When someone in England presents to drug treatment, that individual is categorised based on what drug(s) they are experiencing difficulties with, in one of four categories: opiates, non-opiates, non-opiate and alcohol, or alcohol-only. Where poly-drug use is present – for instance, if a person uses both crack and heroin – they would be labelled as an opiate user by this system.
‘Non-opiate’ users are defined as ‘people who have problems with non-opiate drugs only, such as cannabis, crack and ecstasy’. Of course, these drugs are all very different and may require different specialist interventions to help an individual meet their goals. Nonetheless, in many services we’ve found that people classed as ‘non-opiate’ users are more likely to be sidelined from receiving ‘structured treatment’.
This is defined as a ‘package of concurrent or sequential specialist drug- and alcohol-focused interventions… [which] requires a comprehensive assessment of need, and is delivered according to a recovery care plan, which is regularly reviewed with the client’. Structured treatment is meant to be one or more psychosocial interventions and one or more pharmacological ones, not one or the other – and all groups should be receiving a health assessment at the start of treatment regardless of if there’s expectation of prescribing in the service.
Previously in this series, we’ve highlighted that some drug users do not receive an offer of structured treatment despite a clear need, as in the case of those with benzodiazepine dependences. Today we have another non-opiate group who we’d like to draw attention to – ketamine users.
In recent months, the Release helpline has received a noticeable increase in the number of calls from people using ketamine who are asking for advocacy, often seeking to access residential rehabilitation.
Residential rehabilitation support is a tricky topic for our advocacy – these programmes are very diverse and the evidence supporting them in different cases is quite mixed. In a 2020 study by Wakeman et al, outcomes for more than 40,000 people with opioid use disorder were compared based on form of treatment received against a baseline of no treatment at all. Treatment with ‘buprenorphine or methadone was associated with a 32 per cent relative rate of reduction in serious opioid-related acute care use at three months and a 26 per cent relative rate of reduction at 12 months compared with no treatment’. Meanwhile, individuals who went the detoxification and residential rehab route, and those who received psychosocial treatment only, did not experience either ‘reduced overdose or serious opioid-related acute care use at three or 12 months’.
We do not oppose access to residential rehabilitation nor refuse advocacy support to those who seek it, although we are realistic with people that the guidelines do not offer clear support for this form of treatment. Rather, we take seriously the fact that if the people contacting us – who are very often more knowledgeable than us on these matters – are unified in this desire, then likely something is seriously amiss in their community services.
Castel’s case is one example. Castel has been using ketamine daily for around two years and had been with her local service for a year when she contacted Release. She reported being told by multiple workers in her service that, due to funding restrictions, it was ‘almost impossible’ to access rehabilitation for ketamine use. Castel also said that she’s had to be the one to initiate all her key-working sessions, and when she asked about harm reduction was told that ‘there isn’t really much harm reduction for ketamine’. She also had to educate her keyworker on the risk of bladder damage from regular ketamine use.
Her situation is unfortunately not unique – ketamine users are telling us they don’t feel welcome in drug treatment, nor do they feel any benefit from being there. At the same time, keyworkers at treatment services are often faced with unmanageable caseloads, and little to no time for specialist training. Less experienced or less specialist workers may feel just as lost at sea as the service user when tackling ketamine use in treatment, especially if they’re accustomed to working with people who are also receiving pharmacological treatments, which helps give a structure to the overall treatment plan.
Still, in the ‘Orange Book’ it states that keyworkers need to be able to support ketamine using patients and even identifies ‘ketamine-related urological damage’ at the top of the list of ‘recent areas of developing knowledge’. It has now been nearly a decade since this guidance was published, and given that the number of people entering treatment for ketamine use is now over 12 times higher than it was in 2014-15 we cannot continue to make excuses for the sector when it comes to supporting people struggling with ketamine use.
Through the Release helpline, we’ve heard similar accounts from people using many different ‘non-opiate’ drugs. Of those callers, many are not accessing treatment because they feel there’s nothing available for them. When they do seek help in reducing their use, support is almost always limited to attending recovery groups – rarely does one get an offer of ‘structured treatment’, an option which is seen as reserved for those in the opiate category.
There are, however, many recognised pharmacological interventions for non-opioid users in drug treatment, reflected in the NDTMS adult drug and alcohol treatment definitions – these include different manners of benzodiazepine prescribing (as benzodiazepine dependence maintenance treatment, for stimulant withdrawal and for G withdrawal), carbamazepine for acute alcohol withdrawal, dexamphetamine for stimulant withdrawal, and a general ‘other’ category for otherwise unlisted uses of medication as treatment of drug misuse/dependence/withdrawal and associated symptoms.
Ketamine, when used often and for long periods, has been seen to cause users to experience withdrawal, so why not consider what forms of clinical support might make ketamine cessation more comfortable and achievable for those asking for treatment? It seems ironic that ketamine might sooner be a recognised pharmacological intervention for people in treatment for other drugs than the reverse, when most of the drugs that ketamine has been trialled as a treatment for already have existing pharmacological interventions established.
Of course, there will be no miracle medication that will universally resolve the problems of ketamine users in treatment, as different individuals require different interventions tailored to meet their needs. We also know that ultra-bespoke specialist treatment won’t be available to everyone, because of financial and workforce constraints.
We’re not demanding either a perfect pharmacological or psychotherapeutic response to problematic ketamine use – we’re simply demanding that ketamine users and other non-opiate users have the same opportunity to access a treatment plan at all. None of us should be satisfied with a one-size-fits-all approach that flattens so many different drugs into the ‘non-opiate’ category, and gives so few tools to people who are junior in the sector. As such, we echo recommendation 12 from the ACMD’s latest ketamine review, that:
‘Integrated harm reduction approaches should be developed and delivered, combining education, professional training, access to drug checking and safer use practices. Delivery should be through a range of community-based services and incorporate outreach activities to reach the diverse groups who use ketamine.’
We also demand that resources be committed to improved research and innovation in treatment modalities for different drug users, and that those in treatment be proactively provided with information on what recourse is available to them if their treatment needs aren’t met. This is crucial for people coming into treatment without many peers in that environment, who will be less likely to know what ought to be on offer or where to turn if falling through cracks in the service.
This is the case for ketamine users up and down the country today. But if the sector can get treatment working right for this group, then those users will become tomorrow’s ambassadors – and harm reduction conduits for huge numbers of ketamine users who are not in touch with services.
Riley Johnson is a research assistant and Shayla Schlossenberg is head of drugs service at Release.