POWDER KEG

Ever-increasing rates of ketamine use – coupled with the fact that it takes years for most people to seek help – are storing up huge problems for the future, hears a EUDA webinar.

‘Ketamine is a really interesting substance because it sits in a paradox,’ EUDA scientific analyst Dr Rita Jorge told the agency’s Ketamine in Europe webinar. ‘Two realities exist in the same molecule. On the one side, it’s an essential medicine. On the other, it’s an illicit commodity. That makes it, by nature, a policy challenge.’ 

Availability was constantly increasing, she said, with the wholesale price dropping and growing numbers of seizures in Europe (DDN, March, page 5). ‘The question is where is it coming from – is it from EU production, are people stealing finished medicines, or is it something else? The answer is that it’s something else.’ 

While most illicit supplies of ketamine had been diverted from legal supply chains, this was from the active pharmaceutical ingredient (API) side, she explained, before being passed to an illegal third party. ‘So it’s not the finished medicines, but the large bulk imports’ – typically from India. ‘Because we’re not talking about a strictly illegal substance, the financial incentive with the somewhat lower legal risk might be explaining this large expansion in the market.’ 

Recreational use had increased significantly over the last decade, said urologist at the Jeroen Bosch Hospital’s dedicated ketamine clinic in the Netherlands, Dr Wouter van der Sanden. ‘The problem we’re heading to is that around 25 per cent of recreational users go on to report urological problems.’ 

The drug was cheap, easily accessible and perceived as relatively safe, he said. ‘My patients say things like, “It’s also used in hospitals so how bad can it be?” or “You can’t OD on it” or “It’s not addictive”.’ Some of his patients had also heard about ketamine’s legitimate use in treating depression and were self-medicating with it for their mental health issues – going from recreational use at the weekends to using it daily.  

The physical consequences of these increasing rates of use were something he saw every day. A normal healthy bladder could easily hold around 400-500ml of urine before someone had the urge to urinate, he told the seminar. ‘Think of a severely damaged ketamine bladder as an espresso cup – it only holds around 40-50ml of urine. Now imagine the inside of the bladder covered with sandpaper, and the outside with barbed wire.’ The symptoms could be ‘devastating’, he said. ‘I see young people in wheelchairs because the pain in their pelvic region means they’re unable to walk.’ 

His patients frequently had ‘extreme urinary frequency’, he continued – sometimes every ten to 15 minutes. ‘That’s not an overstatement, and it’s day and night, so it’s impossible to have a normal life. They pass blood and blood clots, they suffer from incontinence and severe sexual dysfunction in both male and female patients. And these are very young and normally otherwise completely healthy patients.’

In some cases this damage was irreversible. ‘Then I have to remove the bladder and put in a urostomy. When you’re 25 you don’t want to live like this for the rest of your life.’ There could also be damage to the kidneys so severe that it required dialysis. ‘So this safe party drug isn’t safe at all in the long run – there can be severe consequences’

‘I really think we’re going to see a “delayed epidemic”,’ he warned. ‘The patients I see today started using ketamine years ago, and the symptoms usually only develop after prolonged and intensive use. What we’re seeing now is only the beginning.’  

So why did people present so late? Early symptoms were often ignored or normalised, he said, with many people increasing their ketamine use to suppress the pain. Added to this was an ongoing lack of awareness among healthcare providers, as well as the stigma – ‘that can really delay diagnosis and access to care.’ 

Patients presenting late with advanced symptoms would also inevitably have an impact on healthcare systems, he added. ‘It means the treatment is really complex and resource intensive, requiring multidisciplinary care. Patients require long-term follow-up, with many of them having chronic disability problems.’ 

His own ketamine clinic had been established in 2022 in response to growing levels of unmet need, he said. Patients did not fit into standard healthcare pathways, as they had serious medical problems at the same time as substance dependency issues. ‘It’s really hard to treat only one of those,’ he stated.

The clinic had its own pathway, with integrated care for urology, addiction, pain and psychosocial support, all in a ‘one-stop-shop’ outpatient centre. The facility was now the national referral centre for ketamine issues in the Netherlands, and was increasingly seeing patients from overseas as well. 

The greatest challenge was that his patients were trapped in a ‘downward spiral’, he said. ‘Ketamine causes bladder pain, so they use more ketamine to suppress that pain. That causes even more damage, so the cycle continues. So one of our biggest goals is breaking this cycle.’ 

However, it was easy for doctors to tell people that their bladder issues wouldn’t heal while they were still using, ‘so come back when you’ve stopped’. That was ‘near impossible’, he said. ‘Most of my patients know that using ketamine is bad for their bodies – they suffer the consequences every ten to 15 minutes. But they tell me, “with ketamine I can at least have an hour of sleep” or “it stops the pain enough for me to get my kids from school”. This is the real world for them.’ 

Breaking this downward spiral required a multidisciplinary approach, he stressed, with urologists, nurses, pain specialists, medication and surgery on one side, and supportive therapy on the other – addiction specialists, psychiatrists, counselling, detox, social care. ‘This is really important.’ 

The clinic had already seen 500 patients this year, with demand constantly increasing and a current waiting list of around three to four months. ‘So we’re very busy.’ The median age of patients was 27, and although they were still predominantly male the percentage of females was increasing all the time. Around half were from urban areas, and half were from rural regions – which was interesting as around 95 per cent of the Netherlands’ population lived in urban areas, he pointed out. 

While most had started using ketamine in their early 20s there were ‘outliers’ who’d begun as early as 12, he said, and people would usually start presenting after around three years of intensive use. And by ‘intensive’ he meant between 4g and 100g every week, with a mean amount of 22g per week. ‘So these are very high numbers, very frequent use, very high dosage. We don’t see people who use it every once in a while.’ 

Occasional use could easily become chronic use, however, but fortunately not all of the physical damage was irreversible, and three quarters of his patients achieved abstinence within six months. ‘If you look at addiction care, these are really good numbers.’  

It was far from just being a medical problem, however. ‘It’s very important that we talk about this, because these are very young people developing chronic illness during the most productive years of their lives’ – leading to disability, healthcare dependency and increased pressure on health systems. 

‘So the rise in ketamine use we see today will become the healthcare problem of tomorrow,’ he stated. ‘But that also means there’s still a window of opportunity.’  DDN