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Ketamine has much support in the use of hard-to-treat depression and suicidal behaviors. Below are studies and their links, including a meta-analysis, which demonstrate the effect of Ketamine. Also a recent trial by Carlos Zarate shows the heterogenous nature of response to Ketamine . It is difficult to say who is going to be lifted from their depression completely or partially respond, but in the study, Dr. Zarate showed that patients with a long history of suicidal thinking and self-harm will have less of a response in some cases.

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Intravenous ketamine may rapidly reduce suicidal thinking in depressed patients << Article link 

Intravenous ketamine may rapidly reduce suicidal thinking in depressed patients

Repeat intravenous treatment with low doses of the anesthetic drug ketamine quickly reduced suicidal thoughts in a small group of patients with treatment-resistant depression. In their report receiving Online First publication in the Journal of Clinical Psychiatry, a team of Massachusetts General Hospital (MGH) investigators report the results of their study in depressed outpatients who had been experiencing suicidal thought for three months or longer.

“Our finding that low doses of ketamine, when added on to current antidepressant medications, quickly decreased suicidal thinking in depressed patients is critically important because we don’t have many safe, effective, and easily available treatments for these patients,” says Dawn Ionescu, MD, of the Depression Clinical and Research Program in the MGH Department of Psychiatry, lead and corresponding author of the paper. “While several previous studies have shown that ketamine quickly decreases symptoms of depression in patients with treatment-resistant depression, many of them excluded patients with current suicidal thinking.”

It is well known that having suicidal thoughts increases the risk that patients will attempt suicide, and the risk for suicide attempts is 20 times higher in patients with depression than the general population. The medications currently used to treat patients with suicidal thinking — including lithium and clozapine — can have serious side effects, requiring careful monitoring of blood levels; and while electroconvulsive therapy also can reduce suicidal thinking, its availability is limited and it can have significant side effects, including memory loss.

Primarily used as a general anesthetic, ketamine has been shown in several studies to provide rapid relief of symptoms of depression. In addition to excluding patients who reported current suicidal thinking, many of those studies involved only a single ketamine dose. The current study was designed not only to examine the antidepressant and antisuicidal effects of repeat, low-dose ketamine infusions in depressed outpatients with suicidal thinking that persisted in spite of antidepressant treatment, but also to examine the safety of increased ketamine dosage.

The study enrolled 14 patients with moderate to severe treatment-resistant depression who had suicidal thoughts for three months or longer. After meeting with the research team three times to insure that they met study criteria and were receiving stable antidepressant treatment, participants received two weekly ketamine infusions over a three-week period. The initial dosage administered was 0.5 mg/kg over a 45 minute period — about five times less than a typical anesthetic dose — and after the first three doses, it was increased to 0.75 mg/kg. During the three-month follow-up phase after the ketamine infusions, participants were assessed every other week.

The same assessment tools were used at each visit before, during and after the active treatment phase. At the treatment visits they were administered about 4 hours after the infusions were completed. The assessments included validated measures of suicidal thinking, in which patients were directly asked to rank whether they had specific suicide-related thoughts, their frequency and intensity.

While only 12 of the 14 enrolled participants completed all treatment visits — one dropped out because of ketamine side effects and one had a scheduling conflict — most of them experienced a decrease in suicidal thinking, and seven achieved complete remission of suicidal thoughts at the end of the treatment period. Of those seven participants, two maintained remission from both suicidal thinking and depression symptoms throughout the follow-up period. While there were no serious adverse events at either dose and no major differences in side effects between the two dosage levels, additional studies in larger groups of patients are required before any conclusions can be drawn.

“In order to qualify for this study, patients had to have suicidal thinking for at least three months, along with persistent depression, so the fact that they experienced any reduction in suicidal thinking, let alone remission, is very exciting,” says Ionescu, who is an instructor in Psychiatry at Harvard Medical School. “We only studied intravenous ketamine, but this result opens the possibility for studying oral and intranasal doses, which may ease administration for patients in suicidal crises.”

She adds, “One main limitation of our study was that all participants knew they were receiving ketamine. We are now finishing up a placebo-controlled study that we hope to have results for soon. Looking towards the future, studies that aim to understand the mechanism by which ketamine and its metabolites work for people with suicidal thinking and depression may help us discover areas of the brain to target with new, even better therapeutic drugs.”

 

Rapid and Sustained Reductions in Current Suicidal Ideation Following Repeated Doses of Intravenous Ketamine: Secondary Analysis of an Open-Label Study  << Article in Clinical Psychiatry

Ketamine for Rapid Reduction of Suicidal Thoughts in Major Depression: A Midazolam-Controlled Randomized Clinical Trial Article link for below:

Ketamine was significantly more effective than a commonly used sedative in reducing suicidal thoughts in depressed patients, according to researchers at Columbia University Medical Center (CUMC). They also found that ketamine’s anti-suicidal effects occurred within hours after its administration.

The findings were published online last week in the American Journal of Psychiatry.

According to the Centers for Disease Control and Prevention, suicide rates in the U.S. increased by 26.5 percent between 1999 and 2015.

“There is a critical window in which depressed patients who are suicidal need rapid relief to prevent self-harm,” said Michael Grunebaum, MD, a research psychiatrist at CUMC, who led the study. “Currently available antidepressants can be effective in reducing suicidal thoughts in patients with depression, but they can take weeks to have an effect. Suicidal, depressed patients need treatments that are rapidly effective in reducing suicidal thoughts when they are at highest risk. Currently, there is no such treatment for rapid relief of suicidal thoughts in depressed patients.”

Most antidepressant trials have excluded patients with suicidal thoughts and behavior, limiting data on the effectiveness of antidepressants in this population. However, previous studies have shown that low doses of ketamine, an anesthetic drug, causes a rapid reduction in depression symptoms and may be accompanied by a decrease in suicidal thoughts.

The 80 depressed adults with clinically significant suicidal thoughts who enrolled in this study were randomly assigned to receive an infusion of low-dose ketamine or midazolam, a sedative. Within 24 hours, the ketamine group had a clinically significant reduction in suicidal thoughts that was greater than with the midazolam group. The improvement in suicidal thoughts and depression in the ketamine group appeared to persist for up to six weeks.

Those in the ketamine group also had greater improvement in overall mood, depression, and fatigue compared with the midazolam group. Ketamine’s effect on depression accounted for approximately one-third of its effect on suicidal thoughts, suggesting the treatment has a specific anti-suicidal effect.

Side effects, mainly dissociation (feeling spacey) and an increase in blood pressure during the infusion, were mild to moderate and typically resolved within minutes to hours after receiving ketamine.

“This study shows that ketamine offers promise as a rapidly acting treatment for reducing suicidal thoughts in patients with depression,” said Dr. Grunebaum. “Additional research to evaluate ketamine’s antidepressant and anti-suicidal effects may pave the way for the development of new antidepressant medications that are faster acting and have the potential to help individuals who do not respond to currently available treatments.”

Ketamine for Rapid Reduction of Suicidal Thoughts in major depression – A midazolam controlled trial PDF article

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Ketamine as a Potential Treatment for Suicidal Ideation A Systematic Review of the Literature 2015

Abstract
Objective To review the published literature on the efficacy
of ketamine for the treatment of suicidal ideation (SI).
Methods The PubMed and Cochrane databases were
searched up to January 2015 for clinical trials and case
reports describing therapeutic ketamine administration to
patients presenting with SI/suicidality. Searches were also
conducted for relevant background material regarding the
pharmacological function of ketamine.
Results Nine publications (six studies and three case
reports) met the search criteria for assessing SI after
administration of subanesthetic ketamine. There were no
studies examining the effect on suicide attempts or death
by suicide. Each study demonstrated a rapid and clinically
significant reduction in SI, with results similar to previously
described data on ketamine and treatment-resistant
depression. A total of 137 patients with SI have been
reported in the literature as receiving therapeutic ketamine.
Seven studies delivered a dose of 0.5 mg/kg intravenously
over 40 min, while one study administered a 0.2 mg/kg
intravenous bolus and another study administered a liquid
suspension. The earliest significant results were seen after
40 min, and the longest results were observed up to
10 days postinfusion.
Conclusion Consistent with clinical research on ketamine
as a rapid and effective treatment for depression, ketamine
has shown early preliminary evidence of a reduction in
depressive symptoms, as well as reducing SI, with minimal
short-term side effects. Additional studies are needed to
further investigate its mechanism of action, long-term
outcomes, and long-term adverse effects (including abuse)
and benefits. In addition, ketamine could potentially be
used as a prototype for further development of rapid-acting
antisuicidal medication with a practical route of administration
and the most favorable risk/benefit ratio.
Key Points
Preliminary data from randomized controlled trials
have demonstrated that ketamine may rapidly and
effectively control treatment-resistant depression,
though the effects are transient.
A small subset of studies has demonstrated similar
results in the effects of ketamine on suicidal ideation.
Ketamine has potential as a rapid treatment for
suicidal ideation and/or a possible model compound
for future drug development.

