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3/7 Scheduling - The case of ketamine

  • Benjamin-Alexandre Jeanroy
  • Apr 29, 2016
  • 14 min read

In 2012, the WHO Expert Committee on Drug Dependence (ECDD) published a technical report, stating that “concerns were raised that if ketamine were placed under international control, this would adversely affect its availability and accessibility. This in turn would limit access to essential and emergency surgery, which would constitute a public health crisis in countries where no affordable alternative anaesthetic is available.” (WHO, 2012) Despite this and earlier recommendations (1), a growing tension among the U.N. member states is arguably building around ketamine - a substance originally used as a veterinary tranquilizer.

On one side, we have actors wishing “to secure adequate availability for its essential medical purposes” (TNI, 2014), on the other, we find countries, notably China and Southeast Asian countries, that are arguing for the placing of ketamine among internationally scheduled substances in the face of an expanding illicit market for recreational use. This has lead to complex policy dilemmas evolving around heterogenous and competitive views on the matter.

According to the U.N. drug control conventions, the WHO’s assessments of a specific substance shall be “determinative as to medical and scientific matters”. (WHO, 2015b) The way the WHO is making its decisions is shown in the graph here bellow.

In a 2007 CND session where the scheduling of dronabinol was heavily debated, several member states delegations openly questioned the validity and the scientific basis of the WHO recommendations (which advised against scheduling of the substance) (IDPC, 2007). However, such critics are explicitly forbidden by both the 1961 and 1971 Conventions, which clearly state that national governments should accept, in good faith, the scientific recommendations of the World Health Organization (UN Convention, 1973, p. 90). In regards to ketamine, the WHO recommendations were similarly strongly criticized during the 2014 57th CND Session, in “flagrant transgression” (TNI, 2014a) of the IDCR conventions (UN Convention, 1973a, p. 69).

Again in 2015, and for the fourth time since 2006, the WHO “recommended that ketamine should not be placed under international control after review of the latest evidence by the WHO Expert Committee on Drug Dependence.” (2) (WHO, 2015b) In this regard, if we ought to understand why the debate surrounding this substance is perduring, we must realize that in practice the WHO recommendations are often of little consequences when a country and the IDCR institutions have decided that a substance must be scheduled (other would say prohibited). Today, the ketamine case clearly shows “both the marginalisation of the WHO and the 'mission creep' of the INCB, and arguably the CND, in relation to their mandates.” (TNI, 2014a) This is not anecdotal and arguably shows that the entire current IDCR scheduling process is not necessarily based on scientific review, but often on cultural and ideological reasons. So let’s rewind a bit to try to see clearer: what exactly is ketamine?

What is ketamine ?

UNODC explains that “ketamine was synthesised as an anaesthetic and marketed as a medical alternative to phencyclidine in the early 1970s.” (UNODC, 2015c) Consequently, although, primarily used by veterinarians, the WHO has in the past, scheduled ketamine as an “essential medicine”, recognizing its wide use around the world as a safe and easily available anesthetic. The crucial importance of the product is explained by a TNI report (2014): “the correct administration of ketamine requires less medical expertise and technical equipment than is required for anaesthesia with, for example, gases such as halothane. While respiratory and heart rate control and other safeguards are essential for the patient’s safety when other types of anaesthesia are used, in the case of ketamine a simple injection is sufficient. In many areas of rural Africa and Asia billions of people therefore depend on the availability of ketamine when requiring surgery.”

, the substance can also be used recreationally. When consumed it can “produce immobility and an intense hallucinogenic experience.” (UNODC, 2013a) If the medical form of the substance is “most commonly an injectable liquid, for recreational purposes it is usually dehydrated to a white powder suitable for snorting or swallowing. It has also become widely used in tablets mixed with caffeine, (pseudo)ephedrine, (meth)amphetamine and/or MDMA.” (TNI, 2014) Known on the streets as “Special K”, “Vitamin K” or simply “K”, the substance is particularly appreciated by dance club aficionados and can allow the vision to take a goofy-like, insufflated tune upon which rhythms and shed of lights can take a whole new meaning. Inner-space explorers have for decades developed a taste for the substance which can allow “uncanny and cosmic out-of-body experiences.” (Davis, 2012) Additionally

