Longitudinal trajectories of ketamine use among young injection drug users

Can We Better Understand, Diagnose, and Treat Ketamine-Induced Uropathy, and Can It Be Reversed? ICI-RS 2024

INTRODUCTION

Ketamine, a versatile anesthetic, has seen increased recreational use, leading to significant health issues, including ketamine-induced uropathy (KIU). KIU manifests with lower urinary tract symptoms (LUTS) and can involve the upper urinary tract. This study aims to provide a comprehensive overview of KIU, addressing its pathophysiology, diagnostic strategies, and treatment options; and to define/identify future research priorities.

METHODS

During the 2024 meeting of the International Consultation on Incontinence Research Society (ICI-RS) in Bristol, a dedicated Proposal (P) convened to explore KIU. This initiative involved a thorough review of existing literature, expert presentations, and consensus-driven discussions. The methodology ensured a comprehensive exploration of KIU from both clinical and pre-clinical perspectives, leading to actionable research recommendations.

RESULTS

Understanding the mechanisms of KIU is crucial for developing effective treatment options targeting specific pathophysiological pathways. Key findings include bladder fibrosis driven by transforming growth factor-β1 (TGF-β1), elevated purinergic responses and upregulated P2X1 purinoceptor expression, decreased barrier function due to increased expression of antiproliferative factor (APF), and functional loss of the bladder through Cav1.2 channel blockade. Research indicates that fibrosis, typically considered irreversible, may be mitigated. However, the exact timing and extent of fibrosis initiation and its impact on long-term outcomes require further research. LUTS typically improve after ketamine cessation but relapse upon resumption, indicating a hypersensitivity mechanism involving elevated serum IgE levels. Advanced stages of KIU do not always correlate with LUTS severity, shedding light on potential systemic effects and the need for evaluating liver enzymes. Furthermore, psychological dependency on ketamine, due to its positive perceptive and mood-altering effects, complicates cessation efforts. Long-term management requires a holistic approach, integrating medical treatments and supportive measures to help patients navigate life with potentially irreversible complications.

CONCLUSION

This comprehensive review spans from fundamental pathology to practical clinical management, addressing both urological and systemic complications, and bridging insights from animal models to human applications. Developing effective treatment strategies necessitates addressing both the physical and psychological aspects of ketamine dependency.

Adverse drug effects as a deterrent against willingness to use in the future among nightclub/festival attendees

INTRODUCTION

It is largely unknown whether adverse effects experienced from recreational drug use affect willingness to use again. This study determined whether adverse effects from select party drugs affect reported willingness to use again in the next month among a high-risk population-people who attend electronic dance music parties at nightclubs or dance festivals.

METHODS

Adults (age ≥ 18) entering nightclubs/festivals were surveyed in New York City in 2018-2022 (n = 2981). Participants were asked about past-month use of common party drugs (cocaine, ecstasy, lysergic acid diethylamide [LSD] and ketamine), whether they had experienced a harmful or very unpleasant effect after use in the past 30 days, and whether they intend to use again in the next 30 days if offered by a friend. The relationship between having experienced an adverse outcome and willingness to use again was examined in a bivariable and multivariable manner.

RESULTS

Experiencing an adverse effect after past-month cocaine (adjusted prevalence ratio [aPR] = 0.58, 95% confidence interval [CI] 0.35-0.95) or ecstasy use (aPR = 0.45, 95% CI 0.25-0.80) was associated with lower risk for willingness to use again. Adverse effects related to LSD use were related to lower risk of being willing to use again in the bivariable model, but in multivariable models, risk was not attenuated for willingness to use LSD or ketamine again.

DISCUSSION AND CONCLUSIONS

Personally experienced adverse effects can deter willingness to use certain party drugs again in this high-risk population. Interventions targeting cessation of recreational party drug use can likely benefit from focusing on deleterious effects of use that have been experienced.

Characteristics of poisonings involving ketamine in the United States, 2019-2021

BACKGROUND

The use of ketamine, a controlled dissociative anesthetic, has become more widespread in recent years with recreational/nonmedical use increasing and ketamine becoming more widely available in clinics to treat depression.

