Clinical Trial Details
— Status: Recruiting
Administrative data
NCT number |
NCT06070766 |
Other study ID # |
RIVER IRB IRB00013708 2023-2 |
Secondary ID |
|
Status |
Recruiting |
Phase |
|
First received |
|
Last updated |
|
Start date |
October 1, 2023 |
Est. completion date |
April 1, 2029 |
Study information
Verified date |
October 2023 |
Source |
RIVER Foundation |
Contact |
Ed Lesofski, M.S. |
Phone |
406-431-4890 |
Email |
ed[@]riverofchange.org |
Is FDA regulated |
No |
Health authority |
|
Study type |
Observational
|
Clinical Trial Summary
Multiple site studies with the recruitment of other sub-investigators and sites. It's
sobering to consider how chronic illness makes us more vulnerable to suicidal thoughts and
behavior. However, the existence of multiple risk factors also means that there are numerous
ways to intervene. Addressing and improving even one risk area will reverberate and improve
other areas and the quality of life.
RIVER Foundation is completing a 500-participant pilot study researching the safety of oral
and nasal ketamine at home with no therapy. The pilot study examined three psychological
scales: P.H.Q. 9, G.A.D. 7, and PCL5 scores. The interim report will be available in Nov 2023
with a final report in June 2024.
The lack of knowledge for the average medical practitioner makes ketamine a boutique
medicine, often costly and unaffordable to those in need. Yet daily medical providers are
eliminating ketamine as a choice in the treatment of chronic conditions.
The pilot study demonstrated the who, and where. The who, was adults with a chronic
condition. The pilot study demonstrated the majority of those who could use ketamine are not
receiving it due to cost. According to the 500-participant study, ketamine is safe and
effective for at-home use thus demonstrating the where (at home with no supervision).
Description:
The why, when, what, and how much needs to be studied. The new study is five years and up to
50,000 participants. With digital technology, many questions can be answered. The study is a
pay-to-participate study in which minimal fees will be charged for the technology.
Lacking in the original RIVER pilot study was when and how often the participants would take
their medication (Ketamine) and which additional add-on protocols make the treatments more
effective. The RIVER protocol was not based on weight but on the severity of symptoms,
history of chronic conditions, and current medications.
Adverse effects were standard nausea; however, there were only three minor adverse effects.
None of the effects were severe enough to halt the research. The results were promising.
Drops in PHQ9 depression scores were reduced overall between 25% and 61%. RIVER Ketamine
protocols were developed, making home use safe and effective.
Suicide rates increased approximately 36% between 2000-2021. Suicide was responsible for
48,183 deaths in 2021, about one every 11 minutes. The number of people who think about or
attempt suicide is even higher. In 2021, an estimated 12.3 million American adults seriously
thought about suicide, 3.5 million planned a suicide attempt, and 1.7 million attempted
suicides.
Oral Ketamine offers a promising pharmacologic adjunct to chronic condition treatments. It
may offer a more approachable alternative to IV or I.M. Ketamine. The results of the RIVER
pilot study warrant further investigation into the safety and efficacy of oral Ketamine for
chronic conditions.
Oral Ketamine is only available at a compounding pharmacy, which can lead to fluctuations in
dosing. Oral Ketamine is used off-label and is becoming a front-line medicine in treating
chronic conditions. Dosing becomes an issue with using multiple compounding pharmacies. In
the pilot study, River Foundation contracted with one pharmacy, Precision Compounding
Pharmacy. RIVER Foundation received accurate dosing and documentation.
Psychedelic therapies involving Ketamine have gained considerable attention for their
potential to facilitate transformative experiences and promote mental well-being. Ketamine is
being explored to treat various mental health conditions, such as post-traumatic stress
disorder, depression, and substance abuse.
The U.S. population suffers from chronic conditions that impact a person's daily living. (45%
in 2018; Raghupathi & Raghupathi). Individuals suffering from a chronic condition are three
times more likely to complete suicide, leading to approximately 800,000 people dying by
suicide each year worldwide. Additionally, nonfatal self-injurious behavior occurs 20x more
frequently.
