Pubdate: Mon, 22 Aug 2005
Source: Philadelphia Inquirer, The (PA)
Copyright: 2005 Philadelphia Newspapers Inc
Author: Shirley Wang, Staff Writer
Bookmark: (Chronic Pain)
Bookmark: (Treatment)


For some people who suffer chronic pain, a drug that is known on the street 
as "Special K" may be the answer.

At his worst, Brett Lovell, 32, of Lebanon, Pa., experienced such searing 
pain that he couldn't straighten his arm, and the fingers of his left hand 
curled up like a claw. The pain had him downing 25 pills a day.

Then he undertook an experimental treatment - a seven-day coma in which he 
was pumped full of a drug called ketamine, which doctors use as an 
anesthetic and street dealers refer to as the recreational drug "Special K."

The experimental procedure gave him fleeting hallucinations, but it helped. 
"I can enjoy life better today," said Lovell, who is down to just one pill 
a day and can maneuver a computer mouse.

Ketamine is now being touted as a revolutionary treatment for a severe pain 

In the treatment, ketamine is infused intravenously and continuously while 
patients are supported by a ventilator - and are virtually dead - for days.

Robert Schwartzman, chairman of neurology at Drexel University College of 
Medicine, is the U.S. pioneer of the experimental treatment, which resets 
the link between the pain sensory neurons and the brain.

He equates the brain to a computer. "For five days we turn your computer 
off so you're not having any pain," he said. When the brain is turned back 
on, the pain system is "rebooted."

Considered a safe anesthetic, ketamine - known in street parlance as K or 
Special K - is chemically similar to PCP and causes inebriation, 
hallucinations and dissociation, a sensation that patients are not in their 
bodies. These side effects have led to its popularity at raves and reports 
of its use as a date-rape drug.

That history was not lost on Sandra Lovell, who watched her son Brett in 
his coma. "All I can describe it as is seeing your child laying there 
dead," she said. "The worst part was when he was coming out of it. It's 
like coming off one of the worst trips from LSD."

One of his hallucinations was of his brother, a police officer, trying to 
shoot him, a vision that greatly distressed his parents.

Yet for Lovell, the trip - which cost about $30,000 - was worth it.

The extreme nature of treatment speaks to the desperation of those with 
chronic regional pain syndrome or reflex sympathetic dystrophy, a condition 
that affects 1.5 million Americans, according to the Reflex Sympathetic 
Dystrophy Syndrome Association.

The syndrome produces intense, burning pain, and causes normally 
non-painful sensations - touch, movement and temperature - to be agonizing.

"It makes you feel like you've been doused in gasoline and set on fire," 
said Cynthia Toussaint, 44, a sufferer in Valley Village, Calif., who runs 
a nonprofit organization to help women in pain.

The condition can result from any type of injury, such as a turned ankle or 
carpal tunnel syndrome. It develops in 1 to 2 percent of fractures and 2 to 
5 percent of peripheral nerve injuries.

The body's pain system, which is necessary to telling us something is 
wrong, goes awry in these cases.

When pain fibers from the injury site activate, they trigger a chain 
reaction that changes the structure of the pain neurons. These changes 
provoke the neurons to fire even more - like a car engine revving out of 
control - which creates more pain, said Daniel Carr, chief executive 
officer of IDDS, a New York City-based company that is testing a ketamine 
nasal spray.

The syndrome often goes misdiagnosed and mistreated, said Schwartzman. Most 
of his patients have already seen 10 other doctors by the time they find him.

And, many, especially children, face skepticism from their doctors, who 
think the patients are just trying to get attention.

"I got such horrible looks from doctors, like I had two heads," said Megan 
Vanatta, 21, of Washingtonville, N.Y., who has had the disorder since she 
was 7. "Doctors would ask, 'Are your parents fighting? Do your parents 
abuse you?' "

The earlier the condition is treated, the more effective it seems to be - 
but there is no cure and no one treatment works universally, experts say. 
The ketamine coma is only for the most serious cases.

A number of U.S. doctors use ketamine in small doses to treat pain while 
patients are awake, but Schwartzman and two German colleagues, Ralph-Thomas 
Kiefer and Peter Rohr, are the first to infuse it in comatose patients for 
up to seven days.

So far, the trio has treated 26 American patients in Germany. All patients 
received significant temporary pain relief, and nine remain completely 
pain-free from nine months to three years after the infusion.

Ketamine is FDA-approved in the United States for two-day use when the 
patient is awake, but Schwartzman holds out little hope that the coma 
procedure will ever be allowed here.

At Hahnemann University Hospital in Philadelphia, Schwartzman studies 
ketamine use for less severe patients and as boosters for those who have 
returned from Germany.

He just finished a study of 50 patients who were awake during five days of 
ketamine use - also not enough, he said - and plans to go back to the FDA 
in a couple of months for approval to try 10-day outpatient infusions.

It may seem strange for a mind-altering substance to be used medically, but 
the history of ketamine is like many other drugs - if it works for one 
thing, scientists say, let's see if it works for another.

"The problem unfortunately is that we have so many horrible diseases 
related to the brain and so few drugs," said Bita Moghaddam, neuroscience 
professor at the University of Pittsburgh who uses ketamine in rats to 
mimic schizophrenic symptoms. "If you have a drug you think is relatively 
safe, you have to use what you have."

Ketamine has also been used to study alcoholism and dementia, and explored 
as a treatment for sleep apnea and addictions and an aid in psychotherapy.

While many severe pain sufferers are enthusiastic about the ketamine coma, 
researchers are more cautious.

"Initial observations are exciting," said Srinivasa Raja, director of pain 
medicine at Johns Hopkins University School of Medicine. "But it has to be 
tempered with the fact that they are not blinded observations. They have to 
be followed through over time."

Timothy Lubenow, a pain specialist at Rush University Medical Center in 
Chicago, had a patient who went to Germany and "had great pain relief up 
until the plane ride back," he said. "She bumped her knee, which was the 
affected part, and the pain came back."

Schwartzman hopes that continuing research on treatments for severe pain 
will yield alternatives to the ketamine coma and that in the future "we 
won't need the ketamine sleep."

But, "right now, for dreadful patients, the only thing I've seen work is to 
have them go to sleep," he said.


For more information about ketamine and reflex sympathy dystrophy, go to 
(http://go.philly)http://go.philly. com/ketamine
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