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ANALGESIA

Ultra-Low Dose Ketamine and Memantine Treatment for Pain in an Opioid-Tolerant Oncology Patient

Lucinda A. Grande, MD^*, Brendan R. O’Donnell, MD^*, Dermot R. Fitzgibbon, MD^*, and Gregory W. Terman, MD, PhD^*

From the *Department of Anesthesiology and Graduate Program in Neurobiology and Behavior, University of Washington, Seattle, Washington.

Address correspondence and reprint requests to Gregory W. Terman, MD, PhD, Department of Anesthesiology and Graduate Program in Neurobiology and Behavior, Box 356540, University of Washington, Seattle, WA 98195. Address e-mail to gwt{at}u.washington.edu.

Abstract

Patients taking high-dose opioids chronically for tumor-related or neuropathic pain may develop pain that is refractory to opioids. One option for control of such pain is the use of the N-methyl-d-aspartate (NMDA) receptor antagonist ketamine. We describe a case of opioid-refractory pain that responded to a low-dose IV infusion of ketamine in the inpatient setting. The patient was then successfully transitioned to oral memantine for long-term outpatient management, in a novel use of this oral NMDA receptor antagonist. We present recent findings from basic research on pain mechanisms to explain why opioid tolerance, as in this patient, may contribute to the analgesic benefit of NMDA receptor antagonists.