"From 2006 to 2013, aggregate E.D. plus inpatient costs of E.D. visits related to suicidal
idealization that resulted in admission to the same hospital increased from $600 million to
$2.2 billion-an average annual increase of 20.4 percent. Aggregate costs of these E.D. visits
rose faster than the actual number of visits, which increased by only 16.2 percent on average
annually from 2006 to 2013."
"Depression is one of the most common mental disorders and can cause tremendous challenge and
burden for individuals and families. It also carries a large economic cost. The economic
burden of major depressive disorder among U.S. adults was an estimated $236 billion in 2018,
an increase of more than 35% since 2010 (year 2020 values), according to research published
in early May in the journal Pharmacoeconomics.
The increase has been greater among younger adults. Young adults, 18 to 34 years, accounted
for nearly half (48%) of adults with depression in 2018, up from 35% in 2010. Young adults
have also been especially impacted by the COVID-19 pandemic. Throughout the pandemic, young
adults have experienced higher levels of depression and anxiety compared to older adults. An
estimated 36% of 18-29-year-olds were experiencing symptoms of depression in early May 2021,
compared to 22% of those 40-49 and 15% of those age 50-59, according to the Centers for
Disease Control and Prevention's (C.D.C.) Household Pulse Survey."
Research is up-and-coming on the use of Ketamine. One study out of the University of Alabama
found great success with Ketamine and suicidal ideation (S.I.).
"We found Ketamine to alleviate suicidal ideation at 90, 120, and 180 min after infusion
according to the B.S.S. and at 120 min according to the MADRS-SI score. Remission from
suicidal ideation was defined by a score of 2 or less on the MADRS-SI item (indicating
fleeting suicidal thoughts or less). Ninety minutes after infusion, eight of nine subjects of
the ketamine group had remission (88%) compared with three of nine (33%) in the placebo group
(p < .05
…The change in depression is a secondary outcome. The reduction in depression fell just short
of a statistically significant difference. This reduction was rapid with the nadir effect
three days after infusion."
Depressed patients often present to the emergency department with complaints of suicidal
thoughts, which accounts for more than half a million admissions annually to the emergency
department in the United States.
Suicide is the 10th leading cause of death in the United States (Heron, 2016), and suicide
rates are rising alarmingly. With the recent lockdowns of COVID, the increase is even more
rapid.
"In the absence of specific treatments for acute S.I., most suicidal patients are
hospitalized for brief stabilization and are often discharged before psychopharmacological
treatments can show efficacy. No strong evidence exists to demonstrate that brief inpatient
hospitalizations are associated with a significant reduction in suicidal potential. Thus,
there is an urgent need to pursue treatment options for suicidal ideation, especially in
emergency department settings." Ketamine is being described as the next wonder drug in
psychiatry. Psychiatric disorders have a limited number of treatments approved by the F.D.A.
With the lack of FDA-approved prescription medicine, the highest rates of off-label
prescriptions are for psychotropic medications.
Off-label prescribing with limited proof of efficacy is commonplace with psychotropic
medications. In recent studies in community clinical practices, 40 to 80 percent of
recipients of commonly prescribed psychotropic medications (including antidepressants,
antipsychotics, and anticonvulsants) were receiving these medications for off-label
indications.
In the primary care setting, a survey on antidepressant medications showed that 84.2 percent
of off-label prescriptions had no convincing evidence of efficacy for the indication.
Off-label prescription has consistently presented a significantly increased risk of adverse
drug events in different patient populations.
The data shows that Ketamine could significantly save billions of dollars annually. As with
any generic drug, there is no incentive to spend millions of dollars to go through the F.D.A.
process of relabeling when it is legal to use as is.
Commercially available Ketamine comes in three variants: R/S, S, and R. An unexpected finding
was the ability of racemate ketamine as a rapid onset and sustained antidepressant for
patients with treatment-resistant depression. Racemate (R) Ketamine is Schedule III and is
not FDA-approved for treating any psychiatric disorder. The use of R Ketamine for any use
other than as an anesthetic is classified as off-label.
