Patterns of use,harm reduction strategies,and their relation to risk behavior and harm in recreational ketamine users

ABSTRACT

Background: Recent studies have shown that ketamine use has serious adverse consequences. However, no studies have focused on the strategies that users carry out to protect themselves from such potential harm. Objectives: (i) analyze harm reduction strategies, risk behaviors, and harms in nonmedical/recreational ketamine users; (ii) analyze the association of their harm reduction strategies and risk behaviors with harms they report. Methods: An anonymous cross-sectional web-based survey of 462 persons who had used ketamine in the past year. We designed a questionnaire to collect information on their risk behaviors, harm, and harm reduction strategies. Results: The harms most reported were unexpected confusion (58.2%), memory impairment (57.4%), and abrupt mood/behavior changes (49.6%). The most frequent strategies were spacing out sessions (60.8% always/almost always did this), spacing out doses within a session (54.5%), and limiting the amount and not going over it (41.3%). The use of these three strategies was related to a lower probability of perceiving negative consequences associated with ketamine use, including memory impairment, healthcare assistance, psychological dependence, and risk behaviors related to driving under the influence of ketamine. Conclusions: This study provides empirical evidence on strategies related to the lower probability of harm associated with ketamine use as employed by recreational ketamine users. Our findings suggest that efforts to minimize harm from ketamine use should focus on increasing awareness of potential harms and the use of identified harm reduction strategies.     

Consequences of chronic ketamine self-administration upon neurocognitive function and psychological wellbeing: a 1-year longitudinal study

Background   'Recreational' use of ketamine is spreading rapidly among young people. In healthy individuals an acute dose of the N-methyl D-aspartate (NMDA) receptor antagonist ketamine induces marked psychosis-like effects and cognitive impairments, but little is known about the long-term effects of the drug.
Aims   To evaluate the long-term neuropsychiatric or cognitive consequences.
Methods   A total of 150 individuals were assessed, 30 in each of five groups: frequent ketamine users, infrequent ketamine users, abstinent users, polydrug controls and non-users of illicit drugs. Twelve months later, 80% of these individuals were re-tested.
Results   Cognitive deficits were mainly observed only in frequent users. In this group, increasing ketamine use over the year was correlated with decreasing performance on spatial working memory and pattern recognition memory tasks. Assessments of psychological wellbeing showed greater dissociative symptoms in frequent users and a dose–response effect on delusional symptoms, with frequent users scoring higher than infrequent, abstinent users and non-users, respectively. Both frequent and abstinent using groups showed increased depression scores over the 12 months.
Conclusions   These findings imply that heavy use of ketamine is harmful to aspects of both cognitive function and psychological wellbeing. Health education campaigns need to raise awareness among young people and clinicians about these negative consequences of ketamine use.     

In and out of the K-hole: a comparison of the acute and residual effects of ketamine in frequent and infrequent ketamine users

Aims. Ketamine, a non-competitive NMDA receptor antagonist, produces acute impairments of working, episodic and semantic memory along with psychotogenic and dissociative effects when a single dose is given to healthy volunteers. In recreational users, Curran & Morgan (2000) showed that ketamine produced the same acute effects but that 3 days after ingestion, ketamine users showed persisting memory impairment and elevated psychotogenic symptoms compared with controls. To explore whether such persisting effects reflect chronic effects of ketamine use, the present study compared frequent with infrequent users of ketamine on the night of drug use and again 3 days later. Design and participants. Eighteen frequent and 19 infrequent ketamine users were assessed on each test day on a range of cognitive tasks tapping memory and attentional function and on subjective scales (schizotypal symptomatology, dissociation, mood). Findings. Groups were broadly matched for polydrug use apart from ketamine which frequent users took significantly more often and in larger quantities than infrequent users. Acute effects on day 0 replicated previous findings. On day 3 frequent users showed significant impairments on tasks tapping episodic and semantic memory but there was no evidence of persisting dissociative or schizotypal symptoms. Conclusion. These findings indicate that frequent use of ketamine produces long-lasting impairments in episodic memory and aspects of retrieval from semantic memory. Such effects accord with animal evidence of the effects of NMDA receptor blockade on memory. Those using, or contemplating using ketamine should be informed of these persisting, detrimental effects of the drug upon human memory.     

Will growth in cryptomarket drug buying increase the harms of illicit drugs?

