Esketamine. Where we at?

Between the TODAY show, CNN, The Washington Post, etc. those of you that follow us are probably wondering, how soon can we start???

First, I am so happy that you are so excited because the impact of depression on lives is crippling. Any of us who struggle personally or see loved one’s suffering know that WE ARE READY!!! Let’s jump in right? Well, hear me out. I promise I am not going to “hate on” Esketamine, I just want to explain a few things.

Those of you who are having ketamine infusions are already getting S-ketamine (see what the drug company did there? The name of the drug is the name of the left-handed enantiomer of ketamine).

Medications are chemical compounds. These chemical compounds often exist as 2 enantiomers (a right handed or “R” and a left handed “S”). If the medication has both enantiomers (the “R” and the “S”) included in the formulation it is considered racemic. So, a regular vial of ketamine, the drug that has been around since the 1970s, is a racemic mix of both “R” and “S” ketamine. Johnson & Johnson (the makers of Esketamine) has separated the “R” from the “S” ketamine. Exciting because there is some evidence that “S” ketamine may have less side effects than a racemic mixture, is seen as a new drug so can/has gotten FDA approval which means insurance will most likely cover it, and the intranasal aspect makes it more accessible to patients. Is this a NEW miracle drug? No. BUT allowing increased accessibility to patients is a BIG deal to us (not just Thrive but all your healthcare providers).

Money talks, right? So, if this is covered by insurance this means my treatment will be cheap, right?

Honestly, right now, I don’t know. I don’t think any of us providers know. What we do know is this:

The list price of the drug will be $590 to $885 per treatment session based on the dosage taken, which will vary between patients. During the first month of therapy, that would add up to a price in the range of $4,720 to $6,785. After the first month, maintenance therapy could range from $2,360 to $3,540.” The Washington Post

We don’t know how much of this cost insurance will cover, and if they do cover the drug itself will they also cover the 2 hours of monitoring after? The North Dakota Board of Nursing has made a statement regarding who can monitor patients during ketamine administration. This changes cost of monitoring. Will this even matter since it is “S” ketamine instead of racemic ketamine? I don’t know.

Because of the high cost of “S” ketamine and because it is already included in the much less expensive vial of racemic ketamine will that mean insurance will start covering racemic ketamine as well to keep costs down? I have no idea. I hope! For a patient without insurance coverage, “S” ketamine is much more expensive than regular ketamine IV. The crazy part, depending on what you are being treated for “R” ketamine may be more beneficial to you than “S” ketamine so using a racemic mixture allows us to cast a wider net.

I really don’t want to hate on anyone. Drug companies need to make money in order to have clinical trials which help keep us all safe. Fiscally, it is almost impossible take a drug that is generic and proceed through clinical trials as you can’t make up the money. I am certainly not an expert on this process, but I experience the frustration of marketing a “new drug for depression” that is technically part of a drug we have had since the 70s.

Esketamine is certainly less invasive (intranasal instead of IV) and should thus be less time, right?

Let me start with the intranasal part. I get it. I hate being stuck with needles as much as you (I actually RAN around a medical office once avoiding a vaccine, mind you I was in MIDDLE SCHOOL!!!). But here is the concern with intranasal delivery… your nasal mucosa changes constantly. Remember that cold you had last month? Your drug absorption of intranasal products will decrease when you have the sniffles. Have chronic post nasal drip and sinus issues like me? Intranasal might be tricky to get you the right dose. With intravenous, we know how much of the drug you are getting EVERY SINGLE TIME. 100%. Obviously, there are many drugs that can be given intranasally and work well and I really hope this is one of them. These are just concerns, not deal breakers, in my opinion.

Time is money right!? A normal IV infusion of ketamine for depression in our office is scheduled for 90 minutes. That includes time for IV start and recovery. Of course, as every patient is an individual and sometimes require longer infusions or longer recoveries, but this is just our general time frame. Esketamine is still going to require an office visit for administration and then a 2-hour monitoring window following. Our policy will require you needing a driver to pick you up after the recovery period (in the same as it is now). The time, in my opinion, the least concerning factor but I thought I would bring it up.

The best part of this whole situation is it will now be more difficult for insurance companies and other providers to claim that ketamine is not effective to treat depression. That is a HUGE step for all patients in order to get access. Please understand that although this is a wonderful medication (we built our business on it!) it is NOT magic and the way to get the best results is to work WITH your mental health provider and us. In the role of mental health, we at Thrive are more the technicians while your mental health provider is the home base. Diet, sleep and nutrition are also important aspects of your wellness that no drug can replace.

Are you a provider that wants the nitty gritty? Contact us and we can send journal articles about Esketamine, ketamine for chronic pain, ketamine for depression etc. We like to share.

Ketamine Could Be the Key to Reversing America’s Rising Suicide Rate

A version of the club drug is expected to be approved for depression in March. Researchers think it could help treat suicidal thinking.

Joe Wright has no doubt that ketamine saved his life. A 34-year-old high school teacher who writes poetry every day on a typewriter, Wright was plagued by suicidal impulses for years. The thoughts started coming on when he was a high schooler himself, on Staten Island, N.Y., and intensified during his first year of college. “It was an internal monologue, emphatic on how pointless it is to exist,” he says. “It’s like being ambushed by your own brain.”

He first tried to kill himself by swallowing a bottle of sleeping pills the summer after his sophomore year. Years of treatment with Prozac, Zoloft, Wellbutrin, and other antidepressants followed, but the desire for an end was never fully resolved. He started cutting himself on his arms and legs with a pencil-sharpener blade. Sometimes he’d burn himself with cigarettes. He remembers few details about his second and third suicide attempts. They were halfhearted; he drank himself into a stupor and once added Xanax into the mix.

