Background
This policy relates to acute administration of ketamine (including esketamine) by intravenous or subcutaneous infusion or by repeated frequent intranasal/inhalational administration as well as other forms of ketamine. Given the blood levels expected to be achieved by such administration, it is assumed the treatment will take place in a suitable location with staffing and monitoring to manage adverse effects, especially airway obstruction, cardiovascular problems, and delirium.
When considering requests for funding any pharmaceutical item, this policy must also be read with the following policies:
What is Ketamine used for?
In Australian medical practice, ketamine is occasionally used as an anesthetic for surgical procedures or retrieving persons from situations of physical trauma. Beyond the surgical and trauma settings, the primary applications are to reduce or reverse opioid tolerance, to manage opioid withdrawal, and to manage chronic non-cancer pain. Recently, there has been consideration of the role ketamine may play in treating depression and post-traumatic stress disorder (PTSD), however these circumstances are typically considered as off-label use. Off-label use is the use of pharmaceutical drugs for an unapproved indication or in an unapproved age group, dosage, or route of administration.
What is the evidence for its use?
There is insufficient evidence to support the use of ketamine as a first line treatment for chronic non-cancer pain, depression and PTSD.
There is however evidence to suggest the use of ketamine in limited circumstances;
- where patients have failed to respond to first-line treatments;
- to reduce opioid use in patients with limited options for managing chronic non-cancer pain, or
- to reduce the use of opioids needed following a surgical procedure
Guidelines
Will WorkSafe pay for Ketamine?
There are other recommended treatment options available for chronic non-cancer pain, as well as treatment resistant depression and PTSD that have robust evidence supporting their efficacy. WorkSafe supports injured workers to access evidence based treatment that can assist their recovery.
WorkSafe does not support the use of ketamine to treat non-cancer pain, depression and PTSD as a first line treatment. This is due to the lack of demonstrated evidence and unreliable information to base clinical decision making. This is supported by the Position Statement of the ANZCA's Faculty of Pain Medicine – The Use of Ketamine in the management of chronic non-cancer pain, The RANZCP clinical memorandum - Use of ketamine in psychiatric practice, as well as an independent evidence review conducted by the Institute for Safety, Compensation and Recovery Research (ISCRR).
WorkSafe recognises that there may be the exceptions where ketamine is an appropriate treatment for a period of time, in circumstances where all other reasonable treatments and services have been exhausted, and will consider paying the reasonable costs of the treatment.
A request for funding of ketamine as a treatment must be in accordance with our Non-established, New or Emerging Treatments and Services Policy, and accompanied by the following to be considered:
- an established and reliable diagnosis of the injured worker’s pain condition (or conditions) that has resulted from a work-related injury or illness
- evidence from the treating specialist that reasonable treatment and services have been trialed for a period of time or that contraindications or side effects have resulted in the treatment not being appropriate
- the treating specialist must document the current medications the injured worker is on and any relevant past medication use and the outcomes of those treatments
- current pain and functional capacity standardised outcome measures
- preferred standardised outcome measure: The Brief Pain Inventory
- evidence by the injured worker's GP, psychologist or psychiatrist that suitable mental health safety measures are in place
When will WorkSafe respond to my request?
Once all required information is received, notification of an outcome will be made within 28 days.
For what period of time will WorkSafe pay for ketamine?
It may be appropriate in some circumstances for further treatment to be given. WorkSafe will review these requests in line with the Clinical Framework for the Delivery of Health Services, including the pre and post treatment standardised outcome measures to ensure adequate improvement in pain and functional capacity or a reduction in opioid medication usage.
For subsequent requests for acute administration of ketamine by intravenous or subcutaneous infusion, repeat treatment cannot be less than three months following the initial treatment. Subsequent repeat treatments cannot be less than six months apart, unless in exceptional circumstances.