Background and aim

Cryptomarkets—on‐line, anonymous market‐places for illicit goods and services that specialize mainly in drugs—account for a small but rapidly growing share of the illicit drug market in many countries. Policy responses so far are based generally on the assumption that their rise will only increase drug harms. In this contribution for debate, we question this assumption.

Methods

We provide a narrative review of the emerging literature connected to drug cryptomarkets. We use MacCoun & Reuter's formula to understand the effect of population‐level increases in use on total harm as depending on the level of harm associated with each unit of use. We then consider the potential for cryptomarkets to increase or decrease the harms and benefits related to each unit of drug use, with specific attention to the quality of drugs sold and the non‐drug‐related harms and benefits for customers.

Results

It is likely that cryptomarkets will increase both the amount and the range of substances that are sold. However, we argue that the effects on harms will depend upon whether cryptomarkets also increase the quality and safety of products that are sold, provide harm‐reducing information to consumers and reduce transactional conflict involved in drug purchasing.

Conclusions

There is an emerging and rapidly growing evidence base connected to the macro and micro harms and benefits of cryptomarkets for drug users. Future researchers should use appropriately matched comparative designs to establish more firmly the differential harms and benefits of sourcing drugs both on‐ and off‐line. While it is unlikely that the on‐line drug trade can be eradicated completely, cryptomarkets will respond to regulation and enforcement in ways that have complex, and sometimes unanticipated, effects on both harms and benefits.     

Ketamine use, cognition and psychological wellbeing: a comparison of frequent, infrequent and ex-users with polydrug and non-using controls

Introduction Preliminary research has indicated that recreational ketamine use may be associated with marked cognitive impairments and elevated psychopathological symptoms, although no study to date has determined how these are affected by differing frequencies of use or whether they are reversible on cessation of use. In this study we aimed to determine how variations in ketamine use and abstention from prior use affect neurocognitive function and psychological wellbeing. Method We assessed a total of 150 individuals: 30 frequent ketamine users, 30 infrequent ketamine users, 30 ex‐ketamine users, 30 polydrug users and 30 controls who did not use illicit drugs. Cognitive tasks included spatial working memory, pattern recognition memory, the Stockings of Cambridge (a variant of the Tower of London task), simple vigilance and verbal and category fluency. Standardized questionnaires were used to assess psychological wellbeing. Hair analysis was used to verify group membership. Results Frequent ketamine users were impaired on spatial working memory, pattern recognition memory, Stockings of Cambridge and category fluency but exhibited preserved verbal fluency and prose recall. There were no differences in the performance of the infrequent ketamine users or ex‐users compared to the other groups. Frequent users showed increased delusional, dissociative and schizotypal symptoms which were also evident to a lesser extent in infrequent and ex‐users. Delusional symptoms correlated positively with the amount of ketamine used currently by the frequent users. Conclusions Frequent ketamine use is associated with impairments in working memory, episodic memory and aspects of executive function as well as reduced psychological wellbeing. ‘Recreational’ ketamine use does not appear to be associated with distinct cognitive impairments although increased levels of delusional and dissociative symptoms were observed. As no performance decrements were observed in the ex‐ketamine users, it is possible that the cognitive impairments observed in the frequent ketamine group are reversible upon cessation of ketamine use, although delusional symptoms persist.     

Who pays for the drinking? Characteristics of the extent and distribution of social harms from others’ drinking

AIMS: To explore the extent and distribution of experienced negative consequences from other people's drinking and to explore what characterizes the victims of these harms. DESIGN, PARTICIPANTS AND MEASUREMENTS: Cross-sectional survey in a national sample of adults. Net sample comprised 2170 respondents. Negative consequences from others' drinking during the past 12 months were assessed by seven items. RESULTS: The more severe types of consequences (being physically hurt or property damage) were reported less often (by 3.1% and 4.8%, respectively) than the least severe type of consequence (being kept awake at night by drunk people, reported by 21.2%), thus leaving the four other types of consequences (being harassed in public places, being harassed in private parties, being scolded at and being afraid of drunk people in public areas) somewhere in between. The extent to which the respondents had been subject to social harm from others' drinking displayed a very skewed distribution. The majority reported not to have experienced any such harms, whereas a small proportion had been harmed repeatedly and in various ways. Multivariate analyses showed that social harms from others' drinking were most often reported by younger persons, women, those with high education level, those who reported a higher annual alcohol intake, more frequent episodes of intoxication and more frequent visits to public drinking places. The impact of intoxication frequency on victimization from alcohol-related social harms was stronger for women than for men. Similar individual characteristics were also associated with victimization from physical harm and victimization in the public sphere. CONCLUSIONS: Relatively minor harms from others' drinking are experienced quite frequently. The social victims of others' drinking tend to drink heavily themselves, yet in contrast to what characterizes social consequences of own drinking, we find that the burden of social harms from others' drinking is to a larger extent carried by women than by men.     