4 Discussion
With an estimated prevalence of mood disorders ranging
from 3.3 to 21.4 % and the substantially increased risk of
suicide among patients with mood disorders, treatment is
certainly warranted [19]. Current treatment options for
suicidality are limited. They include brain stimulation
therapeutics, such as ECT, and pharmacological intervention
(lithium, clozapine). The efficacy of lithium in treating
suicidality has been documented [20, 21] and has recently been reviewed and pooled in a recent meta-analysis of 48
studies [22]. Clozapine has also been shown to reduce
suicide risk in patients with schizophrenia [23, 24]. The
limitations of both lithium and clozapine include a longer
time to efficacy in this psychiatric emergency/urgency,
compared with the early response to ketamine [25]. Ketamine
seems to be gaining substantial evidence as a pharmacological
option for depression with a fast onset of
action, but its long-term effects need further investigation.
In addition, ketamine probably offers a faster onset of
action in terms of SI, but further work is certainly needed
in this area. Given the risk of suicide and even the
increasing rates of suicide in certain subgroups, such as
soldiers and veterans [26, 27], there is an urgent need for
faster therapeutics for SI and TRD. Importantly, suicidality
and suicide pose a high global burden of patient suffering
to families and society. Although several small-to-moderate
sized studies, in addition to several reviews, have been
published that have examined the efficacy of ketamine in
TRD, there are considerably fewer published data
specifically examining ketamine in patients presenting with
SI. Notably, only three studies have directly examined SI
as the primary outcome [11, 16, 17], while the rest
examined SI as the secondary outcome [4, 15, 18], not
including case reports. This review summarizes the current
published literature regarding ketamine as a treatment for
SI. The data so far show promising trends of ketamine
being an effective and rapid treatment with minimal side
effects.
Pharmacologically, ketamine is an N-methyl-D-aspartate
(NMDA) receptor antagonist. It has been used for anesthesia
in the USA since the 1970s. At subanesthetic doses,
ketamine has been shown to increase glutamate levels [3].
This mechanism is relevant, as glutamate regulation and
expression are altered in patients with major depressive
disorder (MDD). Studies have also demonstrated an
abnormal glutamate–glutamine–gamma-aminobutyric acid
cycle in patients with suicidality [28]. Furthermore, ketamine
has also been shown to work on nicotinic and opioid
receptors [29]. No other class of antidepressant medication
works to modulate the glutamatergic system, and research
continues into this, with the goal of characterizing the full
mechanism of action of ketamine and perhaps developing
other compounds that would have similar effects. Thus,
even if the approval and marketing of ketamine as a rapidacting
antisuicidal and antidepressant medication is not
realized, it could well be a prototype for development of
other medication(s) that retain the mechanism of action
with more favorable qualities and a lesser adverse effect
profile (such as a longer duration of action or less or no
addictive potential). Although the mechanisms explaining
the antisuicidal effect and the NMDA receptor antagonism
of ketamine are still unclear, some of the initial evidence
points to an anti-inflammatory action via the kynurenic
acid pathway. Strong suggestions as to the causal relationship
between inflammation and depression/suicidality
has come from studies demonstrating that cytokines [30,
31] and interferon-b [32] induce depression and suicidality.
Other recent studies have added to the notion of implicating
brain immune activation in the pathogenesis of suicidality.
For instance, one study showed microglial
activation of postmortem brain tissue in suicide victims
[33]. Another study found increased levels of the cytokine
interleukin-6 in cerebrospinal fluid from patients who had
attempted suicide [34]. Higher levels of inflammatory
markers have been shown in suicidal patients than in nonsuicidal
depressed patients [33, 35]. Inflammation leads to
production of both quinolinic acid (an NMDA agonist) and
kynurenic acid (a NMDA antagonist). An increased
quinolinic acid to kynurenic acid ratio leads to NMDA
receptor stimulation. The correlation between quinolinic
acid and Suicide Intent Scale scores indicates that changes
in glutamatergic neurotransmission could be specifically
linked to suicidality [36].
Small randomized controlled trials have demonstrated
the efficacy of ketamine in rapidly treating patients with
both TRD and/or bipolar depression [4, 8, 9, 11, 16–18].
Some studies have also examined suicide items as a secondary
measure in their depression rating scales [4, 7]. In
total, the studies examining ketamine and TRD have nearly
consistently demonstrated that ketamine provides relief
from depressive and suicidal symptoms, starting at 40 min
and lasting for as long as 5 days. Questions still remain as
to the long-term effects of this treatment, how much should
be administered and how often, any serious adverse effects,
and the mechanism of action.
Pharmacologically, ketamine has poor bioavailability
and is best administered via injection [37]. In their landmark
study, Berman et al. [4] found that a subanesthetic
dose (0.5 mg/kg) rapidly improved depressive symptoms.
Most of the subsequent studies have delivered ketamine as
a constant infusion for 40 min at a rate of 0.5 mg/kg.
Others have examined its efficacy after multiple infusions
and observed similar results [8, 13, 16, 38]. Currently, it is
recommended that ketamine be administered in a hospital
setting [39].

______________________________________

Characterizing the course of suicidal ideation response to ketamine

Characterizing the course of suicidal ideation response to ketamine PDF

2018 article from Carlos Zarate discussing the variable course outcomes with Ketamine for suicidality and correlations to serum markers and behavior and longevity of self-harm prior to treatment:

 

Background: : No pharmacological treatments exist for active suicidal ideation (SI), but the glutamatergic
modulator ketamine elicits rapid changes in SI. We developed data-driven subgroups of SI trajectories after
ketamine administration, then evaluated clinical, demographic, and neurobiological factors that might predict SI
response to ketamine.
Methods: : Data were pooled from five clinical ketamine trials. Treatment-resistant inpatients (n = 128) with
DSM-IV-TR-diagnosed major depressive disorder (MDD) or bipolar depression received one subanesthetic
(0.5 mg/kg) ketamine infusion over 40 min. Composite SI variable scores were analyzed using growth mixture
modeling to generate SI response classes, and class membership predictors were evaluated using multinomial
logistic regressions. Putative predictors included demographic variables and various peripheral plasma markers.
Results: : The best-fitting growth mixture model comprised three classes: Non-Responders (29%), Responders
(44%), and Remitters (27%). For Responders and Remitters, maximal improvements were achieved by Day 1.
Improvements in SI occurred independently of improvements in a composite Depressed Mood variable for
Responders, and partially independently for Remitters. Indicators of chronic SI and self-injury were associated
with belonging to the Non-Responder group. Higher levels of baseline plasma interleukin-5 (IL-5) were linked to
Remitters rather than Responders.
Limitations: : Subjects were not selected for active suicidal thoughts; findings only extend to Day 3; and plasma,
rather than CSF, markers were used.
Conclusion: : The results underscore the heterogeneity of SI response to ketamine and its potential independence
from changes in Depressed Mood. Individuals reporting symptoms suggesting a longstanding history of chronic
SI were less likely to respond or remit post-ketamine.

