Hello, and greetings!

By way of a direct answer to your question, after spending several hours conducting online searches, I don't know of any VA facilities currently administering ketamine as part of their pain treatment programs. That said, I may have come up with some useful information. To begin with, after reading your post, I started cruising through the webpage of the VA's Palo Alto facility, which is affiliated with Stanford and produces a large amount of very sophisticated research on pain topics. http://www.palo-alto.med.va.gov/researchpa.asp Unfortunately, that facility doesn't appear to even have so much as a pain clinic. I then went national, with somewhat better results. Here is the homepage for VHA Pain Management: http://www1.va.gov/Pain_Management/ As you can see, right at the top it links to a page on "Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach" which is never encouraging when you are looking for medical interventions.

Perhaps the most interesting page is under the heading of Administrative Resources at http://www1.va.gov/Pain_Management/page.cfm?pg=42 If you open the page and look the articles entitled "James A. Haley (Tampa) VA Chronic Pain Rehabilitation Program Policy" and "VHA Pain Management Strategy Overview," you'll see that pain management at the VA appears to be very much of a work in progress, which is really sad, especially compared to the leadership Walter Reed has taken under the direction of Col. (Dr.) Chester C. Buckenmaier III, Chief of Army Regional Anesthesia and Acute Pain Management Initiative. By way of example:

A unique presentation of complex regional pain syndrome type I treated with a continuous sciatic peripheral nerve block and parenteral ketamine infusion: a case report, Everett A, Mclean B, Plunkett A, Buckenmaier C, Pain Med. 2009 Sep;10(6):1136-9. Epub 2009 Sep 9. Free full text at http://www.rsds.org/2/library/articl...n_Plunkett.pdf

Walter Reed Army Medical Center-Army Regional Anesthesia & Pain Medicine, Washington, DC 20307, USA.

OBJECTIVE: To successfully treat a patient with complex regional pain syndrome, refractory to standard therapy, to enable a rapid and full return to professional duties. SETTING: This case report describes the rapid resolution of an unusual presentation of complex regional pain syndrome type I after four days of treatment with a continuous sciatic peripheral nerve block and a concomitant parenteral ketamine infusion. The patient [a first year West Point Cadet] was initially diagnosed with complex regional pain syndrome (CRPS) I of the right lower extremity following an ankle inversion injury. Oral medication with naproxen and gabapentin, as well as desensitization therapy, failed to provide any relief of her symptoms. She was referred to the interventional pain management clinic. A lumbar sympathetic block failed to provide any relief. The patient was diagnosed with CRPS I and was admitted for treatment with a continuous peripheral nerve block and parenteral ketamine. CONCLUSION: This case suggests therapeutic benefit from aggressive treatment of both the peripheral and central components of CRPS.

PMID: 19744217 [PubMed - in process]

http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum

But as to the VA, right now, your best chance may be in taking advantage of the list provided under the heading "VISN Pain Management Point of Contact Information" towards the end of the Administrative Resources page and just start calling some of the people listed. The one that sticks out, just because he appears to have all the right credentials, is:

Amr Zidan, MD
Anesthesiology and Pain Management
Chief, Pain Management
4500 S. Lancaster Rd
Dallas, TX 75216

214-857-0384
Pager: 214-759-2023
Amr.Zidan@va.gov

Alternatively, if you would be more comfortable calling anyone else on the list to begin with, then by all means do so.

I would call, begin by saying that you got his or her name off of the list of contact persons on the VHA Pain Management website, and explain that you are a vet with confirmed diagnoses of TOS, RSD, CPS, DDD etc. Then, briefly describe the failure of your treatments to date, and explain that you understand Col. Buckenmaier at Walter Reed has recently published work on the use of ketamine in the treatment of CRPS (aka RSD) and you would very much like to know where (or when) in his understanding the VA will offer ketamine therapies as well.

For that matter, you may wish to inquire as to what facilities have any expertise in dealing with RSD & TOS, where, just based upon the headings under "Clinical Practice Guidelines" also on the Administrative Resources page, pain management treatments at VA facilities appear to be focussed pretty much on cancer, low back pain and the like. (Please note that although the titles remain, the articles under the sub-heading "VA OPQ Clinical Practice Guidelines pain services" are no longer available.) To put it generously, references to RSD/CRPS are few and far between. However, I have to confess that the VA's latest word on the treatment of chronic pain isn't particularly encouraging. From the VA's National Center for PTSD, check out a document I accessed directly through the VA's search engine (on a search for "reflex sympathetic"), "The Experience of Chronic Pain and PTSD: A Guide for Health Care Providers," Lorie T. DeCarvalho, Ph.D, August 20, 2009, which reads in part as follows:

What is the experience of chronic pain like physically?

There are many forms of chronic pain, including: pain felt in the low back (most pervasive or common), the cervical area, the mouth and face, the temporomandibular joint (TMJ), the pelvis, or the head (e.g., tension and migraine headaches); complex regional pain syndrome (formally reflex sympathetic nerve dystrophy (RSD)); fibromyalgia; and cancer-related pain. Of course, each type of condition results in different experiences of pain. But, as an example, chronic low back pain (CLBP) is known to result in severe disability and limitation of movement. In its most severe forms, CLBP may cause paralysis and numbness, loss of gross motor control, loss of bowel and bladder control, loss of reflexes in lower limbs, spasticity, and nerve degeneration.

Patients with chronic pain tend to experience ongoing pain and sometimes experience disability secondary to their condition. Most resort to invasive assessment or treatment procedures, including surgery, to help ameliorate the pain. Individuals with chronic pain are less able to function in daily life than those who do not suffer from chronic pain. Patients with severe chronic pain and limited mobility oftentimes are unable to perform activities of daily living, such as walking, standing, sitting, lifting light objects, doing paperwork, standing in line at a grocery store, going shopping, or working. Many patients with chronic pain cannot work because of their pain or physical limitations.

* * *

Treating individuals who have chronic pain and PTSD

Cognitive-behavioral therapy (CBT) is a psychotherapeutic intervention that helps patients manage chronic pain (Turk, Meichenbaum, & Genest, 1983). Other types of treatment that help patients with chronic pain include: stress inoculation training, behavior modification/operant conditioning, self-directed treatments, and adjunctive treatments such as biofeedback and relaxation training (Brown & DeCarvalho, 2004). There are also manualized treatments that specifically address avoidance behaviors and hypervigilance, because these behaviors tend to reinforce fear reactions (e.g., Meichenbaum, 1986). Beyond this, Shipherd, Beck, Hamblen, Lackner, and Freeman (2003) piloted a more specific protocol for providing CBT treatments to address PTSD symptoms in patients with chronic pain. Results from this small study suggested that along with positive improvements in patients' psychiatric diagnoses following application of this treatment, there were also improvements in pain-related functioning. This was true even though the pain was specifically not addressed in the intervention, which suggests that the beneficial effects of PTSD treatment may generalize to other problems without the need for direct intervention. Further research is still needed in this area, but this study indicates that when treating patients with chronic pain, it is vital that health care providers address patients' symptoms of PTSD and depression. In so doing, patients are more likely to have improvements in their levels of pain as well as in their physical and emotional functioning.

http://www.ptsd.va.gov/professional/...-providers.asp

Good luck and good hunting!

Mike