In the effort to make things simpler, sometimes the media reaches for a simple analogy. Metadata is just about the envelope. Flapping butterflies are making hurricanes. That drug called ketamine is just for horses and underground rave parties. Or both together.

Which is why it might not be so easy at first to grasp that ketamine is about to be discussed at the UN in the sort of context that could make millions of people around the world less safe when they need surgery.

Yep. Special K is a human rights issue.

A Bit About Horse Drugs

Ketamine is used for horses and it is used by some for recreational purposes. But overwhelmingly it’s used in human anaesthesia and as a pain reliever. Particularly in the developing world. It’s probably the world’s number one anaesthetic agent and there’s a bunch of good reasons.

As an anaesthetic agent, ketamine is quite different to most of the other agents we use. The reflex is to think that all anaesthetic agents are about suppressing activity in the brain. And it’s true that many agents interact with receptors (GABA receptors) that have the primary job of making neurones in parts of the brain fire less.

Ketamine is not the same beast. It is an antagonist at N-methyl-D-aspartate (NMDA) receptors and the patient who has received a dose looks entirely different. They enter a “dissociative” state and instead of just looking sleepy they classically get a slightly glazed look, eyes flicking like they’re watching trains rolling across the landscape. Talk to them and you’ll get no response. They are unaware of all of this.

For a long time explaining this ability to produce anaesthesia while not “looking” like anaesthesia has confounded those looking for the unifying theory of how anaesthesia works. There is some evidence now that it does produce similar effects in communication between brain areas as the agents we’re more accustomed to using. It just has a few bonus effects on the way.

Ketamine also provides excellent pain relief and when used to produce anaesthesia, patients tend to keep breathing pretty well and their blood pressure remains stable. This isn’t the case for some of our other anaesthetic agents and it adds in a bit of a safety margin not apparent in the other options. All these different qualities give ketamine serious advantages when you’re going to give surgical care in a clinic somewhere in west Africa.

That’s why it is such an important drug worldwide. Because it is the most widely available agent that can deliver what should be a human right – freedom from the suffering of surgery while you’re fully aware. It is the agent available more often than not in all those spots around the world where people need an operation, or a woman really needs surgery to deliver a baby but the surgical care amounts to a couple of passionate individuals, not a whole health system. That’s why it is used millions of times every year.

Sounds Good

So that should be where the story finishes, right? Science found a drug that generally provides excellent pain relief and a pretty safe means of providing valuable anaesthesia in the face of urgent surgical need. And you get to reminisce about cereal ads from previous decades while you marvel at this triumph of pharmacology.

Well, no. Because ketamine also has other effects. It can produce some pretty gnarly visions in that dissociative state. Some of them feel fantastic. Some of them are horrifying. But those formers ones can be popular leading some to pursue the dissociative state or their positive experience of the trip. Some are therefore concerned about its potential for abuse. And some people do abuse it. Probably not in the same numbers as the millions who benefit from it of course.

Why bring this up?

At a time when one of the priorities of the World Health Organisation is making safe surgical care the norm, China has lodged a proposal before the UN ‘s Commission on Narcotic Drugs that ketamine be placed on a restrictive schedule which has the potential to limit its availability to medical professionals.

China, with the support of Russia amongst others, seems to feel there should be more concern about the potential for abuse. Of course the same question was addressed in 2006, 2012 and 2014. It’s repeat season.

If the proposal was to pass, it would be devastating for surgical care in low resource countries. Decisions like this are well known to cause big issues for access to health care. It’s only recently that international bodies have been prioritising access to opioid medications so that people throughout the developing world don’t die in the sort of pain most of us would never expect to be left with. The reason opioids have traditionally been hard to access? The 1961 decisions of the UN Single Convention on Narcotic Drugs to regulate access because of fears of abuse.

Sounds familiar, right? But hey, the UN only estimates 5.5 billion people don’t have access to adequate pain relief.

The Push Back

Is the persistence of this proposal likely to change the result? It seems unlikely. There’s been coverage of the issue in the general press and lots of groups raising a collective “no thanks very much that would be somewhere beyond the Magellanic Clouds for intergalactic stupidity” (though a fairly shameful silence from Australian groups near as I can tell).

While we’re all on the ramparts though, it’s probably a timely reminder that access to health care is still a major worldwide issue. It might be something worth talking about when it’s not just partygoers under threat.

If you’d like an example of a direct thing you can do to aid surgical care in developing countries you might like to check out Lifebox. It’s a program endorsed by the World Federation of Societies of Anaesthesiologists amongst others and delivers monitoring we’d consider a basic standard of care to areas it’s not available, with training to boot. I have no links with the program, beyond having donated myself.

I also didn’t go into ketamine as a treatment for depression, because that’s still in the early stages of being tested. But you can read more here.

Edit note: In response to the comment re: hallucinations, I’ve tried to make it even clearer that some people do seek to pursue the dissociative state or their positive experience by inserting the following in the section “Sounds good” – “leading some to pursue the dissociative state or their positive experience of the trip”