1. Introduction
Suicide poses a serious threat to public health. Worldwide, suicide
accounts for approximately 1 million deaths, and 10 million suicide
attempts are reported annually (World Health Organization, 2014). In
the United States, the national suicide rate has increased by approximately
28% over the last 15 years (Curtin et al., 2016). At the same
time, relatively few interventions for suicide risk exist. While treatments
such as clozapine and lithium have demonstrated effects on
suicidal behavior over weeks to months, these effects may be limited to
specific diagnoses (Cipriani et al., 2005; Griffiths et al., 2014). Currently,
no FDA-approved medications exist to treat suicidal ideation
(SI), leaving those who experience a suicidal crisis with limited options
for a reprieve of symptoms. Consequently, a critical need exists for
rapid-acting treatments that can be used in emergency settings.
A promising off-label agent for this purpose is the rapid-acting antidepressant
ketamine, which past studies have suggested reduces suicidal
thoughts (Diazgranados et al., 2010a; Murrough et al., 2015; Price
et al., 2009). A recent meta-analysis of 167 patients with a range of
mood disorder diagnoses found that ketamine reduced suicidal
thoughts compared to placebo as rapidly as within a few hours, with
effects lasting as long as seven days (Wilkinson et al., 2017). These
results are reinforced by newer findings of reduced active suicidal
ideation post-ketamine compared to a midazolam control(Grunebaum et al., 2018). As the efficacy literature develops in the era
of personalized medicine, two important issues must be addressed.
First, little is known about the acute course of SI following ketamine.
The speed with which antidepressant response occurs, and how much
improvement can be expected on average, has been documented for
single administrations of ketamine (Mathew et al., 2012; Sanacora
et al., 2017); in the limited available literature, researchers have
emulated previous studies examining antidepressant effect, where a
cutoff of 50% improvement demarcated response (Nierenberg and
DeCecco, 2001). Nevertheless, it remains unknown whether this categorization
accurately reflects the phenomenon of suicidal thoughts.
Empirically-derived approaches to the description of SI trajectory after
ketamine may be useful in operationalizing “response” in future clinical
trials.
Second, identifying demographic, clinical, or biological predictors
of SI response to ketamine would allow researchers and clinicians to
determine who is most likely to exhibit an SI response to ketamine. A
broad literature describes clinical and demographic predictors for suicide
risk (Franklin et al., 2017), and a smaller literature connects suicidal
thoughts and behaviors to plasma markers such as brain-derived
neurotrophic factor (BDNF) and cytokines (Bay-Richter et al., 2015;
Falcone et al., 2010; Isung et al., 2012; Serafini et al., 2017; Serafini
et al., 2013). However, no biomarkers have been shown to predict SI/
behavior response to intervention, a finding reinforced by the National
Action Alliance for Suicide Prevention’s Research Prioritization Task
Force’s Portfolio Analysis (National Action Alliance for Suicide
Prevention: Research Prioritization Task Force, 2015). Notably, predictor
analyses have the potential to reveal insights into personalized
treatments for suicidal individuals, as well as the neurobiology of SI
response. With respect to antidepressant response, for example, this
approach yielded the observation that individuals with a family history
of alcohol dependence may be more likely to exhibit an antidepressant
response to ketamine (Krystal et al., 2003; Niciu et al., 2014; PermodaOsip
et al., 2014).
The goals of this study were to elucidate trajectories of SI response
and identify predictors of that response, with the ultimate goal of
adding to the growing literature surrounding ketamine’s specific effects
on SI. In particular, we sought to determine whether the heterogeneous
patterns of change in SI after ketamine administration were better explained
by a model with two or more latent groups of trajectories rather
than a single average trajectory, using secondary analyses from previously
published clinical trials. These classes were then used to evaluate
potential clinical, demographic, and plasma biomarker predictors
of SI response to ketamine in order to generate hypotheses.. Discussion
This analysis used a data-driven approach to characterize SI response
to ketamine. The data were best explained by three trajectory
classes: one with severe average baseline SI and little to no response to
ketamine (Non-Responders), one with moderate average baseline levels
of SI and significant response to ketamine (Responders), and a third
with moderate average baseline levels of SI and complete remission of
SI by two days post-ketamine (Remitters). These findings suggest a
diversity of post-ketamine changes in SI that may not be captured under
traditional methods of categorizing response to treatment.
Furthermore, we found evidence that SI response and antidepressant
response could be distinguished from each other; one subset of participants
experienced improvement in SI that was partially explained by
improvements in Depressed Mood, while the other group’s improvements
in SI occurred independently of antidepressant response. With
regard to predictors of SI response trajectory, preliminary results suggest
the individuals least likely to experience improvement in SI postketamine
were those with the most severe SI and a history of self-injury.
Few plasma markers emerged as predictors of SI response in this study,
highlighting the limitations of connecting SI ratings of response with
biological markers.
The growth mixture modeling approach used here underscored the
heterogeneity of SI response to ketamine, which would not have been
captured by simply calculating the average trajectory. The class assignment
from this approach also differed from the definition of response
(50% reduction in symptoms) traditionally used in the antidepressant
literature, which often focuses on a specific timepoint rather
than the entire symptom trajectory. In comparing classification using a
50% response at Day 1 and Day 3 with the latent trajectory classes, we
found representation of almost every SI class across each responder
group, highlighting the potential limitations of the 50% response approach.
Further study is needed to determine which of these approaches
will prove more fruitful. Complete remission of SI has previously been
used as an outcome measure in clinical trials and in a meta-analysis of
ketamine’s efficacy (Grunebaum et al., 2017; Grunebaum et al., 2018;
Wilkinson et al., 2017), as well as in a study examining the relationship
between SI response to ketamine and changes in nocturnal wakefulness
(Vande Voort et al., 2017). One strength of the present study is that this
data-driven approach provides classifications that directly reflect the
phenomena under study as they are, as opposed to what they should be.
Especially when used in larger samples than the current study, this
approach is particularly promising in its ability to provide a more
nuanced understanding of the nature of SI response to ketamine.
Our results also support the idea that SI response in particular can target. First, it should be noted here that SI classes were not distinguishable
by baseline Depressed Mood scores; patients with the most
severe SI did not differ meaningfully in Depressed Mood scores from
those with the mildest SI. Second, while previous analyses of these data
documented that BMI and family history of alcohol dependence predicted
antidepressant response (Niciu et al., 2014), SI response was not
associated with these variables in the current analysis. Third, the antidepressant
response profiles of the SI classes suggest that SI response
and antidepressant response are not wholly redundant. This aligns with
previous clinical trials and meta-analytic reviews of the literature suggesting
that SI response to ketamine occurs partially independently of
antidepressant response (Grunebaum et al., 2018; Wilkinson et al.,
2017). Nevertheless, this independence did not hold true across both SI
response groups. Specifically, antidepressant and SI response were
clearly linked in Remitters, with depression accounting for half of the
changes in SI; however, in Responders, improvements in SI occurred
independently from improvements in Depressed Mood. These discrepancies
could be related to ketamine’s complex neurobiological
mechanisms or to the potentially low levels of clinical severity observed
in the Remitters.
Interestingly, the current analyses found no baseline demographic
variables that reliably distinguished Responders from Remitters. Some
phenotypic characteristics were uniquely associated with belonging to
the Non-Responder group, suggesting that a long-standing history of
self-injury or SI may indicate resistance to rapid changes in SI.
Relatedly, a recent, randomized clinical trial of repeat-dose ketamine
compared to placebo found that ketamine had no effect on SI in a
sample of patients selected for their longstanding, chronic history of SI
(Ionescu, 2017). These results highlight the importance of patient selection,
particularly for suicide risk. It should be stressed, however, that
SI does not necessarily translate to suicidal attempts or deaths; to our
knowledge, no study has yet linked ketamine with reduced risk of
suicidal behavior. Indeed, in the present study the SI Non-Responders
experienced limited antidepressant effects in response to ketamine, but
may nevertheless have improved on other, unmeasured symptoms that
could provide important benefit and relief. As the ketamine literature
develops, it will be important to identify which clinical symptom profiles
are most likely to have a robust anti-SI and anti-suicidal behavior
response to ketamine and which ones may benefit from other interventions.
While we evaluated a range of potential plasma markers previously
linked to suicidal ideation and behavior, in the present analysis only IL5
was associated with the SI Responder subgroup. Ketamine is known to
have anti-inflammatory effects (Zunszain et al., 2013), but the relationship
between antidepressant response and change in cytokine
levels remains unclear (Park et al., 2017). Cytokines have been linked
to suicidal behavior in the past; a recent meta-analysis found that lower
levels of IL-2 and IL-4, and higher levels of TGFbeta, were associated
with suicidal thoughts and behaviors (Serafini et al., 2013); however, toour knowledge IL-5 has not previously been linked to SI. Given the large
number of comparisons and lack of precedent in the literature, this
result may have been spurious and should be interpreted with caution.
A number of other results may reflect meaningful relationships, but the
high degree of variability—and the associated wide confidence intervals—suggests
that larger sample sizes are needed to better elucidate
the nature of any such relationships (e.g. baseline VEGF: χ2 = 6.13,
p = .05, but OR (95% CI) 13.33 (0.93–200.00)). Somewhat surprisingly,
plasma BDNF levels were not associated with responder class.
Previous studies of bipolar, but not MDD, samples found that plasma
BDNF levels were associated with SI response after ketamine
(Grunebaum, 2017; Grunebaum et al., 2017), suggesting that the mixed
diagnostic composition of this study may explain differences from
previous work. Studies exploring the relationship between BDNF and
antidepressant response to ketamine have also yielded mixed findings
(Haile et al., 2014; Machado-Vieira et al., 2009). Other data-driven
approaches have considered both biological and behavioral variables in
characterizing depression (Drysdale et al., 2017); a similar approach
might prove useful for predicting SI response.
The present study is associated with several strengths as well as
limitations. Strengths include the relatively large sample size of participants
who received ketamine, the use of composite SI scores from
previous exploratory factor analyses as opposed to individual items,
and the combination of clinical and biological markers as potential
predictors of class membership. Limitations include patient selection
methods, as these patients were part of an antidepressant trial and were
not selected for active suicidal thoughts, as well as the exploratory
nature of the analysis. As stated above, suicidal thoughts do not necessarily
equate to suicidal behavior, and class membership would thus
not necessarily correspond with an overall reduction in suicide risk.
Another limitation is that results were collapsed across several clinical
trials with slight variations in study design, and findings were thus only
extended to Day 3 rather than a week after ketamine administration. As
a result, only a subset of the sample could be used for predictive analyses.
In addition, plasma—rather than CSF—markers were used, and
the latter might better indicate underlying biology due to proximity to
the brain, though certain markers such as plasma BDNF may be related
to platelet storage, rather than the brain (Chacón-Fernández et al.,
2016). Comparison of results to trajectories of suicide-specific measures,
such as the Scale for Suicide Ideation (Beck et al., 1979), may also
give further insight into specific SI content. Finally, many clinical
predictors were collected upon hospital admission; future analyses
could use formal assessments, such as the Childhood Traumatic Questionnaire
(Bernstein et al., 1994), assessment of personality disorders,
or diagnoses such as post-traumatic stress disorder (PTSD) as potential
indicators of response.
Despite these limitations, the study demonstrates the utility of a
data-driven approach for characterizing the heterogeneity of SI response
to a rapid-acting intervention. This allows for a more finegrained
analysis of symptoms than would be permitted by traditionalapproaches, such as overall average response or dichotomization at
50% reduction in symptoms. This study identified several findings of
note. These included distinguishing at least three patterns of SI response
to ketamine and finding that subjects who exhibited more severe SI at
baseline were not likely to experience an SI response to ketamine.