AIMS

We examined recent trends in adverse effects related to ketamine use.

METHODS

US National Poison Control data were examined, focusing on ketamine exposures among those aged ⩾13 between 2019 and 2021 (n = 758). We examined quarterly trends in exposure and delineated correlates of patients experiencing a major adverse effect or death.

RESULTS

The number of reported exposures increased 81.1% from 2019 Quarter 1 through 2021 Quarter 4, from 37 to 67 (p = 0.018). The majority of patients were male (57.1%), and the plurality of cases involved intentional misuse or "abuse" (39.5%), followed by suspected suicide attempt (19.7%) and unintentional exposure (18.9%). A fifth (19.6%) experienced a major adverse effect or death. A third (33.4%) co-used other drugs; the drugs most commonly co-used were benzodiazepines (14.6%), alcohol (10.3%), and opioids (8.7%). Co-use of gamma-hydroxybutyrate (GHB; adjusted prevalence ratio (aPR) = 3.43, 95% confidence interval (CI): 1.57-7.46) and opioids (aPR = 2.44, 95% CI: 1.46-4.08) was associated with increased risk for a major adverse effect or death, as was injection-only administration (aPR = 2.68, 95% CI: 1.21-5.92).

CONCLUSIONS

Although still rare, poisonings involving ketamine have increased in recent years. Polydrug use-particularly with opioids or GHB-appears to be a particular risk factor for more serious adverse effects. As prevalence of use increases, it is important to monitor adverse effects and co-occurring behaviors to inform timely prevention and harm reduction as needed.

Occurrence of Z-drugs, benzodiazepines, and ketamine in wastewater in the United States and Mexico during the Covid-19 pandemic

Z-drugs, benzodiazepines and ketamine are classes of psychotropic drugs prescribed for treating anxiety, sleep disorders and depression with known side effects including an elevated risk of addiction and substance misuse. These drugs have a strong potential for misuse, which has escalated over the years and was hypothesized here to have been exacerbated during the COVID-19 pandemic. Wastewater-based epidemiology (WBE) constitutes a fast, easy, and relatively inexpensive approach to epidemiological surveys for understanding the incidence and frequency of uses of these drugs. In this study, we analyzed wastewater (n = 376) from 50 cities across the United States and Mexico from July to October 2020 to estimate drug use rates during a pandemic event. Both time and flow proportional composite and grab samples of untreated municipal wastewater were analyzed using solid-phase extraction followed by liquid chromatography-tandem mass spectrometry to determine loadings of alprazolam, clonazepam, diazepam, ketamine, lorazepam, nordiazepam, temazepam, zolpidem, and zaleplon in raw wastewater. Simultaneously, prescription data of the aforementioned drugs were extracted from the Medicaid database from 2019 to 2021. Results showed high detection frequencies of ketamine (90 %), lorazepam (87 %), clonazepam (76 %) and temazepam (73 %) across both Mexico and United States and comparatively lower detection frequencies for zaleplon (22 %), zolpidem (9 %), nordiazepam (<1 %), diazepam (<1 %), and alprazolam (<1 %) during the pandemic. Average mass consumption rates, estimated using WBE and reported in units of mg/day/1000 persons, ranged between 62 (temazepam) and 1100 (clonazepam) in the United States. Results obtained from the Medicaid database also showed a significant change (p < 0.05) in the prescription volume between the first quarter of 2019 (before the pandemic) and the first quarter of 2021 (pandemic event) for alprazolam, clonazepam and lorazepam. Study results include the first detections of zaleplon and zolpidem in wastewater from North America.

The Role of Life Events/Contextual Factors and Cannabis Use in Patterns of Other Drug Use Among Young Adult Cannabis Users in Los Angeles: A Qualitative Inquiry

This analysis examined the role of impactful life events/stressful contextual factors and cannabis use in the patterns of illicit drug use. It utilized semi-structured qualitative interviews with 40 young adult medical cannabis patients and 22 non-patient users collected in Los Angeles during 2014-2015. Three patterns of illicit drug use emerged based on participants' narratives: regular/problematic, recreational/occasional, and never users. Among regular/problematic users, a common theme was the lasting impact of traumatic life events or stressful contextual factors on transition to and away from problematic drug use, and using cannabis to cope with negative after effects of drug use. In contrast, most recreational/occasional and never users, who reported impactful life events or stressful contextual factors, used cannabis to cope with those experiences. Family history of addiction and acceptance of cannabis use within a family as protective factors against illicit drug use among some recreational/occasional and never users was an unexpected finding.

