Ketamine Usage in the UK 1998-2002

1 Introduction

1.1 Ketamine (2-(2-Chlorophenyl)-2-(methylamino)- cyclohexanone) is one of a class of drugs known as dissociative anaesthetics, other drugs in this class include phencyclidine (PCP/angel dust), dextromorphan, and nitrous oxide). Ketamine is widely used in veterinary medicine, and is not currently a controlled drug. Tablets containing ketamine are commonly found on the illicit market, either masquerading as ecstasy or sold as Ketamine itself (known by devotees as special-K).

1.2 Originally used as an animal tranquilliser, ketamine induces a trance-like state described by some users as an out of body experience or tunnel vision, with the user commonly sedated or even immobilised.

1.3 Ketamine has commonly been associated with fake ecstasy tablets, although these are now less common. To counteract the sedative effect, stimulants such as procaine, ephedrine, caffeine or amphetamine are often included in Ketamine tablets. Although tablets are now the most common form of ketamine, it is also found in injection ampoules, bottles or in powder form.

2 Methodology

2.1 The IDMU regular users surveys have been monitoring changes in patterns of drug use since 1994, and annually since 1997, in surveys with a target of 1000-3000 respondents. In the 1994 and 1997 surveys ketamine was the most commonly-reported other psychedelic, among other named drugs written in by respondents, and merited inclusion in its own right in the 1998 survey onwards.

2.2 Anonymous questionnaires were distributed at pop festivals and other outdoor events. Other than basic demographic information, respondents are asked a number of core questions each year, concerning use of and attitudes to legal and illegal drugs, with other questions, and question order, changing year on year. For Ketamine use, the questions were:

Age first use of ketamine

Frequency of/intention to use ketamine

Monthly spending on ketamine

Overall rating of ketamine (marks out of 10)

Ketamine prices

In 2001-2, users were also asked how much they used per week (doses/tabs) and when they had last used the drug.

2.3The purpose of the surveys is to target populations expected to contain a high proportion of drug users in order to conduct research into the illicit drugs market. The vast majority of respondents have used cannabis in the month prior to the survey. In the context of Drug Misuse Declared data, our population would be more representative of drug users as a whole, rather than of the general population.

2.4Please note that figures for 2001 were collected on a restricted basis, with a more biased population (predominantly London area), the smaller sample also giving rise to greater statistical margin of error.

3Sample Demographics

3.1The overall average age of respondents was 28.03 years with the year on year averages varying by up to a year either way. Female respondents were on average around 9 months younger than males. There was a 3:2 male-female ratio, with 8% of respondents declining to state their sex (table 1), and 3.8% declining to state their age.

3.2 The age range of respondents varied from early teens to late middle-age (fig 1), with the highest numbers in the range of 18-30.

Fig 1-Age Range of Respondents

4 Prevalence of Ketamine Use

4.1 In our 1998-2002 surveys (see table 2), 1329 users (14.8% of respondents) had tried ketamine, the vast majority on an experimental or occasional basis, with 279 individuals (3%) claiming to use occasionally or more often. The proportion of users each year is relatively stable between a low of 13.0% in 2000, and a high of 18.4% in the smaller 2001 survey. Similarly current use remains relatively stable at 2-3%, apart from a blip in 2001.

4.2 On the basis of there being 2-3 million UK citizens using drugs in an average month, possibly 300-500 thousand persons will have tried ketamine, with 60-90,000 current users (occasionally or more often).

4.3 In 2001 and 2002, respondents were asked to quantify their ketamine use in doses or tablets per week, with a range of 0-10 doses (fig 2)

Fig 2-Ketamine Tablets/Doses per Week

4.4  In 2001/02 users were also asked to state when they had last used ketamine (table 3) - note the today figures may be skewed as a result of sampling location.

4.5 A total of 134 respondents (98-02) reported monthly spending on ketamine, with a mean of £19.22 and a maximum of £200 (fig 3)

Fig 3-Monthly Spending on Ketamine

5 Initiation to Ketamine Use

5.1Of those individuals who had not used Ketamine, 2222 indicated whether or not they intended to use the drug in the future, 289 (13%) stating they might use, and 87% stating they would never use the drug. The proportion of non-users willing to consider using ketamine fell from 16% in 1998 to 10% in 2002 (table 4).

