Getting real

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MatSouthwell Lana DurjavaThe ‘dream drug’ ketamine can bring its users face to face with some stark realities that aren’t readily understood by health professionals. Mat Southwell and Lana Durjava offer practical advice on under­standing and meeting their needs.

 The story of ketamine is a powerful illustration of the risks of abandoning a public health response and limiting drug policy to crime reduction. UK drug policy has shifted from being driven by public health concerns in the HIV era to being dominated by crime prevention. Indeed, the National Treatment Agency (NTA) refused repeated requests to tackle ketamine, arguing that it was only a regional problem and not a priority because ketamine users did not commit crime.

In the face of this inaction, a coalition of healthcare professionals, academics, drug agencies and drug user activists stepped in with the aim of providing credible information.

Early enthusiasts

The first group of people to recognise ketamine’s non-medical value were psychonauts – adventurers who sought to investigate their minds using intentionally induced altered states of consciousness. Psychonauts’ primary motivation for the use of ketamine-induced spiritual journeys was to transcend the external world, experience the separation of consciousness from the body and gain an insight into the nature of existence and the self. They were in the habit of taking extremely large doses as they were deliberately trying to go into a ‘K-hole’, but since they were mostly using ketamine on a fairly non-regular basis, their risk of developing K-dependency was pretty low.

In the early nineties ketamine arrived on the New York and London gay club scenes, where it found an entirely different body of admirers. If psychonauts appreciated the drug for its hallucinogenic and dissociative properties, the new audience, called klubbers, discovered its potential to act as a highly effective stimulant. Ketamine is one of those drugs that are extremely dose-dependent, and while psychonauts were injecting 100-200ml shots to try to achieve out-of-body experiences, klubbers were taking small bumps of ketamine, which usually did not exceed 25ml per dose.

K-dependency was never a high risk for either of these two groups of ketamine users, given the patterns of dosing, breaks between episodes of using and a pattern of remaining hydrated – a particular feature of dance drug use. In this context, ketamine appeared to be an almost dream drug that managed to offer the cocaine-like stimulation, the opiate-like calming, and the cannabis-like imagery, while at the same time providing a full-on dissociative and hallucinogenic experience, with no apparent disadvantages or collateral damage.

ketamineWhen K went dark

The new century brought several changes to the drug market. On 1 January 2006 ketamine was officially designated a class C drug on the basis of the linkage between its frequent use and kidney and bladder damage, as well as memory impairment. Up to this point ketamine was an unscheduled drug for which one could not be prosecuted for possession, but only for supplying. One might argue that the previous approach towards ketamine was the closest that the UK drug policy ever got to a Portuguese-style model of decriminalising people who used drugs. Reclassification changed this dramatically and contributed to the growing harms associated with the drug’s use.

Because of the increased difficulties with smuggling the drug (which were also connected with post 9/11 hysteria and implementation of harsh anti-terrorism laws), ketamine was no longer available as a liquid on the black market but emerged in crystal form. This led to consumers baking the drug with little knowledge that this procedure actually destroyed the quality of ketamine and resulted in users needing to take more of the drug for the same effect – which also meant increased danger of ketamine-bladder syndrome.

At the same time, the price of the drug dropped drastically. If psychonauts and klubbers has been buying it for about £50 a gram, the new generation of ketamine devotees could get the same amount for a mere £10. A natural consequence was a vast diffusion of the drug’s users, as this new generation of K-users, referred to as wonkers, were coming from a very different cultural and social background from the psychonauts and klubbers. Wonkers were often very young kids from both rural and inner city areas, with limited education about the drug and its risks, who valued ketamine for providing a state of intoxication that offered a way out of challenging, frustrating, alienated and marginalised lives. Some people in these new groups wanted to escape from the trap of repetitive and damaging patterns of drug use.

While diverse in nature and background, the wonkers were rapidly increasing their doses and frequency of use. Since they did not understand how to manage crystal, they were also likely to bake the drug, lowering its quality and requiring them to take more for the same effect. Although very few of them overcame the needle barrier, they were all too often faced with K-bladder, mental health problems, poor attention span and impaired memory, which are all closely related to heavy use of the drug. In addition, ketamine’s potential for dependence has taken the majority of its users by surprise.

However, it is important to recognise that there are both psychonauts and klubbers among the new generations, and these categories are presented as a way of promoting debate and understanding about the diversity of ketamine users, rather than attempting to oversimplify or stereotype. Nonetheless, while accepting this diversity of experience, public perception of ketamine is that it has become a drug that causes significant damage, giving it a status equivalent to heroin and crack. Of greatest concern is the rise in worrying health conditions such as ketamine bladder syndrome and ketamine dependency, which pose new challenges to both people using ketamine and drug services.

ketamineResponse from services

Ketamine users are a diverse population that have not traditionally been engaged by drug services that can remain overly focused on opiate and crack use. However, at its core, the response to problem ketamine use reinforces the importance of a client-centred, empathic approach that responds to ketamine users by offering chances to explore risk reduction, self-control or cessation.

The key harm reduction messages for active ketamine users revolve around dose management and hydration. Understanding how to dose, avoiding dose stacking and learning to take breaks between using sessions are all key to avoiding unintended K-holes and managing the risk of rising tolerance. Learning to grind rather than bake ketamine crystal ensures that it is suitable for sniffing without the product being degraded in quality, which offers a practical way of driving down the amount of ketamine people are putting through their systems. Hydration has been shown to be essential in ensuring that ketamine passes through the body, and particularly the bladder, without hardening the bladder wall and damaging the kidneys and liver.

Coact has also developed the K-check tool, which is a triage, health assessment tool for ketamine users that supports GP and drug workers to objectively assess the risks and harms being faced by problem ketamine users, as a basis for delivering appropriate advice and guidance. Importantly it also helps workers identify and refer on those showing signs of ketamine bladder syndrome. However, it is important that drug services work with urology services to help them manage people who may struggle to stop ketamine use, despite the severe impact on their bladder and kidneys. Frightened and physically damaged young people need help to come to terms with the impact of ketamine bladder syndrome, the challenges of often painful and invasive treatments, and the need to cease ketamine use once the chronic condition has set in.

On a positive note, ketamine dependency is relatively easy to treat and withdrawal symptoms are not too severe; people mostly need time to sleep, help with breaking compulsive using cycles, and encouragement to hydrate and eat. However, ketamine knocks out the conscious mind and with it a person’s capacity to problem-solve, and this can reduce people’s ability to find their way out of dependent use.

Promoting self-control can be a useful step – an interim one for some and an alternative path for others. The challenge is to draw someone into a space where they are taking breaks from ketamine, thus creating the scope for reflective engagement with the conscious mind fully functioning. For those with lengthy histories of regular use, it may take up to three months after cessation for their memory to fully kick back in and this may need to be explained and managed within a treatment or rehabilitation context.

Finally, it is important to understand that many people experiencing problems with ketamine will have particular world views around spirituality, given their journeying with this drug. The blunt application of recovery models has been shown to be off-putting to a group unfamiliar with this discourse. Drug services need to reflect on how to meet this different type of user, acknowledging that practices like yoga, meditation and general mindfulness training may be both effective and culturally attractive to this group of spiritual journeyers who lost their way. DDN

Mat Southwell is partner in Coact and an organiser with Respect. Lana Durjava is a postgraduate student of psychology at the University of Westminster.

For more detailed harm reduction advice on ketamine, please see read the K-check tool from the Coact website: drinkanddrugsnews.com/wp-content/uploads/2013/11/K-Check-v31.pdf