Injecting-related harm and treatment-seeking behaviour among injecting drug users

Aims. This study aims to identify the physical harm associated with injecting drug use and examine the treatment-seeking behaviour of injecting drug users (IDUs). Specific attention is given to the factors associated with presentation and non-presentation of injecting-related problems. Design. Participants were interviewed by research staff using a semi-structured questionnaire, then physically examined by a medical team. Setting. Needles exchanges in Glasgow. Participants. One hundred and twelve injecting drug users. Findings . Respondents' accounts of their current injecting-related problems were found to be consistent with the clinician's findings, suggesting that IDUs are able to self-diagnose injecting-related harm. However, almost three-quarters had not sought help for these problems. Qualitative data suggest the main reasons for non-presentation, or delayed presentation, of injecting-related problems are normalization of injecting-related harm and a reluctance to attend available services. Almost half of those seeking treatment for injecting-related problems did so during an emergency or crisis. Conclusions . Low threshold services, such as needle exchanges, may have to take a more proactive stance to encourage injectors to present with injecting-related problems. This may help reduce injecting-related harms, especially the resulting medical complications, which would in turn relieve the pressure on other services such as hospital Accident and Emergency Departments .     

Cognitive, dissociative and psychotogenic effects of ketamine in recreational users on the night of drug use and 3 days later

Aims. Recreational use of the N-methyl-D-aspartate (NMDA) receptor antagonist, ketamine, is increasing. The present study aimed to examine both the acute and residual effects of this drug on cognitive function, dissociation and schizotypal symptomatology in recreational users . Design and participants. A parallel group design was used to compare 20 volunteers who reported having taken ketamine with 19 volunteers who reported no consumption of ketamine on the relevant night (day 0). All 39 participants were tested on day 0 and again 3 days later. On each test occasion a battery of tests was administered which tapped a wide range of memory functions, attention, dissociation, schizotypal symptomatology and mood. Findings. Groups were broadly matched for polydrug use apart from ketamine. Acute effects on day 0 replicated previous laboratory studies showing a broad spectrum of cognitive impairments following ketamine administration as well as marked dissociative effects and schizotypal symptomatology. Three days later, ketamine users had significantly higher scores than controls on both dissociation and schizotypal symptomatology. On some cognitive measures there were no group differences on day 3; however, on tests tapping semantic memory, the ketamine users showed persisting impairments compared with controls. Conclusions. Ketamine appears to induce acute and severe impairments of working, episodic and semantic memory as well as psychotogenic and dissociative effects. Three days after drug ingestion, recreational users display semantic memory impairment and dissociative and schizotypal symptomatology which could reflect chronic or residual effects of taking the drug or pre-existing differences in ketamine users.     

Drug dependence in therapy of chronic pain]

The use of drugs in pain therapy is characterized by the fear of addiction. As a result strong analgesics are underused. To compensate the missing analgesic effect the additional use of psychotropic drugs is common. There is still little knowledge that just this therapeutic strategy of underuse leads to iatrogenic addiction. To avoid misunderstandings and irritations in the discussion around addiction, there must be clearly distinguished between physical and psychological dependence. There is sufficient evidence that especially tranquilizers and mixed analgesics induce the development of psychological dependence. In pain therapy there is no indication for these substances. In contrast opioids can be used without causing psychological dependence, presuming the guidelines of drug therapy in chronic pain (e.g. WHO guidelines) are attended.     

