SPPCP 2026: Inside the Fudin Debates on Ketamine in Palliative Care

At the Society for Pain and Palliative Care Pharmacists' (SPPCP) 2026 annual conference, Jessica Geiger, PharmD, took the stage for one of the event's most anticipated traditions: the Fudin Debates. Named in honor of the late Jeff Fudin, a beloved pharmacist and mentor who was known for his sharp clinical mind and love of debate, the series challenges participants to argue the merits and limitations of treatments used in pain and palliative care.

This year, Geiger tackled a topic that sparks strong opinions on both sides—the use of ketamine in palliative care and hospice. Pharmacy Times sat down with her to hear her thoughts.

Pharmacy Times: You're participating in the Jeff Uden debates at SPPCP this year. Can you tell us a little bit about the debate and the topic you'll be tackling?

Jessica Geiger, PharmD, MS, BCPS: These debates are part of the Society for Pain and Palliative Care Pharmacists' annual virtual conference focusing on clinical topics in pain management, palliative care, and hospice for pharmacists. The debates were created in honor of Jeff Fuden, a pharmacist who mentored many of us and laid the foundation for a lot of us to be where we are now. He loved to debate and was a wonderful debater—he knew his stuff, had these zingers, and would put people on the spot and make you think critically. This is my first year participating, and the topic my co-presenter and I will be debating is ketamine use in palliative care and hospice—the pros and cons of utilizing that medication in that setting.

Pharmacy Times: For those who may not be as familiar, what is a quick overview of where ketamine currently sits in pain and palliative care practice?

Geiger: Ketamine is a derivative of PCP. Originally, scientists were looking at PCP as an anesthetic, but the emergence phenomenon from it was very violent, so ketamine was developed as an alternative—an anesthetic that could be used without that violent emergence response. It was originally used as a battlefield anesthetic for medical procedures done in the field.

Fast forward through a period of misuse and abuse, and now in palliative and hospice care, we use it mostly as an adjunct when pain is not well controlled. It can be very effective for certain people in reducing neuropathic pain and improving overall pain management, and we can sometimes see opioid use decrease when ketamine is added—though that's not always the case, and the studies are mixed. There is also emerging research on using it for refractory depression, but for the purposes of this debate, we're focusing specifically on its use for pain.

Pharmacy Times: How do you weigh ketamine's benefits against real concerns like abuse potential, diversion, and adverse effects?

Geiger: In this patient population, abuse and misuse don't tend to be at the front of my mind—though they don't go unconsidered. What I think about most are side effects and making sure we match the medication to the right person. At too high a dose, ketamine can cause hallucinations, and in patients with a history of PTSD, it can trigger frightening flashbacks. We don't want to make things worse while trying to make things better. So the first thing I consider is their past medical history, particularly any mental health conditions, so that patients truly understand the risks. It's not an absolute contraindication—there are even settings where ketamine is used to help people process traumatic experiences—but the key is doing a thorough history and matching the medication to the right person so that the benefits outweigh the risks.

Pharmacy Times: Considering all of that, what is your personal opinion and stance in clinical practice on the use of ketamine in palliative care?

Geiger: When I practiced inpatient palliative care, ketamine was never my first line—but it would always come to mind when we had tried many things and still couldn't get someone's pain under control. At that point, a trial of ketamine was worth considering. There are some important limitations, though. In the hospital, the medication is easy to obtain, and the IV formulation can be given as an infusion or even mixed with juice for oral use. But once a patient is discharged, getting the medication on an ongoing basis requires jumping through a lot of hoops—working with pharmacies, coordinating for hospice patients—since it only comes in a parenteral formulation. So most of my experience has been on the inpatient side.

My general approach was this: if the benefits outweigh the risks and it seems like the right fit, give a test dose in the hospital where everyone can monitor the patient, and you'll know right there whether it's going to work.

Pharmacy Times: Ketamine carries a lot of stigma — people hear the word and think of street drug use, tranquilizers, and so on. How do you counsel and educate patients on ketamine to help them feel more comfortable when you think it might be a good option for them?

Geiger: I always start by sitting down and asking, "What do you know about ketamine?" and just letting them talk. That way I understand where they're coming from and can meet them where they are. I don't need to repeat things they already know, and if they're voicing concerns, I know where to focus my teaching. I have no agenda going in—I have a thought about what might help them, but I want to understand what they know, what their worries are, and fill in any gaps. I think of one gentleman who told me, "You mean the horse tranquilizer?"—and I said, yes, that's what I'm talking about, and we also use it in humans.” That opened a great conversation, and by the end he decided he wanted to try it.

On the other hand, I've had patients—veterans with PTSD—who heard the potential side effects and said, "I don't want to relive any of that; let's find something else." And we respected that completely, regrouped as a team, and came back with another option. It all comes down to knowing what someone knows, figuring out what they don't, and meeting them where they are to come up with a plan that works for them—and more importantly, one they're comfortable with.

Pharmacy Times: What do you want pharmacists to walk away thinking about after this debate?

Geiger: Ketamine is one tool in the toolbox for managing pain in palliative and hospice care—there are many others, and it may not be the first one you reach for. But don't forget about it, and make sure you're informed. Beyond that, the bigger message is about meeting someone where they are. You might have a plan before you walk in the door, and it might completely change once you hear how the patient feels about it. Be open to adjusting your plan if needed, be open to considering ketamine if you haven’t before, and also be open to someone saying no—and then going back to the drawing board to find something else.