Submission to ACMD’s call for evidence on ketamine’s harms

In our submission to the ACMD on ketamine’s harms, we highlighted the following points:

General information

• Reasons for illicit use of ketamine include recreational enjoyment, pain management, and mental health support. Its recreational popularity is partly due to its low price (£10-£20 per gram), high concentration and availability, making it much cheaper and easier to transport than comparable amounts of alcohol or stimulants like cocaine.
• Populations most affected by ketamine use include children and young people, due to its low price and high availability. One in six young people in the GM-TRENDS survey reported past-year use, and the OHID report showed an increase in ketamine use among under-17s engaging in treatment. It is also popular among students and young professionals, who enjoy the lack of comedown or hangover.
• We observe significant harms from its criminalisation. This includes employment termination due to workplace drug testing, racial disparities in policing and prosecution (over tenfold increase in prosecution likelihood for Black people), irreparable damage to employment, life prospects, housing, and ability to travel overseas due to criminal records, and impacts on education engagement as students fear punishment for disclosing drug use.
• Despite a rise in ketamine use, the mortality rate associated with it has not increased notably since the 2013 ACMD report, with 244 deaths mentioning ketamine on the death certificate in England and Wales between 2014 and 2023.
• Ketamine consumers are often knowledgeable about ketamine’s harms, but less aware of potential support options, partly because they have historically been a small fraction of the drug treatment population.
• Effective methods for informing ketamine consumers include improved harm reduction-based drug education in schools that introduces risks alongside methods and resources for managing them, and a national public harm reduction information campaign informed by people who use drugs and drug workers.
• Further education for the entire public is needed, including government-led public health campaigns, education on safer drug use, and drug checking. Safer snorting materials are critical for public health by reducing HCV transmission, but their supply is currently prohibited by the Misuse of Drugs Act.
• Recommended actions include creating a national drugs early warning system, increasing funding for harm reduction services, reforming the licensing system for drug checking to make services quick, low-cost, and universally accessible, and eliminating criminal penalties associated with ketamine to encourage users to seek support.

Interventions and access to support

• Our Harm Reduction Hub provides advice and resources, including drug checking services (reagent test kits, sending samples to WEDINOS) for visitors concerned about contamination, and advice on safer snorting.
• Harm reduction education and dedicated referral pathways for ketamine consumers presenting to urology departments are seen as effective interventions for ensuring timely support.
• Barriers to early intervention and treatment for ketamine-related harms are primarily criminalisation and fear of punishment. Surveys show students fear punishment for disclosing drug use, and young people are scared to get medical help for drug-related issues. Research from British Columbia also found significant “police-related barriers” to accessing harm reduction services. The barrier is criminalisation, not just stigma, as ketamine use is widely destigmatized among young people.

Ketamine’s legal classification

• There is no clear evidence that legal classification influences users to reduce frequency or cease use. Previous reclassifications of substances, like mephedrone, showed that a significant portion of users continued use after scheduling.
• Changes in legal classification can promote the appearance of substitute substances (analogues) in the market, which may have higher health risks due to less information on dosage and long-term effects. For example, methoxetamine (MXE) appeared after ketamine’s classification as a Class C substance.
• We have observed increases in ketamine prevalence and related harms following its reclassification from Class C to Class B, with adult treatment presentations for ketamine rising significantly after 2015/16.
• A change to a stricter legal status (e.g., Class B to Class A) would likely reduce people’s willingness to seek support and engage with harm reduction services due to heightened fear of criminalisation and reinforcement of societal stigma.
• Factors most likely to deter ketamine use include drug decriminalisation combined with increased harm reduction funding, as seen in Portugal. Attempts to deter through increased criminalisation or supply disruption have not worked in the UK. Addressing health risks can be a deterrent, but only if criminalisation is removed to enable access to treatment.
• Providing comparably cheap and accessible healthcare solutions (for pain or mental health) could deter illicit use. Lastly, investment in education campaigns alongside increased funding for social and community programs could offer alternatives to recreational use, especially for young people.