Beyond the K-hole: a 3-year longitudinal investigation of the cognitive and subjective effects of ketamine in recreational users who have substantially reduced their use of the drug

RATIONALE: Ketamine is a dissociative anaesthetic that is also a drug of abuse. Previous studies have demonstrated persisting episodic and semantic memory impairments in recreational ketamine users 3 days after taking ketamine. However, the degree to which these deficits might be reversible upon reduction or cessation of ketamine use was not known. OBJECTIVE: To follow-up a population of ketamine users tested 3 years previously and examine whether impairments observed 3 days after drug use are enduring or reversible. METHODS: Eighteen ketamine users and 10 polydrug controls from studies conducted between 3 and 4 years earlier were re-tested on the same battery of cognitive tasks and subjective measures. These tapped episodic, semantic and working memory and executive and attentional functioning. Subjective schizotypal, dissociative, mood and bodily symptoms were also examined and a drug use history recorded. RESULTS: The ketamine users had reduced their frequency of use of ketamine by an average of 88.3%. Performance of ketamine users on tasks tapping semantic memory had improved and this improvement was correlated with their reduction in ketamine use. On tasks tapping episodic memory and attentional functioning, ketamine users still showed deficits compared to polydrug controls. Higher levels of schizotypal symptoms and perceptual distortions were exhibited by the ketamine group, although dissociative symptoms were similar to controls. CONCLUSIONS: These findings indicate that semantic memory impairments associated with recreational ketamine are reversible upon marked reduction of use; however, impairments to episodic memory and possibly attentional functioning appear long-lasting. In addition, schizotypal symptoms and perceptual distortions may persist after cessation of ketamine use. Ketamine users, or potential users, should be aware of the enduring effects of this drug on aspects of memory and subjective experience.     

Buprenorphine diversion and injection in Melbourne,Australia: an emerging issue?

AIMS: To examine indicators of buprenorphine diversion and injection among injecting drug users in Melbourne, Australia and to determine the factors associated with buprenorphine injection. DESIGN: Melbourne arm of the 2002 Illicit Drug Reporting System (IDRS) cross-sectional study. SETTING: Five Needle and Syringe Programme sites in Melbourne, Australia. PARTICIPANTS: A total of 156 current injecting drug users (IDU). Study eligibility criteria were at least monthly injection during the previous 6 months, and Melbourne residence for at least the preceding 12 months. MEASUREMENTS: Structured questionnaire covering demographic characteristics, drug use history, the price, purity and availability of drugs, criminal activity, risk-taking behaviours, health-related issues and general drug use trends. FINDINGS: Over one-third (37%) of the study sample reported injecting buprenorphine in their life-time and 33% reported injecting the drug in the last 6 months. Recent buprenorphine injection was associated with the injection of other drug types (i.e. polydrug injectors), opioid substitution treatment, injection-related health problems and involvement in crime. Almost half (47%) of those who reported recent buprenorphine injection reported obtaining the drug illicitly at least once during that time. CONCLUSIONS: Given the significant health harms associated with intravenous buprenorphine use (e.g. vein damage, abscesses and infections, precipitated withdrawal, blood-borne virus transmission, hospitalization and death), routine monitoring of the misuse of buprenorphine in Melbourne is warranted. These results suggest the need for development of effective countermeasures to address diversion and injection of buprenorphine in this setting.     

Development of a rational scale to assess the harm of drugs of potential misuse

Drug misuse and abuse are major health problems. Harmful drugs are regulated according to classification systems that purport to relate to the harms and risks of each drug. However, the methodology and processes underlying classification systems are generally neither specified nor transparent, which reduces confidence in their accuracy and undermines health education messages. We developed and explored the feasibility of the use of a nine-category matrix of harm, with an expert delphic procedure, to assess the harms of a range of illicit drugs in an evidence-based fashion. We also included five legal drugs of misuse (alcohol, khat, solvents, alkyl nitrites, and tobacco) and one that has since been classified (ketamine) for reference. The process proved practicable, and yielded roughly similar scores and rankings of drug harm when used by two separate groups of experts. The ranking of drugs produced by our assessment of harm differed from those used by current regulatory systems. Our methodology offers a systematic framework and process that could be used by national and international regulatory bodies to assess the harm of current and future drugs of abuse.     

Applying a ‘harm to others’ research framework to illicit drugs: political discourses and ambiguous policy implications

During the past decade, ‘alcohol's harm to others’ (AHTO) has emerged as an international approach to studying alcohol problems and informing policy. The AHTO approach seeks to increase political will for alcohol policy by mapping, measuring and often costing harms beyond the person who drinks (e.g. family members, co-workers). In this paper we consider the implications of a ‘harm to others’ approach for illicit drugs. We ask whether it could and should be used as a policy tool, given the high risks of further stigmatizing people who use drugs. We consider the ways in which the concept and measurement of ‘harm to others’ may be either productive or potentially harmful, depending on the extent to which the AHTO is replicated for illicit drugs. Shifting the language may assist: the term ‘harm from others’ appears to carry less risk of stigma. In addition, all harms inclusive of drug supply and drug consumption need to be included if a full picture of harms that accrue to other people from illicit drugs is to be achieved.     

