Ketamine Episode 3_Response and Harm Reduction

Welcome to Frontline where we are taking a balanced and informed look at Ketamine use and this new four-part podcast series. In part three we'll be exploring how we can respond to ketamine and how we can take a harm reduction approach for those who are actively using. , according to the Office for National Statistics, Ketamine related deaths in England and Wales have been increasing in recent years. Between 2018 and 2023 the number of deaths where ketamine was mentioned on the deaths certificate rose from 21 in 2019 to 37 in 2023. However it's important to note that despite this increase ketamine related deaths remain relatively low when compared to other substances. For instance in 2023 there are 5,448 deaths related to drug poisoning in England and Wales. Ketamine related deaths therefore accounted for approximately 0.68% of the total drug poisoning deaths in England and Wales in 2023. The rise in ketamine related deaths aligns with an increase in its recreational use. In 2023 alone approximately 299,000 individuals in England and Wales reported using ketamine, the highest number on record. This is Jo Moore, the registered manager at the Birchwood at Kaleidoscope House. And also there's the people that aren't getting to us, the people that have sadly passed away who haven't had that support in the community, haven't had the GP awareness. They've attended A&E with their family members and the GPs, the doctors in the hospitals haven't had any idea about ketamine. So they're turned away and that's when it's too late. So we're also working with the parents that have lost their children to set up a family support group to enable people to have somewhere to go where they can gain that support and that information that they need to keep people safe. So despite the harms mentioned in previous episodes most people will not experience the negative effects of ketamine and taking a harm reduction approach with people that use the drug is key. Firstly, consider how it feels when you tell what to do. Signs tell us not to do something can stir up a deep rebellious attitude within us. When this happens we're experiencing a concept known as reactance theory. This is a psychological theory that explains how people react when they perceive their freedom of choice is threatened. The theory suggests that people are motivated to restore their freedom and may do the opposite of what they are pressured to do. If we apply this approach to drug and alcohol use you can therefore see how people might respond negatively if told not to use or that drugs are bad. So what is harm reduction? At its core it's a practical evidence-based approach that focuses on reducing harm rather than punishing drug use. But where did it all begin? It can be traced back as early as the 1920s. Some of the first harm reduction ideas came from public health responses to alcohol such as during prohibition in the US when alcohol was banned for a period of time. The 1950s and 60s are the first trial of opiate substitute prescribing programs where methadone was used to help people with their opioid addictions. However the modern movement truly began in the 1970s and 80s. The Netherlands and the UK led the way. Introducing needle exchange programs to reduce the spread of infections. The need for this approach was increased by the HIV/AIDS crisis in the 1980s. This made harm reduction a global necessity to reduce the spread of something that people did not know much about and could also help to reduce the stigma and shame from those struggling with HIV and AIDS related challenges. The 1990s and 2000s saw harm reduction going global. Countries like Portugal decriminalised drug possession and focused on health-based interventions instead of criminal penalties. It leaned to fewer overdoses and HIV cases. Harm reduction has now gone beyond drugs. It's used in alcohol policy, mental health services and even led to the development of e-cigarettes vaping as alternatives to smoking cigarettes. Further approaches seen in the 21st century includes rapid testing strips for newer substances, naloxone distribution for those using opioids and drug checking services. All of these continue to evolve in response to changing drug trends. Remember, harm reduction is not about enabling drug use. It's about keeping people safe, reducing risks and offering support without judgement. It's an approach that saved lives for decades and continues to adapt to new challenges such as ketamine use. This is Peter Furlong, the National Harm Reduction Lead for Change Grow Live. Some core harm reduction stuff about, you know, trying not to mix it with other drugs, especially alcohol or cocaine, depressants and stimulants, you know, it's going to be, it's going to magnify the risks that you're facing anyway. I think the problem with ketamine is if people are just using it on its own, they sort of feel that it's hangover free. So it's giving people education and information that whilst you might feel the next day, these any come down off, your body is dealing with it very differently and if it merges from occasional use into more regular use, that's when we've got to sort of, given those key messages out, really. As I said earlier, I think, you know, the majority of drugs, if people use them occasionally, a few times a month, ketamine probably won't be an issue for people, but I think what I'd say to other professionals is trying to understand the way it's changed in its use because back in the day, a little bit when it was a club drug, it didn't really present us that much of an issue because it was occasional use, whereas now if people are using it to self Medicaid, to chill out, to party with their close group of friends or just behind closed doors overnight, that's where that we've got to think of tailored and our hand-reduction advice to meet the youth, really. I think, I mean, it's going back to the good old-fashioned core advice about, you know, what is it people are using, how they're using it, drug setting, setting. This is an idea developed by Zimberg in 1984. It's the idea that the effect of a substance isn't just about the drug itself, they're shaped by three key factors. Set, setting and the drug. First, there's set. This is all about the individual, your mindset, your body, your personal history. Things like your mental health, physical health, genetics, how much sleep you've had, what you've eaten that day, any medications