Restricting ketamine would have 'dire consequences' for surgery in low-resource countries, anesthesiologists warn

Drs. Girish P. Joshi of University of Texas Southwestern Medical Center, Dallas, and Bisola Onajin-Obembe of University of Port Harcourt Teaching Hospital, Rivers State, Nigeria, highlight the critical importance of ketamine for anesthesia in low-resource healthcare settings. "If ketamine is placed on the Schedule I list, it will not be available in the LMICs, resulting in dire consequences" for surgery in those countries, the authors write.

Commentaries Highlight Ketamine's Importance in Developing World

Used for more than 50 years, ketamine is a potent anesthetic and analgesic drug that has some major advantages for use in resource-poor environments. Ketamine can be given by several different routes of injection and used in a wide range of surgical procedures. "It is inexpensive and easily available, and unlike modern anesthetic techniques such as inhaled anesthesia, it requires minimal equipment and training," Drs. Joshi and Onajin-Obembe write.

Ketamine can be used in settings where modern anesthesia machines and equipment are rate or nonexistent. "Therefore, in many LMICs, ketamine is the sole anesthetic," according to the authors. They note that ketamine is also an important option in responding to crisis and disaster situations.

So why are efforts being made to restrict access? Ketamine is also used recreationally as a "party drug." Sometimes called "Special K" by users, recreational ketamine has a number of potentially serious harmful effects and the potential for physical dependence. Illegal ketamine use is a major problem in China, which in 2014 called for ketamine to be classified as a Schedule I medication.

But the Schedule I designation is typically reserved for drugs considered to have limited or no medical use -- which is not the case for ketamine, Drs. Joshi and Onajin-Obembe argue. 'Scheduling' ketamine -- that is, placing it in the Schedule I list -- "would restrict essential surgery for populations in the world that have no other alternatives," the authors write. In those countries, loss of ketamine would essentially eliminate the ability to perform any type of major surgery requiring general anesthesia.

An accompanying editorial by Drs. James E. Cottrell and John Hartung of SUNY Downstate Medical Center, Brooklyn, states: "The problem of ketamine use among drug addicts, serious as it is, remains smaller than the benefits ketamine bestows on millions of patients who need surgery in locations where ketamine is the only general anesthetic available."

Fortunately, based on recommendations from the World Health Organization and others, the United Nations Commission on Narcotic Drugs decided not to make ketamine a Schedule I drug. But Drs. Joshi and Onajin-Obembe remain wary of future proposals to restrict its availability. They write, "Thus, it is necessary to remain vigilant in case of future efforts to schedule ketamine."

Dr. Marcel E. Durieux of University of Virginia, Charlottesville, discusses the controversy over ketamine in light of the "uneasy relationship" between high- and lower-resource countries in terms of disparities in medical capabilities, equipment, and medications. He writes, "China's problematic proposal requesting that ketamine be listed on Schedule I is only an excessive example of what still happens on an almost daily basis: the needs of LMICs are not adequately considered."