Ketamine

Ketamine is a medication that is used for anesthesia, pain relief, and the treatment of depression. It is also currently being trialed for use in the treatment of substance dependence. Like nitrous oxide, ketamine differs from other anesthetics by having a dissociative rather than a sedating effect. This involves the sensation of increased distance from reality rather than a mere dulling of the senses.

As a recreational drug, ketamine comes in powder form and is typically taken by snorting. At low doses, the effects can resemble those of alcohol, though more stimulating and less sedating, while higher doses lead to strong dissociation and hallucinogenic effects. Very high doses can be risky as they render the user unable to react to their surroundings and can result in frightening, near-death-like experiences.

Ketamine causes minimal hangover, and it is common to feel an antidepressant afterglow in the days following use of the drug. However, excessive use over time can lead to cognitive and psychological problems. Ketamine does not normally impair the breathing reflex, but combining it with alcohol, GHB, or opioids can be deadly if these are taken in high doses.

Please see our 10 general rules for sensible drug use. You should also be mindful of the following:

• If you have heart problems or high blood pressure, you should be cautious with ketamine and especially avoid combining ketamine with stimulants

• Avoid combining ketamine with alcohol, GHB, or opioids. This increases the risk of losing consciousness and vomiting and can be fatal.

• Be cautious when combining ketamine with other dissociatives, such as nitrous oxide. The substances can then significantly amplify each other's effects.

• Be cautious when combining ketamine with cannabis. This can lead to confusion and anxiety.

• Do not use ketamine in unsafe environments or with people you do not trust. The intoxication makes the user vulnerable to exploitation.

• Start with a low dose if it is your first time, and wait at least 30 minutes between doses.

• If you feel "outside" yourself/reality long after the intoxication has subsided, you should avoid all drugs for a while. Consult a doctor if the condition does not improve.

• Preferably avoid using ketamine weekly or more frequently. If you use ketamine often, you should limit the number of doses per occasion and take regular breaks to avoid tolerance. Excessive use can cause permanent damage to the bladder, and it varies individually how much is needed before damage occurs.

• Consult a doctor if you notice that you need to urinate more frequently, have blood in your urine, or experience pain/cramps in the lower abdomen after using ketamine for an extended period. Damage to the bladder from ketamine requires treatment.

We employ a five-step risk scale with values ranging from "very low" to "very high" within six categories: Acute toxicity, Long-term toxicity, Dependence, Cognitive problems, Unpleasant events, and Interactions.

These values are based on qualitative reviews of available knowledge, and should only be viewed as guidelines. They are also relative, so a score of "very low risk" does not mean the substance is risk-free. The scale assumes users are normal, healthy individuals; beware that even drugs which are well-tolerated by most people may nevertheless be harmful to some users. It also assumes normal use patterns; that is, if a given drug is only harmful when used in a certain way, yet is almost never used in that way, then the drug will be considered less harmful compared to a similar drug which is commonly used in a harmful way.


ACUTE MORTALITY

⦿⦾⦾⦾⦾ (Very low risk)

Ketamine is rarely fatal in cases of overdose, and death usually occurs with intravenous administration of about 11 times the lowest dose typically used in anesthesia.

TOXICITY OVER TIME

⦿⦿⦾⦾⦾ (Low risk)

Ketamine is minimally toxic with sporadic use. However, excessive use of ketamine over time can lead to cyst formation and fibrosis in the bladder, and some extreme users have had to receive artificial bladders. The risk is greatest with daily use in high doses, but mild discomfort is also documented among more moderate regular users. Animal studies suggest that consuming large amounts of epigallocatechin gallate (found in green tea) may limit bladder damage, but it is uncertain whether this applies to humans and what doses are necessary.

DEPENDENCE

⦿⦿⦿⦾⦾ (Moderate risk)

Regular use of ketamine is not associated with a physical withdrawal syndrome, but problematic use can occur among individuals seeking to escape reality. Unlike psychedelics, dissociative drugs like ketamine can be used daily over a long period if the dose is simply increased. However, this quickly leads to the need for very large amounts—often a gram per day or more with prolonged use. This significantly increases the risk of bladder damage. If increased tolerance to the effects of ketamine is noticed, a long break from the drug should be taken to avoid needing to use larger amounts.

COGNITIVE PROBLEMS

⦿⦿⦾⦾⦾ (Low risk)

Sporadic use of ketamine is not associated with mental problems and has an antidepressant effect that typically lasts up to a week or two. However, excessively high use of ketamine over time can lead to delusions and sensory disturbances that persist beyond the intoxication, as well as long-term memory problems.

