Harm Reduction, Part Ten: Ketamine Harm Reduction Strategies

Mandelbrot set, from Wikimedia Commons

Since I am now working therapeutically with ketamine prescribed for mental health support, I am often asked for harm reduction tips specifically for those using ketamine recreationally.  

While as a clinician I prioritize the use of ketamine (and other psychedelics) in therapeutic, relational, and spiritual contexts, I am well aware that much use happens outside these formal settings.

 My goal in providing this information is not to promote such use, but to assist you in doing so with the least risk and most benefit, should you choose to do so. Please see my Harm Reduction series for more information about reducing risk and habit change.

So: if your party scene involves Special K, what do you need to know to keep everyone safe as possible? (Here's one top tip: try your best not to combine it with alcohol!)
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Borrowing heavily from Karl Jansen’s excellent book Ketamine: Dreams and Realities (2001), let’s approach specifics for safer use of ketamine through the lens of drug, set, and setting.

DRUG

Ketamine’s short-term safety record in medical settings is significant; Parke-Davis notes that patients have been given 10 times the anesthetic dose without serious problems, and that there are few directly harmful effects of the drug on the body.

Most notably, there is a temporary rise in blood pressure, so those with cardiovascular issues, uncontrolled hypertension, stroke risk factors, or glaucoma would be well-advised to avoid or minimize use.

Transient side effects such as drowsiness and sedation, blurred vision, nausea, and headache tend to resolve within a few hours. (Nausea and risk of vomiting is greatly reduced by using on an empty stomach and by staying relatively still.)

Long-term chronic use can cause a thickening of the bladder and urinary tract, and is associated with developing ulcerative cystitis. Some long-term heavy users (i.e. a gram/day over years) have experienced recurring pelvic pain and had their bladders removed as a result.

To reduce the potential harm on the bladder:

• Most importantly, use LESS (both amount and frequency) and take frequent breaks, as even weekly use can lead to decreased bladder capacity 

• Hydrate aggressively and urinate frequently, as this will keep ketamine’s metabolites moving through your system and less likely to settle in and scar your bladder

• Avoid foods/beverages that are highly acidic (such as coffee, tea, soda--see one diet resource here), as this can further irritate the bladder

• Pay close attention to your urination habits, and watch for symptoms such as increased frequency or urgency, incontinence, blood in the urine, or pain in the pelvis/bladder/urethra

• Seek medical treatment immediately if you develop symptoms, and be honest about your ketamine use

There are also some specific cautions around each route of administration:

Insufflation (snorting):

• This route can eventually damage the lining of the nose and impair the sense of smell, so make sure powders are finely ground, use nasal irrigation products (Neti Pot or saline nasal spray), and give your nose regular breaks
• Disease can be transferred through nasal passages, so use clean paraphernalia each time (ideally not dollar bills!)
• Greater risk of bladder damage; this is a less bioavailable route, so greater amount of the drug is needed, and hence more metabolites in the system

Injecting (IV or IM):

• Needle use carries the risk of hepatitis, HIV, and other infections if you are not using clean equipment, so learn about needle exchange sites and proper sterilization methods
• If you are IV injecting large amounts over a short period of time, this can interrupt breathing for up to a minute; a 2mg/kg dose given as IV can cause a significant fall in blood oxygen for 10 minutes
• When this dose range is given over 90 seconds, breathing is stabilized (though this increases the risk of a self-injector passing out with the needle still in and tourniquet on)

Oral/sublingual (pills or lozenges):

• The effects can start very quickly on an empty stomach (often 10-15 minutes), so don’t take one without proper preparation or when you have to drive
• On a full stomach, it can take over an hour to work, which can lead to taking more than needed
• Oral administration results in more physical side effects that last longer
• As with snorting, there is a greater risk of bladder damage; this is a less bioavailable route, so greater amount of the drug is needed, and hence more metabolites in the system

Since most ketamine-related fatalities are related to combining it with another drug, there are some very important interactions with other substances to consider:

• Taking another sedative (alcohol, benzodiazepines, sleep aids, opiates, barbiturates, GHB) at same time can suppress breathing and airway reflexes; this is the most risky combination as you may lose consciousness completely

 

• ​Benzodiazepines slow the breakdown of ketamine in the liver, and increase problems with memory, attention, and coordination (so if you take one to sleep, you will be more confused the next day)

 

• Amphetamines and other stimulants (cocaine, MDMA) should not be mixed with ketamine, as this combination can cause very high blood pressure and overload your heart

 

• Other psychedelics (psilocybin, LSD) are much more physically safe in combination with ketamine, though this dramatically intensifies the internal experience, which requires careful psychological preparation

Given these interactions, the best strategy may be to deliberately designate different drugs for each occasion and set some limits around this (e.g. “no cocktails on Special K night”), and make sure other drugs are not readily available when you are high.

