Ketamine vs Opiates for Pain

Written by Thomas Davis

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Low-dose ketamine was non-inferior to IV opioids for acute pain control in adult patients in the emergency department.

Why does this matter?
Whether it be due to concerns over the opioid epidemic, the seemingly constant drug shortages in the United States, or the need to avoid certain opioids in patients with high risk comorbidities such as renal disease, finding alternatives to opioids for pain control is a top priority. ACEP has recommended ketamine as an alternative to opioids. But in a strict head-to-head meta-analysis, does ketamine actually offer analgesia comparable to opioids?

A K.O. for Ketamine Only?
This was a systematic review and meta-analysis that, compared to prior reviews, used more stringent inclusion and exclusion criteria. As a result, it only included three RCTs with a total of 261 patients. Patients were given either IV low-dose ketamine (≤0.5 mg/kg) or IV morphine (0.1mg/kg). The pooled estimate of mean change in pain scores was 0.42, which favored ketamine but was not statistically significant (95% CI, -0.70 to 1.54).

 
 From cited article

From cited article

 

Of note, ketamine did have higher rates of psychiatric/neurologic adverse events compared to morphine. However, recent research suggests that a slow infusion of ketamine rather than bolus dosing greatly reduces the frequency of these side effects.

Source
A Systematic Review and Meta-analysis of Ketamine as an Alternative to Opioids for Acute Pain in the Emergency Department.  Acad Emerg Med. 2018 Jul 17. doi: 10.1111/acem.13502. [Epub ahead of print]
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Another Spoonful
The AAEM has a recent white paper on analgesia in the ED that is a good, quick read.

Reviewed by Clay Smith

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