POPULAÇÃO EM SITUAÇÃO DE RUA, VULNERABILIDADES E DROGAS: UMA REVISÃO SISTEMÁTICA

Resumo O presente artigo tem como objetivo realizar uma revisão sistemática sobre os determinantes pobreza, estigma, raça e vulnerabilidade entre a população em situação de rua usuária de drogas. Para tal, foi realizada uma revisão sistemática utilizando as bases de dados Scielo Br, PepSiC, PubMed e Redalyc. Ao final dos procedimentos foram selecionados 79 artigos. Foi percebida diferença significativa dos estudos realizados nos Estados Unidos e os latino-americanos. Enquanto os primeiros tendem a priorizar estudos com grandes amostras com o foco na análise de riscos e na quantificação de categorias, as pesquisas latinas tendem a contextualizar as condições de desigualdade e pobreza, ao passo que utilizam metodologias participativas e se aproximam de uma análise das vulnerabilidades. Os resultados indicam discussões ainda incipientes que articulem tais categorias e que pouco englobam as diversas vulnerabilidades a que esses sujeitos estão expostos ao longo de suas vidas, bem como apontam para a necessidade de uma nova categoria analítica de compreensão.

Becoming a medical marijuana user

BACKGROUND

Since marijuana became legal for medical use in California in 1996, reasons for medical use among medical marijuana patients (MMP) have become increasingly well described in qualitative studies. However, few studies have detailed how the use of marijuana for medical purposes fits into the broader career trajectories of either becoming a marijuana user or becoming a MMP, including the social influences on medical use.

METHODS

Young adult MMP (N=40) aged 18 to 26 years old were recruited in Los Angeles, CA in 2014-15 and administered a semi-structured interview that included questions focusing on marijuana use practices before and after becoming MMP.

RESULTS

MMP were categorized into three trajectory groups: primarily medical users (n=30); primarily non-medical users (n=3); and medical users who transitioned to non-medical users (n=7). Most medical users discovered medicinal effects from marijuana in the context of non-medical use as adolescents prior to becoming MMP. Becoming a mature MMP followed interactions with dispensary staff or further self-exploration of medical uses and often involved a social process that helped confirm the legitimacy of medical use and identity as a medical user. In some cases, MMP transitioned back to non-medical users as health conditions improved or remained primarily non-medical users even after becoming MMP for reasons unrelated to health, e.g., protection against arrest.

CONCLUSION

Becoming a medical marijuana user was an important career trajectory that was influenced by early discoveries of effective medicinal use, interaction with proponents of medical use at dispensaries, experiences with new kinds of medical use, and the demands of particular health condition requiring more or less treatment with marijuana.

Health conditions and motivations for marijuana use among young adult medical marijuana patients and non-patient marijuana users

INTRODUCTION

While marijuana has been legal for medical purposes in California since 1996, little is known about the health histories of young adult medical marijuana patients who are a significant proportion of medical marijuana patients. We examined whether young adult medical marijuana patients reported health conditions and motivations for use that were consistent with medical use of marijuana in California.

METHODS

Young adults (N = 366) aged 18 to 26 years were sampled in Los Angeles in 2014-2015 and segmented into medical marijuana 'patients' (n = 210), marijuana users with a current recommendation, and non-patient users or 'non-patients' (n = 156), marijuana users who never had a medical marijuana recommendation. Differences between patients and non-patients regarding self-reported health histories and past/current motivations for marijuana use were expressed as unadjusted risk ratios.

RESULTS

Compared with non-patients, patients were significantly more likely to report a range of lifetime health problems, such as psychological, physical pain and gastrointestinal. In the past 90 days, patients were significantly more likely to report motivations for marijuana use than non-patients concerning sleep, anxiety, physical pain and focusing. Psychological and pain problems were the most common health conditions reported to receive a medical marijuana recommendation. Patients were significantly less likely than non-patients to report any privacy concerns about obtaining a medical marijuana recommendation.