(On a benefit maximization note, medical practitioners report that using alcohol 48 hours before/after ketamine can wipe out the potential mood-elevating and antidepressant effects. So why not get the very most out of your party drug by using it a little more strategically?)


The final issue around the drug itself is the question of its purity and the reliability of your source​:

• Many more dangerous substances are sold to club-goers who believe they are taking ketamine

• Much of the trouble ketamine causes in recreational environments arise when it is sold as something else (such as MDMA or cocaine), as the effects are quite distinct and require different preparation/settings

If you buy substances in recreational settings, it might be wise to purchase a reliable test kit and test anything before you take it.
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SET

The ketamine experience, like that of other psychedelics, can be greatly shaped by the mindset of the user.

As with all drug use, please evaluate your current well-being, as negative or anxious mood states can be exaggerated and lead to further distress.

Another crucial factor is your general and historical mental health. Ketamine can trigger psychotic symptoms in those with psychotic disorders, and its mood-elevating properties can induce a manic episode for those with  bipolar disorder not controlled by a prescribed mood stabilizer. 

Depersonalization and dissociative symptoms can also occur, especially for those with a dissociative reaction to trauma, so any history with these experiences might mean that this is not the party drug for you.
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SETTING

The real physical dangers of ketamine are often not so much from the drug itself as from the context of its use.
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Its anesthetic properties leave the user much more helpless than most recreational drugs (aside from large doses of alcohol), and that disconnection from the body can be dangerous if not safely reclining.

​(Additionally, as previously mentioned, nausea is limited by being still.)

Difficulty with walking and balance means that in recreational settings, ketamine’s primary physical danger is the risk of falling over and sustaining injury.(Bathrooms are particularly treacherous, given the hard, angular surfaces and risk of drowning.)

Much like with alcohol, this loss of motor control means that you should not drive or operate any heavy equipment. It is similarly dangerous to have anything (such as a cigarette) burning, as this could ignite clothing or bedding while you are dissociated.

Involving your community--especially sober sitters--is protective; most recreational use deaths happened when the person was alone (i.e in the bathtub, up in a tree). The increased vulnerability of the ketamine state also creates a real risk for sexual assault and other harm, which underscores the importance of involving only those that you trust.

Additionally, since ketamine, like other psychedelics, can induce a state of high suggestibility, it is important to carefully consider your choice of music, companions, and environment. Adverse ideas may be implanted and program the dissociated mind in a harmful way.

Sensory sensitivity can be enhanced, tempting you to get up to lower the lights or sound, so the ideal setting for a potentially beautiful experience might be a calm environment with low lighting levels and music at a moderate volume, with people you trust and plenty of comfortable places to recline. (Think soft pillows!)

TOLERANCE AND DEPENDENCE

Unlike other psychedelics, ketamine does not lose its efficacy immediately following use, which can then tempt the user into the “repeated use trap” (so named by infamous psychonaut and ketamine enthusiast John Lilly).

Tolerance builds with frequency, and many feel that much of the drug’s magic is lost with compulsive, uncontrolled use. (Be cautious here; once your relationship with this substance becomes compulsive, it seems impossible to return to that original feeling of magic.) Withdrawal symptoms are primarily psychological, as the urges for ketamine can primarily become about escape from this reality and disconnection from the self.

The treatment of ketamine dependence lies outside the scope of this post, but I would like to close with a particularly potent quote from Jansen’s book about the protective nature of community and ritual:

Psychedelic drugs played an important part in some pre-industrial societies. However, these cultures did not have “drug problems” with psychedelics because the drugs were treated with reverence, and taken in a ritualized, sacred, and socially approved or socially demanded manner, usually under the guidance of a shaman who was both priest and doctor.
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The loss of ritual, which includes basic safety procedures, may be an indicator of problem use... A possible harm minimization step is this to re-establish safety rituals where they have been eroded, if there is no intention of stopping use completely.


Summing it up: what would OPTIMAL recreational use of ketamine look like?

It would be a special occasion with trusted friends, while you are feeling physically and psychologically well, and without any medical contraindications.

Ideally you wouldn't eat or drink anything for a few hours beforehand, drink lots of water and eat light food after you've come down, and hydrate well on the days before and after.

You would test your drugs ahead of time, use clean snorting straws/needles, and not combine it with other substances (especially alcohol).

You would have a comfortable place to recline and enjoy the experience, with appropriate lighting and evocative, beautiful music, and not move around much till the effects have passed. You might also ask someone you trust to stay sober and watch over you.

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As always, I thank you for reading this post, and I welcome your questions and comments!

Disclaimer​: Using ketamine outside a medical setting is prohibited, and this site does not recommend the activities described here. This information is provided for educational purposes only, and to assist those who have already decided to use substances to do so in the safest and most beneficial manner possible. It is your responsibility to assume the risks associated with these activities. Please consult with a medical professional beforehand, especially if you have a preexisting physical or mental/emotional concerns, or are on medication.