(3). Several countries have argued that the product can lead to crime and violence. But it could be argued that only someone which has never tasted the substance could put forward that this product can serve for crime and malignant actions. Criminals using the drug to commit their forfeit would make the easiest target for law enforcement, as the sole function of standing would become increasingly difficult, let alone seeing and acting in an efficient manner

Southeast Asia and China situations

Because it is produced legally, substantive amount of the product is effectively diverted for recreational use towards consumers countries - such as China. As reported by journalist Robert Hunwick (2013), in “The Great K-Hole of China”, “ketamine, together with substances like ‘ice’ and ecstasy, became a very popular party drug in southern China and Hong Kong in the early 2000s, where it is known as K’ or ‘K fen’ or ‘king’. Indeed, the country, with its vast consumer markets has become “arguably the epicenter of global ketamine consumption and production.” (Ibid.) UNODC (2015c).reports that between 2006 and 2010, “an average of 5.4 mt of ketamine has been seized in China annually.” (Drug Abuse Information Network for Asia and the Pacific - DAINAP). Similarly, the substance is also widely popular in other countries in the region since the 1980’s and 1990’s.

As it became increasingly used for recreational purposes, notably in Hong-Kong (4), China has in the past years tightened its control on the substance supply. Consequently, traffickers began to find the active ingredients necessary to ketamine production elsewhere, notably in Southern India, via a Southeast Asian trade road. However, as reported by UNODC, traffickers recently again began to find the necessary precursors in China, “this time sourcing from clandestine laboratories and making low-volume yet high-frequency shipments.” (ADEC Hong Kong, 2011) In 2009, the China National Narcotics Control Commission declared that “nearly 9 mt of the primary precursor for ketamine (hydroxylamine hydrochloride) had been seized in the country.” (NNCC, 2011)

In the Southeast Asian region, ketamine is also used for recreational purposes in Malaysia (ADEC, Malaysia 2010), Vietnam (mainly along the Sino border) and to a lesser degree, in Manila, Singapore, Taiwan and Thailand (5). “Most of this supply comes from India, particularly Chennai in southern India” (HONLAP Thailand, 2010), notably through “commercial flights and sea routes by Indian nationals.” (ADEC Malaysia, 2010) The product is usually transferred to Bangkok, and “then further trafficked overland by commercial bus into Malaysia” (Ibid.), and by boat to Taiwan and Hong-Kong, with some smaller quantities trafficked onward to Singapore.

In China, penalty for drug trafficking remain severe and often include the use of the capital punishment. Furthermore, as in many parts of the world, addiction is seen as a personal and familial failure. Perceived “addicts” are highly stigmatized and their medical treatment is not considered as a priority by the public nor by the government (6). Official registration of “drug addict” amount to 2.5 million individuals (Foreign Policy, 2015) with a steady increase since the first national yearly report on the topic in 1998. Previously dominated by heroine, China's consumers market has witnessed a rise in synthetic drugs, in particular crystal methamphetamine and ketamine, partly due to the massive crackdown on heroine users orchestrated by the country during the 1990’s as-well as the effective forced eradication of illegal opium cultivation. Methamphetamine and heroine found in China are mostly produced in Myanmar (7). The ketamine market finds itself in a different configuration as the product is not prohibited under international scheduling, which explains the continuous institutional push by China to change this state of affair.

Map 6 and Figure 17 Source: UNODC, 2015c.

