Britain has a long history of responding progressively, pragmatically and with tolerance towards drug use. It was one of the pioneers of harm reduction long before the term itself was actually coined; for example, opiate substitution therapy in the UK goes back all the way to the 1920s. This progressive tradition continued throughout the vast part of the last century and reached its peak in the 1980s with the steady growth of opioid substitution therapies (such as methadone maintenance), outreach work, safer sex campaigns and the introduction of needle exchange programmes in 1986, which was at the time a landmark matched only by the Netherlands.

Although it is often assumed that pragmatic and progressive drug policies derive from left-wing governments, it was actually under Margaret Thatcher's that evidence-based, harm reduction approaches officially became part of national policy, as part of the UK’s highly effective and much commended response to HIV. Sadly, despite all the positive results, it was only 10 years later that Tony Blair informed the nation that the time had arrived for a radical change in UK drug policy. Since the threat of HIV was no longer a significant driver, Blair adopted an approach where the focus was no longer public health but instead an approach intended to reduce crime.

Needless to say, this ‘new’ approach to drug policy and practice failed miserably. Despite the establishment of the National Treatment Agency, it soon became clear that the crime reduction imperative meant that the focus of treatment was not on those who wanted help but on those who were considered by society to have needed the treatment because they were causing social harm. Ketamine users did not fit into the category of being the criminal needy and were therefore not considered to be a priority since the damage caused by the drug affected the individual to a much higher level than it affected the wider society. With a drug policy now heavily focused on crime reduction, there was increasingly little space or resources for health improvement and harm reduction. One consequence of this blinkered approach was the NTA’s refusal to respond to, or provide leadership in the face of, the alarming growth of problems related to ketamine use, despite repeated calls from both drug user activists and drug specialists.

So what is the story behind this novelty drug with such catastrophic health and social consequences?

Ketamine: enlightenment

Ketamine has been around for quite some time, dating back to 1962 when the American scientist Calvin Stevens first synthesized it. Originally patented in Belgium a year later, ketamine soon made its way onto the list of approved substances for use on humans and was put to use in the Vietnam War as a battlefield drug, which soldiers could intramuscularly inject into their wounded buddies without the fear of overdosing and accidentally killing them; an all too frequent problem with the peer administration of morphine. Despite ketamine having subsequently been shown to have significant value for the treatment of post-traumatic stress disorder in numerous experiments and trials, it was soon realized that administration of ketamine in the middle of the battle acted to amplify psychological trauma. However, ketamine's anaesthetic properties led to its wide use in human and veterinary medicine.

The immensely wide margin between the drug’s highest medical and lethal dose makes death by overdose pretty much impossible, and this ensured that ketamine was approved for a large number of trials, resulting in it becoming one of the most researched drugs of our times. On the other hand, its ability to produce hallucinogenic and dissociative effects within minutes of administration meant the drug's potential for recreational use was swiftly noticed.

The first group of people who recognised ketamine's non-medical value were psychonauts; mind explorers and adventurers into psyche who sought to investigate their minds using intentionally induced altered states of consciousness. These often highly educated and socially privileged pioneers of this fairly unknown drug were using it as a tool for their spiritual and psychological journeying. Psychonauts injected high doses of ketamine intramuscularly, mostly in the safety of their homes where they could fully experience the drug without any interruptions from the outer world. To allow complete separation from the external reality, some of them used sensory deprivation tanks where they would lie in the water in complete darkness, reducing external social or internal personal stimuli, to allow them to focus on the experience.

Psychonauts' primary motivation for the use of ketamine was to transcend the external world, experience the separation of consciousness from the body, gain an insight into the nature of existence and the Self, recover forgotten memories and attain near-death and re-birth experiences. They were in the habit of taking large doses, deliberately trying to go into a K-hole, crossing the veil from conscious to unconscious. As the psychonauts were mostly using ketamine on a non-regular basis, their risk of developing K-dependency was relatively low.

