Pilot Randomized Control Trial Comparing Oral Ketamine and Oral Oxycodone for Pain Control in Emergency Department Patients

In an effort to combat the ongoing opioid crisis, healthcare providers continue to search for alternatives to opioids that are both safe and effective. While no medicine has an ideal profile, oral ketamine have attributes that may serve emergency department (ED) patients well when dealing with painful conditions. While IV ketamine has been well-studied in the ED setting and oral ketamine has been studied in the post-operative setting, there is limited data describing the safety and effectiveness of oral ketamine in the ED setting. Guided by colleagues from the Anesthesia Acute Pain Service, the Albany Medical Center (AMC) ED has begun giving oral ketamine to appropriate ED patients with painful conditions. We aim to conduct a pilot, un-blinded randomized controlled trial to compare the benefits and detriments of oral ketamine vs. oxycodone in ED patients who require 'second line' pain medicine.

A convenience sample of emergency department patients will be randomized to receive either:

Oxycodone arm:

o The treating provider will order oral oxycodone 5 mg times one

or

o The treating provider has made a deliberate decision that the patient requires (because of weight, prior exposures, etc.) greater than oxycodone 5mg times one

Oral ketamine arm:

o The treating provider will order ketamine 0.75 mg/kg oral times one (max 80mg)

Outcomes measured

Participants will be assessed for

• Pain scores at 30 and 60 minutes after either study drug administration
• Whether they received opioids at 6 hours, 12 hours, and 24 hours after receiving either study drug
• For admitted patients, whether they received opioids upon admission to the hospital, and whether they were discharged with a prescription for opioids
• Whether the participation has received opioid pain medicines, ketamine, or other recreational drugs during the one month after enrolling in the study
• Whether the participation has received opioid pain medicines, ketamine, or other recreational drugs during the three months after enrolling in the study

We will calculate a difference in change in mean pain scores before and after the intervention in each study arm. We will also compare morphine milli-equivalents use during the time intervals above, as well as usage of opioids, ketamine, and recreational drugs during the one month and three month period after enrollment.

Because this is a pilot study, we have not calculated an effect size.

Inclusion criteria

• ED patient aged 18 years or older AND
• English proficient AND
• Able to give informed consent AND
• Has a painful condition in the ED that includes any of the following: Musculoskeletal extremity pain, Musculoskeletal back or neck pain, Other nociceptive extremity pain
• AND treating provider has deemed the patient necessitating 'second line pain therapy' (meaning: opioids or ketamine)

Exclusion criteria

Any of the following:

• Prisoner status
• Pregnant
• Non-English proficient
• Cannot give informed consent
• Requires emergent intravenous pain medicine (as deemed by the treating provider)
• Prior participation in the study
• Previous diagnosis of opioid use disorder
• Previous ketamine addiction
• Patient is in hospice or other palliative care measures
• Contraindication to ketamine, including: Cystitis or bladder pain, Intracranial hypertension, Known coronary artery disease, Age greater than 75 years old, History of prior adverse reaction to ketamine or oxycodone, History or current major psychiatric disorder (as deemed by the treating ED clinician) or history of psychosis