The institutional push

it did not recommend ketamine for scheduling under the UN Conventions(8).” (TNI, 2014) But the INCB, and the CND, supported by some countries, arguably decided not to accept the recommendation of the Committee and kept calling for move towards a tighter control of the product, notably through the INCB annual report (INCB, 2014, p. 70 & 86) and CND resolutions . As a result, the WHO was requested, again by China, to evaluate the substance and to present their result at the 36th ECDD meeting in June 2014. One again, the WHO resisted and maintained its stance not to place the substance under international scheduling.In 2013 and 2014, the WHO Expert Committee on Drug Dependence (ECDD) evaluated ketamine during its 34th and 35th Sessions. On both occasion, the Committee assessed that “

a substance that has a closely related chemical structure to the internationally controlled substance phencyclidine, listed in Schedule II of the 1971 Convention on Psychotropic Substances.” (UNODC, 2015c) Therefore the substance should be treated similarly.The CND and the INCB are not the only two International Drug Control Regime (IDCR) agencies intending to support China’s request. In an effort to give credibility to the push for international scheduling, UNODC in their 2015 “The Challenge of Synthetic Drugs in East and South-East Asia and Oceania” Report, noted that ketamine is “

On March 13th, 2015, the possibility to place ketamine under international control came back to the CND table. China initially intended to place the substance under Schedule I of the 1971 Convention, the most restrictive placement possible for synthetic substances. In an effort targeting undecided countries, “China amended its proposal to the less strict Schedule IV of the same convention.” (IDPC, 2015) Ultimately, pacing the Commission institutional necessity for consensus and strong opposition, China retracted its proposal under the pretext of the need to collect more data. The CND (9), in a somehow expected similar move, “then decided to postpone its decision on scheduling ketamine to a future date to allow more information to be gathered.” (IDPC, 2015)

It must be noted that in support to the WHO firm decision, civil society organizations were actively engaged, to the most of their institutional capacities and of the limits of the CND functioning, against the push from China to prohibit ketamine. The related IDPC (2015) fact sheet notably received 87 personal endorsements from national representatives and several other NGO’s actively and the organizations were able to successfully lobby delegates against the prohibitionist Chinese and CND move. As for now.

What is striking in this very case, is that countries pushing for international control over ketamine have already added the substance to their respective classification systems (10). For this reason, it could be argued that placing this product under international regulation, for example under Schedule I, or even Schedule IV of the 1971 UN Convention as China had proposed (UNODC, 2014e), would not significantly change their domestic respective configuration, particularly since legal production in these countries is still nationally based. In other regions such as sub-Saharan Africa and Central Asia, where few countries have placed the substance under control schedule, the result could be drastically different and have dreadful consequences. As noted by the 2014 TNI report, “in contrast to India or China, where local pharmaceutical companies produce ketamine in large quantities, most African countries depend on imports that would become subjected to treaty restrictions and mandatory rigours of procurement.” (TNI, 2014) U.N. scheduling could thus force most non-prohibitive countries to adapt national legislation by placing ketamine under restriction. Many have predict that such move, could seriously damage the medical availability of the substance for surgery “despite the fact that they do not experience any local problems with misuse or diversion.” (TNI, 2014)

Today, more than 50 countries worldwide have scheduled ketamine in their national registration system (IDPC, 2015). In these countries, medical practitioners, are already experiencing shortage of the product for their medical operations. As one of the duty of the IDCR is theoretically to ensure the availability for all of illicit drugs for medical and scientific purposes, U.N. agencies, member states and civil organization should keep pushing the call to the international community to uphold to this legally binding promise.

Perhaps because of the very push from China and the CND, and of the 2016 U.N. Special Session on illicit drugs, observers argue that the climate is slowly changing. Indeed, “after some of the preparatory meetings, someone mentioned that this was the first time ever that the countries at the CND discussed medicines availability for over three hours. Never before there was such a focus at the international level on the relation between drug control and medicines availability. Therefore, this is the moment that most drug controllers around the world are seeing that drug control has also the negative side for public health of medicines unavailability.” (IDPC, 2015) What is shown here is the very fact that once placed under international scheduling, a substance becomes increasingly hard to be used for medical and scientific purposes, despite the very objective of the IDCR to ensure the availability of these substances in such cases. Reality on the ground is showing that the regime is not upholding its very objectives.

