Why ‘Special K’ Is Good Medicine

It’s on the WHO’s list of essential medicines, and is invaluable in developing countries. So why is the UN discussing increased regulation of ketamine?

In the global world of illicit drug policies, the granddaddy of them all is the United States. But as the U.S. starts to, perhaps, question the effectiveness of its abstinence-or-incarceration approach, China seems more than happy to pick up and go where the U.S. hasn’t gone.

Next week, the United Nations Commission on Narcotic Drugs (CND) will decide whether or not to schedule the drug ketamine internationally, as China has suggested it should. In fact, China is cheering for ketamine’s placement in the U.N.’s Schedule I, meaning it must be tightly regulated. In practice, this means the drug has little recognized therapeutic value and is prohibited from use except by those “directly under control of the government.”

Except, ketamine does have medicinal value. Here in the U.S. it’s Schedule 3, meaning it’s not likely to be abused and has recognized medicinal value.

“Ketamine is a ‘dissociative anesthetic,’” explains Alex Wodak, president of the Australian Drug Law Reform Foundation. “This means that it provides anesthesia without impairing airway control or depressing respiration.”

While veterinarians mostly use ketamine in the U.S., in the developing world it’s a life-saving anesthetic used on humans. Its current un-scheduled status makes it accessible for very poor countries where anesthesiologists and sophisticated equipment are in short—or nonexistent—supply.

“Ketamine is a great drug to have in poor and rural and developing countries,” says Allan Clear, executive director of the Harm Reduction Coalition in New York. If it’s scheduled, even in Schedule 3 or 4, “those countries will no longer look at it as a viable drug, and won’t be able to use ketamine as an anesthetic, which means people won’t be able to get medical care,” Clear says.

Ketamine, says Clear, is portable, easy to use, and the “best medication you can have in an emergency situation. It’s not easily replaced,” he says. “If it was, we wouldn’t have this issue.”

The World Health Organization agrees. “It is on the WHO list of essential medicines… so there’s some question if CND is over stepping,” says Clear.

Diederik Lohman, associate health director at Human Rights Watch, is also concerned about the potential scheduling. “One of the things that makes [ketamine] a good medicine to use in basic settings is that if you’re in a field hospital without much equipment or personnel, that means you can perform surgeries using ketamine; otherwise, you’re unable to perform surgery with anesthetic.”

That means, in a rural part of Africa, a woman needing an emergency C-section “might not be able to get that anymore at the local clinic and will have to travel elsewhere, which could be deadly,” Lohman says.

In addition, earthquakes, natural disasters, and battlefield emergency operations would be impacted. “But in rich countries, it won’t be quite as bad,” says Wodak.

Africa, however, says Lohman, has weak health systems and will be the least capable of complying with new regulations, even if ketamine is put in Schedule 3 or 4. That means it will simply become unavailable, because the effort to get the drug into the country and comply with the bureaucracy will be too cumbersome.

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Any scheduling will create a regulatory burden. “In the end, the pharmacists and government officials that will have to deal with this say they don’t have the manpower,” Lohman says. “Ketamine is very inexpensive, the profit margin is very small, [and] pharmacies will have to deal with additional paperwork. Either the price goes up or pharmacies lose interest in supplying the medication. It’s a lot of headache for very little profit.”

Clear explains the reason behind the desire to schedule it: “China has their problems with diversion of ketamine, in the same way it’s used in this country: Special K. It’s not a drug for wide use here, but much more in China.”

“[Ketamine] has been consumed for recreational purposes in recent decades,” says Wodak. “Consumers enjoy the temporary impairment of consciousness and hallucinations. While authorities may not be entirely comfortable that some young people are taking an unsanctioned drug, they should be grateful that at least ketamine is not as dangerous as many others.”

Adds Lohman, “The stated reason [from China for scheduling] is to combat non-medical use of the medication. Now it’s not entirely clear to me, and China has not done a good job explaining how international scheduling will prevent the misuse of the medication.”

In order to resolve the recreational use problem, Lohman says, China is trying to impose international regulations to restrict an important drug in the countries it’s most therapeutic, including countries that don’t have problems with non-medical use.

China has already made it a controlled substance under their national law, and is now pushing for controlling it under international law, says Lohman. “We feel that even with a lower level schedule, it’ll interfere with access, especially in countries with weaker systems.”

But will scheduling make any difference to recreational use? “I doubt it,” says Wodak, “but if it does, the market will shift to other drugs.”

“It’s hard to understand what China hopes to achieve,” says Wodak. “But the more you study drug policy, the more you realize that logic, rationality and evidence are not the major driving forces… We should remind ourselves of the principle ‘first do no harm.’”

The UN Commission on Narcotic Drugs (CND) will meet in Vienna March 9-17 and should vote on Ketamine March 13. There are 53 members of CND, and 2/3 must vote yes to schedule.