Ketamine review: Chemical restraints may have been ‘disproportionately’ used on ‘communities of color’

Problem Solvers

DENVER (KDVR) — More than a year after the state health department promised to do an “immediate and thorough” review of the program that allows paramedics to sedate patients with ketamine outside of a hospital setting, the Colorado Department of Public Health and Environment’s Ketamine Investigatory Review Panel has found some people may have unnecessarily received the drug.

“The panel agreed that ketamine is a safe drug if used properly and monitored closely by properly trained and qualified paramedics,” according to an executive summary of the review released to the Problem Solvers. “However, certain adverse events appear to have arisen primarily from the administration of ketamine and other sedatives to individuals who may not have a medical need for these medications and who could have been managed with a less assertive alternative.

“Further, other societal and systemic factors at play may have allowed chemical restraints to be disproportionately applied to marginalized populations and communities of color in Colorado and across the nation,” the summary states.

State: COVID delayed ketamine waiver review

The state health department first announced it would review its waiver program in August 2020 after the Problem Solvers uncovered questionable cases in which the drug was used on patients involved in police situations.

However, the review panel did not convene until February, according to Dr. Eric France, the chief medical officer for CDPHE.

“It has been a while since we made that announcement, and there’s been this thing called COVID that kind of crept in,” France said.

France said he was unable to assign any other CDPHE staff member to handle the ketamine review panel while he was also managing the health department’s response to the pandemic.

“I felt that this is a medical review, and as the chief medical officer, the work needed to be overseen by a physician … I just didn’t have anybody on staff who could take that lead and felt that I needed to be involved,” France said.

The following people served on the panel:

  • Dr. Gene Eby, an emergency medicine physician,
  • Dr. Janetta Iwanicki, a medical toxicologist and emergency medicine physician,
  • Dr. Luis A. Verduzco, an anesthesiologist,
  • Dr. Lesley Brooks, a family medicine and addiction medicine physician,
  • Dr. Christopher T. Stephens, an anesthesiologist and former paramedic,
  • Dr. Scott Bourn, an RN, MSN, PhD in Health and Behavioral Sciences,
  • and Dr. Jamira T. Jones, MPH, an emergency medicine physician.

What did the ketamine review panel recommend?

The panel made several recommendations for improving how the medicine is used, but the state health department will continue suspending the use of the drug right now, France said.

“The panel recommends that Excited Delirium Syndrome no longer be used as a condition that warrants waivers for the administration of ketamine. While making this recommendation, the panel acknowledges that in the prehospital setting, a patient’s agitation and disorientation can present a direct threat to the patient’s safety as well as to the safety of the public and first responders,” the executive summary said.

The panel also made recommendations for dosing, reviewing whether there is a disproportionate use of the drug on communities of color, monitoring of a patient and training.

“It was really important to me that the medical community speak to the inequitable diagnosis that is excited delirium — to the bias and to the subjectivity of a diagnosis that is largely found in the pre-hospital setting that is largely found in engagement with law enforcement, and that is so incredibly subjective,” said Brooks, a family medicine and addiction medicine physician who served on the panel.

“That includes things like failure to respond to police commands,” Brooks said. “That includes things like super-human strength. All of which can be misplaced, misassessed, misplaced and disproportionately applied to people of color, and if that biased diagnosis then leads to deployment of a drug in a way that is also inequitable, I wanted to make sure that the medical community spoke to those issues.”

Verduzco, an anesthesiologist on the panel, said he participated on the panel to make sure his own concerns, along with those of the American Society of Anesthesiologists and the Colorado Society of Anesthesiologists, were also heard.

“I wanted to make sure (these medical concerns) were conveyed at the table when these decisions were being made,” Verduzco said. He said he wanted to make sure his voice was heard as a person of color.

“I too share many of the concerns that minorities have,” he said. “I wanted to be a part of the committee that put safeguards for the use of ketamine in a pre-hospital setting.”

The Problem Solvers asked Verduzco whether he believes paramedics should be permitted to return to using ketamine in a pre-hospital setting now that the review has been completed.

“I don’t know what’s going to happen with the use of ketamine. I was part of the panel to help create a guideline that if that were to happen, this is our recommendation,” he said.

“There’s a lot of work to do still to see if there is a role for ketamine moving forward,” France said.

The use of ketamine became controversial following the death of Elijah McClain. In 2019, he was confronted by three Aurora police officers who used the carotid hold to subdue him, and paramedics injected with ketamine before he went into cardiac arrest and later died. His family recently settled a civil lawsuit with the City of Aurora for $15 million.

This summer, the governor signed a new law spearheaded by Reps. Leslie Herod and Yadira Caraveo, which limits how the drug can be used by paramedics in law enforcement settings.

“Ketamine is a powerful drug that can have potentially fatal consequences if used improperly,” Herod said. “I’m heartened to see CDPHE’s Ketamine Review Group establish a careful process for the oversight and administration of the drug and require data collection on its disproportionate use against Black and Brown Coloradans. I am particularly supportive of their rejection of ‘excited delirium’ as a basis for ketamine administration and the panel’s confirmation of what we’ve long known: that the use of excited delirium as a basis for ketamine administration is prone to racism. I’m proud of the work we did in the legislature last session to end the misuse of ketamine by law enforcement, and I expect better outcomes for Coloradans based on these recommendations.”

The panel of experts who worked to review ketamine also relied on data and information from a variety of medical professionals from around the country, including Dr. Brent Myers, a ketamine researcher who is triple-board certified in emergency medicine, EMS and clinical informatics.

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