But the crucially needed anesthetic effects of the substance are potentially not the only medical application of the drug. Studies carried out at the University of Yale and published in October 2012 in the journal Science, have confirmed precedent reports showing that ketamine “offers remarkable, nearly instantaneous relief for people who suffer from forms of major depression impervious to other treatment methods." (11) Several journalistic reports also linked this Yale research with the recent development of a new form of antidepressants, such as Naurex’s GLYX-13 (12) (Schwartz, 2015). As such, rarely, has scientific research on “neuro-reductionism been so naked in its repackaging of human experience.” (Davis, 2012) Researches do not suggest that heavily depressed people feel better because they go on a ketamine trip, but merely that the mind has the capacity to potentially heal itself because of its connexion created by the substance which can allow “mind-bending modes of transpersonal consciousness whose subjective power might itself boot the mind out of its most mirthless ruts.” (Ibid.)

Subject to political and ideological pressures, the IDCR scheduling system is currently under closer scrutiny, despite the rather` inconclusive UNGASS 2016 on the matter. If it was not for the WHO strong and arguably admirable resistance, and the energetic and successful work of several NGOs, the drug could be today placed under tight scheduling, with important negative consequences for populations all over the world. Other substances, because they have been scheduled during the draft of the conventions or before civil society had become sufficiently and efficiently organized, are today prohibited, under non-scientific reasons, and so with dreadful consequences. This problematic lies at the core of the current IDCR. One substance, however, did not suffer this fate and has been widely abused, with dramatic impact on the health of the world population. Let us discuss the case of tobacco in the next article.

(1) Already in 2006, the WHO noted that “reports of such dependence in humans are very limited.” (WHO, 2006) Again, in 2007, “the WHO representative at the CND was “astonished” that the Board had called on states to place ketamine under national drug control legislation, urging countries to ignore it.” (TNI, 2014).

(2) The Committee concluded that “ketamine abuse does not pose a global public health threat, while controlling it could limit access to the only anaesthetic and pain killer available in large areas of the developing world.” (WHO, 2015b)

(3) “Though ketamine is not terribly different in either structure or effects from the notoriously violent street drug phencyclidine, or PCP, the cultural profiles of the two substances are worlds apart — a distance that some observers suggest has more to do with class and social context than with strict psychopharmacology.” (Davis, 2012)

(4) Mostly use in low-dose in the Hong-Kong night club scene, UNODC reports that “ketamine users accounted for some 38% of all registered drug users in Hong Kong in 2010. Among registered drug users below the age of 21, ketamine users comprised 84%.” (China, 2011)

(5) In Thailand, it is know as ‘ya-K’ in reference to the famous Ya-Ba methamphetamine which we will discuss in length in later articles.

(6) “Drug treatment is mostly administered by the criminal justice system through enrolment in compulsory detoxification centers for first-timers and imprisonment in “education-through-labor” camps for repeat offenders”. However, as we will see in the China section of Chapter 2, it must be noted that, “more humane approaches are emerging. Methadone maintenance therapy (MMT) clinics have been increasing rapidly across the country and needle exchange programs are being used to prevent the spread of HIV.” (Foreign Policy, 2015)

(7) “Myanmar is believed to be the single largest supplier of China’s drug market. In 2013, 92.2 percent of the heroin and 95.2 percent of methamphetamine seized in China were traced to Myanmar.” (Foreign Policy, 2015)

(8) “At the 2014 CND session another resolution was tabled, this time by Thailand (most likely at the instigation of China and the INCB via the Thai Board member), noting that 48 countries had introduced national controls and that placing ketamine under international control should be considered, and asking WHO to reconsider once again its advice against it.” (TNI,2014)

(9) A transcript of the CND debate is available here: IDPC, 2015j

(10) To date in March 2016, six countries in Asia had internally scheduled ketamine: China, India, Malaysia, Singapore, Taiwan and Thailand.

(11) The studies interpret depression “as a hardware problem largely caused by the loss of synaptic connections” (Davis, 2012). In other words, researchers argue that ketamine can work “by encouraging sprightly neural growth in brain regions correlated with memory and mood.” (Davis, 2012)

(12) This new vein of antidepressants have supposedly the neurone-fertilising power of ketamine without, as one report describes them, the “schizophrenia-like effects.” (Schwartz, 2015)


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