Wright decided to try again in 2016, this time using a cocktail of drugs he’d ground into a powder. As he tells the story now, he was preparing to mix the powder into water and drink it when his dog jumped onto his lap. Suddenly he had a moment of clarity that shocked him into action. He started doing research and came upon a Columbia University study of a pharmaceutical treatment for severe depression and suicidality. It involved an infusion of ketamine, a decades-old anesthetic that’s also an infamous party drug. He immediately volunteered.

His first—and only—ketamine infusion made him feel dreamlike, goofy, and euphoric. He almost immediately started feeling more hopeful about life. He was more receptive to therapy. Less than a year later, he married. Today he says his dark moods are remote and manageable. Suicidal thoughts are largely gone. “If they had told me how much it would affect me, I wouldn’t have believed it,” Wright says. “It is unconscionable that it is not already approved for suicidal patients.”

The reasons it isn’t aren’t strictly medical. Over the past three decades, pharmaceutical companies have conducted hundreds of trials for at least 10 antidepressants to treat severe PMS, social anxiety disorder, and any number of conditions. What they’ve almost never done is test their drugs on the sickest people, those on the verge of suicide. There are ethical considerations: Doctors don’t want to give a placebo to a person who’s about to kill himself. And reputational concerns: A suicide in a drug trial could hurt a medication’s sales prospects.

The risk-benefit calculation has changed amid the suicide epidemic in the U.S. From 1999 to 2016, the rate of suicides increased by 30 percent. It’s now the second-leading cause of death for 10- to 34-year-olds, behind accidents. (Globally the opposite is true: Suicide is decreasing.) Growing economic disparity, returning veterans traumatized by war, the opioid crisis, easy access to guns—these have all been cited as reasons for the rise in America. There’s been no breakthrough in easing any of these circumstances.

But there is, finally, a serious quest for a suicide cure. Ketamine is at the center, and crucially the pharmaceutical industry now sees a path. The first ketamine-based drug, from Johnson & Johnson, could be approved for treatment-resistant depression by March and suicidal thinking within two years. Allergan Plc is not far behind in developing its own fast-acting antidepressant that could help suicidal patients. How this happened is one of the most hopeful tales of scientific research in recent memory.

Dennis Charney, dean of the Icahn School of Medicine at Mount Sinai in New York, works from an office filled with family pictures, diplomas, and awards from a long career in research. One thing on the wall is different from the rest: a patent for the use of a nasal-spray form of ketamine as a treatment for suicidal patients. The story of the drug is in some ways the story of Charney’s career.

In the 1990s he was a psychiatry professor, mentoring then associate professor John Krystal at Yale and trying to figure out how a deficit of serotonin played into depression. Back then, depression research was all about serotonin. The 1987 approval of Prozac, the first selective serotonin reuptake inhibitor, or SSRI, ushered in an era of what people in the industry call me-too drug development, research that seeks to improve on existing medicines rather than exploring new approaches. Within this narrow range, pharmaceutical companies churned out blockbuster after blockbuster. One in eight Americans age 12 and older reported using antidepressants within the past month, according to a survey conducted from 2011 to 2014 by the U.S. Centers for Disease Control and Prevention.

Charney was a depression guy; Krystal was interested in schizophrenia. Their curiosity led them to the same place: the glutamate system, what Krystal calls the “main information highway of the higher brain.” (Glutamate is an excitatory neurotransmitter, which helps brain cells communicate. It’s considered crucial in learning and memory formation.) They had already used ketamine to temporarily produce schizophrenia-like symptoms, to better understand glutamate’s role in that condition. In the mid-1990s they decided to conduct a single-dose study of ketamine on nine patients (two ultimately dropped out) at the Yale-affiliated VA Connecticut Healthcare System in West Haven to see how depressed people would react to the drug.

Outside the field of anesthesiology, ketamine is known, if it’s known at all, for its abuse potential. Street users sometimes take doses large enough to enter what’s known as a “K hole,” a state in which they’re unable to interact with the world around them. Over the course of a day, those recreational doses can be as much as 100 times greater than the tiny amount Charney and Krystal were planning to give to patients. Nonetheless, they decided to monitor patients for 72 hours—well beyond the two hours that ketamine produces obvious behavioral effects—just to be careful not to miss any negative effects that might crop up. “If we had done the typical thing that we do with these drug tests,” Krystal says, “we would have completely missed the antidepressant effect of ketamine.”

Checking on patients four hours after the drug had been administered, the researchers saw something unexpected. “To our surprise,” Charney says, “the patients started saying they were better, they were better in a few hours.” This was unheard of. Antidepressants are known for taking weeks or months to work, and about a third of patients aren’t sufficiently helped by the drugs. “We were shocked,” says Krystal, who now chairs the Yale psychiatry department. “We didn’t submit the results for publication for several years.”

When Charney and Krystal did publish their findings, in 2000, they attracted almost no notice. Perhaps that was because the trial was so small and the results were almost too good to be true. Or maybe it was ketamine’s reputation as an illicit drug. Or the side effects, which have always been problematic: Ketamine can cause patients to disassociate, meaning they enter a state in which they feel as if their mind and body aren’t connected.

