Addiction journal has published an editorial that offers clinical perspectives on two parallel storylines about ketamine in the media: excitement about the therapeutic potential of prescribed ketamine, and concerns about increasing harms from illicit ketamine. The SSA’s Natalie Davies explores this timely contribution to the public discourse on a drug often portrayed as ‘helpful’ in one context, and ‘harmful’ in another.
Professor Owen Bowden-Jones CBE is an addiction psychiatrist who established the UK’s first club drug clinic, offering treatment for emerging drug problems, including novel psychoactive substances and club drugs. He spoke to the SSA about a new editorial he has co-authored with Mr Arun Sahai, a consultant urological surgeon, and Professor Paul Dargan, a consultant physician and clinical toxicologist.
In ‘Responding to medicinal and non-medicinal ketamine use’, Professor Bowden-Jones, Mr Sahai, and Professor Dargan present a way to understand the “apparent contradiction” that the harms from illicit ketamine are rising, while there is great excitement about the therapeutic potential of prescribed ketamine. They discuss the potential benefits, desirable effects, and risks of ketamine use in these two different contexts, and identify changes to policy and treatment that would mitigate the harms to people who use medical and non-medical ketamine.
Understanding ketamine
“Ketamine challenges our consideration of drug benefit and harm and how these two opposing concepts should be balanced by clinicians, policy makers and the public.” Excerpt from editorial
Ketamine is several things at once: it is a well-established anaesthetic, featured on the World Health Organization’s list of essential medicines; it is a novel treatment for depression and other mental health problems; and, it is an illicit substance, which carries a penalty in the UK of up to five years in prison for possession.
The drug was first synthesised in 1962. It has a “complex neurochemical profile” and can produce a range of effects, including numbness, pain relief, memory loss, loss of consciousness, feeling calm, sleepy, or drowsy, and feeling disconnected from your body, thoughts, or surroundings.
The profile of ketamine has made it an effective anaesthetic in human and veterinary healthcare, and a favoured drug in battlefield situations for providing rapid pain relief and sedation without slowing breathing, heart rate, and blood pressure (1 2). There has also been great interest in ketamine as a treatment for various mental health problems, particularly where more conventional medications and talking therapies have failed to meet the needs or expectations of patients.
New medical uses
“In some countries the demand for novel treatments, coupled with a desire to meet this demand, has led to ketamine prescribing moving ahead of the scientific and clinical consensus.” Excerpt from editorial
Ketamine is described in the editorial as an “emerging medicine” for mental health and other problems. The authors note that there is “genuine excitement among researchers about the potential for ketamine […] to deliver new treatment options for patients”, and point to over 1,500 clinical trials that have been registered to investigate ketamine treatments.
Much of the hope surrounding ketamine has been pinned on its potential to manage more severe and ‘treatment-resistant’ types of depression. One of the two enantiomers (mirror-image forms) of ketamine, S-ketamine, has been developed into a nasal spray and approved for the management of treatment-resistant depression in the UK and US, and for major depressive disorder with suicidal ideation or behaviour in the US. Ketamine itself is not yet licensed for treating depression or other mental health conditions; however, medical professionals can prescribe it ‘off label’, meaning that they can prescribe it outside the purpose, dose, method, and group of patients for which it is officially approved.
In the US alone, the ‘ketamine clinic’ market was worth $3.4 billion in 2023. This large market value could be explained by various factors, including a rising demand for novel treatments and the expansion of private ketamine clinics. The potential downside or risk of this level of commercial interest is that it could lead to clinics overselling the effectiveness of the drug or promoting it for conditions for which there is little or no supporting research.
Non-medical uses
“Non-pharmaceutical use of ketamine has increased across the world, with harms including accidental injury, psychological dependence and urinary tract damage.” Excerpt from editorial
Ketamine isn’t a new recreational drug; it first became popular in the UK in the 1990s. However, according to national statistics, there has been a sharp rise in the use of ketamine in the UK since 2016, as well as a sharp rise in the number of adults seeking treatment for ketamine use disorders since 2015.
This apparent change in use and harms has been on the radar of the UK Government, which has indicated that it may reconsider the legal classification of ketamine under the Misuse of Drugs Act 1971. In January 2025, policing minister Dame Diana Johnson wrote to the Advisory Council on the Misuse of Drugs (ACMD) to commission advice about whether ketamine should remain controlled as a Class B substance or become a Class A drug. This change would bring about greater penalties for people in possession of ketamine or supplying ketamine.