Administration of very high doses of ketamine over an extended period damages the brains of experimental animals, but it is uncertain to what extent the same occurs in humans. With daily use of high doses of ketamine over time, poor cognitive function can be seen long after discontinuation, but function improves with abstinence for a few months. In a study where patients received six high doses of ketamine over 12 days, there was no sign of reduced cognitive function. Patients treated with ketamine for depression typically experience improved cognitive function as a result of reduced depression symptoms.

Individuals with psychotic disorders may experience a stronger dissociative and hallucinogenic effect of ketamine than other users, but it is not documented that ketamine triggers psychoses that last beyond the intoxication. People with bipolar disorder are currently treated with ketamine for depression, but the use of ketamine is discouraged during hypomanic or manic periods, as ketamine can cause temporary worsening of symptoms.

UNWANTED EVENTS

⦿⦿⦿⦿⦾ (High risk)

Dissociative drugs like ketamine can be very disorienting when used in high doses, and it is possible to feel completely "gone" even though one appears awake outwardly. The intoxication also impairs motor skills, and it is common to stagger or not be able to stand up after a large dose. This presents a high risk of accidents when using ketamine in the wrong setting—for example, in traffic, walking in rugged terrain, or while swimming.

A strong ketamine intoxication can also render one unable to react to the surroundings and has been used as a drug to facilitate assaults, theft, and other forms of exploitation. Therefore, as far as possible, avoid using ketamine in high doses with people you do not trust, and always be cautious with the use of ketamine in settings where people might engage in sexual activity.

INTERACTIONS

⦿⦿⦿⦾⦾ (Moderate risk)

Simultaneous use of ketamine with alcohol, GHB, opioids, and some other central depressants can increase the risk of unconsciousness and vomiting, possibly even respiratory arrest if the central depressants are taken in large enough quantities. (Ketamine itself, however, does not act as a central depressant for normally healthy individuals.)

Ketamine is often used to dampen the "comedown" from central stimulants like amphetamine or MDMA. This is probably not particularly dangerous but is discouraged if one has gone a long time without sleep, as ketamine usually prolongs wakefulness and can exacerbate manic tendencies. People with heart problems should not combine ketamine with central stimulants, as this causes increased pulse and blood pressure.

Many also combine ketamine with substances like MDMA or LSD to achieve a psychedelic-dissociative mixed intoxication. Such a combination is apparently not very dangerous but can lead to very intense intoxication experiences. Combination with cannabis is discouraged, as it can cause confusion and anxiety.

Combination with other dissociatives, such as nitrous oxide, can lead to the substances strongly amplifying each other's effects.

Ketamine has relatively few problematic interactions with other medications.

Before taking any drug, it is very important to make sure that the substance you have in front of you really is what you think it is, or what it is claimed to be. By far the safest and best way to do this is through a professional chemical analysis service (such as Energy Control in Spain), but if this is not possible, it is highly recommended to at least use a reagent test kit (such as those offered by DanceSafe in the UK). These are easy-to-use reagents that produce a characteristic color change when they come into contact with a particular drug, allowing users to identify the drug from a table of known color changes. Remember to store the reagents in the fridge and check the expiration date before using them, as expired tests can give misleading color changes.

The Mecke rapid test should be used first. It should react without color with ketamine.

Next, the Liebermann rapid test should be used. This should react with a very faint yellow color.

Then, the Froehde rapid test should be used. This should react without color.

Finally, the Mandelin rapid test should be used. This test (which is yellow to begin with) should normally react with an orange/red color, but other color reactions may occur, such as light green. Therefore, it is important to use all of the mentioned rapid tests.

DOSAGE

A typical recreational dose of ketamine is usually between 20 and 50 mg when snorted, depending on the user's body weight and the desired effect. However, users seeking more hallucinogenic experiences, or those who have developed a tolerance from regular use, often consume larger amounts.

Beware that different individuals can have very different levels of sensitivity to a drug, regardless of prior use. Therefore, first-time users should only take a small dose and observe the effects before possibly taking more.

OVERDOSE

The use of ketamine carries a low acute risk of death. The World Health Organization estimates that a normally healthy person would need to consume more than 11 times the lowest recommended dose for anesthesia to die from ketamine. However, combining ketamine with strong central depressants—such as alcohol, GHB, or opioids—can increase the risk of a fatal overdose if the central depressant is consumed in a large amount.

Used by itself, ketamine does not normally reduce breathing capacity unless the body's adrenaline stores are depleted, for example, in connection with a severe injury. If the body's breathing reflex is so severely weakened by other substances that the user only breathes as long as he/she remains conscious, combining it with ketamine can reduce consciousness enough that the user stops breathing.

FORM

Ketamine is usually obtained as a hydrochloride salt in powder form. It also comes in tablets, but these are often sold as other substances, for example, MDMA or 2C-B.