Under the lights

In the early nineties, ketamine arrived on the New York and London gay club scene where it found an entirely different body of users. If psychonauts appreciated the drug for its hallucinogenic and dissociative properties, the new audience, called the klubbers, discovered its possibility to act as a highly effective stimulant. Ketamine is one of those drugs which are extremely dose-dependent, and while psychonauts were injecting 200mg shots when trying to achieve out-of-body experiences, klubbers were usually snorting small bumps of ketamine, normally around 25mg per dose. While klubbers in New York mostly used just ketamine as their primary drug of choice, those klubbers on the London scene were initially MDMA users, taking ketamine to intensify the feeling of ecstasy.

Klubbers went on to discover that ketamine was, when taken in larger doses, also a very useful drug for chilling out after dancing all night. As a result, some of these klubbers went on to take higher doses of ketamine and joined the ranks of the psychonauts. While those who went on extended journeys with ketamine could find themselves facing health challenges, the spontaneous patterns of using among klubbers turned out to be protective. Klubbers tended to take breaks between episodes of using and had learned, from their MDMA use, the importance of remaining hydrated.

So in the late nineties, more than 20 years after ketamine made its debut as a drug used by spiritual journeyers, it became widespread among a much wider group of users on the club scene. To many of these new enthusiasts, ketamine had the appearance of 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 it provided a full-on dissociative and hallucinogenic experience with no apparent disadvantages or collateral damage.

Well, that impression was soon to be changed.

When ketamine went dark

The new century brought along several changes on the drug market. On the 1st January 2006, ketamine was officially reclassified to a Class C drug on the basis of linkage between its frequent use and kidney and bladder damage, as well as the impairment of memory. While this causal relationship is not to be completely dismissed, it is worth pointing out that the reclassification made the situation with regard to public health remarkably worse. Up until 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 use drugs. Reclassification changed this dramatically.

Due to the increased difficulties with smuggling the drug (which were also connected with the implementation of harsh anti-terrorism laws in the wake of 9/11), ketamine was no longer being smuggled as a liquid, but now in two different crystal forms. This led to much confusion among the new generations of ketamine users. One response was for consumers to dissolve the crystal in water before dehydrating the liquid by cooking it in pans or in microwaves. However, this process actually had no value and unintentionally degraded and ultimately destroyed the drug, which resulted in ketamine users needing to take more of the drug to achieve the desired effect. This meant that more ketamine was being processed through the body via the bladder, and with high doses, no breaks to allow tolerance to re-balance, and poor hydration, users were exposed to a poorly understood risk, that of ketamine failing to clear the bladder safely. The consequence is initially hardening of the bladder wall, and in the worst cases the need for the bladder to be removed. Kidney damage can also occur in what is now known as ketamine bladder syndrome.

At the same time, the price of ketamine dropped drastically. Whereas psychonauts and klubbers were buying the drug for about £50 per gram, the new generation of ketamine devotees could get the same amount for a mere £10. A natural consequence was a vast diffusion of ketamine into previously uncharted peer groups. These new K-users, referred to as wobblers, were from a very different cultural and social background than the psychonauts and klubbers. Wobblers were not highly experienced and privileged drug users; they were often very young kids from both rural and inner city areas, with limited education about ketamine and its risks, who valued the drug for providing a state of intoxication that offered a way out of their frustrating, alienated and marginalised lives. Their primary motivation for using ketamine was a far cry from attempts to reach intense visions, life reviews, out-of-body experiences and mystical states. Wobblers did not want to enrich their lives with an occasional trip into the drug-induced dream world, instead they just wanted to get out of it and often found themselves trapped in repetitive and damaging patterns of drug use. If for psychonauts ketamine was all about the journey across the veil with the full intention of coming back, enriched by the experience, wobblers' main desire was to go across the veil and block out reality, often using without breaks.

Because wobblers tended to use ketamine to escape their lives, detach from environment and make the unbearableness bearable, they had a much greater pre-vulnerability for exposure to the negative consequences of the heavy use of the drug. While constantly increasing the dose and the frequency of use, they at the same time seemed to be unaware of ketamine's potential for dependency and physical damage. This lack of knowledge was due to two factors; on the one hand there was a very low level of technical knowledge within these new peer groups, and greater criminalisation and the limited official response made it nearly impossible for them to acquire information in their natural environment. This left this new generation of wobblers too often unaware of the social and health damage the drug could cause when not being managed optimally.

