Orange is a new black: a short story about ketamine

Once upon a time, I started General Surgery rotation in urgent care. It was around 2am when we admitted a healthy muscular young fellow with perianal abscess. He needed a so-called I&D (incision and drainage), or, put it simply, to get the pus out. In 1986, not every surgical intervention required the attendance of an anesthetist. Nurses or medical students would take blood pressure and measure pulse and administer sedative drugs. My surgeon asked me, at that time, medical student,  to inject "Calypsol" a drug that I subsequently learnt had another name - ketamine. The surgeon explained the medication will allow him to make incision without knocking the patient completely out. The surgery went well, and after 15 min, we were on our way to the recovery room. Here things went unexpectedly odd. The patient became somewhat agitated, his muscles tensed, and he developed a visible erection.  He was mumbling something incomprehensible. Only after he woke up, he broke into a slew of emotional comments full of profanities and described vivid dreams, hallucinations and "out of body experience." 

Later in my work as an anesthetist, I used ketamine so often in trauma setting when an accidental drop of the blood pressure and depression of breathing were undesirable.  At that time, I already knew about "funny" sides of ketamine and always added medications to prevent or forget psychedelic experiences. 

Fast forward into my later years, we started using ketamine during and after surgeries for patients on high doses of opioids. It resulted in a dramatic decrease in morphine consumption and better pain control. 

My fourth and ongoing encounter with ketamine started one year ago. I finally overcame my skepticism related to reported miracles after ketamine infusions for chronic pain. As a matter of fact, I was familiar with publications concerning high-dose administration in an intensive care setting over several days for managing severe pain due to so-called Chronic Regional Pain Syndrome (CRPS). However, ketamine low-dose infusions in an ambulatory setting just did not sit well with me. Anyhow, after persuasion by colleagues and reading more literature, I tried it on a very carefully selected patient. I anxiously waited for her next appointment fearing to hear a horror movie story with hallucinations and other adventures. To my astonishment, the lady assured me that "it was the best experience" and her burning pain of the past 5 years disappeared. She also commented her mood and vitality have dramatically improved. Ever since I became a strong advocate for this therapy. In my experience, neuropathic pain (e.g., diabetic neuropathy, CRPS, phantom pain) is the most appropriate indication, following by a widespread fibromyalgia-type.  Even when the severity of pain remained the same, pain unpleasantness and other disturbing sensations tend to diminish.

Last but not least positive side effect is antidepressive. I do not treat depression, and when asked, send patients to mental health specialists. Nonetheless, chronic pain and depression are interwoven. Improved mood results in a decreased perception of suffering, gives more willpower for self-management and reactivation. 

Who would believe that the old drug with hallucinogenic properties similar to LSD and "magic mushrooms" will be a powerful remedy to fight chronic pain?