A review of the nonmedical use of ketamine: use, users and consequences

Ketamine is a dissociative anesthetic with an accepted place in human medicine. Ketamine also has psychedelic properties, and there has been a recent increase in nonmedical use linked with the growth of the "dance culture." This has attracted little comment in the formal literature but has been the subject of many reports in the media. Myths and misunderstandings are common. The psychedelic properties of ketamine have also led to its use as an adjunct to psychotherapy. This review is intended as a resource for the wide range of persons now requesting accurate information about the nonmedical use of ketamine. It accepts the current necessity of sometimes referring to anecdotal reports while seeking to encourage an increase in formal research. The review includes the history of ketamine, its growing role as a "dance drug," the sought-after effects (including the near-death experience) for which it is taken in a nonmedical context, how these are produced, common mental and physical adverse effects, and the ketamine model of schizophrenia.     

Methamphetamine use among young adults: health and social consequences

The current research analyzed the relationship between methamphetamine use and health and social outcomes. Interviews were conducted with a sample of 106 respondents. Virtually all of the respondents experienced negative consequences of methamphetamine use. The most serious, but least prevalent, methamphetamine-related health problem was seizures and convulsions. The most prevalent health effect was weight lose. A substantial number of respondents experienced severe psychological symptoms: depression, hallucinations, and paranoia. Of the 106 respondents, 34.9% had committed violence while under the influence of methamphetamine. The data suggest that methamphetamine-based violence was more likely to occur within private domestic contexts, both family and acquaintance relationships. It is apparent from the findings that methamphetamine use heightens the risk for negative health, psychological, and social outcomes. Having said this, it is crucial to acknowledge that there was no evidence of a single, uniform career path that all chronic methamphetamine users follow. Furthermore, a significant number of sample members experienced limited or no serious social, psychological, or physical dysfunction as a result of their methamphetamine use.     

Patterns of use and harms associated with non-medical ketamine use

AIM: To (1) identify current patterns of non-medical ketamine use; and (2) identify potential harms associated with non-medical ketamine use. DESIGN: Cross sectional survey of lifetime ketamine users. SETTING: Semi-structured interviews took place in public and private settings in Sydney Australia. PARTICIPANTS: One Hundred ketamine users. MEASUREMENTS: Self-reported experiences with and attitudes towards ketamine use. FINDINGS: Ketamine appeared to be added to an already extensive drug use repertoire of a well-educated and informed sample. Many users reported regularly experiencing effects such as an inability to speak, blurred vision, lack of co-ordination and increased body temperature, which resulted in some either reducing their dose or stopping use. CONCLUSIONS: Many users had experienced significant negative effects, such that some had either reduced their dose or stopped use altogether and expressed concerns over some others. This study reinforces the need to develop harm minimisation campaigns that match the experiences and attitudes of their target group through careful needs assessment and appropriate evaluation.     

The nonmedical use of ketamine, part two: A review of problem use and dependence

This is the second part of a review of the nonmedical use of ketamine. Part one discussed the history of ketamine, the sought-after effects for which it is taken in a nonmedical context, how these are produced, common adverse effects, the ketamine schizophrenia model and the neurotoxicity issue. Part two reviews what is currently known about problem use of ketamine, ketamine dependence, treatment options and harm minimization issues. Some ketamine users become dependent on the drug in a manner resembling cocaine dependence, with craving and a high tolerance but no evidence of a physiological withdrawal syndrome. The likely mechanisms of this dependence are discussed in terms of what is known about the neurochemistry of ketamine, its psychological effects, and published case histories in both the formal and informal literature. The conclusions are that ketamine dependence is linked with effects that this complex drug has in common with not only cocaine and amphetamine but also with opiates, alcohol and cannabis, as well as the psychological attractions of its distinctive psychedelic properties.     

