Dr. Mark Gostine, co-founder of Michigan Pain Consultants, said chronic pain and depression go hand in hand, which is why 40 to 50 percent of his practice’s patients are on anti-depressants.
“People with chronic pain frequently suffer from depression,” Gostine said. “It alters their lifestyle, and there is the suffering component of pain, so not uncommonly, we see depression as part of the whole pain experience.”
Gostine said about two years ago, Michigan Pain Consultants, which has multiple locations across the state, began using the anesthetic drug ketamine to treat depression.
Ketamine increases neural connectivity across an individual’s prefrontal cortex, which is the part of the brain under the forehead where higher-level thinking takes place. While researchers don’t know exactly how ketamine works as an anti-depressant, Gostine said the increased connectivity seems to be associated with the anti-depression effect.
“What is really fascinating is that those physical changes are pretty durable after a single hour-long infusion,” Gostine said. “So, a single ketamine infusion provides about three to four weeks of relief for a patient.”
Ketamine is a relatively new depression treatment, and Gostine said most people are not aware that it’s a treatment option in Michigan.
“I don’t know anyone else in Michigan doing it besides us,” he said. “There aren’t a lot of doctors with the skill set of the physicians at Michigan Pain Consultants.”
Gostine said to administer ketamine safely, doctors need a combined training in anesthesiology and depression treatment. He said Michigan Pain Consultants has 20 physicians in its network in Michigan with the training required to administer ketamine. It also employs behavioral therapists.
“If you are giving a patient a potent drug used in anesthesia, you have to be able to manage the airway and provide life support if the patient’s body reacts adversely to the ketamine,” he said. “You also need to know how to treat and address depression.”
He said while ketamine is a safe drug that actually supports respiration, complications could still occur that require a trained anesthesiologist.
Gostine said ketamine does have side effects that individuals should be aware of as well, including hallucinations and dysphoria.
“People can cry or get weepy,” he said. “But we tend to administer it with other drugs, so that experience is very rare.”
Gostine said another reason ketamine is not in widespread use by physicians is because many insurance plans don’t cover it, especially if it’s being used specifically to treat depression rather than as part of an overall pain management treatment plan.
“We bill insurance, but it doesn’t pay a great deal,” he said. “Most physicians don’t accept insurance, because it pays inadequately.”
Another barrier in the use of ketamine is that it can only be administered intravenously, but Gostine expects an oral drug is on the horizon.
“The pharmaceutical community realizes depression is an unmet need. The current anti-depression drugs we have don’t work. They may have a 10 percent advantage over a placebo,” he said. “We need new drugs. Ketamine and drugs based on ketamine will fill that need. We are going to see analogs of ketamine emerge that are also orally available.”
In fact, he said Michigan Pain Consultants recently signed on to be part of an FDA trial for an oral ketamine drug developed by Naurex, but the company was purchased by Allegan Pharmaceutical, putting the trial on hold.
Gostine said treating depression is integral to pain management, because depression is a key barrier to the self-care that can help someone improve the impacts of their underlying health condition.
“Severe untreated depression is why so much self-care is not addressed and undertaken,” he said. “You see a diabetic, who is 300 pounds and is in danger of losing a leg, why would they not take care of themselves?
“It’s because they are depressed. Where self-care fails is basically because of depression, so we will absolutely see this space mined for drugs that work similar to ketamine, but perhaps without the side effects.”
Michigan Pain Consultants is part of North American Partners in Anesthesia.