How much can treatment reduce national drug problems?

AIMS: Treatment of drug addiction has been the subject of substantial research and, in contrast to several other methods of reducing drug use, has been found to be both effective and cost-effective. This review considers what is known about how much a nation can reduce its drug problems through treatment alone and what is known at the aggregate level about the effectiveness of prevention and enforcement. METHODS: The literature on the effectiveness of treatment, prevention and enforcement are reviewed, and set in a policy analytical framework. FINDINGS: Many studies have found treatment to have large effects on individuals' consumption and harms. However, there is an absence of evidence that even relatively well-funded treatment systems have much reduced the number of people in a nation who engage in problematic drug use. For prevention, the scientific literature shows useful and modest effects at the individual level but there is little support for substantial aggregate effects. For enforcement, research has failed almost uniformly to show that intensified policing or sanctions have reduced either drug prevalence or drug-related harm. Nor-outside the UK-is there more than a modest effort to improve the evidence base for making decisions about the appropriate level of enforcement of drug prohibitions. CONCLUSIONS: Treatment can justify itself in terms of reductions in harms to individuals and communities. However, even treatment systems that offer generous access to good quality services will leave a nation with substantial drug problem. Finding effective complementary programs remains a major challenge.     

Vascular fibrinoid necrosis in the urinary bladder of ketamine abusers: A new finding that may provide a clue to the pathogenesis of ketamine‐induced vesicopathy

Two 31‐year‐old women who had abused ketamine, 1 for 8 years and 1 for 5 years, presented with ketamine‐induced vesicopathy with urinary frequency, decreased bladder capacity, and detrusor overactivity. An enterocystoplasty was performed in both cases. The pathology of the urinary bladders in both women showed ulcerative cystitis and fibrinoid necrosis of vessels; the latter was confirmed by Masson trichrome staining. Fibrinoid necrosis of vessels is a kind of immune complex‐mediated vasculitis that induces the release of inflammatory mediators, with subsequent thrombosis, ischemic injury, and eventual tissue necrosis in localized areas, the so‐called Arthus reaction. The new finding of fibrinoid necrosis in the urinary bladders of ketamine abusers may provide a new clue to the pathogenesis of ketamine‐induced vesicopathy.     

Opiates: are there under-utilized and unexplored areas of prevention?

This paper explores the varied and potentially conflicting goals of preventive measures as applied to opiate use. These goals relate both to the overall extent of opiate use and the amount of harm arising from this drug use. Prevention involves the control both of the supply side and the demand for opiates. Particular targets may include sharing equipment, injecting, progression to more harmful routes of administration, prevention of development of dependence, harmful sequelae of opiate use and co-morbidity. There may be a place for manipulating the black market for opiates to channel users in directions that achieve particular prevention goals, and being more selective about targeting particular groups of users at particular times. It is the role of scientists to quantify the dimensions of harm and the likely impact on these dimensions of particular interventions. It is then up to elected representatives to determine the priorities.     

Factors affecting cognitive functioning in a sample of human immunodeficiency virus-positive injection drug users

Injection drug users represent a major vector of human immunodeficiency virus (HIV) infection in the nation's inner cities, and are an important population for harm reduction treatment interventions to target. However, there has been relatively little research examining the specific contribution of the multiple factors contributing to cognitive functioning among injection drug users that may affect engagement in, and response to, addiction and HIV-related interventions. The current study examined the independent contributions to neuropsychological (NP) test performance of premorbid educational attainment, medical and psychiatric history, long- and short-term drug use, assessed by laboratory, observation, and self-report measures, and HIV disease, assessed by plasma HIV-1 RNA viral load and CD4+ count, in a sample of 90 HIV-positive injection drug users dually addicted to heroin and cocaine. Fully 88% of the sample showed evidence of impairment (>1 standard deviation below the population mean) on an NP test battery selected to assess processes associated with successful engagement in the treatment of substance abuse and HIV, such as learning and memory of verbal information, capacity to solve new problems and deal with more than one stimulus at a time, visual-motor coordination, and visual tracking and cognitive flexibility. In addition to drug use, independent predictors of NP test performance were HIV viral load, educational attainment, and premorbid medical and psychiatric problems. Findings underscore the multiplicity of factors that contribute to cognitive impairment in HIV-positive drug-abusing individuals in addition to drug use. Clinical implications are discussed.     