But probably none of these factors mattered as much as the bald economic reality. The pharmaceutical industry is not in the business of spending hundreds of millions of dollars to do large-scale studies of an old, cheap drug like ketamine. Originally developed as a safer alternative to the anesthetic phencyclidine, better known as PCP or angel dust, ketamine has been approved since 1970. There’s rarely profit in developing a medication that’s been off patent a long time, even if scientists find an entirely new use for it.

Somehow, even with all of this baggage, research into ketamine inched forward. The small study that almost wasn’t published has now been cited more than 2,000 times.

Suicide is described in medicine as resulting from a range of mental disorders and hardships—a tragedy with many possible roots. Conditions such as severe depression, bipolar disorder, and schizophrenia are known risk factors. Childhood trauma or abuse may also be a contributor, and there may be genetic risk factors as well.

From these facts, John Mann, an Australian-born psychiatrist with a doctorate in neurochemistry, made a leap. If suicide has many causes, he hypothesized, then all suicidal brains might have certain characteristics in common. He’s since done some of the most high-profile work to illuminate what researchers call the biology of suicide. The phrase itself represents a bold idea—that there’s an underlying physiological susceptibility to suicide, apart from depression or another psychiatric disorder.

Mann moved to New York in 1978, and in 1982, at Cornell University, he started collecting the brains of people who’d killed themselves. He recruited Victoria Arango, now a leading expert in the field of suicide biology. The practice of studying postmortem brain tissue had largely fallen out of favor, and Mann wanted to reboot it. “He was very proud to take me to the freezer,” Arango says of the day Mann introduced her to the brain collection, which then numbered about 15. “I said, ‘What am I supposed to do with this?’ ”

They took the work, and the brains, first to the University of Pittsburgh, and then, in 1994, to Columbia. They’ve now amassed a collection of some 1,000 human brains—some from suicide victims, the others, control brains—filed neatly in freezers kept at –112F. The small Balkan country of Macedonia contributes the newest brains, thanks to a Columbia faculty member from there who helped arrange it. The Macedonian brains are frozen immediately after being removed and flown in trunks, chaperoned, some 4,700 miles to end up in shoe-box-size, QR-coded black boxes. Inside are dissected sections of pink tissue in plastic bags notated with markers: right side, left side, date of collection.

In the early 1990s, Mann and Arango discovered that depressed patients who killed themselves have subtle alterations in serotonin in certain regions of the brain. Mann remembers sitting with Arango and neurophysiologist Mark Underwood, her husband and longtime research partner, and analyzing the parts of the brain affected by the deficit. They struggled to make sense of it, until it dawned on them that these were the same brain regions described in a famous psychiatric case study. In 1848, Phineas Gage, an American railroad worker, was impaled through the skull by a 43-inch-long tamping iron when the explosives he was working with went off prematurely. He survived, but his personality was permanently altered. In a paper titled “Recovery From the Passage of an Iron Bar Through the Head,” his doctor wrote that Gage’s “animal propensities” had emerged and described him as using the “grossest profanity.” Modern research has shown that the tamping iron destroyed key areas of the brain involved in inhibition—the same areas that were altered in the depressed patients who’d committed suicide. For the group, this was a clue that the differences in the brain of suicidal patients were anatomically important.

“Most people inhibit suicide. They find a reason not to do it,” Underwood says. Thanks to subtle changes in the part of the brain that might normally control inhibition and top-down control, people who kill themselves “don’t find a reason not to do it,” he says.

About eight years ago, Mann saw ketamine research taking off in other corners of the scientific world and added the drug to his own work. In one trial, his group found that ketamine treatment could ease suicidal thoughts in 24 hours more effectively than a control drug. Crucially, they found that the antisuicidal effects of ketamine were to some extent independent of the antidepressant effect of the drug, which helped support their thesis that suicidal impulses aren’t necessarily just a byproduct of depression. It was this study, led by Michael Grunebaum, a colleague of Mann’s, that made a believer of Joe Wright.

In 2000, the National Institutes of Health hired Charney to run both mood disorder and experimental drug research. It was the perfect place for him to forge ahead with ketamine. There he did the work to replicate what he and his colleagues at Yale had discovered. In a study published in 2006, led by researcher Carlos Zarate Jr., who now oversees NIH studies of ketamine and suicidality, an NIH team found that patients had “robust and rapid antidepressant effects” from a single dose of the drug within two hours. “We could not believe it. In the first few subjects we were like, ‘Oh, you can always find one patient or two who gets better,’ ” Zarate recalls.

In a 2009 study done at Mount Sinai, patients suffering from treatment-resistant depression showed rapid improvement in suicidal thinking within 24 hours. The next year, Zarate’s group demonstrated antisuicidal effects within 40 minutes. “That you could replicate the findings, the rapid findings, was quite eerie,” Zarate says.

Finally ketamine crossed back into commercial drug development. In 2009, Johnson & Johnson lured away Husseini Manji, a prominent NIH researcher who’d worked on the drug, to run its neuroscience division. J&J didn’t hire him explicitly to develop ketamine into a new pharmaceutical, but a few years into his tenure, Manji decided to look into it. This time it would come in a nasal-spray form of esketamine, a close chemical cousin. That would allow for patent protection. Further, the nasal spray removes some of the challenges that an IV form of the drug would present. Psychiatrists, for one thing, aren’t typically equipped to administer IV drugs in their offices.

While these wheels were slowly turning, some doctors—mostly psychiatrists and anesthesiologists—took action. Around 2012 they started opening ketamine clinics. Dozens have now popped up in major metropolitan areas. Insurance typically won’t touch it, but at these centers people can pay about $500 for an infusion of the drug. It was at one time a cultural phenomenon—a 2015 Bloomberg Businessweek story called it “the club drug cure.” Since then, the sense of novelty has dissipated. In September the American Society of Ketamine Physicians convened its first medical meeting about the unconventional use of the drug.