 

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Traditional antidepressants may take weeks to work on individuals. There have been associations with increased suicidality in some studies. The need for a more rapidly acting antidepressant is important. The study below investigated the antidepressant effect of Ketamine by looking through an FDA database and observing associations of pain and depression reduction with the use of Ketamine. They were clearly present. Of note, minocycline and Diclofenac also seemed to be associated with improved depression parameters.

Ketamine provides both pain relief and anti-depression effects in refractory patients, who by definition, have failed multiple therapies.   ::

 

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Ketamine for Pain Management, Treatment of Depression << Article Link

Article below:

Ketamine may alleviate depression, pain, and adverse effects associated with opioid treatment, and may thus represent an attractive adjunct therapy for pain management, according to a novel population analysis recently published in Scientific Reports.1

Nearly half of all patients with depression taking conventional antidepressants discontinue their treatment prematurely.2 Researchers have sought alternatives to standard antidepressants, for which therapeutic effects are delayed by 2 to 10 weeks.3

Ketamine, an N-methyl-D-aspartate antagonist, was shown to provide acute benefits for treatment-resistant depression, bipolar depression, and major depressive disorder with suicidal ideation, when administered intravenously, however, those studies were conducted on limited samples (20 to 57 participants).4-7

The history of ketamine as an illicit drug favored for its hallucinogenic effects presents ethical obstacles to its use in large clinical trials. Researchers from the University of California San Diego in La Jolla, therefore employed an Inverse-Frequency Analysis approach to investigate whether ketamine, when administered in addition to other therapeutics, has antidepressant properties.

The team applied the inverse frequency analysis method, which looks for negative statistical patterns in the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) post-marketing database of more than 8 million patient records. They observed reductions in depression and pain in patients receiving ketamine, as indicated by negative log odds ratio (logOR) values (logOR, -0.67 ± 0.034 and logOR, -0.41 ± 0.019, respectively). “The data we analyzed are indirect and skewed by cases of bad or lethal adverse effects. Nevertheless the statistics were sufficient to notice the trends,” explained study co-author, Ruben Abagyan, PhD, in an interview with Clinical Pain Advisor.

According to Dr Abagyan, a study recently published by a British team indicates that ketamine might be effective in nearly 40% of patients with severe, treatment-resistant depression, results that are concordant with those from the current study.8

The IFA method was also used to evaluate ketamine efficacy and associated side effects reported in the FAERS database. The investigators found significant reductions in a number of side effects associated with opioid therapies, including constipation (LogOR −0.17 ± 0.023), vomiting (LogOR −0.16 ± 0.025), and nausea (LogOR −0.45 ± 0.034) compared with other drug combinations used for pain management.

The authors concluded that their findings are in line with those from smaller studies, indicating beneficial effects for ketamine as a monotherapy or adjunctive therapy for depression, particularly treatment-resistant depression, with particular indication for patients with suicide ideation, because of its rapid onset of action. “The results should serve as a motivation to conduct a proper clinical trial for the rapid onset treatment of severe depression,” Dr Abagyan noted.

The novel analysis employed in this study may help investigate off-label indications for other drugs. “Ideally the method we proposed should be applied to the actual clinical data rather than the somewhat biased set of un-normalized FAERS reports,” Dr Abagyan added. “The method [can be used] to observe unexpected effects of a treatment by looking at the reduction of the baseline of this effect upon treatment. It can be applied to any effect that is being recorded including cancer, viral diseases mortality, longevity.” he concluded.

 

References

  1. Cohen IV, Makunts T, Atayee R, Abagyan R. Population scale data reveals the antidepressant effects of ketamine and other therapeutics approved for non-psychiatric indicationsSci Rep 2017;7:1450.
  2. Sansone RA, Sansone LA. Antidepressant adherence: are patients taking their medications?. Innov Clin Neurosci. 2012;9(5-6):41-46.
  3. Frazer A, Benmansour S. Mol Psychiatry. Delayed pharmacological effects of antidepressantsMol Psychiatry 2002;7:S23-8.
  4. Price RB, Iosifescu DV, Murrough JW,  et al. Effects of ketamine on explicit and implicit suicidal cognition: a randomized controlled trial in treatment-resistant depressionDepress Anxiety 2014;31:335-343.
  5. DiazGranados N, Ibrahim LA, Brutsche NE, et al. Rapid resolution of suicidal ideation after a single infusion of an N-methyl-D-aspartate antagonist in patients with treatment-resistant major depressive disorderJ Clin Psychiatry 2010;71:1605-1611.
  6. Alberich S, Martínez-Cengotitabengoa M, López P,et al. Efficacy and safety of ketamine in bipolar depression: A systematic reviewRev Psiquiatr Salud Ment 2017;10:104-112.
  7. Larkin, G. L. & Beautrais, A. L. A preliminary naturalistic study of low-dose ketamine for depression and suicide ideation in the emergency departmentInt J Neuropsychopharmacol 2011;8:1127-31.
  8. Singh I, Morgan C, Curran V, et al. Ketamine treatment for depression: opportunities for clinical innovation and ethical foresightLancet Psychiatry 2017;4:419-42

 

Population scale data reveals the antidepressant effects of Ketamine  ::  << Article below

Population scale data reveals the
antidepressant effects of ketamine
and other therapeutics approved
for non-psychiatric indications

Isaac V. Cohen, Tigran Makunts, Rabia Atayee & Ruben Abagyan

Current therapeutic approaches to depression fail for millions of patients due to lag in clinical response
and non-adherence. Here we provide new support for the antidepressant efect of an anesthetic
drug, ketamine, by Inverse-Frequency Analysis of eight million reports from the FDA Adverse Efect
Reporting System. The results of the examination of population scale data revealed that patients who
received ketamine had signifcantly lower frequency of reports of depression than patients who took
any other combination of drugs for pain. The analysis also revealed that patients who took ketamine
had signifcantly lower frequency of reports of pain and opioid induced side efects, implying ketamine’s
potential to act as a benefcial adjunct agent in pain management pharmacotherapy. Further, the
Inverse-Frequency Analysis methodology provides robust statistical support for the antidepressant
action of other currently approved therapeutics including diclofenac and minocycline.

We found that patients listed in the FAERS database who received ketamine in addition to other therapeutics
had signifcantly lower frequency of reports of depression than patients who took any other combination of drugs
for pain (LogOR−0.67±0.034)

Te analysis of the whole FAERS database revealed several other unintentional depression reducing drugs
among antibiotics, cosmeceuticals and NSAIDS.Our data supported previous studies that observed the
psychiatric polypharmacology of minocycline, a tetracycline antibiotic.The NSAID, diclofenac, was also
observed to have some antidepressant properties.It is theorized that both of these drugs may accomplish
antidepressant effects through an anti-inflammatory mechanism.Because of the antidepressant activity of several
NSAIDs, we further separated the non-ketamine pain cohort. Ketamine patients were then compared to
patients who received any other combination of drugs for pain excluding NSAIDs. It was observed that depression
event rates remained low (LogOR−0.56±0.035).As an important side note, we also evaluated efcacy and side efects with the use of ketamine for pain management.
We found that patients who were on ketamine had reduced opioid induced side effects including constipation, vomiting, and nausea. Our data supports ketamine’s
opioid-sparing properties and alludes to the fact that patients may receive benefts of improved pain, reduced
requirement of opioids, and ultimately less opioid reduced side effects.

References
1. Murray, C. J. & Lopez, A. D. Evidence-based health policy–lessons from the Global Burden of Disease Study. Science 274, 740–743,
doi:10.1126/science.274.5288.740 (1996).
2. Kessler, R. C. et al. Te epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication
(NCS-R). JAMA 289, 3095–3105, doi:10.1001/jama.289.23.3095 (2003).
3. Bromet, E. et al. Cross-national epidemiology of DSM-IV major depressive episode. BMC Med 9, 90, doi:10.1186/1741-7015-9-90
(2011).
4. Andrade, L. et al. The epidemiology of major depressive episodes: results from the International Consortium of Psychiatric
Epidemiology (ICPE) Surveys. Int J Methods Psychiatr Res 12, 3–21, doi:10.1002/(ISSN)1557-0657 (2003).
5. Sansone, R. A. & Sansone, L. A. Antidepressant adherence: are patients taking their medications? Innov Clin Neurosci 9, 41–46
(2012).
6. Frazer, A. & Benmansour, S. Delayed pharmacological effects of antidepressants. Mol Psychiatry 7, S23–28, doi:10.1038/
sj.mp.4001015 (2002). Suppl 1.
7. Braun, C., Bschor, T., Franklin, J. & Baethge, C. Suicides and Suicide Attempts during Long-Term Treatment with Antidepressants:
A Meta-Analysis of 29 Placebo-Controlled Studies Including 6,934 Patients with Major Depressive Disorder. Psychother Psychosom
85, 171–179, doi:10.1159/000442293 (2016).
8. Seemüller, F. et al. Te controversial link between antidepressants and suicidality risks in adults: data from a naturalistic study on a
large sample of in-patients with a major depressive episode. Int J Neuropsychopharmacol 12, 181–189, doi:10.1017/
S1461145708009139 (2009).
9. Rush, A. J. et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D
report. Am J Psychiatry 163, 1905–1917, doi:10.1176/ajp.2006.163.11.1905 (2006).
10. Price, R. B. et al. Efects of ketamine on explicit and implicit suicidal cognition: a randomized controlled trial in treatment-resistant
depression. Depress Anxiety 31, 335–343, doi:10.1002/da.22253 (2014).

