc).  What if depression is lack of optimal conditions? Don’t just paint the brown leaves green. -Omid J. Naim, MD

• It’s important to have a daily mind-body practice after ketamine infusions, i.e. yoga, mindfulness, intimate time in nature, prayer, intimate time in community. This ritual calms the reptilian brainstem.  -Omid J. Naim, MD

• Gamma waves are a pattern of neural oscillation 25-50hz and may be implicated in creating unity consciousness perception. Ketamine seems to increase gamma wave forms.” -Jeffrey Becker, MD

• Long term meditators self induce high amplitude gamma synchrony during mental practice. -Jeffrey Becker, MD

• Ketamine disconnects and disables the default mode network BUT turns on various nodes within the default mode. -Jeffrey Becker, MD

• Remember, you are on a heroic journey and maybe you are just coming out of the woods now.  -Jeffrey Becker, MD

• In one study looking at 100 adult patients undergoing spinal anesthesia, a positive suggestion right before ketamine IV administration influenced the effect and there were no unpleasant dreams in the suggestion group. - Jeffrey Becker, MD

• Up to a third of cancer patients have difficulty getting opioids to control their pain. -Jennifer Winegarden, DO

• Opioids can stimulate the NMDA receptor and astrocytes propagating pain. -Jennifer Winegarden, DO

• Topical ketamine application (10% ketamine, clonidine 0.2%, gabapentin 4%/mL cream) can be effective for treating chronic neuropathic pain without mood-altering effects or dissociation.  -Jennifer Winegarden, DO

• Scopolamine (either IV or the patch) can be considered for those patients who are non-responders to ketamine or for prolonging the effects of ketamine. 

• Some clinics are using ketamine infusions simultaneously with TMS (transcranial magnetic stimulation) treatments and getting significant improvements.

• Ketamine assisted psychotherapy (KAP) is another way to help patients process depression, anxiety, & trauma.

Wow! You made it to the end of this post. Congratulations and thanks for taking the time to read it! If you want to check out a short post from the first conference in Austin, TX in Sept 2018, click here. 

Did you learn something new? Feel free to leave a comment below. And please share this post with someone who may be interested in therapeutic ketamine!

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