The epidemiology of smoking: health consequences and benefits of cessation

Tobacco use is the single most important preventable health risk in the developed world, and an important cause of premature death worldwide. Smoking causes a wide range of diseases, including many types of cancer, chronic obstructive pulmonary disease, coronary heart disease, stroke, peripheral vascular disease, and peptic ulcer disease. In addition, smoking during pregnancy adversely affects fetal and neonatal growth and development. Recent decades have seen a massive expansion in tobacco use in the developing world and accelerating growth in smoking among women in the developed world. Globally, smoking-related mortality is set to rise from 3 million annually (1995 estimate) to 10 million annually by 2030, with 70% of these deaths occurring in developing countries. Many of the adverse health effects of smoking are reversible, and smoking cessation treatments represent some of the most cost effective of all healthcare interventions. Although the greatest benefit accrues from ceasing smoking when young, even quitting in middle age avoids much of the excess healthcare risk associated with smoking. In order to improve smoking cessation rates, effective behavioural and pharmacological treatments, coupled with professional counselling and advice, are required. Since smoking duration is the principal risk factor for smoking-related morbidity, the treatment goal should be early cessation and prevention of relapse.     

Route of drug use and its implications for drug effect, risk of dependence and health consequences

Route of administration has a profound, but often overlooked, influence on the actual experience of the drug use itself, on the risk of resulting development of dependence, and on the nature of the harms to which drug users are exposing themselves. These three areas are reviewed. The influence of route of administration on drug effect is considered first with regard to overall effectiveness of absorption, and also with regard to speed of onset of effect. The implications for risk of dependence cover animal and human laboratory studies of reinforcement schedules, epidemiological studies, the attitudes of drug users themselves to the different routes of possible drug use and associated dependence risk and the postulated influences on progression to dependence. Finally, the relationship between route of drug use and health sequelae is explored for the three most widely used routes of administration of illicit drugs-snorting, smoking and injecting.     

Developmental neurotoxicity of ketamine in pediatric clinical use

Ketamine is widely used as an anesthetic, analgesic, and sedative in pediatric clinical practice and it is also listed as an illicit drug by most countries. Recent in vivo and in vitro animal studies have confirmed that ketamine can induce neuronal cell death in the immature brain, resulting from widespread neuronal apoptosis. These effects can disturb normal development further altering the structure and functions of the brain. Our recent studies further indicate that ketamine can alter neurogenesis from neural stem progenitor cells in the developing brain. Taken together, these findings identify a novel complication associated with ketamine use in premature infants, term newborns, and pregnant women. Recent data on the developmental neurotoxicity of ketamine are reviewed with proposed future directions for evaluating the safety of ketamine in these patient populations.     

Epidemiology and public health consequences of diabetes

In the world of diabetes a number of outdated terms are still in use and some myths exist. Among the former are 'juvenile onset' and 'maturity onset' which, given the changing epidemiology of diabetes, need to be abandoned once and for all. A dangerous myth is that type 2 diabetes is 'mild diabetes'. Diabetes, particularly that of longer duration, but whether type 1 or type 2, is associated with microvascular and macrovascular complications. The former comprise retinopathy, nephropathy and neuropathy, the latter coronary heart disease, cerebrovascular disease and peripheral vascular disease. The public health challenges of diabetes are that of delivering effective health care to meet current demands and planning for the future to cope with the predicted epidemic of diabetes worldwide. The latter can only be accomplished if primary prevention is taken seriously as the main method by which future demands can be decreased to a sustainable level.     

Drug scene,drug use and drug-related health consequences and responses in Kulob and Khorog,Tajikistan

