Ketamine Appointment Instructions
Please have someone available to drive you home after the infusion
Plan to be at the clinic 1.5 hours minimum for a 40 min infusion or for 5 hours for a 4 hour infusion
Please do not eat 8 hours prior to the infusion
You may drink 2 hours prior to the infusion
Avoid benzodiazepines (for example Xanax and Ativan) and marijuana the day of your procedure
Do not take opioid pain medications 6 hours before the procedure
We recommend that you find a soothing music playlist to listen to during your infusion as this helps with calming effects. We recommend music specific for psychedelic therapy. You are welcome to bring your own headphones, eye mask and blanket as well though we will have all of these accommodations should you need them.
Ketamine Patient FAQ
What is ketamine?
Ketamine is approved by the FDA for use in children and adults for anesthesia and as a pain reliever during medical procedures. Ketamine has an excellent safety record and several applications in medicine: since 1970, it has been a successful anesthetic used in hospitals, dentist offices, and veterinary practices. In the past 10 years, Ketamine has also been identified as having beneficial effects on patients with depression, suicidal ideation, and certain neuropathic pain syndromes.
What conditions can ketamine treat?
With the approval of a prescribing physician, ketamine can be used off-label to treat both physical and psychological struggles.
Some of the conditions we treat with ketamine here at Nervana Medical are:
Chronic Pain secondary to fibromyalgia, Complex Regional Pain Syndrome (CRPS), pain associated with cancer, and general neuropathic pain.
Mental Health: Depression, anxiety, suicidality, and PTSD
Research suggests that ketamine therapy can be both more effective and less risky than conventional pharmaceuticals (like opioids and SSRIs). Ketamine’s high success rate and low risk of side effects makes it a popular choice for patients seeking relief from depression and chronic pain.
The Burden of Depression
300 million sufferers around the world
Leading cause of disability worldwide
1 in 5 Americans diagnosed in lifetime
Fewer than half of sufferers receive effective treatment
How does ketamine work?
Researchers are still investigating why ketamine works so well for so many conditions. What we do know is that ketamine increases the neuroplasticity of the brain, meaning it helps the brain “relearn” and “re-develop” new pathways as well as improving brain communication by stimulating the growth of neurons and synapses in the brain.
Ketamine’s Mechanism of Action
Receptor-level glutamate modulator: Glutamate is the primary excitatory neurotransmitter in mammalian brains, serving in about 60% of synapses
Ketamine normalizes glutamate levels, increasing glutamate activity where it is depressed and decreasing activity where it is in excess
Network-level optimization: With depression, brain activity may become habitual and constrained within narrow limits Ketamine normalizes brain connectivity, stimulates synaptogenesis, and temporarily induces levels of brain plasticity that approach levels seen in early development critical period, enhancing biological support for changes in belief and behavior
Anti-inflammatory: Pro-inflammatory cytokines can cause symptoms of depression, and ketamine is a powerful anti-inflammatory
Increased diversity of brain signals: The powerful psychedelic experiences that accompany entropic brain states may foster transformative subjective experiences that disrupt habits of thought and belief at the level of experience as well
Disrupts habitual cognitive activity
Is ketamine treatment legal in the United States?
Our ketamine infusion treatments are 100% legal, safe, and bound to strict clinical protocols and oversight.
Under the Controlled Substances Act (CSA)(21 U.S.C. 801 et seq.) Ketamine is a Schedule III drug: moderate to low potential for physical and psychological dependence.
CSA Schedule Risk Level Examples
● Schedule I no accepted medical use heroin, LSD
● Schedule II high potential for abuse oxycodone, fentanyl
● Schedule III moderate to low abuse risk ketamine, testosterone
● Schedule IV low abuse/dependence risk xanax, ambien
● Schedule V lower abuse/dependence risk robitussen AC, lyrica
Are there any medications that will interfere with ketamine treatments? Some medications and recreational drugs can interact with or reduce the effectiveness of ketamine. Common drugs that may impact ketamine therapy include alcohol, benzodiazepines, and certain medications used for treating epilepsy.
Make sure to inform us of all drugs and medications you use. We will work with your prescribing physician to coordinate your care and ensure that you can safely undergo treatment.