you've taken, can all influence how ketamine affects you. Even you move before taking it plays a role. If you feel anxious, stressed or down, for example, that can change the experience entirely. Next, this setting. This is the environment where ketamine is used. Are you with trusted friends? Are you in a risky or unfamiliar place? Are there potential hazards, like open water, busy roads or lack of access to medical help? Finally, there's the drug itself. This includes what's actually being taken and there's no guarantees that a person will be taking just ketamine. It also includes how much you use, how potent or pure it is and how it's consumed. Is it used alongside alcohol, medication or other substances? Even small changes in these factors can dramatically alter the risks and effects. What's important about this framework is that it reminds us that drug-related harm isn't just about the drug. Two people taking the same substance might have completely different experiences depending on their set, the setting and the drug itself. This is John Moore, the registered manager at the Birchwood at Kaleidoscope House. I suppose from a harm reduction point of view, it's teaching the service user to not mix their drugs. It's teaching them to be able to crush the powder really finely so that they're not having those complications from an ENT perspective. Never ever go and use a bath or shower after you've used drink or drugs. There's an increase in people passing away due to people having drugs and using a bath. We say use naloxone and testing kits. So go to drug and alcohol service. If you want to use ketamine, allow it to take effect. Don't use too much, go little and often. Test your drugs. You know, you've got wedinos, you've got the testing kits and the community services. Wedinos is a harm reduction project providing anonymous and free testing service. It also reflects trends in substance use. More information can be found at wedinos.org. And use where other people are. So don't use the drugs alone. Tell somebody what you're doing that you can confide in and they're aware of where you are at that point in time and then be aware of the naloxone kits. So we know that these batches can be mixed with all sorts of synthetic opioids. Some might be mixed with heroin, fentanyl, nitrosine, and it's about being able to understand the kit. You might have a nasal kit, you might have an IM kit and be able to use that and read the pamphlets that come with them so that you are aware so you can help somebody else. Teach your family. You know, teach your friends if you're going to use with somebody else. Understand how you can reverse that opioid issue. And it's always better to use it if you're not sure and somebody becomes sedated or unconscious. You need to obviously ring 999 but you also need to start CPR and give that naloxone. This is Lisa Buckley, the National Lead for Detox and Rehab with CGL. I think firstly it's about asking the person what they want really. And hopefully you've developed that relationship where trust, you're in a place where people feel able to trust. Not being afraid to ask a question as well. If you think something's going on or you're struggling to engage with somebody, because that's going to be regardless of who you work for. If somebody is using ketamine and a chronically incontinence and they're struggling to engage with a housing worker or a mental health worker, again it's about meeting people where they're at, adding flexibility into your appointments so you can go on a home visit or you can call them rather than expecting them to come and see you because that might be the first point of contact that then leads into a referral into a drug and alcohol service. So flexibility, openness and building that trust. Why is taking a harm reduction approach so important? When it comes to ketamine use a strict just don't do it approach just doesn't work. In fact it can sometimes do more harm than good. If professionals or even friends and family dismiss someone's ketamine use or simply tell them to stop, it can create shame and stigma. And when people feel judged they're less likely to reach out for help, ask questions or access support. Ignoring or avoiding signs of use doesn't make the risk disappear, it actually increases them. When people feel like they can't talk openly about their drug use, they may be more likely to use in unsafe ways or in isolation, which can lead to greater harms like overdoses or medical complications. The following interviews are from people currently in recovery and the Birchwood at Clydescope House. Yeah an understanding of it, like understand it's probably not like many other drugs out there like you haven't got a time span like most drugs it will straight up demolish your body or kill you like and that's instant knowing that it's younger people taking it so it's a different way to talk to them and just knowing like the actual harms of it because I feel like I was never told the harms they just treated it like because I was here like alcohol and stuff is a death of a thousand slashes and cats not like it's a couple stab wounds and you're out of it because like the way it damages your bladder your kidneys like your heart your whole body your bowels is I've never heard of a drug like it to be fair and same with hospitals like I was going to hospital constantly in all this pain and they basically just look down at me like you're causing this yourself and it's like if I could stop I would have and they tell me there's nothing wrong with me send me home give me nothing give me no advice and to the point where I just stop going to hospital I'd rather take care and know that the pain is gonna go for a little bit then someone look down at me judge me and then tell me there's nothing wrong with me when I clearly know there is because the best people to listen to are the people who have been through this because we're not being seen by specialists we're not we're not being seen by people that have the knowledge to say like right there's no point in him to keep on suffering like this if like for example right we need to take your bladder out or we need to put a bag in or we need to give you put a catheter in it's not nice it's embarrassing but it could save your kidneys it could save your bladder and and just take the pain away it's excruciating and since I've been here I've been I've been there for four months and four of my friends have died through taking