However, the "S" form of Ketamine, which is derived from Ketamine and known as Spravato
(esketamine), is a Schedule III controlled substance that was approved by F.D.A. in 2019 as a
nasal spray for treatment-resistant depression in adults and depressive symptoms in adults
with major depressive disorder with acute suicidal ideation or behavior, in conjunction with
an oral antidepressant.
The ketamine molecule contains an asymmetrical carbon atom with two enantiomers. The S (+)
isomer is three times more potent and longer acting than the R (-) isomer.
Ketamine contains a chiral center at the C-2 carbon of the cyclohexanone ring so that two
enantiomers exist, S (+) ketamine and R (-) ketamine. Commercially available racemic ketamine
preparations (such as Ketalar) contain equal concentrations of the two enantiomers. The
dextro-S(-)-isomer of Ketamine has approximately 3- to 4-fold the potency of the levo-R(-)-
isomer.85 The S(+)-isomer appears to be cleared more rapidly than the R(-) isomer, resulting
in a shorter duration of effect and more rapid recovery. (Adams et al., 1994)
Equipotent doses of the S(+)-isomer and the racemate appear to have similar effects on
physiologic parameters. Evidence suggests that the R(-)-isomer produces a higher rate of
emergence reactions and more agitated behavior than the S(+) isomer. (Geisslinger et al.,
1999) It has been known since the late 1970s that the ketamine enantiomers exhibit
pharmacologic and clinical differences. Receptor studies in animal models show that S(+)
ketamine has approximately fourfold greater affinity at phencyclidine binding sites on the
NMDA receptor than R(-) Ketamine.
Not all of Ketamine's effects are stereoselective. Norepinephrine release is inhibited in a
nonstereoselective manner at clinically relevant concentrations. However, its uptake is
influenced stereoselectively: both isomers inhibit neuronal uptake, whereas S(+) ketamine
additionally inhibits extraneuronal uptake. Muscarinic receptors and Ca channels are
inhibited nonstereoselectively. Interestingly, serotonin transport is inhibited twofold more
potently by R(-) Ketamine. (Schwartzman et al 2011)
Animal studies have not revealed significant pharmacokinetic differences between the
enantiomers and the racemic mixture. After subcutaneous application, similar plasma and brain
concentration curves have been found. In a clinical study, however, a significantly higher
elimination rate was observed for S(+) Ketamine compared with the racemate.
The increased inhibitory potency at the NMDA receptor combined with similar pharmacokinetics
suggests that S(+) ketamine may be an interesting clinical drug, and its pharmacological
properties have been studied in some detail.
Recent research suggests that neuroinflammation, an immune response in the brain, may have
counter-productive effects on the efficacy of these psychedelic treatments. Vital to the
ability of Ketamine to affect a change in neuronal functioning that leads ultimately to
improved mental health is the ability to be recognized by specific cell receptors.
In the presence of neuroinflammation, most frequently induced by trauma, is a change in the
composition of the brain's biochemistry from one that is neuro-permissive to that of
neuro-restrictive.
Neurons and glial cells exposed to a neuropermissive environment function optimally,
producing neurotransmitters, enzymes, neuroreceptors, neurosteroids, and various
neurochemicals to support a healthy brain. Contrary to this is a neurorestrictive environment
that induces activation of glial cells with the release of pro-inflammatory cytokine that
fosters an increase in oxidative stress, leading to more inflammation, mitochondrial
dysfunction, apoptosis, and loss of neurotransmitters and their receptors.
It's important to note that the effects of psychedelic medications on brain function are
complex and can vary depending on the individual, the dose, and the composition of the
brain's neurochemistry. This paper is not about delivering Ketamine but optimizing its
beneficial effects by modifying and controlling adverse conditions such as neuroinflammation.
Think of neuroinflammation as a wall that needs to be surmounted by the psychedelic agent.
Lowering this barrier will allow for micro-dosing efficacy to be enhanced, as well as
improving the surrounding neurochemistry to support the biological changes induced by the
Ketamine.