Earlier this year, the associations governing medical doctors in both Saskatchewan (CPSS) and Alberta (CPSA) released information regarding their positions on the use of ketamine for off-label treatments, including chronic pain and a variety of mental health conditions. The CPSS issued a letter to an MD in January, 2021, and the CPSA released a Clinical Toolkit in May, 2021.

While the CPSS doesn’t list specific conditions to be treated with off-label use of ketamine, it does explicitly state that the use of off-label medications is not prohibited. A clinical toolkit released by the CPSA lists specific conditions that have been demonstrated to have positive effects with the treatment of ketamine, including:

• Major depressive disorder (MDD)
• Bipolar depression
• Suicidal ideation
• PTSD
• Complex regional pain syndrome (CRPS)
• Traumatic spinal cord injury pain
• Chronic neuropathic pain

The CPSA also suggests that the evidence for the use of ketamine in the treatment of certain pain conditions, including fibromyalgia, cancer pain and headaches is weak.

In Saskatchewan, off-label use of ketamine is only permitted in non-hospital treatment facilities (NHTF) when administered subcutaneously (SQ), intramuscularly (IM), or intravenously (IV). Due to differences in legal definitions between the two provinces, only the IV method of ketamine administration requires a NSHF accreditation in Alberta. The CPSA states that all other forms of administration, including subcutaneous, intramuscular, oral, sublingual, or intranasal may be offered in community settings if within the scope of practice of the prescriber, who may be a psychiatrist or family physician with appropriate training in consultation with a psychiatrist. 

The prescriber must use a triplicate prescription pad as ketamine is a Schedule 1 drug in Alberta. In addition to listing conditions for which evidence supports the off-label use of ketamine, the Alberta toolkit also lists adverse effects and contraindications for its use. 

According to a discussion with the CPSA, this Clinical Toolkit only applies to existing NHSFs. New NHSF applications for ketamine administration are not currently being processed until a formal IV ketamine ruling is made by the CPSA in the coming year or later. 

While the CPSS’s guidance doesn’t discuss clinical coverage required for parenteral (IV, IM, or SQ) administration of ketamine in an NHTF, the CPSA clearly states that IV ketamine administration must be supported by a multidisciplinary team, including an anesthesiologist, and an ACLS-qualified physician or an ACLS-qualified nurse. The CPSA indicates that IM and IV are the most predictable and bioavailable according to literature. The CPSS offers no guidance on this topic.

Both documents discuss the release of Spravato (intranasal esketamine) for treatment resistant depression, which is defined as the “failure of two or more antidepressant medications at adequate doses and duration.” The monograph for Spravato “requires patient monitoring for at least 2 hours during and after administration for any reactions.”

The major difference between the two documents is the difference in ruling around administration of IM and SQ ketamine in community settings, where it is allowed in Alberta, but not Saskatchewan. Neither document acknowledges this difference or discusses differences in risk between IV, IM & SQ administration. 

While the Alberta Clinical Toolkit provides clarity in what is presented, the guidance from the CPSS remains broad and non-specific.  Safety is highlighted as a top priority in both, including recommendations for sufficient documentation of safeguards taken and informed consents to ensure that patients are aware of the risks and benefits.

Ultimately further information is required from both provincial colleges suggesting, recommendations around set and setting, and examples of appropriate safeguards and clinical responsibilities. Also, the documented benefits of ketamine, like neuroplasticity and neurogenesis would be helpful for readers to understand why it is helpful in these off-label uses. 

Author Sabrina Syne RN