11. DiazGranados, N. et al. Rapid resolution of suicidal ideation afer a single infusion of an N-methyl-D-aspartate antagonist in
patients with treatment-resistant major depressive disorder. J Clin Psychiatry 71, 1605–1611, doi:10.4088/JCP.09m05327blu (2010).
12. Alberich, S. et al. Efcacy and safety of ketamine in bipolar depression: A systematic review. Rev Psiquiatr Salud Ment (2016).
13. Larkin, G. L. & Beautrais, A. L. A preliminary naturalistic study of low-dose ketamine for depression and suicide ideation in the
emergency department. Int J Neuropsychopharmacol 14, 1127–1131, doi:10.1017/S1461145711000629 (2011).
14. Miyaoka, T. et al. Minocycline as adjunctive therapy for patients with unipolar psychotic depression: an open-label study. Prog
Neuropsychopharmacol Biol Psychiatry 37, 222–226, doi:10.1016/j.pnpbp.2012.02.002 (2012).
15. Rosenblat, J. D. et al. Anti-infammatory agents in the treatment of bipolar depression: a systematic review and meta-analysis.
Bipolar Disord 18, 89–101, doi:10.1111/bdi.2016.18.issue-2 (2016).
16. FDA Adverse Event Reporting System (FAERS): Latest Quarterly Data Files. http://www.fda.gov/Drugs/
GuidanceComplianceRegulatoryInformation/Surveillance/AdverseDrugEfects/ucm082193.htm (Accessed 2016).
17. The Adverse Event Reporting System (AERS): Older Quarterly Data Files. http://www.fda.gov/Drugs/
GuidanceComplianceRegulatoryInformation/Surveillance/AdverseDrugEfects/ucm083765.htm (Accessed 2016).
18. Questions and Answers on FDA’s Adverse Event Reporting System (FAERS) http://www.fda.gov/Drugs/
GuidanceComplianceRegulatoryInformation/Surveillance/AdverseDrugEfects/default.htm (Acessed 2016).

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Ketamine has helped numerous people who have failed so many mainstay therapies. It has treated suicidal thoughts, depression, PTSD, and many other mood disorders in individuals who have gone through multiple standard therapies. How can such an effective therapy not be offered to patients who are failing in standard therapies?

Ketamine For Severe Depression: ‘How Do You Not Offer This Drug To People?’

AUDIE CORNISH, HOST:

Doctors have treated thousands of people suffering from severe depression with ketamine. It’s a hallucinogenic club drug also known as Special K, and it isn’t approved for treating depression. But as NPR’s Jon Hamilton reports, more and more doctors are giving ketamine to patients who’ve run out of other options.

JON HAMILTON, BYLINE: Gerard Sanacora is a psychiatrist at Yale University who has given ketamine to hundreds of patients. As a street drug, ketamine can be dangerous, and for medical purposes, it’s approved only as an anesthetic. So Sanacora says sometimes other doctors tell him…

GERARD SANACORA: This is unethical. How can you be offering this to patients based on a limited amount of information that’s out there and not knowing the potential long-term risk?

HAMILTON: But Sanacora says ketamine often does something no other drug can. It relieves even suicidal depression in a matter of hours.

SANACORA: So if you have patients that are likely to seriously injure themselves or kill themselves within a short period of time and they’ve in fact tried the standard treatments, how do you not offer this treatment to people?

HAMILTON: More and more doctors seem to agree. Dozens of clinics in the U.S. now offer ketamine, and Sanacora says at least 3,000 patients have been treated so far. Early this month, he and other members of a task force from the American Psychiatric Association published a consensus statement on ketamine. It concludes that there is now compelling evidence that ketamine usually work even when other drugs have failed. But there are still lots of questions about ketamine. James Murrough is a psychiatrist at Mount Sinai Hospital in New York.

JAMES MURROUGH: We haven’t had large-scale trials. We don’t know how much or how often it should be given for it to be effective or safe.

HAMILTON: Murrough is an author of another assessment of ketamine that appears in the journal Nature Reviews Drug Discovery. He says there’s an urgent need to answer questions about the drug’s long-term safety because many patients require a dose every couple of weeks to keep depression at bay. Still, Murrough thinks the case for using ketamine is much stronger than it was just a few years ago.

MURROUGH: There’s warranted caution that’s balanced with, you know, an optimism which says we’ve never had a new medication for depression since the era of Prozac.

HAMILTON: Prozac arrived in the 1980s and became the first of a class of depression drugs that target the neurotransmitter serotonin. Ketamine acts on a different neurotransmitter called glutamate. And Murrough says that has got drug firms excited about the possibility of creating a whole new class of drugs for depression.

MURROUGH: Companies are reopening programs. They’re pulling drugs off the shelf that they’ve already developed that they know act on the glutamate system.

HAMILTON: One promising candidate is a chemical sibling of ketamine called esketamine. It’s now in the final phase of testing before consideration by the FDA. Yale psychiatrist Sanacora, who consults for companies developing ketamine-like drugs, says he’s optimistic.

SANACORA: This is probably the most interesting and exciting new development that I’ve seen in my career and probably going back over the past 50, 60 years.

 

 

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Stopping Alcohol Abuse with Ketamine

ReachMD Ketmaine on Roundtable talk

ketamine-to-treat-alcoholism transcript

Stopping Alcohol Abuse with Ketamine   << Article Link

A currently ongoing study based at University College London (UCL) involves giving a dose of ketamine to alcohol abusers. Yes, you read that correctly. Ketamine is a legal tranquilizer, used mainly on small animals by veterinarians. However, ‘Special K’ doubles as a recreational drug, found most often at dance parties and nightclubs. So how the heck does ketamine stop alcohol abuse? The answer is by manipulating alcohol-associated memories.

Let’s start over.

ketamine-picture

Certain things make drinkers want to drink. Ask anyone who consumes alcohol often, and they’ll tell you it’s true. Maybe the smell of alcohol triggers the desire to drink. Maybe it’s a certain place, or some classic rock song. When this happens, the drinker’s memories of alcohol giving pleasure are recalled, and his or her brain wants that alcohol-induced pleasure again. This is the precursor to alcoholism, wherein the brain can’t function without alcohol.

Cravings are essentially fond memories. You are recalling the pleasure of something and desiring it again. During this memory recall, “…the neural connections that encode [the memory] are temporarily destabilized, meaning that our recollection can be slightly altered before it goes back into storage,” as written in The Guardian, linked above.

Ketamine causes memory loss and/or disruption, by blocking a receptor in the brain called NMDA. This particular receptor is partly responsible for our ability to form memories. The UCL research team believes they can use this effect of ketamine to ‘erase’ the memories associated with craving alcohol. “There is evidence that it could be useful as a treatment for alcoholism,” said lead researcher Ravi Das.

The Library Book Metaphor

Every time you access a memory, you are basically removing it from your mental library. In a real library, a book can be removed and read, like a memory can, but it also becomes vulnerable. The book borrower could rip a page out, cross out some text, or even damage the book. The same thing goes for memories. This is why we give slightly different accounts of our past each time we do so.

Because ketamine disrupts the memory-formation process, the idea of the UCL study is to trigger alcohol cravings in participants, and then give them ketamine. The hope is to weaken the alcohol-related memories, ultimately to the point of non-existence.

A dose of ketamine administered at the time of alcohol-related memory recall, the researchers hope, will make it so you lose the book of alcohol-craving from your mental library. The ‘temporary destabilization’ of our memories, when recalled, acts as the window of opportunity for ketamine to work. The ultimate goal is to eliminate the triggers for craving a drink.

The UCL Study

The research team consists of psychologists from University of Exeter, Imperial College London, and UCL. Participants must consume at least forty drinks per week, drinking four or more days per week. This qualifies them as heavy drinkers. However, participants cannot be clinical alcoholics. Anyone with diagnosable alcohol dependence would be excluded. They are aiming for 90 people to participate, and at the time of a July 2016 publication, over 50 people were already in.

Apparently no further details have been published yet about whether or not the quota has been met. Some details on what the study involves have been published, and as of the time of this writing, a flyer advertising the study is still online. So far, here’s what we know the study entails:

The psychologists intentionally trigger the craving for alcohol in the participants. A glass of beer is placed directly in front of each person. This is a surefire trigger – no scientific explanation needed. The details of what happens next are being withheld by the team. However, according the Guardian, “They will then disrupt the memory, by surprising the participant (the team is not disclosing the exact details as this could bias the results).”

The ketamine comes next. After the memory is triggered and disrupted, each participant is either given “a ketamine infusion, with a concentration equivalent to a high recreational dose, or a placebo.” The team then stays in touch with all 90 people for one full year after the ketamine dose, to see how their drinking habits have changed.