The logical consequence of this educational vacuum was that the wobblers had to learn the lesson on the dangers of ketamine themselves, and they learned it the hard way. Wobblers did not generally have this theoretical or experiential knowledge of the drug common among the psychonauts and even the klubbers. So they were rapidly increasing their doses and frequency of use, and, since they did not understand how to manage crystal, they were also baking the drug, thus lowering its quality and resulting in users needing to take more ketamine for the same effect. Also ketamine's potential for dependency took the majority of its users by surprise, as most were unaware of the dependency profile of this psychedelic, dissociative drug.

Besides young kids in rural areas, there was another group of people that gradually moved into the pattern of daily use of ketamine. This group had historically been on the squat party scene, constituted of squatters, artists and activists mostly from East and South London. [The effect of a high dose of ketamine is to render the user seemingly unconscious for up to an hour.] Ketamine was at one point seen by some party organisers to be destroying London’s squat party scene, as it suddenly became common to have [apparently] unconscious people sprawled out in parties, which attracted criminals, making both rape and robbery a risk. Similar patterns were also seen in areas that had either been centres of the squat or free party dance scenes. This is reflected in pockets of problem ketamine use that have appeared across the UK.

Within a few years therefore a seemingly harmless substance, consumed by more elite drug users, became a drug that caused significant damage, earning it and its users a stigmatised status equivalent to heroin and crack. The resulting spread of the darker side of ketamine - K-bladder, K-dependency and impaired cognitive function - resulted in people seeking help from both emergency health and drug services. However, with some commendable exceptions, there was very limited knowledge of ketamine in drug services and options in services were focused almost exclusively on heroin and crack. This was in line with the Government agenda to base the national drug policy on the imperative of crime reduction, and the lack of ketamine-related crime ensured the drug did not gain the required attention or appear on the NTA’s policy radar. That is not to say that ketamine users did not face the danger of being criminally charged; ever since its reclassification into a Class C drug, ketamine users actually faced a real danger of getting a criminal record, disastrous for young people who had trained for particular professions, investing substantial amounts of time and money attending University.

Managing the realities

In the light of the refusal of the National Treatment Agency to engage with ketamine, an informal alliance of drug user activists, neuroscientists, psychiatrists, drug services, GPs and urologists was formed in order to develop a range of dynamic peer support and practice responses to ketamine. This collaboration has included dynamic new findings and understanding about the risks of ketamine and significantly how these problems can be reduced and managed. Further, harm reduction strategies and models of self-control and detoxification have been developed and adapted. The informal networks behind these projects have been based on collaboration and a commitment to open source working. This work was subsequently developed into a series of harm reduction guidelines that were presented on social media and at various conferences allowing for a process of peer review and information sharing. This work culminated in Respect, a UK grassroots hard drug user group, presenting the peer perspective and experiential learning to the Advisory Council on the Misuse of Drugs Working Group on Ketamine. The Home Office had asked the ACMD to review their work on ketamine and update their advice, given their inclination to further increase the classification of ketamine in response to the emergence of health problems that in part can be tracked to the last equally mistaken reclassification.

Respect’s recommendations, presented to the ACMD, included education about harm reduction for ketamine users, trainings of drugs and health professionals that addressed both knowledge gaps and stigma reduction, investment in an interactive, peer-led but professionally supported online service, development of healthcare referral pathways for ketamine users experiencing chronic problems, promotion of joint work between urology and drug services to help manage long-term care of those with ketamine bladder syndrome and removal of criminal sanctions under Misuse of Drugs Act for ketamine.

The recommendations to the AMCD are supported by various groups of scientists, researchers, activists and health professionals, and there are significant concerns that re-classification will not only lead to greater risk for illicit ketamine users but it will also end all the research into the potential new uses of ketamine including for the treatment of PTSD, depression and alcohol dependency. As such there is urgent need for the ACMD to give strong and clear recommendations that argue against further increases in the criminalisation of ketamine, and for a coordinated and collaborative response to this growing crisis. However, the fear remains that a positive set of recommendations from the ACMD will be ignored by the current Conservative Home Secretary, Theresa May MP, who is earning a reputation for systematically acting contrary to expert advice.