5.2 The mean age of initiation is 22 years, 9 months, with a stable or upward age trend. There is no evidence that younger users are at increasing risk of being exposed to ketamine, very few individuals had tried the drug before adulthood, with most first trying ketamine between ages 18 and 30 (fig 4). The vast majority had first used ketamine between 1990 and 2000.

Fig 4-Age of First Ketamine Use (raw & cumulative)

5.3 A significant proportion of those having tried ketamine claimed to have given up using the drug. Of those who had not yet used ketamine, there was a 6:1 ratio between those who stated they would never use the drug, and those who might try it if offered.

6Attitudes towards Ketamine

6.1Ketamine has historically had a bad press among drug users, in the 1970s Furry Freak Brothers comics it was credited as causing a 12 hour nightmare (when sold as bad LSD). Ketamines reputation among the drug subculture is patchy, users generally give a negative rating (mean 2.58/10), with the majority giving it a zero, but an even spread of attitudes among other responses (fig 5).

Fig 5 - Subjective Ratings of Ketamine

6.2 There has been a decline in user ratings since 1999-the drug appears to becoming less popular over time (table 4).

6.3 The user-rating does vary significantly with frequency of use (Table 5), the lowest ratings were given by those who stated would never use the drug (1.18) the highest (7.24) by regular (weekly/monthly but not daily) users.

7. Ketamine prices

7.1 In many instances, a user will buy a ketamine tablet believing it to be ecstasy, with ketamine/ephedrine/procaine tablets very common during the 1990s. More recently, the advent of over-the-counter ecstasy testing kits - available in the UK since early 1998 - coupled with an interactive web database and "users grapevine", has coincided with an increase in the quality of ecstasy tablets (most now contain MDMA, usually within range of 50-100mg), and a reduced incidence of "fake" tablets containing ketamine.

7.2 At the same time, a niche market has developed for ketamine per se either in tablet or powder form, such that the street price of a tablet sold as ketamine is likely to exceed that of a genuine ecstasy tablet (Table 6). At higher levels of the market (10-100 tabs), tablet prices are similar to those for ecstasy. No clear year on year price trends are apparent, as the prices vary widely, with single tablets/doses available from £2 to £20 each (fig 6)

Fig 6-Ketamine Price Distributions 1998-2002

8 Literature & Web Resources for Ketamine

8.1 There is a wealth of scientific references (over 6000) relating to ketamine, mostly involving biochemical, toxicological or veterinary aspects. In addition, there are over 2000 web pages with references to ketamine.

8.2 Ketamine sold under its own right as K or Special K re-emerged in the early 1990s among the rave subculture. In an article for the Face magazine, McDermott[i] describes the emergence of ecstasy and ketamine in the UK, then ketamine was mainly obtained via medical supplies, although ketamine tablets showed up as early as 1990, particularly where ecstasy demand outstripped supply. He quotes one user who took 3-4 tablets: "You can't move, you can't think, you can't function -- all you can do is experience". McDermott also commented "Ketamine is a damn sight easier to produce than Ecstasy - the precursor chemicals are easier to get hold of, and because it isn't illegal, you are unlikely to do time if you get caught. So some unscrupulous drug dealers are still trying to pass Ketamine off as "E". Others, no doubt working on the basis that you can't fool all of the people, all of the time, have thought ahead and worked out a clever marketing strategy. ... In order to promote a rebirthing mind-set, some "K" dealers are providing jars of baby food and dummies". He also described hospitalisations attributed to ketamine tablets, "people who entered catatonic states after taking what they believed were "E" but turned out to be K". He did not consider that Ketamine would become a widespread drug of abuse, "as Ketamine lacks the euphoric and social properties that led to the widespread use of MDMA, the drug is likely to disappear as suddenly as it seems to have emerged".

