Harm reduction | Health advice Ketamine: just a harmless party drug? When Kat Deans, Rachel Ayres and Pete Weinstock began to see more long-term ketamine users at Bristol Drug Project, they joined forces with local urologist Angela Cottrell to devise more targeted advice
frequently and suddenly, and leakage of urine. These effects seemed to be directlyrelated to the damage done to the bladder lining, which bled as it became inflamed. More worryingly, the scarring found in the bladder might also appear in the ureters
At the beginning of this year,Sue visited the daily drop-in at the Bristol Drugs
Project (BDP) asking to see a drugs worker to talk about her ketamine use. She was experiencing unwanted physical and emotional side effects fromusing up to 7gm of ketamine a day, but finding it extremely difficult to cut
(tubes from kidneys to bladder) and ultimately lead to kidney damage.
down. Sue was also seeing her GP on a regular basis for treatment for chronic cystitis,
Some patients were unable to cope with the severe and frequent pain and had
but as the prescribed antibiotics weren’t alleviating her symptoms, Sue’s GP referred
had a catheter inserted; one patient in the South West had their bladder removed
her to a urologist. At this point neither Sue nor her GP were aware that there could be
as their symptoms were so bad. With patients tending to be very young (in their
a link between her urinary tract problems and her ketamine use.
20s), these were not decisions to be taken lightly. The prognosis of patients who
Sue was not the only service user being seen by BDP for help with problematic
have bladder damage following ketamine use is unknown. Some patients’ symptoms
ketamine use, and we realised that two other ketamine users were being treated by
worsen as they continue to take ketamine; others improve if they stop, but others
urologists in the area. We liaised with Dr Angela Cottrell from Bristol Urological Institute
continue to get worse despite stopping ketamine. There are reports of similar cases
at Southmead Hospital, who told us that the local urology department was seeing an
following long-term prescribed use of ‘pure’ ketamine for pain control.
increased number of patients with similar symptoms who had a history of heavy
Since the beginning of the year, our understanding of the short and long-term
ketamine use. She informed us that that there had been reports of urinary tract
problems related to ketamine has increased greatly and we have been able to get a
problems associated with chronic ketamine use in Hong Kong and Canada, but no
better picture of the problem. We are aware that ketamine (classified ‘C’ in January
2006) is widely used in Bristol and surrounding areas, particularly among young
Back in January there were seven young people being investigated by local urologists
people. It is cheap to buy, at between £6 and £10 a gram. The general perception,
for possible bladder damage associated with ketamine use; by June this number had
both locally and nationally, seems to be that users do not experience major physical
more that doubled. It was clear that we as drug service providers, as well as our
problems if they are taking small amounts. Recreational users with low tolerance will
colleagues in urology, needed more information on the scale of the problem.
experience a mild ‘trippy’ euphoric feeling from a dose (a ‘bump’) of 10-30mg.
We began by running two well-attended workshops for users, and another for
As the dose increases, the dissociative effect that most users seek, becomes more
professionals – which to our surprise, attracted 45 people. In April of this year the first
marked. This state can be reached with around 50-100mg, the size of a small line. At
UK case of urinary-tract pathology associated with ketamine was published in the
higher doses (anything over 100mg) users talk about entering the K hole, when the body
British Medical Journal. We responded with a letter highlighting the increasing number
starts to pass from a dissociative state to anaesthesia. As to be expected from an
of cases in the South West. As we began to ask service users at BDP about urinary
anaesthetic drug, this means that the user may become unconscious or paralysed for
problems, it became apparent that many ketamine users had experienced similar
a while. In these situations ketamine users are extremely vulnerable, and unable to look
symptoms – in fact this was common experience among heavy users. Chronic
after themselves and their belongings. Ketamine is associated with socially and sexually
ketamine users told us of a list of typical symptoms varying with severity, such as
risky behaviours and can be a serious compromise to personal safety.
pain and burning on passing urine, blood in the urine, necessity to pass urine
The majority of our local ketamine users snort the drug or take it orally. However,
10 | drinkanddrugsnews | 28 July 2008 www.drinkanddrugs.net Harm reduction | Health advice ‘Despite severe health problems, many people find it difficult to stop using ketamine, and tolerance of the drug and dependence on it can follow surprisingly rapidly.’
many of the older injecting drug users using the needle exchange at BDP injectketamine as part of their poly-drug repertoire, as it seems to temporarily reduce their
tolerance and therefore increase the effectiveness of opiates.
Like Sue, many of the ketamine users that we have seen this year have also
suffered from ‘K-cramps’ – prolonged and severe abdominal pain – and may need to
BDP offers some basic harm reduction advice to ketamine users
be admitted to an A&E department. Our workshops revealed a wealth of acquiredwisdom about the origin of K-cramps, including swallowing rather than snorting, and
Guard against vulnerability and forgetfulness by making sure you’re with people you can trust. Mixing ketamine with other drugs or alcohol will
ketamine being cut with other substances. Several online user-forum sites advise
using pharmaceutical grade liquid ketamine only, to avoid this.