Occasionally, ketamine is available in liquid injection solution for medical use. Those who use ketamine recreationally will often slowly boil the solution in a pot until the liquid evaporates and only powder remains.

MECHANISM OF ACTION

Like other dissociatives, ketamine is an antagonist at the brain's NMDA receptors, where it blocks the action of the neurotransmitter glutamate. It also has a weak agonist effect at dopamine-D2 and μ-opioid receptors.

Similar to psychedelic substances like LSD and psilocybin, which act on a different system in the brain than ketamine, ketamine reduces the activity in the brain's default mode network and stimulates the formation of new synaptic connections in the hippocampus and prefrontal cortex. These common effects are believed to be the reason why both ketamine and psychedelic substances have an antidepressant effect, despite different mechanisms of action.

With excessive long-term use of ketamine, the brain's NMDA receptors can become upregulated, making the brain overly sensitive to the neurotransmitter glutamate. This leads to an accumulation of calcium in the cells, which can cause cell death.

DURATION

When ketamine is snorted, the main effects typically last from 45 to 90 minutes, depending on the dose.

INTOXICATING EFFECTS

Mild doses of ketamine typically produce an intoxication that is both mildly stimulating and relaxing, not very different from a low blood alcohol level.

Moderate doses cause a more noticeable feeling of dissociation, i.e., being somewhat "disconnected" from the body. Here, one can experience strange, dream-like thoughts not unlike those seen with the use of psychedelics. The body feels numb and motor skills become clumsy. From 40-50 mg and up, the intoxication experience can become surreal and confusing, and it may be difficult to function in social settings.

At high doses, strong dissociation and disorientation are experienced, and at very high doses, one can enter a "near-death" like state—a so-called K-hole—where thoughts become incoherent, time moves extremely slowly, and one is unable to move. This is fundamentally not dangerous as long as one is in a safe environment and can lie down, but people with claustrophobia or a fear of losing control may find the condition very unpleasant and frightening.

SIDE EFFECTS

During intoxication, ketamine can lead to impaired motor control, visual disturbances/double vision, vomiting, and difficulty falling asleep. The numbing effect makes the user less sensitive to touch and can cause difficulties with arousal and orgasm during sex. Larger doses can also numb the tongue and cause slurred speech.

Ketamine typically does not cause much of a hangover, and it is not uncommon to feel light-hearted in the days following use—provided one has gotten enough sleep and has not used other drugs as well.

There is evidence that excessive use of dissociative drugs over time can lead to derealization/depersonalization. This is a condition where one constantly feels "outside" oneself or reality even when not recently using drugs. If this is experienced, one should abstain from all further drug use and contact a doctor.

Ketamine is not considered a narcotic in Norway, but it is a prescription drug in prescription group A.

It is illegal for private individuals to import a prescription drug into Norway by mail. This is stipulated by the Medicines Act § 31, cf. the regulation on the manufacture and import of medicinal products § 3-2 sixth paragraph, and the Medicines Act § 13 fourth paragraph. However, one can legally bring up to one year's supply of a prescription drug from another EEA country—or three months' supply from a non-EEA country—as long as it can be documented that the drug was legally acquired in the country of purchase for personal use, and the drug is not listed as a narcotic in Norway. This follows from § 3-2 first paragraph of the regulation on the manufacture and import of medicinal products.

The sale of medicines, or the production of medicines intended for sale, is punishable without permission from the Ministry of Health and Care Services. This is stipulated by the Medicines Act § 31 cf. §§ 13 and 16, and the regulation on the manufacture and import of medicinal products § 3-2. Production for personal use, however, is not regulated by law. Any transfer (with or without payment) of a prescription drug can also be punished under the Medicines Act § 31 third paragraph if there are "particularly aggravating circumstances." According to Ot. prp. 23 (1983-1984), this depends on the drug's danger and potential for dependency and other circumstances – for example, the amount and whether the drug is transferred to children. It is unclear to what extent this provision affects the transfer of small amounts to adults, and it is very rarely used in practice.

In addition, it is punishable under the Penal Code § 334 (minor receiving of stolen goods) to receive or obtain a small amount of prescription drugs for one's own use if one knows or accepts the possibility that they have been illegally produced, imported, or sold/transferred—or that they stem from another criminal act, e.g., theft/embezzlement.

When dealing with a larger amount of drugs of criminal origin, the Penal Code §§ 332 or 333 (ordinary or gross receiving of stolen goods) may also apply, and one can then also be punished under the Penal Code § 335 (negligent receiving of stolen goods) for receiving or obtaining drugs that one should have understood originated from a criminal act. If one stores drugs of criminal origin for sale, the Penal Code § 332 can likely also apply even if the amount is small.