Frank Bures: What is ketamine?

August 5, 2018

Dr. Frank Bures

A recent controversy about use of an injectable drug called ketamine by paramedics in emergency ambulance cases at Hennepin County hospital involving police has been reported. According to several articles from the Minneapolis Star-Tribune some “paramedics and civil rights investigators have independently expressed concern that Minneapolis police officers urged medical responders to use it to subdue members of the public when responding to difficult calls” (6/17/18).

“Dr. William Heegaard, chief medical officer for Hennepin Healthcare (formerly HCMC), said that ketamine can save lives when dealing with those showing signs of ‘excited delirium’ a condition in which the person is severely agitated and aggressive. ... It is a medication that is complex. It can be abused, and unfortunately that happens with almost all medications.”

The president of the American Society of Anesthesiologists said, “Outside the clinic, ketamine can cause tragedies, but in the right hands, it is a miracle.”

So, what is ketamine? It is labeled a dissociative anesthetic. Huh? It is mainly used in humans to start and maintain anesthesia, along with a tricky cocktail of IV and inhaled anesthetics. It induces a trance-like state and provides pain relief, sedation and temporary memory loss. It takes effect in about five minutes. Compared to many other anesthetics, heart function, breathing and airways reflexes remain functional and not depressed. When coming out of it, the side effects can be problematic, with confusion, agitation, and hallucinations among others.

It was derived in 1962 from the known drug phencyclidine (fen-Sigh-kla-deen), another dissociative anesthetic we know better as PCP, a drug highly abused for hallucinatory qualities. PCP was created in 1926 as an anesthetic, but had too many dissociative results to be used. Ketamine was patented in Belgium in 1963 for veterinary use. It was tried in humans in 1964, and approved as an official human anesthetic in 1970. Because it doesn’t require support for heart or breathing suppression, it became commonly used for field surgeries in Vietnam. It is commonly used in veterinary surgeries.

Ketamine is in the class of NMDA (N-methyl-D-aspartate) receptor antagonists or dissociative anesthetics. The first one ever synthesized was nitrous oxide in 1772, aka laughing gas. It became an “abused drug” in our terms because laughing gas parties were organized primarily for the British upper class. Its anesthetic use came in 1844. Some others include dextromethorphan (DXM) used in cough remedies, and methoxetamine (MXE).

They all can cause “out of body” feelings at higher doses, especially ketamine, called the “K hole”. They have been used/abused recreationally, including DXM at really high doses. Ketamine is often stolen from veterinary places as the injectable and evaporated into a powder, which can be used by various routes. Ketamine has several street drug names, like Special K, K, cat Valium, jet, super green, etc. The drug abuse tale is too long to tell here.

Most of these drugs effects, beneficial vs. detrimental, are dose related. More recently, ketamine at sub-anesthetic doses has been found to treat some very difficult major depression and manic-depressive/bi-polar diseases. Some testimonials make it sound like a miracle. It was first found in 2000, but only now has gained recognition as worthy of study. Its effects become evident in a couple days vs. most anti-depressant medicines, which take weeks. For some patients nothing but ketamine has worked and given them back their lives.

This very brief summary of an incredibly complex, incompletely understood chemical with a background both positive and negative per its purpose and use, may give a tiny perspective to the quandary of its use in emergency medicine. If you read the reports of the Hennepin County controversy, remember the Minneapolis issues are about ethical boundaries, not medical.

I’ll resort to my standard remedy for legally getting “good” feeling from a drug: poppyseed packed pastries, especially Czech ones called kolaches. Eating one can turn your heroin test positive for hours but isn’t really mind altering — it just tastes good. And the only real side effect is, if you consume enough, it will make your sides — and backside — swell (side effect, heh, heh).

But that can happen with chocolate, too.

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