“You are literally saving lives,” Steven Mandel, an anesthesiologist-turned-ketamine provider, told a room of about 100 people, mostly doctors and nurse practitioners, who gathered in Austin to hear him and other early adopters talk about how they use the drug. Sporadic cheers interrupted the speakers as they presented anecdotes about its effectiveness.

There were also issues to address. A consensus statement in JAMA Psychiatry published in 2017 said there was an “urgent need for some guidance” on ketamine use. The authors were particularly concerned with the lack of data about the safety of prolonged use of the drug in people with mood disorders, citing “major gaps” in the medical community’s knowledge about its long-term impact.

The context for the off-label use of ketamine is a shrinking landscape for psychiatry treatment. An effort to deinstitutionalize the U.S. mental health system, which took hold in the 1960s, has almost resulted in the disappearance of psychiatric hospitals and even psychiatric beds within general hospitals. There were 37,679 psychiatric beds in state hospitals in 2016, down from 558,922 in 1955, according to the Treatment Advocacy Center. Today a person is often discharged from a hospital within days of a suicide attempt, setting up a risky situation in which someone who may not have fully recovered ends up at home with a bunch of antidepressants that could take weeks to lift his mood, if they work at all.

A ketamine clinic can be the way out of this scenario—for people with access and means. For Dana Manning, a 53-year-old Maine resident who suffers from bipolar disorder, $500 is out of reach. “I want to die every day,” she says.

After trying to end her life in 2003 by overdosing on a cocktail of drugs including Xanax and Percocet, Manning tried virtually every drug approved for bipolar disorder. None stopped the mood swings. In 2010 the depression came back so intensely that she could barely get out of bed and had to quit her job as a medical records specialist. Electroconvulsive therapy, the last-ditch treatment for depressed patients who don’t respond to drugs, didn’t help.

Her psychiatrist went deep into the medical literature to find options and finally suggested ketamine. He was even able to get the state Medicaid program to cover it, she says. She received a total of four weekly infusions before she moved to Pennsylvania, where there were more family members nearby to care for her.

The first several weeks following her ketamine regimen were “the only time I can say I have felt normal” in 15 years, she says. “It’s like you have 50 pounds on your shoulders, and the ketamine takes 40 pounds off.”

She’s now back in Maine, and the depression has returned. Her current Medicare insurance won’t cover ketamine. She lives on $1,300 a month in disability income. “Knowing it is there and I can’t have it is beyond frustrating,” she says.

Ketamine is considered a “dirty” drug by scientists—it affects so many pathways and systems in the brain at the same time that it’s hard to single out the exact reason it works in the patients it does help. That’s one reason researchers continue to look for better versions of the drug. Another, of course, is that new versions are patentable. Should Johnson & Johnson’s esketamine hit the market, the ketamine pioneers and their research institutions stand to benefit. Yale’s Krystal, NIH’s Zarate, and Sinai’s Charney, all of whom are on the patent on Charney’s wall, will collect royalties based on the drug’s sales. J&J hasn’t said anything about potential pricing, but there’s every reason to believe the biggest breakthrough in depression treatment since Prozac will be expensive.

The company’s initial esketamine study in suicidal patients involved 68 people at high risk. To avoid concerns about using placebos on actively suicidal subjects, everyone received antidepressants and other standard treatments. About 40 percent of those who received esketamine were deemed no longer at risk of killing themselves within 24 hours. Two much larger trials are under way.

When Johnson & Johnson unveiled data from its esketamine study in treatment-resistant depression at the American Psychiatric Association meeting in May, the presentation was jammed. Esketamine could become the first-ever rapid-acting antidepressant, and physicians and investors are clamoring for any information about how it works. The results in suicidal patients should come later this year and could pave the way for a Food and Drug Administration filing for use in suicidal depressed patients in 2020. Allergan expects to have results from its suicide study next year, too.

“The truth is, what everybody cares about is, do they decrease suicide attempts?” says Gregory Simon, a psychiatrist and mental health researcher at Kaiser Permanente Washington Health Research Institute. “That is an incredibly important question that we hope to be able to answer, and we are planning for when these treatments become available.”

Exactly how ketamine and its cousin esketamine work is still the subject of intense debate. In essence, the drugs appear to provide a quick molecular reset button for brains impaired by stress or depression. Both ketamine and esketamine release a burst of glutamate. This, in turn, may trigger the growth of synapses, or neural connections, in brain areas that may play a role in mood and the ability to feel pleasure. It’s possible the drug works to prevent suicide by boosting those circuits while also reestablishing some of the inhibition needed to prevent a person from killing himself. “We certainly think that esketamine is working exactly on the circuitry of depression,” Manji says. “Are we homing in exactly on where suicidal ideation resides?” His former colleagues at NIH are trying to find that spot in the brain as well. Using polysomnography—sleep tests in which patients have nodes connected to various parts of their head to monitor brain activity—as well as MRIs and positron emission tomography, or PET scans, researchers can see how a patient’s brain responds to ketamine, to better understand exactly what it’s doing to quash suicidal thinking.

Concerns about the side effects of ketamine-style drugs linger. Some patients taking esketamine have reported experiencing disassociation symptoms. Johnson & Johnson calls the effects manageable and says they cropped up within an hour of the treatment, a period in which a person on the drug would likely be kept in the doctor’s office for monitoring. Some patients also experienced modest spikes in blood pressure within the same timeframe.