ketamine two of them have had a heart attack one of them took an intentional overdose and one of them crashed in the car whilst under the influence of ketamine so if I just sort of dwell into I made that overdose the overdose because of the pain he was in too much pain and and the doctors wouldn't help him plus he was a sort of guy he sort of liked to power through things and and not act like he was in pain so not a lot of people really knew what he was going through so if he would have seen a doctor and actually showing the doctor how much pain he was in maybe he would have got some more help same with me I think if I would have just been honest and just been honest in the fact that like I'm being honest with you but you're not giving me the help that I need maybe I do need to stop but before I before I do that we need to deal with this acute pain that's happening right now whether it's to put a catheter in whether it's to put some little deal with that so that the pain can sort of be reduced so that I don't have to keep on turning to that drug if you take them to the doctors and the doctor maybe doesn't know what they're what to do something like that if it's like one time two times I'd say on the third time that you take them say to them I need a referral to the hospital GPs I think once they know that it's ketamine involved they should just refer them straight away there's a ketamine clinic in most hospitals now and if not to specialist urology and cases like things like that because it's it's that it's that waiting for that referral that does a lot of a lot of damage to the body what they need to do is realize that some of these people on ketamine it's not that they don't want their help it's that they are literally dying in their houses for the help they can't get to you they're just they're literally wasting away in the in wherever they are taking more ketamine for the pain and then they might get up but by the time they get to you they're not much pain or they're needed to we that much that they're in their heads they're just like I'd rather just stay in my house I must have looked like a stick animal in do base that was laying in my bed crying because of the pain speak to your DGP make sure you speak to GP straight away make sure your GP's got a bit more understanding of what he's actually talking about if we have your GP hasn't got the understanding you need to go to a drug service that's more ketamine you know there's not a lot of inside but you need to be speaking to somebody that's that knows about what you what the effects of ketamine is and what what you're doing to your body and the way that it makes you how I destroys your body from the inside out your organs and things like that speak to somebody that's that's got the most best professional help you possibly can if a GP don't know about it then go to a drug service if that drug service doesn't know then you research it and go further up to somebody or speak to somebody try and go to I mean enrolling a group that's like an narcotics anonymous and they'll have ketamine users there but it's it's gonna become it's gonna be the understanding will come very very soon because I think there's gonna be a hell of a lot more people that's gonna be in the service like this in the next couple of years just right kind of I know one thing if I have one if I come out of here and I've won a little bit I can't say to myself all I just have one little bag and then that'll be it because that'll be it boom I'll be off again this is James Mahini the senior social worker and strategic safeguarding lead for change girl live sent Helen's the most significant thing is the relationship that you build with somebody and building that relationship based on trust will enable them to access support in a multitude of different ways so I feel like that's really significant really important and working side by side together like it really really does need a partnership approach it can't just be one single agency on their own you need to be working with our health services need to work together our drug and alcohol services our children's social pay like one of the benefits of working in the area that are working is in you know we're all linked in we regularly have we have our own cutting and partnership meeting that's really significant in terms of making sure that we're all aware of the same issues that we're working together setting up them pathways and processes in the community and so developing your own kind of partnership will be really significant and really key to and you know making sure that we provide the best service for children but I think as time's gone on I think we've learned that partnership working is the way forward really and there are experts within their individual fields with it with the stakeholder partnerships that we can kind of utilize that knowledge and expertise and I think that works really well where everybody comes together public health campaigns involving the Department of Health I had an idea the other day actually when I'd noticed they were talking about nice we're talking about the importance of GPs asking questions around gambling harms you know it'd be good if we could engage with nice and look to see whether they could do the same thing with Ketamin as well you know and I appreciate there's lots of things that GPs need to discuss includes of weight and how much you're drinking etc but it's so critical and what we want to avoid is a generation of people who have got lifelong health issues as a result of the Ketamin use you know and that's what harm reduction is about as well isn't it it's about getting in there early and if people are going to continue to use supporting them to reduce the damage you know that the drug that they use in where you can really so it with one of the big signs is young people attending presenting at GP surgeries with repeat urine infections and not asking the question not saying are you using Ketamin and this is something that the St Helen's service services have worked really closely with GPs in their region and they've introduced this screening tool it's the Ketamin screening tool and it will ask various things around signs and symptoms and it specifically asks around Ketamin use and it's critical really that GPs get the training we've got lots of services that have relationships within shared care for example within one of my own services previously we used to do training sessions to