Short-term Results are Promising

One participant, who already received the ketamine dose, claims that it worked. According to the Guardian article, 31-year-old Nikki, a consultant in London, took part in the study when she realized she was drinking heavily. She was even drinking more than she wanted to. “It’s just in the culture. That’s what all my friends are like… everyone drinks to excess,” she said before the study.

After her alcohol craving was triggered and her memory was manipulated, Nikki was given her ketamine dose. She described the experience as overwhelming and intense, but not unpleasant. “It was quite psychedelic. I felt untethered from my body,” she said.

One week later, Nikki reported an “incredible positive mood,” and said she was much more aware of her decisions regarding drinking. She didn’t say she gave up alcohol completely. However, she did praise the study. “In the past, there were occasions where I would be drinking and I’d be on autopilot: ‘Let’s get another drink’,” said Nikki.

Although one week is only 1/52nd of a year, Nikki’s story proves as a promising example of how a ketamine dose could prevent heavy drinking.

Similar Approaches to Different Problems

Using one drug to fight the abuse of another drug is not unheard of. Actually, two years ago, Merel Kindt and Marieke Soeter of University of Amsterdam performed a study that used a beta-blocker to get rid of arachnophobia. Beta-blockers are used primarily for cardiac care. The particular one used in the study, propranolol, treats high blood pressure, and is also used to reduce performance anxiety.

Fifteen participants with diagnosed arachnophobia, a fear of spiders, were shown a giant tarantula, and told they had to touch it. Then they were each given a dose of propranolol. The arachnophobia was gone for good.

According to the article linked above, “They erased their spider fear memories and then rewrote them with one of triumph — touching the tarantula a week after their treatment. When they returned to her lab three months and a year later, the effects stuck.”

Michael Saladin is attempting to end tobacco addiction with a similar approach. He is a professor at the Medical University of South Carolina, and he believes smoking addictions can be ended by getting rid of the cues (triggers) that make addicts smoke.

“There is a vast animal research literature that suggests memories can be manipulated following reactivation,” Saladin said. “I am convinced that there is sufficient evidence to believe that memory reconsolidation can be harnessed for clinical purposes.”

Memory Reconsolidation

The process being utilized in the UCL study, as well as in both studies mentioned above, is known as memory reconsolidation. The entire concept is relatively new. Essentially, the idea is to replace the bad memories associated with certain things with good memories, feelings of accomplishment and healthy pride. In the case of resisting alcohol, the already-consolidated memories of drinking will be replaced with new memories of feeling proud of not drinking. The ketamine allows this process to occur.

This may seem futuristic to you, and frankly it is. Scientists discover new information every day, and in the age of the microchip, our limits are becoming harder to see. New methods for how we do just about everything are being found. Yet when the use of illegal drugs, (ketamine is illegal to possess and is not a prescribed drug), becomes one of the methods that scientists discover, there tends to be a lot of pushback.

The scientists wish people would stop resisting.

Just because something is illegal and/or looked down on by society doesn’t mean that something isn’t effective in another way. We are seeing this nationwide with marijuana.

The Pushback

Lead researcher Das spoke to this resistance the public has for illegal/illicit drugs being used as medicines: “There’s just the general social attitude that everything that’s illegal is terrible. There will obviously be that kind of narrow-sighted pushback, but if it’s safe and effective enough it should be recommended.”

Das isn’t implying that ketamine is safe to use for anyone who wants to fix a bad memory. What he’s implying is that in a controlled, medical environment, a one-time dose of ketamine could help heavy drinkers relax on the booze.

Quoted in the Guardian article, Andrew Misell is a spokesman for Alcohol Concern, a non-profit charity working to reduce alcohol harm in the UK. Speaking about the UCL study in particular, he said, “The researchers have quite rightly highlighted what a lot of people in recovery from alcohol problems know from experience, namely that cues or triggers like the smell of beer can cause a relapse even after long periods of abstinence. Any work looking at how people can overcome these pitfalls is going to be useful.”

Misell added that he knows ketamine-based therapy has risks. What Misell didn’t add is that alcohol abuse has much more inherent risk than drug-based therapy. Not to mention, ketamine itself is significantly safer, and much less abused, than xanax, the number one drug used in all of psychotherapy.

Why the Pushback?

Medicine is medicine. Unless you the reader are a scientist or a doctor, you and I have no influence on what becomes medicine. If a one-time dose of ketamine can prevent alcoholism, why would anyone resist? Xanax is the most prescribed drug in all of psychotherapy, yet people abuse it WAY more often than ketamine. The NY Post published an article just last year explaining this, going so far as to say that xanax is ruining lives.

OxyContin, a drug used rather commonly for chronic pain, legal with a prescription, ends the lives of 100,000 people every single year. So why the pushback for ketamine?

In Conclusion

Drug/alcohol abuse is a horrible thing. People are dying in mass numbers from drug/alcohol abuse, and not just in America. This author does not condone the abuse of alcohol, nor does this author condone the use of illicit drugs. However, as this author wrote prior, what becomes a medicine is not a decision for anyone but scientists and doctors. If yours truly was a heavy drinker, and a doctor told me that habit could be stripped away with a one-time dose of ketamine, believe that no more questions would be asked.

One can only wait for the final results from the UCL study to see how many more participants turn out like Nikki. If and when the study proves effective for more and more people, we may begin to see a radical change in the way we fight addiction. It may seem like fighting fire with fire, but sometimes it works. Brushfires that spread rapidly are sometimes stopped by deliberately burning a section of earth where the fire is headed. Maybe ketamine is that deliberate burn in the realm of alcohol addiction

Tip sheets:

Prof Evgeny Krupitsky – Ketamine Psychotherapy For Heroin Addiction: Immediate Effects and Two-Year Follow- up

 1997 Apr-Jun;29(2):165-83.

Ketamine psychedelic therapy (KPT): a review of the results of ten years of research.

Abstract

Ketamine is a prescription drug used for general anesthesia. In subanesthetic doses, it induces profound psychedelic experiences and hallucinations. The subanesthetic effect of ketamine was the hypothesized therapeutic mechanism in the authors’ use of ketamine-assisted psychotherapy for alcoholism. The results of a controlled clinical trial demonstrated a considerable increase in efficacy of the authors’ standard alcoholism treatment when supplemented by ketamine psychedelic therapy (KPT). Total abstinence for more than one year was observed in 73 out of 111 (65.8%) alcoholic patients in the KPT group, compared to 24% (24 out of 100 patients) of the conventional treatment control group (p < 0.01). The authors’ studies of the underlying psychological mechanisms of KPT have indicated that ketamine-assisted psychedelic therapy of alcoholic patients induces a harmonization of the Minnesota Multiphasic Personality Inventory (MMPI) personality profile, positive transformation of nonverbalized (mostly unconscious) self-concept and emotional attitudes to various aspects of self and other people, positive changes in life values and purposes, important insights into the meaning of life and an increase in the level of spiritual development. Most importantly, these psychological changes were shown to favor a sober lifestyle. The data from biochemical investigations showed that pharmacological action of KPT affects both monoaminergic and opioidergic neurotransmitter metabolism, i.e., those neurochemical systems which are involved in the pathogenesis of alcohol dependence. The data from EEG computer-assisted analysis demonstrated that ketamine increases theta activity in cerebrocortical regions of alcoholic patients. This is evidence of the reinforcement of limbic cortex interaction during KPT session.

Ketamine is gaining widespread acceptance as a fast and effective treatment for depression. It is so successful that ketamine has been called “the most important discovery in depression research in half a century” says Ronald Duman MD, Professor of Psychiatry at the Yale University School of Medicine. “A single dose of ketamine alleviates depressive symptoms within hours in patients who have failed to respond to two or more conventional antidepressants” he states in a scientific article published in the respected journal Science.

Researchers now believe it can treat more than depression and anxiety. Ketamine has recently generated a lot of interest among psychiatrists and addiction medicine physicians as a potential new and rapidly effective approach to treating struggling with other difficult-to-treat conditions such as substance abuse disorders and alcohol dependence.

“Current treatments benefits for alcoholism are at best modest, about three quarters of people return to drinking after 6 months, so there is a great need for new and more effective therapies” said Dr. Grass, Director of the Ketamine Institute in Pensacola Fl. “Many patients who come to us for ketamine therapy with conditions such as depression, anxiety or PTSD have self-medicated with alcohol or opioids to find relief. Initially, they find that alcohol seems to help their symptoms until it doesn’t anymore and it then become another serious medical issue in their lives” says Dr. Grass.

Can Ketamine Cure Alcoholism or Drug Addiction?

Research studies are currently underway at Yale and Columbia University in the United States and the University of Exeter in the United Kingdom to explore the beneficial effects of ketamine infusions on substance abuse disorders. Ketamine has already been shown to be an effective for depression, something that many people with substance abuse issues encounter as they try to become sober. As an antidepressant, it’s unique in that it acts very quickly, with patients often reporting an improvement in their mood over just one or two days. That could make it ideal for treating active, as well as, recovering alcoholics, who often suffer from depression immediately after quitting.