Ketamine is most commonly snorted, but it can also be mixed into a drink, wrapped in a cigarette paper, put in a gel capsule, or injected into the muscle. Desirable effects at lower doses can include visual and auditory hallucinations, and distortions of time and space; at higher doses, people can experience intense dissociation and sedation. Although ketamine is known as a ‘party drug’, many people may be using ketamine for relief or respite from their mental health problems, including the symptoms of post-traumatic stress disorder.
People who use ketamine can be vulnerable to a range of harms, some of which are unique to the drug itself. Immediate or situational harms can include accidents such as falling or drowning, and assault while vulnerable and intoxicated. Longer-term harms from persistent use can include psychological dependence, cognitive impairment, liver damage, and ketamine-related urinary tract damage (also known as ‘ketamine bladder’). The latter has received quite a lot of media attention recently. Symptoms of ketamine bladder include pain, incontinence, muscle spasms or cramps, and blood in the urine. In advanced cases, people can also experience urinary tract obstruction, renal failure, and the need for surgical intervention.
Mitigating the harms
In ‘Responding to medicinal and non-medicinal ketamine use’, Professor Bowden-Jones, Mr Sahai, and Professor Dargan provide insight into why people might seek out both medical and non-medical ketamine, and propose changes to policy and treatment that would mitigate the harms of ketamine use in both contexts.
For managing the harms of medical ketamine (i.e. ketamine as a novel treatment for mental health and other problems), the authors stress the importance of facilitating innovative research and drug development, and doing so within regulatory frameworks that keep patients safe. Giving examples of the current gaps that could leave patients vulnerable to harm, they say that “Better understanding is needed of which health conditions respond to ketamine treatment, the most effective prescribing regimens for these conditions, the likelihood and severity of adverse effects, and the profiles of patients most likely to benefit from treatment”.
For managing the harms of non-medical ketamine (i.e. ketamine as an illicit drug), the authors highlight the need for: research into whether standard treatments for substance use disorders will also work for ketamine; frontline drug treatment staff to improve their skills in the assessment and treatment of ketamine use disorders; treatment services to develop appropriate screening, referral pathways, and joint working protocols with urology services; co-produced harm reduction information for people who use ketamine, particularly higher risk groups including young people, people using the night-time economy, and people using ketamine for sexual enhancement; and national and global surveillance systems to better capture changes in patterns of ketamine supply, use, and harm.
- Read the editorial: https://onlinelibrary.wiley.com/doi/10.1111/add.70075
- Watch the interview: https://youtu.be/DtXXc0eearE
- For media enquiries, contact the SSA’s Head of Communications, Natalie Davies.
The SSA owns Addiction and invests journal income back into the sector to support people, projects, and research in addiction science.
Professor Owen Bowden-Jones CBE is a medical doctor, psychiatrist, and researcher who established the Club Drug Clinic, which offers treatment for people who have begun to experience problems with their use of recreational drugs. He is also an Honorary Professor at University College London, Chair of the Advisory Council on the Misuse of Drugs (ACMD), Policy Fellow at the University of Cambridge, board member at the International Society for the Study of Emerging Drugs, special adviser to the Universities UK drugs taskforce, and President of the SSA. Professor Bowden-Jones wrote the editorial in his professional capacity as an addiction psychiatrist.
Mr Arun Sahai is a consultant urological surgeon in functional urology at Guy’s and St Thomas’ NHS Foundation Trust and an honorary senior lecturer at King’s College London. He is a member of the British Association of Urological Surgeons (BAUS), sits on the BAUS committee of female, neurological and urodynamic urology, is a frequent reviewer for many international urology journals, and is on the editorial board of neurourology and urodynamics.
Professor Paul Dargan is professor of clinical toxicology at King’s College London, a consultant physician and clinical toxicologist at Guy’s and St Thomas’ NHS Foundation Trust, and the Caldicott Guardian at Guy’s and St Thomas’ NHS Foundation Trust. He is an expert adviser to several bodies including the US Food and Drug Administration (FDA), the United Nations Office On Drugs and Crime (UNODC), and the World Health Organisation (WHO).