share care GPs involved in the scheme and they're really kind of great opportunities to have those conversations to deliver the training not just give them the screening tool and say get on with it and that would be the same with A&E as well because people will be turning up at A&E whether they've passed out and they've ended up in there if staff aren't aware they don't know to ask the question do they and it's all you know all about kind of education really and you know we've demonstrated with the St Helen service that it works if you take that approach deliver the training to the GPs get that screening tool implemented and then they've seen an increase in referrals that have come through GPs and then it really is about that fast track response that's needed as well it's not hanging about waiting for people to develop catastrophic physical health issues as a result it's about getting in there early to support people before that happens so if you don't know don't let it just wait to fall in your lap go out there and speak to the Ketamin users go out there and find information that's what we've done we haven't been given any of this information other than from us going out there working hard to find out what's going on and then spreading the word to others so if you find something new tell other people alert your public health team you know tell somebody that there's a mix of fentanyl that's in a batch that's local you need to let the CDLO officer aware in that local area to say look we've got a concern here inform the police so we need to make sure that people are communicating effectively but also it is their their duty to find out about these things and and look at statistics so we're looking at our service users and trying to gain information that is helping other professionals I think that you know it's everybody's duty to find out about these drugs and and look at their own policies and procedure and make their own guidance on it from an internal perspective so we didn't have a prescribing guideline we looked at evidence-based based practice looked at nice guidelines the BMG you know we looked at all these things and we formulated a guideline around our prescribing and our regimes and then we learned from the clients and we saw how the evidence-based practice went and that's how we got to where we are today when I first got here I was on I can't remember what it's called medication my bladder I couldn't hold my urine for more than like 10-15 minutes and to be first embarrassing as a 20 year old like you can't even get a cab somewhere about asking to pull over to have a piss like just yeah it's embarrassing I ended up back in the hospital and my mom was getting worried and she realized what was what I was doing so she said to me like you have to be honest we're good doctor I'm gonna go with you and you have to tell him what what exactly you're doing so I went back I spoke to him and I told him what was going on and he just said to me just stop that was all that was his only advice that he could give me was just just stop and I kept like saying to my mom it's really not as easy as this I know that I've a lot you guys might not see a huge difference in me but psychologically I'm not the same this thing it's like I'm going to sleep thinking about it I'm waking up thinking about it I'm doing it and when I go to bed I'm doing it when I wake up if not I'm searching straight on my phone to find out who's got to where it is how I can get it and and then if especially if I'm in pain I know that going to the hospital in A&E the only thing that they do is give you maybe a diazepam as a muscle relax and some oral morph to calm the pain down and and then they just send you on your way and then what they say to you is contact your GP in the morning and get him to either refer you to the hospital or give you some more pain medication but when you do that your GP doesn't refer you to the hospital because you're on drugs and doesn't really give you anything that will help the pain because they're addictive some of them they're addictive for prescription medications so the best he can say is takes mercy and won't stop I'm 28 and I'm in a really really bad part of my life it's got a lot better but I'm still I'm still in a huge fight to sort of get my my life back into some sort of form of normality and it's really scary because sort of it just happens overnight you don't realize what's happening you sort of just sit there watching yourself waste away but in your head you're having the time of your life you don't care it's not a worry it's not a problem it's not an issue you could put that we'll deal with that tomorrow we'll deal with that tomorrow we'll deal with that sort of mentality and then tomorrow comes and all you care about is picking up again and it got to the point where luckily I think of weed blood once that was from sort of trying to we strain in too much but I mean I am now in a wheelchair I can't use the toilet properly and it's got a bit better but I mean I was going to the toilet every 15-20 minutes so remember the core messages for anyone taking ketamine go very slow take your time and only read us after the effects are fully withdrawn you can always add more avoid mixing with other substances including alcohol medication ketamine is very unpredictable mixing it with anything else can make it much worse when snorting it use straws not rolled up banknotes and don't share with others to ensure you limit the transmission of viruses ketamine slows reflexes in impaired coordination so minor accidents are common encourage people to stay in safe places due to its anaesthetic effects any sign of pain is significantly reduced so limit hazardous acts ketamine severely impaired coordination so make no attempt to drive or operate machinery and also it can distort your perception so staying one place away from hazards and if you are doing simple things like crossing roads take extra precaution and finally remember if anyone is experiencing any bladder issues urinary issues or any abdominal pain seek medical support immediately in our final episode we're going to explore how we can respond to ketamine beyond harm reduction explore good practice and consider the wider political debates such as making it a class a substance thank you this has been frontline a risk and resilience production , thank you for watching, please subscribe and like, share and comment. I'll see you in the next video. Bye! you