“This form of therapy is not new, says Dr. Grass. We have known for almost 30 years that ketamine may be effective in dealing with substance abuse issues.” In the 1990’s, Dr. Evgeny Krupitsky published research documenting over 10 years of observations utilizing ketamine for substance abuse disorders. His results suggest that ketamine can be remarkably more effective that current treatment options. Few people with substance abuse disorders can maintain abstinence following therapy with traditional approaches. However, Krupitsky found that as many as 66% remained alcohol free after one years as compared to only 24% with traditional treatment.

In addition, Krupitsky also found that the beneficial effects were dose dependent and that those people who received higher dosages of ketamine did better than those who received lower amounts. Following the study, psychological testing revealed that ketamine treated patients showed improvement on tests such as the Minnesota Multiphasic Personality Inventory (MMPI) personality profile. Changes seen included a positive transformation of self-concept and emotional attitudes, positive changes in life values and purposes. Patients also experienced important insights into the meaning of life and an increase in the level of spiritual development. Most importantly, these psychological changes tend to favor a sober lifestyle.

“We see many patients with depression, anxiety or PTSD who have at one point or another turned to alcohol or other substances to find relief only to become dependent upon these drugs”, says Dr. Grass. “A ketamine infusion, given at the right dose, can be a remarkably effective therapy in reversing these symptoms and alleviating their dependence upon alcohol or opioids. Often after just several ketamine treatments they can stop drinking and have no interest in alcohol or drugs after that.”

Ketamine – It’s Just the Beginning

Although more research is needed to determine exactly why there’s such a strong correlation between ketamine therapy and decreased use of alcohol and opioids, this observation does appear to validate the experiences of many people who have found substances like ketamine be life-changing tools that have helped them lead happier, more fulfilling lives. For many, this therapy has helped them cut back or quit their use of alcohol, opioids or other substances with which they have had a problematic relationship. One day, doctors may use ketamine routinely not only to help severely depressed people, but many who suffer from related conditions such as alcohol and substance abuse issues. “While the science is very promising, ketamine is not to be considered lightly and must be carefully monitored when used. But with the excitement generated by early results, we will have more information soon,” Grass says.


References:

Duman RS, Aghajanian GK, (2012) Synaptic Dysfunction in Depression: Potential Therapeutic Targets. Science. 338(6103):68-72.

Synaptic Dysfunction in Depression Potential Therapeutic Targets

Krupitsky EM, Grinenko AY, (1997) Ketamine Psychedelic Therapy (KPT): A Review of the Results of Ten Years of Research. Journal of Psychoactive Drugs. 29(2):165-83

Ketamine therapy in Virginia | Ketamine for depression \ 703-844-0184 | Dr. Sendi | Ketamine for alcohol and drug abuse | Ketmaine psychotherappy

ketamine-and-rehab-therapy – Thailand

Ketamine Therapy

One of the most controversial issues surrounding ketamine is that it has been found to be an effective tool in therapy for addiction and depression. Researchers studied the effects of the drug on individuals who suffered severe depression and found that it was effective in relieving both symptoms and increased the effectiveness of psychotherapy. The drug has had interesting and astonishing results when used on patients who suffer from difficult depressive conditions, including bipolar disorder. The fast-acting nature of the drug proved to be the most interesting anti-depressant effect. Typically, anti-depressant medications can take days or weeks to start working which can prove ineffective if someone is suffering from a depression crisis. Administration of ketamine has provided immediate and short-acting results against depression, though it has been found ineffective in the long term.

Ketamine has been used as an alternative drug and alcohol therapy for nearly 30 years. The drug is administered under clinical conditions to individuals who are suffering the effects of chronic addiction and depression and the results have proved to be effective for some people. The drug has been found to only provide positive outcomes after detoxification from other drugs has occurred, and it is combined with effective professional psychotherapy. One study showed that there was a significant increase in the level of anhedonia, depression and anxiety that recovering heroin addicts experienced when they had been through ketamine psychedelic therapy. This is a significant result and such information may increase the use of ketamine as a therapeutic tool.

 

 

Clinical Trial:

https://clinicaltrials.gov/ct2/show/NCT01551329

Detailed Description:

Major depression and alcohol dependence are both within the ten disorders for highest worldwide disease burden as identified by the World Health Organization (WHO), and these disorders frequently co-occur, especially in high-service utilizing patients with severe and persistent mental illness. Currently available treatments are inadequate for both chronic conditions alone, and the inadequacy is even clearer in people meeting criteria for both disorders. Ketamine was first reported as a rapidly-acting antidepressant in 2000 via research occurring at Yale, and, since that time, in several small randomized controlled trials, a single subanesthetic dose of intravenous ketamine has demonstrated efficacy in improving mood in unipolar and bipolar depression within only hours after administration. These effects can last at least a week. Interestingly, ketamine has been demonstrated to produce a more robust effect in treatment-refractory unipolar depressed subjects with a family history of alcoholism relative to similarly difficult-to-treat subjects without a family history of alcohol problems. In addition, recently-detoxified alcoholics have been safely administered subanesthetic doses of ketamine, and, during these infusions, alcoholics (and even those with only a family history of alcoholism) displayed a differential response to ketamine, e.g. blunted psychotic-like and cognitive effects, relative to healthy controls. Therefore, ketamine may reduce depressive symptoms and alcohol consumption compared to placebo in patients with comorbid major depression and current alcohol dependence. Positive results will mark a major advance in the clinical care of those being treated for both conditions and will open the door for further scientific investigations into the clinical neuroscience of these highly comorbid and prevalent conditions.

This is a two phase, double-blind, randomized, placebo-controlled, cross-over, proof-of-concept study designed to determine the effects of a single dose of ketamine, administered IV, on mood and alcohol consumption, in psychotropic medication-free patients meeting DSM-IV-TR criteria for a major depressive episode (MDE) and current alcohol dependence. Participants will be assigned randomly to receive either intravenous ketamine (0.5mg/kg) or saline solution 2 weeks apart in a cross over design. The ketamine dose was based on previous studies in patients with depression and bipolar disorder. A team member experienced with ketamine infusions will administer the study medication over a 40-minute infusion in a blinded fashion at the Biological Studies Unit at the WHVA.

20 depressed alcohol dependent subjects between the ages of 21-65 will be recruited for this study through advertising and the West Haven VA clinics. Subjects will complete an informed consent process and will be thoroughly screened for inclusion and exclusion criteria as described below. Individuals will be given a post consent test to evaluate their understanding of the procedure. For subjects who provide incorrect answers to any of the test items, the research staff will review the correct answers with the subject and show the subject where the correct answers are found in the consent form. Those who get more than 60% of the questions wrong and are still unable to understand the procedure after reviewing it with the research staff will be excluded from the study. They will be referred to appropriate resources for outpatient treatment of their depression and alcoholism. Before start of the study all patients will be free of any psychotropic medications.

Ketamine for cocaine treatment

On the motivational properties of reward cues Individual differences

Subanesthetic ketamine decreases the incentive-motivational value of reward-related cues.

The effects of subanesthetic ketamine infusions on motivation to quit and cue-induced craving in cocaine-dependent research volunteers.

Ketamine emerging as top treatment for cocaine dependence

EXPERT ANALYSIS FROM THE ECNP CONGRESS

 

– The prospect on the horizon of two new effective therapies for chronic cocaine dependence – sustained-release dextroamphetamine and subanesthetic ketamine infusions – was among the top developments of the year in addiction medicine, Wim van den Brink, MD, PhD, said at the annual congress of the European College of Neuropsychopharmacology.Other highlights on his list included:• Studies establishing that comorbid attention-deficit/hyperactivity disorder (ADHD) and substance use disorder now can be treated effectively with either extended-release mixed amphetamine salts or high-dose methylphenidate.

Dr. Wim van den Brink

Dr. Wim van den Brink

• Evidence that the alpha-1 blocker doxazosin is an effective treatment for alcoholism in a specific well-defined subset of patients, opening the door to a personalized medicine approach to this disease.• Release of a puzzling array of conflicting studies on the use of high-dose baclofen for treatment of alcohol dependence. It’s tough to reconcile this mishmash of polar opposite results. And that dictates it’s time to declare a moratorium on the use of this therapy in clinical practice, which in many places is now widespread, said Dr. van den Brink, professor of psychiatry and addiction at the University of Amsterdam and director of the Amsterdam Institute for Addiction Research.

“It’s too strange that we have such conflicting evidence out there. Too many people are prescribing crazy-high doses of baclofen with no strong supporting evidence,” Dr. van den Brink said.

Cocaine dependence

Dr. van den Brink was a coinvestigator in a Dutch multicenter randomized, double-blind, placebo-controlled trial of multitreatment-refractory comorbid cocaine dependence in 73 heroin-dependent patients in heroin-assisted treatment. Patients assigned to 60 mg/day of sustained-release dextroamphetamine, in addition to the background methadone and diacetylmorphine all participants were on for their heroin dependence, had significantly fewer days of cocaine use in the 12-week study: a mean of 44.9 days, compared with 60.6 days in placebo-treated controls. Adverse events were transient and well tolerated (Lancet. 2016 May 28;387[10034]:2226-34).