Nasal-spray dosing brings other issues. The Black Dog Institute in Australia and the University of New South Wales in Sydney, which teamed up to study a nasal-spray form of ketamine, published their findings last March in the Journal of Psychopharmacology. The researchers found that absorption rates were variable among patients. J&J says its own studies with esketamine contradict these findings.

But in the wake of the opioid crisis, perhaps the biggest worry is that loosening the reins too much on the use of ketamine and similar drugs could lead to a new abuse crisis. That’s why Wall Street analysts are particularly excited by Allergan’s rapid-acting antidepressant, rapastinel, which is about a year behind esketamine in testing. Researchers say it likely acts on the same target in the brain as ketamine, the NMDA receptor, but in a more subtle way that may avoid the disassociation side effects and abuse potential. Studies in lab animals show the drug doesn’t lead creatures to seek more of it, as they sometimes do with ketamine, says Allergan Vice President Armin Szegedi. Allergan’s medicine is an IV drug, but the company is developing an oral drug.

For its suicide study, Allergan is working hard to enroll veterans, one of the populations most affected by the recent spike in suicides, and has included several U.S. Department of Veterans Affairs medical centers as sites in the trial. More than 6,000 veterans died by suicide each year from 2008 to 2016, a rate that’s 50 percent higher than in the general population even after adjusting for demographics, according to VA data.

“How the brain mediates what makes us who we are is still a mystery, and maybe we will never fully understand it,” Szegedi says. “What really changed the landscape here is you had clinical data showing ‘This really does the trick.’ Once you find something in the darkness, you really have to figure out: Can you do something better, faster, safer?”


Original article

By Cynthia Koons and Robert Langreth


What better way for you all to get to know Kelli and me at Thrive Anesthesia Services than for us to write a blog introducing ourselves, right?! But let’s put a spin on it to keep it interesting. Lura is going to introduce you to Kelli and Kelli is going to write the introduction to Lura. Great way to base a partnership and friendship on bringing out each other’s flaws publicly. Who’s ready for a roast?

Kelli is just a small-town girl, living in a lonely world… wait that’s a song… Kelli is a small-town girl from Steele, ND. She was active in sports, including cheerleading (seriously this surprised me to no end, still does) as well as basketball and anything else to keep her busy from actually attending school. Good thing she is super smart. I don’t think she was her teachers’ favorite student as she had a sticker on the blackboard that she had to put her nose on everyday due to talking (Kelli actually does not have an indoor voice, it’s been proven). After high school, she dreamed of moving to the big city (not Bismarck people) and was on her way to Chicago. Somehow with living in Chicago she met Chris while he was living in Bismarck. They courted from afar, broke up over a churro on Navy Pier and then got married. Onto Grand Forks they went for college… but then came back to Bismarck and Kelli graduated from MedCenter One School of Nursing (she’s so old it doesn’t even exist anymore) while 9 months pregnant with her Ella. Big changes went down in May of 2005: Kelli had a baby and she met me. Onward to work at CHI’s ICU where Kelli excelled and she realized we were best friends. As Kelli is not one to sit still she decided it is off to anesthesia school I go to Texas Wesleyan University in Fort, Worth, Texas. Kelli loves Texas. She wants to go back every weekend. Kelli was in clinical rotation and I was her boss (best days of my life) but then she graduated and I couldn’t boss her around anymore. She continued her work as a staff CRNA at CHI St. Alexius Health until we jumped off the cliff into Thrive Anesthesia Services.

Kelli’s husband, Chris, is an every other day hero (he’s a fireman and works like 11 days a month, it’s a joke, fireman are heroes and awesome, chill out). In his free time, which he has plenty of, he is a hockey dad. That is a full-time job. He coaches and coordinates. He’s a great guy but his clothing choices are questionable. Chris is also a volunteer receptionist at Thrive Anesthesia Services. His job seems to include following me around and talking to the back of my head. He tells very elaborate, long stories.

Chris and Kelli’s daughter, Ella, is a great combination of the two and they deserve her. She is attitude, sass and spunk all rolled up into a super tall teenager. Ella is a hockey lover and snap chat enthusiast except when she is rocking a flip phone because her phone is either broken or she is grounded. She is in charge of keeping Kelli and I looking fetch and such…

For someone as bad at geography as Kelli is, she sure gets around. Kelli volunteers and is a board member of Citizens of the World Foundation. Kelli makes bi-annual trips to Haiti to teach and help with equipment procurement for anesthesia providers in Haiti. Kelli is one of the hardest working, compassionate and loving people I know. She is a fighter who isn’t going to take no for an answer (which is really annoying sometimes). We broke up once for 6 months and I was incomplete. We’ve been through some of the best and worst times of our lives together and she is my ride or die.  She challenges me daily to be better and know more. I am so happy to have her in my life as a friend and now business partner.


Second installment of Thrive Anesthesia Services mind blowing and incredibly engaging blog. Let’s be clear right from the start. I, Kelli Gabel, am a creative procrastinator that has mastered the art of diversion when I don’t want to do something. That is exactly what has left you all pining after my witty translation of who Lura Jo Spears is. I have been wondering for weeks how I can accurately introduce you to the one person who is connected to every aspect of my life. Well, be prepared for a wildly over descriptive ride for this creative writing assignment.