The epidemiology of cannabis use and cannabis‐related harm in Australia 1993–2007

Aims To examine trends in patterns of cannabis use and related harm in the Australian population between 1993 and 2007. Design Analysis of prospectively collected data from: (1) the National Drug Strategy Household Survey (NDSHS) and Australian Secondary Student Alcohol and Drug Survey (ASSADS); (2) the National Hospital Morbidity Database (NHMD); and (3) the Alcohol and Other Drug Treatment Services National Minimum Dataset (AODTS‐NMDS). Participants Australians aged 14 years and over from the general population; students aged 12–17 years; public and private hospital in‐patients; public and private in‐patients and out‐patients attending for drug treatment. Measurement Prevalence of 12‐month cannabis use among the general population and secondary students. Proportions in the general population by age group reporting: daily cannabis use; difficulties in controlling cannabis use; and heavy cannabis use on each occasion. Number of hospital and treatment presentations for cannabis‐related problems. Findings Prevalence of past‐year cannabis use has declined in the Australian population since the late 1990s. Among those reporting past‐year use, daily use is prevalent among 40–49‐year‐olds, while heavy patterns of use are prevalent among 14–19‐year‐olds. Hospital presentations for cannabis‐related problems reflect similar trends. Past‐year cannabis use has decreased among the 10–19‐year age group, but those who are daily users in this age group report using large quantities of cannabis. Conclusions Despite declines in the prevalence of cannabis use, continued public health campaigns warning of the harms associated with cannabis use are essential, aimed particularly at users who are already experiencing problems. The increasing demand for treatment for cannabis problems in Australia suggests the need for more accessible and more effective interventions for cannabis use disorders.     

The impact of regular ecstasy use on memory function

Aim  To assess memory impairment in a group of regular users of ecstasy compared with a group of regular users of cannabis, after accounting for possible confounding factors such as other drug use, premorbid intelligence and psychopathology.
METHOD  Comparative and regression analysis was used to determine the presence or absence of a difference in memory function between 40 regular ecstasy users and 37 regular users of cannabis, who were interviewed at the National Drug and Alcohol Research Centre in Sydney, Australia. Regression analysis was used to find associations between life-time exposure to ecstasy use and memory performance. Memory function was assessed using an age-standardized memory test. Other scales were used to assess premorbid intelligence, physical and psychological health, drug withdrawal and other drug use.
Results  Initial comparative analysis showed a trend towards a significantly poorer performance by the regular ecstasy-using group on the 'auditory immediate memory' and 'auditory delayed memory' indices. When regression analysis was performed an estimate of verbal intelligence was found to be the most predictive of most memory indices including 'auditory immediate memory' and 'auditory delayed memory'. Life-time exposure to ecstasy was not predictive of the memory indices. The current frequency of cannabis use was found to have some predictive effect for immediate and delayed visual memory.
Conclusion  This study does not show memory impairment in a group of ecstasy users relative to cannabis using controls. The previously reported association of life-time exposure to ecstasy and memory was not found. The findings may indicate a confounding role of cannabis use, as has been recently reported.     

Current misunderstandings in the management of ulcerative colitis

Past and ongoing therapeutic concepts for ulcerative colitis have only been moderately successful. A significant proportion of patients with ulcerative colitis will still have to undergo colectomy and overall half of the patients do not achieve sustained remission, leading to impairment of physical and mental health, social life, employment issues and sexual activity. Reluctance to treat patients early on with sufficiently potent drug regimens is obvious. Several popular misconceptions might have led to this situation. First, ulcerative colitis is still considered a more 'benign' disease than Crohn's disease. Furthermore, the general assumption is often that colectomy can 'cure' the disease. Mucosal healing as a therapeutic target has not been widely accepted. Finally, the use of antitumour necrosis factor antibodies in ulcerative colitis has been low because this treatment is considered to be less effective than in Crohn's disease. In the current review we try to disprove these misunderstandings by discussing relevant studies showing how harmful this disease can be and explaining why future studies targeting sustained suppression of inflammation could have an enormous impact on the natural course of the disease. Until these studies are available, we encourage physicians to intensify and maintain treatment until sustained remission and mucosal healing has been reached.