“A lot of medications have been tried for treatment of cocaine dependence, but actually none of them has been shown to be effective with the exception of substitution treatment with stimulants. Ours is one of the most successful trials. These patients were using cocaine an average of 24 days per month along with a lot of other drugs, despite being in heroin treatment for 4 years,” Dr. van den Brink said. “Patients were very willing to take the sustained-release dextroamphetamine. In the last 4 weeks, 84% of them used at least 80% of their medication. And they were blinded to what they were using.

“We saw good effect sizes: 0.6-0.7 for self-report measures and 0.31 for negative urine samples. So this is a very promising approach. But it also means that, like with tobacco dependence or alcohol dependence, we have to start thinking about substitution therapy in stimulant-dependent patients,” he said.

Dr. van den Brink said subanesthetic ketamine as a novel treatment for cocaine dependence is not yet ready for prime time use in clinical practice, because it’s just not practical to bring patients in for a roughly hour-long intravenous infusion on a daily basis, as was done in a highly impressive proof-of-concept study. But new formulations of ketamine are under development that should better lend themselves to use in clinical practice.

In the proof-of-concept study, investigators at the New York State Psychiatric Institute brought into the laboratory cocaine-dependent volunteers not seeking treatment or abstinence and administered 52-minute infusions of ketamine at 0.41 or 71 mg/kg or lorazepam at 2 mg (Biol Psychiatry. 2014 Jul 1;76[1]:40-6). Lorazepam had absolutely no effect on motivation to change, but ketamine was a different story.

“As soon as you give a low dose of ketamine, you see a wonderful effect on motivation to change and on craving ratings in assessments at 24 hours post infusion. This looks like another promising way of treating cocaine dependence,” he said.

Doxazosin for alcoholism

Investigators at the National Institute on Alcohol Abuse and Alcoholism and several U.S. universities hypothesized that the norepinephrine system could be an important treatment target in alcohol dependence. They conducted a double-blind, placebo-controlled randomized trial in which alcohol-dependent patients seeking outpatient treatment were assigned to the alpha1-adrenergic blocker doxazosin (Cardura) titrated to a maximum of 16 mg/day or placebo. They found doxazosin significantly reduced drinks per week and the number of heavy drinking days per week, but only in the subgroup of patients with a strong family history of alcoholism. In patients without such a family history, doxazosin paradoxically increased drinking (Addict Biol. 2016 Jul;21[4]:904-14).

One of the reasons adult ADHD is greatly underrecognized is that it tends to occur in combination with flashier substance use disorders. “Addiction is very comorbid with all kinds of disorders, but especially with externalizing childhood disorders like conduct disorder and ADHD,” Dr. van den Brink said.

It was shown half-a-decade ago that normal doses of methylphenidate have no effect on ADHD symptoms or substance use in comorbid adults. Then Swedish investigators reported that treating criminal offenders with high-dose methylphenidate – roughly three times greater than standard dosing – was effective in reducing both ADHD symptoms and comorbid substance use in criminal offenders. Those findings prompted investigators at the New York State Psychiatric Institute and the University of Minnesota to examine whether prescribing extended-release mixed amphetamine salts in adults with comorbid cocaine use disorder and ADHD would achieve improvement in both conditions. Indeed, it did, Dr. van den Brink said.

One hundred twenty-six affected patients were randomized to 60 or 80 mg/day of extended-release mixed amphetamine salts or placebo for 13 weeks coupled with weekly individual cognitive-behavioral therapy for all in this double-blind, three-arm clinical trial.

“They showed a number-needed-to-treat of about 2.5 in order to achieve a significant reduction in cocaine use and a very nice reduction in ADHD symptoms with a number-needed-to-treat of 3,” Dr. van den Brink said.

The rate of continuous cocaine abstinence in the last 3 weeks of the trial was 30% in the 80-mg group and 17.5% with 60 mg of extended-release mixed amphetamine salts, compared with just 7% with placebo (JAMA Psychiatry. 2015 Jun;72[6]:593-602).

Interpreting baclofen studies

The first high-quality multicenter, randomized, placebo-controlled, double-blind clinical trial, conducted in Germany, showed baclofen (Lioresal) at a mean dose of 180 mg/day was effective in maintaining alcohol abstinence (Eur Neuropsychopharmacol. 2015 Aug;25[8]:1167-77).

“They got wonderful results, with a number-needed-to-treat of 2.3. That is something we’re not used to seeing in the treatment of alcoholism. But there was no dose-response effect, which is a little unusual,” the psychiatrist observed.

Then a multicenter group of Dutch investigators, including Dr. van den Brink, carried out what they believed would be a confirmatory randomized, double-blind, placebo-controlled trial. However, it showed no difference between high- or low-dose baclofen and placebo in time to relapse (Eur Neuropsychopharmacol. 2016 Dec;26[12]:1950-9).

Little further light was shed by the two large French randomized, placebo-controlled clinical trials presented at the 2016 World Congress for Alcohol and Alcoholism in Berlin. One, the BACLOVILLE trial, included 320 patients treated in 60 family practice clinics; it showed strongly positive results for high-dose baclofen. In contrast, the 316-patient ALPADIR study proved negative. These conflicting results were particularly disappointing because France has been at the forefront of using high-dose baclofen to treat alcoholism, Dr. van den Brink said.

“Maybe some 100,000 people have been treated with high-dose baclofen for alcoholism in France,” he said. “What is the conclusion from all these baclofen studies? You can interpret them in many ways. Maybe there are two positive trials and two negative trials, or maybe there are two positive trials and two failed trials. The debate is not closed, even after four randomized trials.”

https://www.mdedge.com/clinicalpsychiatrynews/article/121238/addiction-medicine/ketamine-emerging-top-treatment-cocaine

Ketamine trials –

Researchers in the UK and US are running studies to see if ketamine could help prevent alcoholics from relapsing.

Ketmaine 703-844-0184 infusions| Fairfax, Va | 22308 |Woodbridge Ketamine | Ketamine for depression

People looking to quit problematic drinking in the UK could one day have access to a new, quick-acting treatment to help them cope with the difficult first few weeks of sobriety: ketamine.

In a new trial taking place at the University of Exeter and University College Hospital in London, researchers are using small shots of the tranquilizer—perhaps best known in the country as a popular party drug that can ruin the bladder lining of heavy users—alongside standard psychotherapy treatments to see if it can help treat alcoholism.

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“Current effects of treatments for alcoholism are at best modest, about three quarters of people return to drinking after 6 months, so there is a dire need for new treatments,” said Celia Morgan, a professor of psychopharmacology at the University of Exeter, and one of the lead researchers on the study.

“It could help people who are stuck in a rut with alcoholism. It may prime your brain to take on new experiences from the world.”

Ketamine has already been shown to be an effective treatment for depression, something that’s done a lot to rehabilitate its reputation. As an antidepressant it’s unique in that it acts very quickly, with patients often reporting an improvement in their mood over just one or two days.

That could make it ideal for treating recovering alcoholics, who often suffer from depression immediately after quitting.

“We know that in alcohol dependence, depression is a predictor of relapse in the first couple of weeks. So we’re able to give people the ketamine package in the time at which they might be particularly susceptible to relapse,” said Morgan.

The trial, which is funded by the UK government’s medical research charity, will have participants take part in seven therapy sessions, three with shots of ketamine. Control groups will receive no drug and no therapy conditions. Ideally, the ketamine will act as a sort of stabiliser for depression, and possibly increase the power of the therapy.

Morgan said experiments with animals show that ketamine may help form neuronal connections in the brain, and that could mean that in humans the therapy will be more effective or more likely to “stick.”

“There’s new scientific evidence in animal models suggesting that their brains might be primed to learn more [after taking ketamine,]” she said. “So it could help people who are stuck in a rut with alcoholism. It may prime your brain to take on new experiences from the world.”

“We’re not going for the full-blown mystical experience”

Morgan is not the only one pursuing this theory. Elias Dakwar, a Professor of Clinical Psychiatry at Columbia University in New York, is currently recruiting patients for a similar trial that will use ketamine treatment alongside motivational therapy for alcoholism. He says that the way people’s brains adapt to addiction is similar to that of depression.

“People sort of forswear their own agency and self-efficacy, and there’s a sense of resignation,” he said. “The thinking on ketamine’s effect on depression is that it reverses depression-related adaptation through neuroplasticity.”

In other words, it could make the brain more ready to create new connections and move away from old patterns of behaviour, making it an ideal companion for therapy that’s meant to help people re-evaluate and change their lives.

The ketamine doses Morgan plans to use are higher than those used in standard depression treatment, but they’re not quite enough to cause the sort of total dissociation that has led some scientists to class ketamine as a psychedelic drug, and far less than the maximum safe dose as an anaesthetic.

“We’re not going for the full-blown mystical experience,” Morgan said. “We’re looking at treatment we can do within the National Health Service as well; this is something that is funded by the government, so we are looking at things that are acceptable in that context.”

Both trials are still in the early stages: Morgan’s started in June and is set to run until 2017, and Dakwar’s should wrap up next year. But if the results are positive, ketamine’s use could expand quickly. Alcoholism, like most addictions, is notoriously difficult to treat, with few effective drugs available. And according to the NHS, nine percent of men and four percent of women in the UK show signs of alcohol dependence.

“It’s one of those really intractable disorders that people have been trying to find a drug therapy for some time,” said Dr Dakwar.