Still Working From a 2018 Map: Ketamine for Pain in the Absence of an Update

A colleague asked me recently what the guideline says about ketamine for her patient's condition. I gave her the honest answer. The last society consensus is from 2018, and the review it scheduled for itself was due three years ago. She assumed I was wrong, or out of date. I wasn't. That document is still the map, and most of us are practicing off a map drawn before the current infusion-clinic landscape existed.

That gap between what the field is doing and what the field has formally agreed on is not a footnote. For ketamine and chronic pain, it is the whole clinical situation.

The 2018 ASRA/AAPM/ASA consensus on intravenous ketamine for chronic pain is more measured than most clinic marketing would suggest. Its evidence grades are specific and worth knowing cold:

The panel wrote that the guidelines would be reviewed again in 2023. As of this writing in mid-2026, I have not been able to locate a revised consensus from these societies. If one has been published, I would update this post, because being right matters more than being first. But the practical reality clinicians face is a guidance document that is now several years past its own review date.

In that same window, off-label ketamine for pain expanded considerably, and the number of infusion clinics grew. The map stayed still while the territory changed.

When the official standard is stale, defensible care does not mean freelancing. It means being more explicit, not less. A few practices hold up under scrutiny:

1. Match the indication to the evidence tier the guideline names. Offering ketamine for CRPS sits on moderate evidence. Offering it for fibromyalgia or low-back pain sits on weak-to-no evidence, and you should know which one you are doing.
2. Define a positive response in advance. The 2018 document addressed what counts as a treatment response. Set that threshold with the patient before the first infusion, and set a stop rule.
3. Document off-label reasoning and consent. If you go beyond what the guideline supports, say so in the note and in the consent conversation.
4. Assess mood, not just pain. Recent cohort data suggest depression may be driving much of ketamine's analgesic effect in treatment-resistant pain, which is exactly the kind of nuance a 2018 guideline could not incorporate.

A guidance vacuum is not neutral. It gets filled, and it tends to get filled by whoever has a financial reason to fill it. Clinics advertise ketamine for conditions the consensus rates as weak or unsupported, patients pay out of pocket because insurance rarely covers it, and the absence of a current guideline becomes a feature rather than a problem for the businesses operating in that space.

That is not an accusation against individual clinicians, many of whom are careful. It is a description of what happens to standards of care when the official standard ages out and nobody is required to replace it. 

The reframe is simple. Do not treat the 2018 guideline as either gospel or garbage. Treat it as the floor you are still standing on, know exactly where its evidence is strong and where it is thin, and make your own reasoning legible wherever you step past it. When the map is old, the answer is a better-documented walk, not a confident stride in an unknown direction.

The most recent society consensus is the 2018 ASRA/AAPM/ASA guideline. It was slated for review in 2023, and no revised version has been located as of mid-2026. It remains the reference document, which means clinicians are working from guidance that predates much of the current infusion-clinic landscape and recent mechanistic research.

The 2018 consensus found moderate evidence only for CRPS, supporting improvement for up to roughly 12 weeks. For mixed neuropathic pain, phantom limb pain, postherpetic neuralgia, fibromyalgia, cancer pain, ischemic pain, migraine, and low-back pain, it found weak or no evidence for immediate relief, and outside CRPS, no evidence for lasting improvement.

Off-label practice is legal and sometimes reasonable, but it raises the bar for documentation and consent, not lowers it. If you offer ketamine for a weak-evidence indication, name that explicitly in the consent conversation, define what a positive response looks like in advance, and set a stop rule. "The guideline does not support this strongly" is information the patient is owed.

Peter H. Addy, PhD, LPC, LMHC is a Portland-based licensed therapist and the founder of Psychedelic Affirming Education, an NBCC-approved continuing education provider for licensed mental health professionals and Oregon Psilocybin Services facilitators. His research background includes work at Yale School of Medicine on psychedelic substances.

Practicing past a stale guideline is an ethics problem before it is a clinical one, and it is one you can train for. Our Ethical Guidelines for Ketamine Clinicians course (2 CE credits) works through consent, documentation, and defensible decision-making for exactly this kind of gray zone.