Can ketamine treatment be used in patients with active alcohol use disorder?

From the Guidelines

Ketamine treatment can be used in patients with active alcohol use disorder, but with important cautions and considerations. The use of ketamine in patients with active alcohol use disorder is a complex issue that requires careful evaluation of the potential benefits and risks.

• Ketamine therapy may actually be beneficial for some patients with alcohol use disorder as it has shown promise in reducing cravings and helping with abstinence in early research 1.
• However, patients should be carefully screened for contraindications such as uncontrolled hypertension, severe cardiac disease, psychosis, or pregnancy.
• The typical protocol involves either intravenous infusions (0.5-1.0 mg/kg over 40-60 minutes) or intramuscular injections (0.5-1.0 mg/kg), administered in a controlled clinical setting with vital sign monitoring.
• Treatment courses often involve 4-6 initial sessions over 2-3 weeks, followed by maintenance as needed.
• Patients should abstain from alcohol for at least 24 hours before each ketamine session to reduce risks of adverse interactions.
• The mechanism behind ketamine's potential benefit involves NMDA receptor antagonism and neuroplasticity enhancement, which may help disrupt addiction pathways.
• Patients should be enrolled in comprehensive addiction treatment alongside ketamine therapy, as it works best as part of a multimodal approach rather than as a standalone treatment.
• It is essential to note that ketamine lacks long-term efficacy and safety trials in major depressive disorder, and the bulk of the evidence on short-term efficacy is from studies in patients who have previously not responded to adequate trials of antidepressants 1.
• Additionally, ketamine and esketamine are not recommended as initial treatment but are reserved for patients for whom previous therapies have failed or who have not tolerated previous therapies 1.

From the FDA Drug Label

Concomitant use of ketamine with opioid analgesics, benzodiazepines, or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death [see Drug Interactions (7. 3)]. Closely monitor neurological status and respiratory parameters, including respiratory rate and pulse oximetry, when ketamine hydrochloride and opioid analgesics, benzodiazepines, or other CNS depressants are co-administered. Consider dose adjustment individualized to the patient’s clinical situation

Ketamine treatment should be used with caution in patients with active alcohol use disorder due to the risk of profound sedation, respiratory depression, coma, and death.

• Key considerations:
  • Closely monitor neurological status and respiratory parameters.
  • Consider dose adjustment individualized to the patient’s clinical situation 2.

From the Research

Ketamine Treatment for Active Alcohol Use Disorder

• Ketamine has been studied as a potential treatment for alcohol use disorder (AUD), with some evidence suggesting its efficacy in reducing alcohol intake and promoting sobriety 3, 4.
• A study published in 2014 found that ketamine's antidepressant efficacy was extended for at least four weeks in subjects with a family history of an alcohol use disorder, suggesting potential benefits for individuals with AUD 5.
• However, the safety of repeated ketamine infusions for AUD treatment is still being investigated, and more research is needed to fully understand its therapeutic and addictive properties 3.
• Current pharmacotherapies for AUD, such as disulfiram, naltrexone, and acamprosate, have limitations, and novel therapeutics like ketamine are being explored to address the complex pathology of AUD 4, 6.

Considerations for Ketamine Treatment

• Ketamine's potential for addiction is a concern, and repeated treatment regimens may be necessary to maintain sobriety, raising questions about its long-term safety and efficacy for AUD treatment 3.
• The diagnosis and pharmacotherapy of AUD are critical components of treatment, and medications like naltrexone have been shown to reduce the likelihood of return to drinking and binge-drinking risk 6.
• Recent studies have highlighted the promise of novel drug candidates, including psychedelics and phosphodiesterase-4 inhibitors, for the treatment of AUD, although further evaluation is needed before they can be used clinically 7.

Current State of Research

• While there is evidence to suggest that ketamine may be a useful treatment for AUD, more research is needed to fully understand its effects and potential benefits 3, 4.
• The current state of research on ketamine treatment for AUD is ongoing, with clinical trials and studies investigating its safety and efficacy 3, 4.