Are there health risks associated with ketamine therapy? Ketamine infusion treatments are typically well tolerated and have low risk for significant adverse reactions at the low dose used for this treatment. The dose used for therapeutic infusions is significantly lower than doses used in medical procedures such as surgery.Use of ketamine by people with conditions such as unstable heart disease risks aggravating these conditions. It is important that you fill out the medical questionnaire fully and truthfully, so we can properly evaluate whether ketamine therapy is a medically appropriate component of your treatment plan
At Nervana Medical, we strive to provide the best patient care and experience while maintaining safety as our utmost priority. Our Ketamine clinical staff has decades of medical experience and have primarily been in intensive care settings. Not only do we maintain all of the appropriate certifications, we also take pride in additional training and certifications to ensure we provide the highest quality of care. At Nervana Medical, we carry state of the art equipment that goes far beyond the recommended equipment to safely care for a patient should they have any significant reactions.
Our clinical staff will closely monitor your vital signs using next generation technology. We utilize continuous physiologic monitoring captured by FDA approved pulse decomposition analysis technology and finger sensor enable continuous, non-invasive beat-by-beat blood pressure monitoring within AAMI accuracy standards. In other words, we keep you safe and monitor your vital signs using technology that best suits your mind’s needs during your infusion because let's be honest, the last thing you want to experience during your infusion is a blood pressure cuff inflating!
What does ketamine infusion feel like?
This is a very hard question to answer; but coming from our medical director, it's comparable to the movie Inception, origami, kaleidoscope, and adult minecraft. Every individual will have different experiences but for the most part, you will likely experience a euphoric adventure of lots of geometric shapes that unravel your mind into multiple different adventures.
How do I find out if I'm eligible for treatment?
If you have a medical diagnosis for a pain or mental health condition, you may be eligible to receive ketamine therapy. The first step to receiving treatment is to book a consultation. The consultation can be done in our clinic or over our telehealth platform.
How soon will my symptoms improve?
Many patients feel better during the treatment itself, while others notice a marked improvement in mood or pain levels within a day of treatment. Every patient will experience different results as every patient has different depths of illness. We do recommend following our suggested protocol regarding the number of infusions within a certain time frame as these are the most current recommended guidelines for highest efficacy and longevity. We then encourage occasional, as-needed maintenance treatments in order to sustain these benefits.
A 2018 meta-analysis reviewed 20 studies comparing psychotherapy plus conventional antidepressant therapy to antidepressant therapy only and came to the following conclusions:
Standard antidepressant treatments alone are not substantially better than psychotherapy
Conventional antidepressants plus psychotherapy produced moderately better results than antidepressants without psychotherapy
While studies demonstrate that ketamine only treatment is effective for treatment resistant depression, we strongly recommend psychotherapy in combination with ketamine infusions.
In a 2019 study of 41 adults with TRD received repeated infusions of ketamine without psychotherapy and showed a robust response rate.Participants received six infusions over a two-week period 59% of treatment-resistant individuals responded with a reduction in depressive symptoms of 50% or more after an average of 3 infusions
Ketamine alone effects clinical response in about 60% of individuals with TRD
Psychotherapy with ketamine improves rate of clinical response and durability of effect
Human factors in the psychotherapy relationship are more important than the style of psychotherapy
Ketamine helps make the brain ready for changes in thoughts, beliefs, and behaviors, and psychotherapy helps implement those changes.
Will I be asleep during ketamine treatment?
You will be mildly sedated during your infusion. The dosage used for ketamine infusion therapy is not high enough to cause you to fall asleep, but you may feel a bit drowsy during and shortly after the treatment.
What are the common side effects of ketamine?
Most side effects experienced as a result of ketamine infusions will go away within an hour of treatment. The most commonly reported side effects include mild nausea, headache, drowsiness, and a temporary increase in blood pressure. At Nervana Medical, we have implemented a protocol that we find very effective in combating most side effects as well improving the efficacy and longevity of its success. Less common side effects include vivid dreams, mood swings, or agitation. If you do experience side effects during your infusion, they can quickly be controlled by adjusting the dosage of ketamine or administering additional medication.
Possible side effects may include and are not limited to:
fast or irregular heart beats
increased saliva or thirst
increased/decreased blood pressure
lack of appetite
vivid dreams
headaches
confusion
metallic taste
irritation or excitement
Constipation
floating sensation (“out-of-body”)
blurry or double vision
Twitching, muscle jerks and tension
Nausea or vomiting
Memory confusion changes
Urinary frequency
Rare side effects of Ketamine are:
Allergic reactions
Hallucinations
Pain at the site of injection
Euphoria
Increase in pressure inside the eye
Involuntary eye movements
Inflammation in the bladder
Low mood or suicidal thoughts
Respiratory complications
What Safety Precautions Must You Take?