8.3  Notable internet sites include the Erowid Ketamine Vault[ii], which includes users description of experiences produced by doses of between 100mg and 250mg intranasally (snorted) or via intramuscular injection. These accounts range from the enthusiastic to negative and cautionary. In particular, White[iii] reviews evidence of NMDA antagonist neurotoxicity, with potential risks for memory and cognitive function, and suggests use of GABA-ergic drugs to counter neurotoxic effects, and avoidance of drugs with known interactions which can increase the risk (e.g. yohimbine, antipsychotics, anticholingergics, ecstasy type drugs or hallucinogens, and monoamine oxidase inhibitors), cautioning Ive heard of far too many people who rolled the dice and lost their sanity, their loved ones, their emotions and even their lives. Lets try to keep this sort of thing to a minimum . The risk of ketamine-induced neurodegeneration has been raised in the British Medical Journal[iv]. . Other Erowid links include research by MAPS (the multidisciplinary association for psychedelic study) into the use of ketamine in psychotherapy, including the management of alcohol and opiate addiction. Their main Ketamine page had had 48000 hits in just over two years.

8.4 A Plymouth drugs advice website[v] notes the following "(Ketamine) usually comes as a liquid in its pharmaceutical form (stolen vets supplies will probably come in this form) although it is also found as a white powder or pill. A wrap of ketamine powder will cost between 6 and 25 pounds sterling with the price varying widely with location and availability. It can be either snorted or swallowed as a powder and either swallowed or injected as a liquid. Injectors usually inject into the muscles rather than a vein. Ketamine is called "dissociative" in action, which means that it feels as if the mind is "separated" from the body. Ketamine causes hallucinations (the user may feel as if they have entered another reality) and as an anaesthetic stops the user feeling pain, which could lead the user to cause unwitting injury to him or herself. Ketamine does not depress respiratory functions. Ketamine is a prescription only medicine and so is not covered by the Misuse of Drugs Act. This means that possession of ketamine is not a criminal offence. However, under the Medicines Act unauthorised supply is illegal."

8.5 Another university-based Ketamine site[vi] gives the following advice:"Ketamine does not treat music so well. Expect a narrowing of your auditory bandwidth. Music will sound neat but not correct and not transcending. You will selectively lose frequencies. Use mellow music with a psychedelic flavour, and keep the volume less than loud because your perception of overall volume will increase. Visual hallucinations are most notable in low light. Touch is exceptional. Smells and tastes will be nulled. Do not expect to talk, although you may. Expect general reflection but not exceptional emotionality. Oral Dose: A Line Dose is about 2.0 mg/lb. body mass. Anaesthetic doses are above 4.0 mg/lb. A maximum oral dose of 3 mg/lb. should be set for adequate recovery. Above line dose, increasing doses yield little psychedelic advantage except for greater temporary memory loss. A good first dose is 300-350 mg for average weight woman, and 350-375 mg for average weight men. A minimum dose of 150-175 mg will give a good psychedelic experience. IM Dose: Intramuscular doses begin at perhaps .4 mg/lb. for a Line Dose. Anaesthetic doses to IM are about 1 mg/lb. Two injections should be made instead of one. Sterility of the bottle and needle are imperative. 100 mg seems to be a good IM dose for everyone... IV Dose: I do not recommend IV doses".

8.6 A prevention-orientated US website[vii] and a UK-based youth culture website[viii] both start their ketamine pages with the following advice: "Ketamine is a short-acting general anaesthetic that has hallucinogenic and painkilling qualities that seem to affect people in very differently ways. Some people describe a speedy rush within a few minutes of sniffing the powder (20 minutes if taken as a pill), leading to powerful hallucinations and even out of body experiences, along with physical incapacitation. If you're on a dance floor, music can sound heavy, weird and strangely compelling, lights seem very intense and physical co-ordination can fall apart along with an overall feeling of numbness. Some people feel paralysed by the drug, unable to speak without slurring, while others either feel sick or actually throw up. Be extremely careful how much Ketamine you take as it is stronger than the same amount of speed or coke. Accept that you may well be in for a rough ride with the drug as its effects are unpredictable and sometimes very confusing. Try not to mix it with other drugs, particularly alcohol. You may turn into a gibbering, spaced out bore, mumbling and slurring away while your dancing may begin to resemble Bill and Ben on acid. Your movements may become as swift as a spliffed-up tortoise crawling across an extra-sticky big bun on a very hot day. You may be unable to move at all. "

8.7 Another UK website[ix] states use in South Yorkshire is still comparatively rare. The supply is thought to come mainly from opportunistic thefts from vets premises and vehicles. It usually comes as a liquid in its pharmaceutical form (stolen vets supplies will probably come in this form) although it is also found as a white powder or pill. Some users are sold ketamine believing it to be ecstasy, therefore its purchase and use is often around the "rave scene".

