Youth Injecting Ketamine

1. Youth Injecting Ketamine Contributing editor and Presenter: Alex Dunlop, counsellor, Toronto Public Health, The Works

2. Overview • What is Ketamine and how is it used? • What are its effects? • Who is injecting it? • What are the risks? • Harm Reduction • Peer Education • Future Challenges

3. What Is Ketamine? Common & Street Names: Ketamine; K; Special K; Cat Valium Effects Classification Dissociative Anaesthetic; Psychedelic Chemical Name 2-(2-chlorophenyl)-2(methylamino)-cyclohexanone Description Ketamine is a dissociative psychedelic, used medically as a veterinary and human anaesthetic. It is one of the few dependence forming psychedelics

4. History • Ketamine was invented in 1961 by scientists looking for a dissociative anasthetic with fewer mental side effects than PCP (phencylidine) • Ketamine was used during the Viet Nam war in the field • Ketamine is still used on children, and asthmatics. It is considered safe and reliable as it does not cause respiratory depression or low blood pressure. It is not commonly used because of psychedelic effects • Ketamine is a common veterinary anaesthetic

5. How is Ketamine Used Recreationally? • Ketamine is most often snorted or bumped(intranasal) or injected intravenously or intramuscularly • Street Ketamine is usually purchased in powder form

6. How is Ketamine used? cont’d • The typical dose for ketamine is between 15mg and 125 mg for intranasal and between 50mg and 100mg for injection • For injection, Ketamine is diluted in 60-70 mL of water and heated until dissolved • Effects are felt within 5 minutes of snorting, within 1-3 minutes of IM injection, and within 30 seconds of IV injection

7. How is Ketamine Used? Cont’d • A fatal dose (LD50) is 5g, although fatal overdose can occur at lower doses, especially when other sedatives (downers) are used, such as alcohol or opiates

8. The Ketamine “High” • At lower (sub-anaesthetic) doses, users describe a floating feeling with some changes in time perception and mild sensory hallucinations • At higher doses, users enter k-hole which is a barely conscious dream-like state. Users feel “out-of-body” and experience mystical or spiritual insights and more hallucinations

9. “K-Hole” • K-hole is the intended outcome of injection ketamine use • Users are semi or unconscious and unresponsive, eyes may be open, glazed over, and staring into space, pupils dilated • Body may still be in motion but without conscious or protective reflexes

10. “K-Hole” cont’d • Users experience mystical or spiritual insights • Experience accompanied by amnesia

11. Who is using Ketamine? • Recreational ketamine use began with the dance/rave music culture scene in the 80’s and 90’s and became a “club-drug” • Used by youth in various settings

12. Who is using Ketamine? Cont’d. • Street involved or seasonally homeless youth have been experimenting with ketamine experiences in Toronto and other urban centres • Highschool students have been experimenting with ketamine due to less stigma attached to IM injection • Opiate users have found using ketamine helps regulate opiate tolerance, although ketamine users often switch to opiates to avoid ketamine side-effects

13. Immediate Risks of Ketamine Use • Can produce racing heart and breathing difficulties (apnea) • Nausea/vomitting • Involuntary movements causing injury, sometimes seizures • At risk of being robbed, or assaulted while in vulnerable states

14. Immediate Risks cont’d • Ketamine may be “cut” (adulterated) with undesirable substances • Youth are inexperienced drug users and may lack knowledge of injection drug use safety techniques • Mixing with other drugs or too large a dose can cause negative experience

15. Long-term Effects • Amnesia • Paranoia and delusional thoughts or “exotic brain states” involving alternate plains of reality • Dependence • K-pains • Bladder damage

16. K-pains • After frequent heavy use, users may experience severe pains in abdomen and chest • Medical tests are not diagnostic, pain may have to do with sensitive pain receptors after withdrawal or other physical effects of ketamine • May last for days or longer • Users may turn to opiates to help manage pain and curb use

17. Ketamine Bladder Syndrome • Chronic ketamine use can cause irritation, ulceration and scarring and shrinking of the bladder causing long term pain and incontinence • This condition is misdiagnosed as a urinary tract infection by health care providers • Treatment is temporary and expensive or unpleasant

18. Harm Reduction for Ketamine • Start with a small dose and see how it affects you • Always make sure you are in a safe and comfortable place before you inject ketamine ie. Lying or sitting down away from potential hazards in a safe environmnt • Have a “trip sitter” on hand: an experienced peer who is not using at the same time

19. Harm Reduction for Ketamine cont’d • Avoid eating for at least 90 minutes before use (ketamine suppresses gag reflex) • Teach safe IM and IV injection safety techniques • Provide ketamine specific kits with appropriate information and harm reduction materials for injection • Work with peer educators on outreach and education

20. Harm Reduction for Ketamine • Educate potential and current users on the effects and potential for complications • Avoid chronic daily use • Find supportive health care professionals for referral • Educate health care providers • Provide support for users who are struggling to reduce use

21. IM Deltoid Injection

22. Intra-muscular Injection- Deltoid • To find this site you will form an imaginary box on the upper arm. Find the knobby top of the arm (acromion process). Measure 2 fingers down from here. • Draw an imaginary horizontal line. This is the top border of the box. • The bottom border is an imaginary line running from the crease of the armpit, from front to back.

23. IM Injection Tips _Deltoid • To make the two side borders, divide the arm into three equal sections, from front to back. • The injection site is in the center of the middle third. • Rub alcohol swab in one direction over this area • Stretch the skin and then bunch up the muscle.

24. IM Injection - Deltoid • Insert the 1 inch or 5/8th inch needle at a right angle to your skin. (90 degrees). • Insert needle all the way. • Draw back slightly on the plunger to make sure you are not getting blood and using a vein. • Our nurse can show you how.

25. Peer based outreach/education • Recruit and partner with youth who have experience using ketamine • Meet regularly. Value experience. • Identify questions and find answers • Teach harm reduction • Empower peers by strengthening skills and knowledge. • Develop peer endorsed outreach materials

26. Peer based outreach/education • Advocate and inform other youth focused communities and service providers • Be youth friendly and approachable • Respect youth!!! Listen and learn!

27. Examples of peer involvement • Toronto Raver Information Project* partnered with the Works to develop educational material on injection ketamine • Youth led peer group to develop outreach materials that are youth friendly. • Youth opinions sought on supplies given out by The Works

28. Ongoing Challenges • Youth are transient and hard to locate • Trust issues, often hesitant to talk about their drug use • Needle exchanges are geared toward and older population • Medical professionals judge drug users

29. Ongoing Challenges • Schools and youth services are often resistant to harm reduction messages • Many youth do not think of IM injection as “injection drug use”

30. References • Many thanks to Jeff, Andrew, Lisa and Tasha for their knowledge, experience and ideas • Thanks to Karen Parrott R.N for her contributing research • Toronto Raver Information Project (T.R.I.P.) www.tripproject.ca • The Vaults of Erowid www.erowid.org

31. References Cont’d • www.ketamine.com • www.lycaeum.org • www.rxlist.com/ketamine • Dance Safe www.dancesafe.org