Despite severe health problems, many people find it difficult to stop using
Avoid severe and long lasting abdominal pain (referred to as K cramps) by
ketamine, and tolerance to the drug and dependence on it can follow surprisingly
not swallowing the drug – there is a strong belief that ketamine in the
rapidly. As users move from recreational use of less than 1mg once or twice a week,
stomach makes cramps worse. Seek medical advice and mention your
to several grams per day, they seem to stop experiencing the originally desired effects
ketamine use to the doctor. If you sit in the bath to soothe the pain there
and find themselves using to feel well, and even to control the pain from their
is a risk of unconsciousness and drowning.
unwanted symptoms. The shift from recreational to problematic use is poorly
If you have a panic or anxiety attack stay with your friends. Make sure
understood. We don’t know how long it takes for tolerance to build up, or which groups
someone is looking after you. Relax through slow, controlled breathing.
Habitual daily use may leave users feeling paranoid and with a diminished capacity
If you experience urination problems be aware that the symptoms will
to cope with everyday life situations and emotions. Several workshop participants
not respond to cystitis treatments. Drink plenty of water. Seek medical
reported feeling anxious, having poor concentration and longer-term memory loss.
help, tell your GP that you use ketamine and ask for a referral to an
In our still-limited experience, anxiety and depression seem to be a feature of
urologist to reduce the risk of permanent harm.
ketamine withdrawal. Ketamine is known to stimulate the production of dopamine in
If you find yourself needing to use higher and higher doses and are using
the reward parts of the brain, as well as producing adrenalin and endorphins. Perhaps
more frequently than intended, monitor yourself. Give yourself breaks
low mood following a reduction, or cessation of use, is not surprising and may be
treated symptomatically, as for stimulant detoxes.
At BDP we continue to support Sue through our community detox programme. If you feel depressed and anxious when stopping or reducing ketamine
However, we now know of two ketamine users that have recently completed ten-day
use, get some professional help to manage your symptoms during agradual reduction. Try to distract yourself with purposeful and enjoyable
inpatient detoxes in Bristol, and these were managed symptomatically, as for a
benzodiazepine detox. Our next priority at BDP is to further develop and promote ourharm reduction and detox support guidelines. We need to be imaginative in how we get
Injecting ketamine brings the additional risks of damaging your veins, skin
messages out to people who do not traditionally come to drugs agencies and we need
infections and contracting blood borne viruses such as Hepatitis or HIV.
to adapt them to different target groups. Some questions still remain: What are the
Get safer injecting advice from your nearest needle exchange.
risks of using ketamine during pregnancy? What is ketamine cut with? Domanufacturers have a record of patients experiencing similar problems whereketamine has been prescribed therapeutically?
How do you support a ketamine detox?
It seems that as ketamine use increases recreationally, so more users will move
Encourage a slow reduction so the body can adjust to lower dose levels and
into problematic use and present to us, as well as to medical services. Locally there
new, positive routines can be built into their day, advises Pete Weinstock,
is an increasing demand for information; since writing the first draft of this article we
who drew up guidelines in consultation with BDP’s local prescribing service,
have run another well-attended workshop for professionals in Bath, have one planned
in-patient detox unit and service users. Each symptom should be treated
for local youth workers next week and two more user workshops planned before mid-
separately, but chlordiazepoxide (Librium) can alleviate anxiety. Short-
August, for which we have a waiting list. We are keen to continue to gather information
term promethazine (Phenergan) and complementary therapies can also be
and get clear messages out to ketamine users, other services and to our local GPs.
Kat Deans is harm reduction worker, Rachel Ayres is volunteer manager, and Pete
The person is likely to have difficulty sleeping initially or may need a
Weinstock is senior practitioner for community detox and shared care plus at Bristol
considerable amount of sleep during the first few days of detox, and they
Drugs Project. ‘Sue’ is a fictional name, representing actual service users at BDP. For
will feel lethargic. Their mood may be low and they will feel demotivated,
more information or feedback, contact Bristol Drugs Project on 0117 987 6000, or email
as serotonin and dopamine levels will be depleted by their drug use. Plan
[email protected] or [email protected]
routine and structure, using meaningful and enjoyable activities to
Angela Cottrell is clinical research fellow at Bristol Urological Institute, Southmead
stimulate and reinforce positive progress.
Hospital, Bristol. If you have any experience working with people with bladder symptoms
Encourage users to eat and drink regularly and healthily, and to avoid
associated with chronic ketamine use, please email her at [email protected]
isolation. Engaging in a social support network can help to continue
Full references for this article are available by emailing [email protected]Cartoon by Chris Keegan, volunteer at Bristol Drug Project. www.drinkanddrugs.net 28 July 2008 | drinkanddrugsnews | 11
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Seminars in Neonatology (2003) 8 , 223–232 Surgical treatment of infants with necrotizing enterocolitis Agostino Pierro*, Nigel Hall Department of Paediatric Surgery, The Institute of Child Health and Great Ormond Street Hospital forChildren NHS Trust, University College London, London, UK Summary With the improvements in neonatal intensive care, necrotizing enterocolitis KEYWORD