It was April 27, 1983. Pretty sure if Lura was telling this story she would confidently claim that THIS was the most significantly joyful day of Larry (Larski) and Kristy Haisley’s life. It was the day of her birth. Born into an era of land lines, VCRs, stretch pants (not to be confused with yoga pants or leggings) and probably the greatest boy band of all time, WHAM. Back then you actually had to use a camera with a flash bulb and film to show off what your momma gave you (which for Lura was an exponential amount of luxurious dark brown hair).

Born and raised in Bismarck, N.D. by not only her loving parents but also “Pud.” Some would assume this refers to a babysitter, a beloved neighbor, a big brother or a stuffed animal. Nope. “Pud,” as most people knew him (in fact I am not 100% sure of his real name), is Lura’s uncle, Larry’s brother, who was a burly man with a gentle soul that showered all of his family & friends with more love, kindness, and presents then most of us have ever seen in our entire lifetime. I do feel it’s important to mention that in this small but gregarious family, Pud affectionately provided everyone with a good laugh and a nickname. In January of 2017, Lura “Smurfer” Spears and many others lost this great man to the highway to heaven. He will be eternally missed, loved and celebrated by all.

The years flew by for Lura as she was gifted many things which greatly enhanced her already charmed life. One happened to be her sweet baby sister, Teha, and many dogs. Lura exceeded all expectations academically, was widely popular with all who met her, became a Century Centahna in the late 90s and graced the soccer field for the Century Patriots. Ok. Ok. Ok. I can’t imagine her playing soccer either but let’s give her the benefit of the doubt here, people.

From Century High School, she went on to rule the school at the University of North Dakota, she was very well known at the Chester Fitz Library and Tabula scene. Turns out that paid off because she only spent 4 years there (unlike most people I knew when I was there) and graduated at the top of her Baccalaureate nursing class which earned her a coveted spot in the Intensive Care Unit (alongside me of course) at St. Alexius Medical Center, back to Bismarck, and eventually to attain her Master’s is Nurse Anesthesia!

Prior to returning to her old stomping grounds she managed to tranquilize, tag and eventually marry a lanky, northern Minnesota brown bear, Karl Spears. Over the years, I have come to find that Karl has not only mastered the qualities of a bear such as hunting, fishing, climbing, protecting and surviving (which is a real skill sometimes at the Spears’s household) but he is also a generalized wizard that can literally accomplish anything. He is the seasoned captain of the “Big Bertha Douche Canoe” and he has the best laugh of all time. However, his most endearing quality is the fact that he is also the Lord Commander of the “Quarry Lane Wall”.

The “Quarry Lane Wall” is the thwarter of all intrusion, wanted or unwanted, into the Spears’ family home. It is a gauntlet of bicycles, skate boards, tree stumps, table saws, 2 x 4s and rummage sale treasures galore. You know, your standard garage……. which no one dares to enter unless its daylight, someone knows your coming and you are tethered to either your car or the entrance door to ensure someone can find you if you don’t make it alive.

Now let’s get to the best part about Lura ….. the boys. Ajura, age 11, and Ahmi, age 9 are Lura and Karl’s boys. They are biological brothers from Ethiopia that became a beloved part of the family in May of 2012. They have grown so fast and changed so much over the last 6 years. Specifically, communication has become much easier even though we know the universal language of boys is a grunt or a giggle.

Ajura has grown into a full-sized man…. for real. He may be 11 years old but he more similarly resembles a tight end for the Minnesota Vikings. He is built for strength not speed. I think it’s his big heart that slows him down. He is a kind and gentle giant who loves country music, basketball, football and the family dogs, Nali and Kinde. Ajura is also the lover and protector of all things Crosby (his 1 year old cousin that he adores). He is a pre-teen so he also lacks the need and want to pursue personal hygiene or household tasks. If things continue to go this way I think Ahmi will have a roommate for life!

Ahmi is a sleek little gentleman of few words, unless he is laying down some master rhymes or beat boxing. Ahmi is still in the amateur stages of football and basketball but he is a true “beast slayer” and master of the most graceful “exits” that I have ever seen. He has a great smile but never let it fool you. It is NOT an invitation for a hug or snuggle of any kind. Under no circumstances does he want a hug, except maybe on a holiday or YOUR birthday and even then he is going to make you work for it!

Well it’s time to wrap this up but I have just a few more things to add about my friend and partner in not only business but almost all shenanigans. Lura is complex. She is dedicated, stubborn, elegant, sincere, ironic and intelligent. In just these few short pages I cannot begin to introduce you to the woman who has supported me, encouraged me and dared me to take risks, follow my passions, and put my heart into greatness instead of financial security!

She is a woman of many surprises. She can rock a pair of leggings and a sleeve of tattoos to pretty much any event or outing imaginable. She loves her nephew Crosby, her dogs and a lizard named “Corndog.” She claims to be a winter enthusiast and lover of the great outdoors which is a lie on most accounts. She truly prefers to spend winter in her house wearing her tie-dyed onesie, on a beach, or visiting friends in Haiti. I will give her credit in the sense that she will usually try anything twice. Except camping – no camping, at all, EVER! This is clearly an issue she bamboozled Karl on. Let’s just be honest, she straight up lied to him about this fact until the marriage licensed was signed.

The moral to all of this gibberish is that they say most people require many friends to provide all the basic needs of “friendship” and you can’t get it all in one person. Well I did.