BackgroundTajikistan and other Central Asian republics are facing intertwined epidemics of injecting drug use and HIV. This paper aims to examine drug scene, drug use, drug-related infectious diseases, drug treatment and other responses to health consequences of drug injecting in two Tajik cities of Kulob (Khatlon Region) and Khorog (Gorno-Badakhshan Autonomous Oblast).MethodsWe conducted 12 focus group discussions in Kulob and Khorog and analysed peer-reviewed literature, published and unpublished programme and country reports and other publications that focused on substance use and/or HIV/AIDS in Tajikistan and included the Khatlon and Gorno-Badakhshan regions.ResultsIn both Kulob and Khorog, heroin is used by the overwhelming majority of people who inject drugs (PWID), with one dose of heroin in Khorog costing less than a bottle of vodka. Opioid overdose among PWID in Tajikistan is a serious issue that appears to be substantially underestimated and inadequately addressed at the policy and practice levels. In integrated bio-behavioural surveys (IBBS), HIV and HCV prevalence in both Kulob and Khorog varied widely over a short period of time, raising questions over the quality and reliability of these data. Access to opioid substitution therapy (OST) and antiretroviral therapy (ART) by PWID is either lacking or inadequate. Very few women who inject drugs access needle and syringe programmes in Kulob and Khorog. HCV treatment cannot be afforded by the overwhelming majority of PWID due to high costs.ConclusionTajikistan IBBS data point to the potential problems in using composite national prevalence as an adequate reflection of the HIV epidemic among PWID in the country and highlight the importance of examining site-specific prevalence rates for better understanding of the dynamics of the epidemic over time as well as potential problems related to the reliability of data. Furthermore, our analysis highlights that in a country where almost all PWID inject opiates, agonist treatment should be an intervention of choice. Scaling-up both OST and ART coverage must be seen as the top priority for reducing HIV prevalence and incidence in Tajikistan. Naloxone distribution programmes need to be expanded and drug treatment, harm reduction and HIV services that meet the specific needs of female injecting drug users should be put in place.     

Public health decisions: Actions and consequences

The goal of public health is to promote the best possible health for the whole population. Public health issues are numerous and can be unbelievably complex in form, scope, and possible consequence. Most public health decisions involve assessing several different options, weighing the respective benefits and risks of those options, and making difficult decisions that hopefully provide the greatest benefit to the affected populations. Many risk management decisions involve a variety of societal factors which modify risk assessment choices. The purpose of this paper is to point out difficulties in making decisions that impact public health. The intent of such decisions is to improve public health, but as illustrated in the paper, there can be unintended adverse consequences. Such unplanned issues require continued attention and efforts for responsible officials in the protection of environmental public health. This article presents examples of such events, when in the past, it was necessary to assess and regulate a number of potentially hazardous chemicals commonly used as insecticides, gasoline additives, and wood preservatives.     

Parental substance use consequences and adolescent psychopathology

OBJECTIVE: This study examines the relationship between parental substance use consequences and adolescent psychological problems by gender of the adolescent and gender of the parent. METHOD: The data in this study were collected between 1989 and 1994 from 173 (116 proband and 57 control) families participating in the Collaborative Study on the Genetics of Alcoholism (COGA) project. All 173 adolescents (89 [51%] boys) completed the Structured Assessment Record of Alcoholic Homes (SARAH) to assess parental substance use consequences. In addition, the Semi-Structured Assessment for the Genetics of Alcoholism for Adolescents (C-SSAGA-A) was administered to all adolescents to obtain clinical psychiatric diagnoses. RESULTS: Concern about mother's substance use was significantly associated with adolescent alcohol dependence and major depressive disorder. In addition, concern about father's substance use was significantly related to adolescent alcohol dependence. Avoidance of mother when she was drinking or using drugs and maternal anger when drinking or using drugs also was significantly associated with adolescent alcohol dependence, conduct disorder and major depressive disorder. In contrast, avoidance of father and paternal anger when drinking or using drugs was not related to any of the adolescent diagnoses. CONCLUSIONS: These results suggest that maternal substance use consequences may be more closely linked to adolescent psychological adjustment than are paternal substance use consequences.     

Patterns of ketamine use among young injection drug users

Ketamine is a dissociative anesthetic that has emerged as an increasingly popular choice among young drug users. Recent research indicates the presence of hidden populations of young people who inject ketamine in New York and other U.S. cities. Applying an ethno-epidemiological approach, the authors recruited 40 young injection drug users (IDUs) (< 25 years old) in New York City to explore health risks associated with ketamine use. This analysis looks at the varying patterns and frequencies of ketamine injection by examining personal, social, and cultural aspects of these young people's lives. We learned that drug-using histories, experiential dimensions, sociocultural characteristics, and associations with other young people help account for the different patterns of injecting ketamine within the sample. In particular, these findings indicate that young people who were more frequent ketamine injectors had the following characteristics: initiated injection drug use with ketamine; enjoyed the effects of ketamine, were stably housed; lived in the vicinity of New York City; and associated with others who also injected ketamine.     