8.8  A Florida based site[x] states: Ketamine is currently one of the most popular drugs among youths. In the rave and club scene, the substance is often sold under the name of "Special K" and is known as "K", "KitKat", "Vitamin K", and "Ket". The synthesis of ketamine is a complicated multi-step process and to date the diversion of legitimate product is the only known source for roughly 90% of the quantity sold. This desire for ketamine has resulted in an increase in animal hospital burglaries. A South African Ravesafe site[xi] advises thus: "Physical effects are loss of motor control (difficulty in walking, standing and talking), temporary memory loss, numbness, drowsiness, nausea. Ketamine is a strong drug which produces an "out-of-body" experience: your mind dissociates itself from your body. It blocks normal thinking, memory recall and most sensory input. In the absence of external input, the brain tends to fill the void with a "new reality" - extreme hallucinations known as "emergence phenomena". It's like you enter another world and can't even see the people next to you. Ketamine causes physical incapacition as well as very hard trips, and is unlikely to make you want to dance."

8.9  The US government-backed Clearing House for Alcohol & Drug information[xii] report Ketamine " ...is being abused by an increasing number of young people as a "club drug," and is often distributed at "raves" and parties. Some street names for ketamine are: K, Ket, Special K, Vitamin K, Vit K, Kit Kat, Keller, Kelly's day, Green, Blind squid, Cat valium, Purple, Special la coke, Super acid, and Super C. Slang for experiences related to ketamine or effects of ketamine include, "k-hole," "K-land," "baby food," and "God." "The effects of a ketamine 'high' usually last an hour but they can last for 4-6 hours, and 24-48 hours are generally required before the user will feel completely "normal" again."

8.10  At least one website was found where Ketamine can be purchased over the internet[xiii], The India-based company supplies 10ml vials containing 50mg ketamine for $2.00 each (minimum order 400) by international courier. Contraindications are stated to be "Increased intracranial or intraocular pressure, Psychiatric disorders. Cardiovascular disease such as uncontrolled hypertension, unstable angina or recent myocardial infarction, right or left heart failure, aneurysms.",and dosage recommended as "i.v. route - Initial dose... 1 to 4.5 mg / kg over a period of 1 minute. Maintenance dose - increments of 50% of full induction dose repeatedly. i.m. route - 6.5 to 13 mg / kg.". Precautions listed as"Rapid Injection or overdosage may cause respiratory depression. Post operative confusional states may occur. Periodic assessment of cardiovascular functions. Alcohol Intoxicated patients. Increased CSF and Intraocular pressure" . Side-effects were listed as"Hypotension, Increased BP / pulse rate, bradycardia, arrhythmia, respiratory depression, illusions, vivid dreams, hallucinations diplopia, nystagmus, clonic & tonic movements, anorexia, nausea, vomiting.".

8.11  Karch[xiv] reports thus: "Recent reports from London, and from both coasts of the United States, suggest that ketamine (known on the streets as Special K), a close relative of phencyclidine (PCP), has become the hot new club drug. There are no published reports of toxicity in recreational users, perhaps because when it is used as a recreational drug, it is usually snorted in doses smaller than those used to produce anesthesia in a hospital." "When used as an intravenous anesthetic in adults, doses range from 1 to 4.5 mg/kg given over a period of about one minute. Anesthesia can also be induced using much higher doses (6.5 to 13 mg kg) via intramuscular injection. When snorted by drug users, the dose, according to street lore and reports on the Internet, is usually 50 to 100 mg."

9  Conclusions

9.1 Ketamine has most frequently been encountered by ecstasy users in the club scene as fake tablets masquerading as ecstasy. Since DIY pill testing kits were made available the late 1990s the incidence of fake ecstasy tablets has fallen, and the number of cases of accidental exposure to ketamine would thus be expected to fall.