  1. The funny friend – you guys already read installation one of our blog so I think you get it.
  2. The shopping friend- I feel this needs little explanation. Most humans know Lura & I have a problem. Specifically, with Lululemon, however we don’t do yoga…?
  3. The motivating friend – this is situational & subjective. She is a Taurus so when she decides something is worth our time & resources…. you best get out the way because we are doing it.
  4. The lazy friend – she is not actually lazy but if I haven’t cleaned my house in a month I am certainly not going to frantically clean it up before she comes over.
  5. The old friend – going on 13 years so I no longer feel a need to fill her in on endless back stories of my shenanigans nor explain my poor life choices.
  6. The artsy friend – one month ago I would have assured you that this is where Lura falls short…. and then my daughter got a personally hand-crafted knitted beanie from her for Christmas.
  7. The out-of-town friend – normally this would apply to that friend who you only see on occasion because they live in some elusive amazing place that you can only imagine because you live here. You are always HERE. This applies to Lura only because I feel she spends ¼  of her year out of town or out of the country. Immigration has verbally stated that she is “almost Haitian.”
  8. The crazy friend – well she is vegan…enough said. HAHAHAH. For real, she’s the one who talked me into wake skating (or rather wake face planting?), she dragged me to a Ludacris concert in Vegas, and we have shared many a karaoke microphone sessions at her prompting.

All in all, we, as well as our families, have gained and learned much together. Life skills like the kids teaching each other how to tie their shoes, how to catch fish with canned corn, free a ski rope from jet boat with a paring knife and a needle nose pliers, but most of all that it takes a village to make life work. Our village looks more like a smattering of rugged wildlings most days but it has made this life amazing….so far.


What is chronic pain?

This seems like it would be the easiest question to answer, but even in the medical community this answer is tricky. If we break it down, chronic means persisting for a long time or constantly recurring. For example: I struggle with back pain. Thankfully, at this point, I manage it medically with steroid injections and I only have a really bad flair up about once a year. This is still chronic pain.

Pain is even more complicated. Pain is a noxious stimulus that is conducted by peripheral nerves and then perceived by the brain. Most people know that if you place your hand on a hot stove this will illicit pain. In pain’s normal form, it is actually a good thing. It protects us (I bet you don’t put your hand on the stove again, or in my family’s case, in which my sister burned her arm on a hot oven door as a child, that little Gretel never did that again!). Pain also controls us after a surgery to protect the injury and not overdo it. However, as in all complicated things, sometimes this protective mechanism goes haywire. Suddenly pain occurs when there is not injury or that injury has already healed. People who have severe neuropathic pain can’t even handle a sheet to be placed on the painful area. This is NOT a normal, protective response. This is the pain we want to attack.

The best way I can describe this chronic pain cycle is think of a dirt road. Initially, that dirt road is slippery with loose gravel. Imagine this is a normal functioning nerve. You can get from point A to point B although it isn’t easy. Make sense? Okay. Now let’s say this is your way home from work and you’ve been driving it for a while. The loose gravel has slid away and you can really put the pedal to the medal. This is pain following a surgery (for example), it is expected and those pain fibers are fired up and it is (unfortunately) easy for that signal to get to your brain because it just hurts! Next step, now the road is so well traveled that there are deep ruts, in fact, you can’t even drive outside those ruts because you are pretty much stuck. Staying in those specific ruts are now the easiest path home. This is chronic pain. Your nerves get so used to that same painful path that now non-painful stimuli are going to take the rutted painful route because it’s easier. Isn’t that a bunch of bologna? And often, this is where people get stuck. My kids actually named a road “Mommy stuck road” because we actually did get stuck in ruts on a non-fictional road… but I digress…

I know that is probably clear as mud but the point of this blog post is to explain that chronic pain is really hard to treat because the nervous system is basically giving you the finger. It has gone rogue. What the science is showing is ketamine infusions are remapping the nervous system, almost like a grader to that road (now I am talking about big machinery which I know nothing about). It makes the road (or your pain) protective again instead of life-consuming. It will not fix a bulging disc, BUT if that bulging disc has been surgically removed or calmed down by other methods and the pain is still occurring THEN ketamine infusions can help get that pain under control. Ketamine will NOT cure your diabetes BUT it can allow you to put a sheet on your legs without jumping out the window.

So, when pain is no longer protecting you but holding you back from life it is time to give us a call. Take care of yourself!


DYNAMIC!!! So the definition of Kelli’s favorite word is: marked by usually continuous and productive activity or change. I tease Kelli about the overuse of this word but when it comes to Thrive Anesthesia Services that adjective pretty much hits the nail on the head.

I was speaking with a patient and spouse yesterday and the spouse commented on how interesting it is to come in for maintenance infusions because of the changes that are occurring. We are not talking about changes in how Thrive looks but on how Thrive manages our patient’s care. First, every one of our patients has a different story, a different disease process. This isn’t a “one-size fits all” type of therapy. Some people respond slowly, others immediately. Some jump right out of the chair after infusion, others need time to recover. Some have mind blowing results and sadly some do not. Either way our therapies are as individual as the person who is receiving them and although that makes our job trickier we are keeping it that way.

Secondly, the information is as dynamic as our patients. We attend webinars, follow the American Society of Ketamine Physicians (ASKP) online forum, participate on providers only Ketamine Infusion Facebook group and are always on the lookout for continuing education in this new field. As the registration page for the Ketamine and Related Compounds for Psychiatric Disorders conference states, “clinical experience has moved ahead of research-an unusual situation which creates opportunities as well as risks.” This statement is referring to the fact that ketamine is being used all over the world to treat psychiatric disorders and chronic pain and there are thousands of positive case reports BUT the actual research that usually comes before such usage is lacking. Successful protocols are often held as top-secret information as they are earned from experience because there are few protocols to use as a guide. Organizations such as ASKP,  KRIYA institute and administrators/participants in Facebook forums are opening up these secret vaults by sharing protocols, encouraging communication between providers and setting up conferences. The goal of these sources is not a one-up-manship between businesses but a legitimizing of science-based theory that is helping thousands of people world-wide. The clinics and providers that are involved in these groups want our patients to have the best results possible with the least number of visits and side effects. I can’t describe how exciting it is to put these constant changes into our practice in order for our patients to get the most up-to-date and effective infusion process possible.