20个国家/地区氯胺酮使用及管理情况的调查

目的:了解氯胺酮在国际上的使用、管理和滥用情况。方法:采用自拟问卷,于2015年6月-9月通过电子邮件的形式向国际麻醉品管制局(INCB)的成员国或地区发送调查问卷,收集氯胺酮目前在各国/地区的医疗使用、管理和滥用情况等内容,并于2015年9月15日收回20个国家/地区的反馈。结果:本次调查的20个国家/地区中,有14个来自欧洲,3个来自亚洲,各有1个分别来自北美洲、大洋洲和非洲。除了拉脱维亚,其余19个国家/地区目前均将氯胺酮作为麻醉药在临床使用,并且有12个(63.2%)国家/地区将其作为医疗机构中麻醉科主要使用的麻醉用药,但这些国家/地区均有可替代氯胺酮的其他药品。2012-2014年用于医疗目的的氯胺酮数量以摩尔多瓦、捷克、冰岛、土耳其、乌克兰五个国家为最多(>100 kg/年)。除五个国家/地区未作回答外,共13个国家/地区存在氯胺酮的滥用,其中10个为欧洲国家。这些国家/地区氯胺酮的主要来源以黑市走私贩运(8/13)和药品的非法流失(6/13)为主。2012-2014年查获非法来源的氯胺酮的数量较多(>100 kg/年)的国家/地区有摩尔多瓦、中国香港及克罗地亚。在20个国家/地区中,有13个国家/地区(占65%)将氯胺酮列入管制,并且其中8个国家/地区(66.7%)认为氯胺酮的管制没有对其临床使用造成影响。而将氯胺酮列管的主要原因是预防其滥用(12/13),发生了流行性滥用(6/13)及其药品不良反应(1/13)。结论:氯胺酮在绝大多数国家/地区仍作为麻醉药在临床使用,其滥用出现在以欧洲为主的多个国家/地区。在对氯胺酮进行管制的国家/地区中,氯胺酮的临床使用基本未受到影响。     

Effects of chronic ketamine use on frontal and medial temporal cognition

Background

Recreational ketamine use has been on the rise worldwide. Previous studies have demonstrated that it disrupts various memory systems, but few studies have examined how it affects learning and frontal functioning. The present study investigates the effects of repeated ketamine self-administration on frontal fluency, attention, learning, and memory along the verbal/nonverbal axis.

Methods

Twenty-five ketamine users and 30 healthy controls took a battery of neuropsychological tests. Frontal fluency was measured by the Verbal Fluency Test for semantic organization ability and the Figural Fluency Test for nonverbal executive functioning. Learning and memory were measured with the Chinese Auditory-Verbal Learning Test for acquisition and retention abilities of verbal information, as well as with the Continuous Visual Memory Test for nonverbal information. Participants also took several tests tapping subdomains of attention. To test for the potential effects of other drug use, 10 polydrug controls were included for comparison with the ketamine users and healthy controls.

Results

Ketamine users had impaired verbal fluency, cognitive processing speed, and verbal learning. Verbal learning impairment was strongly correlated with estimated lifetime ketamine use. Ketamine users showed no impairments in figural fluency, sustained attention, selective attention, visual learning, or verbal/nonverbal memory. However, heavier lifetime ketamine use was significantly correlated with deficits in verbal memory (both immediate recall and delayed recall) and visual recognition memory. Deficits in cognitive processing speed and verbal learning persisted even after polydrug controls were included in the control group, but their inclusion did make the impairment in verbal fluency barely reach statistical significance.

Conclusions

This study suggests that repeated ketamine use causes differential impairment to multiple domains of frontal and medial temporal functioning, possibly specific to verbal information processing.