The College’s Regulatory Bylaw 26.1 was amended to allow for a physician to make an application for an exemption to use agents that can produce sedation without the facility being approved as a nonhospital treatment facility, by adding the following as paragraphs (e)(viii) and (ix):

…

(viii) Notwithstanding anything contained in this bylaw 26.1, a physician who seeks to

provide medical care which involves the use of drugs which are intended or may

induce sedation requiring the monitoring of vital signs may apply to the College

for an exemption from the requirement that the facility be approved as a nonhospital

treatment facility to utilize such drugs.

(ix) The College may grant an exemption under paragraph (viii) subject to any terms

and conditions and may require the physician to provide an undertaking to the

College related to the request for the exemption.

…

The full bylaw is available on the College website.

The College will NOT be accepting applications for the administration of Intravenous Ketamine in community-based settings at this time. The administration of Ketamine by any other route (Intramuscular/subcutaneous/oral/sublingual/intranasal), in a community-based setting may be applied for to the College under this Bylaw amendment.

For the purpose of this document, a community-based setting refers to a Physician’s Office or designated clinic that is not affiliated with a hospital, Health Authority, nor a Non-Hospital Treatment facility.

For the purpose of this document, when the referring to Ketamine, it will include all salts and/or enantiomers, in all dosage forms, as a single active ingredient or as a combination product.

Expectations:

1. The Colleges Complementary and Alternative Therapies policy applies.
2. For physicians who consider the prescribing and/or administration of Ketamine outside of what would be considered the usual scope of practice for the physician’s discipline, training, and experience. must apply for a scope-of practice change to comply with the College’s Regulatory Bylaw 4.1, Returning to Practice in Saskatchewan after an absence or disability, inactive practise, or change in scope of practice
3. When used off-label for treatment resistant Major Depressive Disorder (MDD):
   1. Prescribing be limited to or guided by a psychiatrist, or a qualified physician in a related field,
   2. The CANMAT recommendations for the Use of Racemic Ketamine in Adults with Treatment-resistant Depression (TRD) be followed,
   3. For Spravato®, only available currently through the Janssen Journey, that manufacturer specific guidelines must be followed, and
   4. For intranasal racemic Ketamine, doses must be congruent with clinical guidelines and consensus statements, and administration must meet the same criteria and guidelines as intranasal esketamine.
4. When use off-label for pain management:
   1. Prescribing be limited to physicians with training and experience in pain medicine or duly qualified physicians in related fields.
5. Practitioners in community-based settings must only administer Ketamine in sub-dissociative/sub-anesthetic doses, that:
   1. is congruent with clinical guidelines and consensus statements for the specific treatment indication, and
   2. could not be reasonably foreseen to cause a decreased level of consciousness/alertness.
6. Ketamine administration and monitoring should be limited to physicians who:
   • are trained in the use of Ketamine for sedation and anesthesia (anesthesiologists, ED physicians, critical care, GP anesthesia, pain fellowships etc),
   • can perform the appropriate monitoring, and
   • possess the appropriate training, skills, and currency in the use of this medication and in the appropriate emergency response to any adverse events.
7. Emergency preparedness:
   1. Ketamine should only be administered in a setting that has the proper infrastructure, personnel, and equipment to safely use the anesthetic agent and manage any reasonably foreseeable emergency (e.g., emergency cart, qualified staff).
   2. There should be a second regulated health professional (i.e., nurse, another physician) immediately available to assist in the event of an emergency in addition to the physician performing the procedure.
   3. The Emergency Cart should be checked every procedural day before the start of the first case of the day to ensure the cart is appropriately stocked, medications are within their labeled expiry date, and the equipment is in proper working order.
   4. Written policy and procedures for medical emergencies (e.g., cardiac arrest, respiratory emergencies) including patient transfer to a hospital should be in place.
8. Physicians who administer and/or direct the administration of Ketamine in a community-based setting must hold current basic life support certification for health professionals (BLS provider), and preferably ACLS. Certification should be renewed as required.

The College of Physicians and Surgeons of Saskatchewan recognizes the College of Physicians and Surgeons of BC (CPSBC) and College of Physicians and Surgeons of Alberta (CPSA), regarding guidelines and standards for the prescribing and administration of Ketamine.

The CPSS acknowledges the use of the communique of the College of Physicians and Surgeons of British Columbia Interim Guidance Ketamine Administration via Intramuscular, Oral, Sublingual, and Intranasal Routes as Treatment for Mental Health Conditions and Chronic Pain in the Community Setting

The CPSA has a clinical toolkit, Ketamine and Esketamine: Key considerations, which may be helpful in decision making

Physicians are encouraged to contact the CMPA for advice before proceeding with therapies that are not considered conventional treatment options.

References:

• CADTH Rapid Response Report: Summary with Critical Appraisal,
  Ketamine for Chronic Non-Cancer Pain: A Review of Clinical Effectiveness, Cost-Effectiveness, and Guidelines
• The Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force Recommendations for the Use of Racemic Ketamine in Adults with Major Depressive Disorder
• The CPSA clinical toolkit, Ketamine and Esketamine: Key considerations,
• College of Physicians and Surgeons of British Columbia Interim Guidance Ketamine Administration via Intramuscular, Oral, Sublingual, and Intranasal Routes as Treatment for Mental Health Conditions and Chronic Pain in the Community Setting
• American Society of Regional Anesthesia and Pain Medicine: Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain
• JAMA: A Consensus Statement on the Use of Ketamine in the Treatment of Mood Disorders