9.2 Intentional use of ketamine is largely confined to a niche market among clubbers and others within the rave culture, with possibly 30,000 users taking the drug on an occasional or regular basis. The drug enjoys brief periods of publicity where more individuals are likely to try the drug, although only around one in four individuals who start taking ketamine ever progress beyond experimental use. Those users who have unpleasant experiences tend not to repeat the behaviour.

9.3 The general perception of ketamine among drug users as a whole is negative, only a small minority of non-ketamine users, who take other illicit drugs, would consider trying Ketamine.

9.4 The user-ratings of ketamine are low, reflecting a low probability of significantly increased usage, and appear to be on a downward trend from a low baseline.

9.5 Prices of ketamine tablets are currently higher than those of genuine ecstasy tablets, although at higher market levels purchase prices are broadly equivalent.

9.6 It is accepted that ketamine can have profound psychological effects on the recreational or unwitting user, however it has been used as an anaesthetic for many years and has, by all accounts, a good safety record.

10.  Recommendations

10.1  The current poor reputation of Ketamine among drug users is the most effective deterrent to more widespread use. Classifying ketamine as a controlled drug could risk glamourising the drug, increasing the user-ratings, and the likelihood of increased use.

10.2 Prevalence levels of ketamine use among drug users as a whole are low, and are at worst stable, more probably on a downward trend due to the reduced incidence of fake ecstasy tablets. Where a person is found to offer ketamine tablets as ecstasy (e.g. where tablets bear common ecstasy logos), he or she can still be prosecuted for attempted supply of a class A drug. There would appear to be no imperative in favour of adding ketamine to the list of controlled drugs at the present time.

10.3 Ketamine has a number of legitimate applications in human and veterinary medicine. The costs of added bureaucracy and safeguards arising from classifying ketamine as a controlled drug could have an adverse impact on the rural economy.

10.4 Note on GHB: IDMU has also been monitoring the usage of gamma-hydroxybutyrate (GHB) since 1998, and have baseline prevalence and attitudinal data in the years leading up to prohibition of the substance in 2003. Our 2004 survey will be the first to monitor post-prohibition attitudes-i.e. whether user ratings have decreased, increased or been unaffected. Should prevalence or user-ratings for GHB rise in the year following prohibition, it would be reasonable to presume that a change in legislation could have a similar effect on perceptions of ketamine.

10.5 It is therefore recommended that no action be taken in respect of ketamine at the present time, and that the effects on prevalence and attitudes of re-scheduling GHB be reviewed when 2004 survey data becomes available (spring 2005), before any final decision on classification of ketamine is taken.

Matthew J Atha - Director

Simon Davis-Research Co-ordinator

References

[i]           McDermott P (1992) Ketamine: Trick or treat? The Face June 1992

[ii]           http://www.erowid.org/entheogens/ketamine

[iii]          White WE (1998) This is your brain on dissociatives: The bad news is finally in. v0.1 28-11-98. http://www.frognet.net/~dxm/olney.html

[iv]          Shewan D, Dalgarno P (1996) Ecstasy and neurodegeneration. ...such as ketamine. BMJ 313(7054):424

[v]           http://area51.upsu.plym.ac.uk/~harl/ketamine.html

[vi]          http://orathost.cfa.ilstu.edu/classes/studentwork/pmmaher/public_html/keta2.htm

[vii]          http://xrules.com/drugs/ketamine.htm

[viii]         http://www.urban75.com/Drugs/drugketa.html

[ix]          http://www.rickwilk.demon.co.uk/ketamine.htm

[x]           http://207.100.97.5/OSI/Drug_Alerts/

[xi]          http://www.pcb.co.za/users/ravesafe/ketamine.htm

[xii]          http://www.health.org/pubs/qdocs/ketamine/ketafact.htm

[xiii]         http://www.bicserve.com/htm/ketotal1.htm

[xiv]         Karch SB (1997) Ketamine: the hot new drug of abuse. Forensic Drug Abuse Advisor 9(6), cited at http://www.inform.umd.edu/EdRes/Colleges/BSOS/Depts/Cesar/drugs/KETA-ART.HTML