VA Tennessee Valley Healthcare System Using New Treatment For Opioid Dependency

Thursday, February 22, 2018 - by Chris Vadnais

“I felt alive again. I wanted to live again.”


These are the words of a veteran who was shot in the hip in Vietnam nearly 50 years ago and has suffered from Complex Regional Pain Syndrome (CRPS) Type II, ever since. He started taking opioids in 2010 to treat his chronic pain and post-traumatic stress.

His body eventually built up a tolerance and the medication started to affect his mood, and he decided he no longer wanted to take opioids.


“I tried to get off by myself, but I couldn’t,” he said. “I was sick as a dog every time I tried. I was fed up and I told my doctor they had do something.”


This could be the story of any of thousands of Veterans who feel trapped in opioid dependency. However, this veteran found a solution at the VA Tennessee Valley Healthcare System (TVHS). After five years of research and consultation with his own VA doctor, he traveled from Pennsylvania to Nashville to meet the only VA doctor administering a new type of treatment: ketamine by infusion.


Historically, the VA has been an innovative force in American medicine. From conducting the first successful liver transplant to implementing electronic medical records, VA has played a leading role in setting standards for the healthcare industry.


Given that, it should come as no surprise this cutting-edge treatment for opioid dependency and chronic pain was born in a VA hospital.


Dr. Randall Malchow, a graduate of the U.S. Military Academy at West Point, has served as an anesthesiologist for TVHS since 2016.  Deep study and an understanding of the effects of opioids on the body allowed Malchow to create the VA’s first Ketamine Infusion Clinic, treating Veterans with a history of long-term opioid use for chronic pain and PTSD.


“The goals of the program are to reduce pain and hopefully, stop the use of opiates altogether,” said Dr. Malchow.


With a 74% success rate, he has reason to be excited about the program, which is built on understanding the impact opiates have on chronic pain.


“Opiates lower a person’s pain threshold, lessening their ability to handle and manage pain,” said Dr. Malchow. “Having a lower threshold for pain, patients then build up a tolerance to opiates.” 


Dr. Malchow said lower pain threshold equals a higher dosage required to treat the pain, therefore causing the body to become physiologically dependent. Further, Dr. Malchow said the use of opioids can amplify symptoms associated with PTSD such as anxiety and depression, which are often triggered by pain.


Ketamine is used as a primary anesthetic in operating rooms around the world. According to the International Anesthesia Research Society, it is one of the safest available. In the last five to seven years, research has indicated the unique properties of ketamine have had profound effects on anxiety, depression, and pain.


People who suffer from these symptoms have received low-dose injections of ketamine at various clinics throughout the U.S. -- with mixed results. However, Dr. Malchow takes the idea a step further, administering moderate dose ketamine infusions to Veterans with these symptoms.


“Ketamine has the effect of resetting excited pain receptors, allowing patients to feel pain in a normal way -- a manageable way,” he said. Further, he noted a major difference between the effect of opioids and ketamine, explaining, “with opioids, pain begets pain, which excites pain hormones.”


Malchow has found ketamine to decrease those pain hormones and allow Veterans to manage pain with anti-inflammatory medication, non-steroid pain medication, and even whole health practices which include yoga, tai chi, mindfulness, and chiropractic care.


49 Veterans have received ketamine infusion therapy at the Nashville VA hospital. Many note they felt almost immediate reduced levels of pain and relief from PTSD symptoms, but most of all, they report feeling free from dependency on opioids to get through the day.


A Navy veteran recalled her struggle with opioids, “I tried so hard to get off opioids myself. I was so sick, I couldn’t do it.” She told her doctor she needed hospitalization because she wouldn’t take another pill. Instead, she was referred to the ketamine clinic. Referring to how she felt after the infusion she shared, “the difference was like night and day.”


Dr. Malchow understands opioid addiction to be a national problem, and believes he’s doing his part to help carry out VA’s mission, “To care for him whom shall have borne the battle.” This includes using more effective pain management solutions like ketamine infusions in conjunction with other alternatives like whole health, nerve blockers, and non-opioid pain medication to help Veterans feel alive again.


TVHS is an integrated tertiary health care system comprised of two hospitals, the Alvin C. York Campus in Murfreesboro and the Nashville Campus, as well as more than a dozen community-based outpatient clinics located in Tennessee and Kentucky. TVHS provides ambulatory care, primary care, and secondary care in acute medicine and surgery, specialized tertiary care, transplant services, spinal cord injury outpatient care, and a full range of extended care and mental health services.


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