You may not eat or drink 8 hours before the infusion, water is the only exception.
You may drink water up to 2 hours before the infusions.
You may NOT drive a car, operate hazardous equipment, or engage in hazardous activities for at least 24 hours after each treatment as reflexes may be slow or impaired. Another adult will need to drive you home and must be present prior to your discharge.
You must refrain from alcohol 24 hours prior-to and following ketamine administration. You must refrain from other illegal substances during your ketamine infusion treatment.
You must tell the clinic about all medications you are taking, especially narcotic pain relievers, benzodiazepines, barbiturates and muscle relaxers. * These increase the risk of adverse reactions including possible need for airway management requiring intubation, cardiovascular collapse requiring cpr and even death.
Ketamine use during pregnancy is not generally recommended. Females will be asked to submit a urine sample for a pregnancy test prior to your first infusion and every 2 weeks thereafter.
If you are seeking infusions for chronic pain, we will draw some labs prior to initiating your first treatment to ensure your liver function will tolerate the longer infusions. ● To qualify to receive ketamine therapy for mental health conditions, you must notify and share the contact information for the mental health provider treating your psychiatric symptoms or your current primary care provider.
If you experience a minor side effect while you are at home, you should contact Nervana Medical at (801) 335-5243 otherwise contact your medical provider or call 911
Recommended protocols that have proven thus far to be most beneficial:
A series of infusions is recommended so that symptom relief has a longer duration of action. While the goal is improvement of symptoms, individual results cannot be guaranteed.
Mental Health: A series of six- 40 minute infusions over 2-3 weeks followed by as needed maintenance infusions.
Chronic Pain: A series of five-4 hour infusions for 5 consecutive days or every other day for 5 treatments and followed by as needed maintenance infusions.
Maintenance infusions: The frequency of these will vary depending on patient response. Additional maintenance treatments may or may not be suggested, typical maintenance is recommended at about 2 weeks after initial protocol and then at one month with the goal of needing them less frequently thereafter.
Why isn't one ketamine infusion enough?
As with any medication, the benefits of ketamine will eventually wear off after it has left your system. However, unlike medicine that must be taken every day, the benefits of ketamine can be sustained by undergoing an additional treatment session just every few months. You can think of ketamine as an antidepressant or pain medication that, due to its efficacy, simply isn’t needed as often as other treatments.
Do you offer therapy or mental health counseling?
We do offer integrative ketamine therapy for an additional charge if interested.
Is ketamine therapy covered by insurance?
Depending on your eligibility and individual insurance plan, your ketamine infusions may be eligible for partial or complete reimbursement though historically reimbursement does appear to be rare currently. We can provide a superbill to any of our patients who request one, which will allow you to submit a claim to your insurance company for reimbursement. We do not deal with insurance companies otherwise and do require payment at the time of service.
What financing options are available?
Nervana Medical has partnered with Advance Care Patient Financing, a flexible 3rd-party finance company that helps patients finance treatment payments for up to 15 months, no interest financing. This partner is a budget-conscious loan processor that utilizes innovative technology design that allows them to process a diversity of credit levels and then connect you to the right partner lender.
Do you provide assistance with submitting an insurance claim for reimbursement?
Yes. We can provide a superbill to any of our patients who request one, which will allow you to submit a claim to your insurance company for reimbursement.
How do I prepare for my appointment?
Noise canceling headphones (we have some available for use if you don't have your own!)
Music to help integrate a positive psychedelic experience; flowing, uplifting, meditative, no intelligible words. We have found success with the soundtrack:”Music for psychedelic therapy” Jon Hopkins
Eyeshades support to help focus on inner experience without distraction from distorted vision (we also provide these).
Peak synaptogenesis occurs from 24-48 hours post-treatment, providing biological substrate that can support changes in behavior and belief. Timing psychotherapy to coincide with peak synaptogenesis provides optimal support for therapeutic change.
Ketamine Scheduling / Survey Information
We track your progress by administering three simple surveys before each Ketamine treatment. The three surveys we utilize are: a self-assessed mood score, amore in-depth PHQ-9 to benchmark and monitor overall depression symptoms and the GAD generalized anxiety disorder survey. Please answer the questions to the best accuracy possible as we actively collect data for continuing to improve future research/best practice standards and protocols.