We are so thankful for our patients who embrace the fact that this is an evolving science. We appreciate their cooperation as we close our clinic to attend a conference because they know we are going to come back with new ammunition for this war they are fighting. We are thankful for the kindness and openness of strangers in this quickly evolving practice who share their success and failures in order to help others. These strangers are providers and patients. We admire and look up to the pioneers in this DYNAMIC practice who were brave enough to commit to something new and then to share it with others. We promise to act like sponges and to pay that forward. There is no room for ego in this process. Ego is not your amigo (saw it on a shirt and feels like it fits, not an original phrase) 🙂

Last Hope

During consultations and often at the end of the first infusion our patients become very emotional and often state “This is my last hope.” The silent tears rolling down their cheeks are battle wounds from years of suffering with depression, anxiety, and/or chronic pain. One can never feel more honored and humbled by those words when they are laid down in front of you. But our response may surprise you…we acknowledge the feeling but say “This is NOT your last hope.”

The war against chronic pain and mental health is insidious and brutal. Our patients have tried EVERYTHING. They have spent thousands of dollars and hundreds of hours seeking management of their chronic health disease. They arrive at our clinic vulnerable and skeptical. Afraid of judgement and another hope dashed. The scariest part is we are frank in that we CANNOT “fix” everything. We don’t know how long relief will last IF you get relief. We know that this treatment has changed lives, but we don’t know if it will change yours. We also know that in order for remission to be lasting it requires a collaboration between us and other health care providers. We also need you to commit to learning new skills and allowing yourself to be vulnerable in this safe environment. This is NOT a miracle medication that fixes all problems. We are not selling snake oil and lies.

This is NOT your last hope because no matter your response to the treatment, at Thrive, we are in it for the long haul. We don’t give up on our patients. That may mean we consider other therapies and refer you to other providers. It may mean we send you an email weekly just to say: hi, we are thinking of you today. We will try to help you find a provider that understands you and you feel comfortable with. It may mean trying other medications for infusions. It always means we are CONSTANTLY learning and reading on this evolving practice and we will always give you the best we know. It isn’t the easy and most profitable path, but it is the path we have committed ourselves to. Our treatment schedules have changed, we’ve added medications and changed dosages and we participate in conferences, webinars and Facebook groups in order to be on the cutting edge of treatment options. Perhaps you’ve noticed Kelli and my super mature matching friendship necklaces that say “BROS.” It’s from a song that perfectly describes our friendship and relationship and the chorus “You tell me all the time, I got plans.” We don’t jump into anything without plans. Kelli and I joke that we are often healthcare concierges because we have been working in the Bismarck/Mandan healthcare community since 2005, we know amazing healthcare providers in our very own backyard.

We take your vulnerability of placing your “last hope” with us personal. We’ve read your medical history and we are only a bystander to the road you have walked but we see in those tears the years of hopelessness. Just know that Thrive Anesthesia Services will never be your last hope but your reset, restart, refocus and recover.


Kate Spade, Anthony Bourdain, Chester Bennington, Robin Williams. This is most certainly a short list of people in the spotlight who have committed suicide. They had fame, often fortune and lived under a microscope. And then we have the “not famous” people who we all know who have committed suicide. Some that have the fortune but perhaps not the fame. Those that exist amongst the marginalized and certainly not in the spotlight. Those that have private battles and some have public battles. Suicide is not a win or a loss of a battle. It is not a selfish or selfless act. It is not strength or weakness. It is pain.

Kelli and I wear matching “gr;t” tattoos. For those of you who are unfamiliar with the semicolon project I highly recommend a google search as I feel it would be insightful. Essentially the semicolon symbolizes “my story isn’t over yet.” Grit comes from a best friend who kindly renamed our stubbornness to “having grit.” This tattoo that we wear is in solidarity and openness to the mental health community. Those of you that feel invisible, we see you and we are not the only ones.

Imagine if you experienced ALL the beauty and ALL the pain of the world. Most of us are wired for self-preservation so that we filter the world we see in front of us. Yes, that sky is beautiful but it doesn’t make me cry. Yes, the commercial with starving children makes me want to act but I shelter myself from the pain of their hunger. Myself, for example, I can’t watch movies about animals being hurt or killed. It impacts me more than it “should.” That’s one part of me that I am unable to filter. Now imagine if your filter leaks (like mine for animals) and you experience all the pain and beauty of the world. It is not about weakness because it takes strength to wake up everyday knowing that you live with the responsibility of the worlds’ happiness on your shoulders.

My point is, I beg you to stand together. To have compassion and dare I say empathy for your friends, family, neighbors and loved ones. Those that are left behind are reeling from their loss and yet feel shamed by the cause of death. Embrace them and tell them that you don’t care about the how, you care about the loss. To the beautiful souls who are struggling to carry the burdens of the world, share them with someone else because no person can hold those on their own and you might be surprised by who is willing to share your burden. If we were all defined by our most emotionally reactive decision we would all be shocked at ourselves. To all, let’s stop this hiding and shaming. We are better than that. I know we are.