After completing your initial paperwork and first survey you will need to schedule a medical history and exam clearance appointment prior to your first infusion. The cost of this exam is $50 and does not include the cost of labs if labs are indicated (primarily for patients with a history of extensive co-morbidities or those interested in the chronic pain infusion therapy). If you and the provider decide to pursue a series of six infusions, the $50 exam fee is applied to the cost of the infusions. If you have had a recent physical exam, then you are welcome to email it to us for our review and this fee will be waived
Scheduling
Our mental health protocol recommends 6 infusions over 2 weeks (please ensure you are able to block off time to ensure you are able to complete the recommended protocol). If you desire your current therapist to be present during the infusion for psychotherapy assistance, you will need to arrange that with them. If they are unable to attend but you would still like psycho assisted therapy during your infusion, then we are happy to provide you with referrals (the price of this would be dependent upon the therapist).
Appointment 1 - Medical History and Exam/Clearance
Appointment 2 - Infusion #1
Appointment 3 - Infusion #2
Appointment 4 - Infusion #3
Appointment 5 - Infusion #4
Appointment 6 - Infusion #5
Appointment 7 - Infusion #6
We will provide you with a recommended book list that we find useful to go along with your infusions as you pursue the journey of improving your mental health. Please consider looking into these books in further detail as they can be beneficial in your overall progress.
Nervana's Ketamine Mental Health Protocol Rationale
Why do we pre-treat with zofran and toradol?
Ketamine side effects include nausea and headaches. We utilize zofran ODT + IV for a few reasons; ODT zofran is helpful if the patient is receiving NAD+ IM as side effects of NAD+ are similar to a niacin rush including abdominal cramping/bloating.
Toradol is used to mitigate headaches as with the additional IVF (for when we infuse an entire liter rather than 50 ml on the syringe pump). Most patients who experience headaches from ketamine seem to be more on the dehydrated side, which isn't uncommon if they've been NPO for a while (scheduled towards the end of the day).
Why do we give magnesium in our infusions?
Magnesium is an essential cation involved in many functions within the central nervous system, including transmission and intracellular signal transduction. Several studies have shown its usefulness in neurological and psychiatric diseases. Furthermore, it seems that magnesium levels are lowered in the course of several mental disorders, especially depression.
Why do we give Vitamin D IM?
Growing evidence points to the role of vitamin D in the pathobiology and treatment of depression.Many people who have depression may also have low circulating levels of vitamin D in their blood. However, research findings on this potential link are mixed. More research is needed.
Why do we give/recommend NAD+ IM?
How does ketamine help to reduce inflammation? It turns out that ketamine acts on the “kynurenine pathway” in the brain (Kopra et al., 2021), which is responsible for synthesizing the helper molecule (coenzyme) NAD+ from tryptophan found in protein in our diet.
Ketamine and NAD+ are both important for keeping the kynurenine pathway in a healthy “neuroprotective” mode that guards brain cells against damage (Ogyu et al., 2018). When this pathway gets out of balance, brain cells are exposed to harmful “oxidative stress”, which can lead to inflammation and depression.
Some scientists believe that a root cause of a range of mental health disorders, including depression, is depletion of NAD+ stores in cells (Morris et al., 2020). This lack of NAD+ leads to “bioenergetic failure” — causing increased oxidative stress, inflammation, and potentially depression.
Keeping NAD+ stores topped up could therefore be an important defense against depression. Along with natural ways of boosting NAD+, both NAD+ supplements and intravenous (IV) NAD+ injection have been proven to be effective ways of raising NAD+ levels in the body (Grant et al., 2019; Yoshino et al., 2021).
In combination, NAD+ and ketamine treatment could help to treat depression by reducing oxidative stress and inflammation. The kynurenine pathway seems to be the critical link between the two, and scientists are continuing to study its role in depression (Ogyu et al., 2018; Kopra et al., 2019)
As this research progresses, traditional antidepressants targeting the serotonin system are being complemented by novel approaches, such as NAD+ and ketamine treatment. Building on the hard work of many scientists, these breakthrough treatments are offering new hope to people worldwide who suffer from depression.
Please do not hesitate to contact us if you have any questions at all.
References:
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