CONCLUSIONS

Patients were significantly more likely to report a range of health conditions and motivations associated with medical use than non-patients. A great majority of patients reported obtaining a medical marijuana recommendation for health problems in accordance with the California law. [Lankenau SE, Ataiants J,Mohanty S, Schrager S, Iverson E, Wong CF.Health conditions and motivations for marijuana use among young adultmedical marijuana patients and non-patient marijuana users. Drug Alcohol Rev 2017;00:000-000].

Pharmacological and non-pharmacological factors that regulate the acquisition of ketamine self-administration in rats

BACKGROUND

Recreational ketamine use may be modulated by factors such as ketamine infusion patterns, associated conditioned stimuli and spatial-temporal contexts. Our aim was to study the pharmacological and non-pharmacological factors that regulate the acquisition of ketamine use.

METHODS

In experiment 1, four groups of male rats were trained to self-administer ketamine during nine 1-h daily sessions, under four reinforcement schedules: i) pre-session ketamine priming (Priming-[KET]), ii) conditioned stimulus (CS) paired to the ketamine infusions ([KET + CS]), iii) neither priming nor CS ([KET]), iv) combination of both (Priming-[KET + CS]). In experiment 2, two groups of male rats were trained to self-administer ketamine during nine 1-h daily or weekly sessions, under the Priming-[KET + CS] schedule. Lever pressing was then extinguished by saline substitution for ketamine infusion. Afterwards, ketamine was made available again upon responding under the same schedule.

RESULTS

The Priming-[KET + CS] schedule of reinforcement showed a significant increase in the number of ketamine reinforcements and a significant discrimination between active vs. inactive levers. The same schedule allowed the establishment of ketamine self-administration on a weekly basis. During the extinction phase, rate of responding significantly dropped in both weekly and daily groups although it was twofold longer in the former, which showed a lack of reacquisition.

CONCLUSIONS

Both pre-session ketamine priming and a conditioned stimulus paired to the ketamine infusions are required for the acquisition of ketamine self-administration. The longer extinction and the lack of reacquisition in the weekly group could be due to changes in temporal context that might affect the conditioning process.

Repeated ketamine administration alters N-methyl-D-aspartic acid receptor subunit gene expression: implication of genetic vulnerability for ketamine abuse and ketamine psychosis in humans

For more than 40 years following its approval by the Food and Drug Administration (FDA) as an anesthetic, ketamine, a non-competitive N-methyl-D-aspartic acid (NMDA) receptor antagonist, has been used as a tool of psychiatric research. As a psychedelic drug, ketamine induces psychotic symptoms, cognitive impairment, and mood elevation, which resemble some symptoms of schizophrenia. Recreational use of ketamine has been increasing in recent years. However, little is known of the underlying molecular mechanisms responsible for ketamine-associated psychosis. Recent animal studies have shown that repeated ketamine administration significantly increases NMDA receptor subunit gene expression, in particular subunit 1 (NR1 or GluN1) levels. This results in neurodegeneration, supporting a potential mechanism where up-regulation of NMDA receptors could produce cognitive deficits in chronic ketamine abuse patients. In other studies, NMDA receptor gene variants are associated with addictive behavior. Here, we focus on the roles of NMDA receptor gene subunits in ketamine abuse and ketamine psychosis and propose that full sequencing of NMDA receptor genes may help explain individual vulnerability to ketamine abuse and ketamine-associated psychosis.

Drugs currently in Phase II clinical trials for cocaine addiction

INTRODUCTION

There are no FDA-approved pharmacotherapies for treating cocaine addiction; thus, developing drugs to treat cocaine dependence is an unmet critical need. Fortunately, there are a number of drugs that are currently in Phase II clinical trial/s. This is due in part to the advances from in vivo imaging in humans which provided a roadmap of the neurochemistry of the cocaine-dependent brain. Most drugs currently in Phase II clinical trials attempt to modulate the disturbed neurochemistry in cocaine dependents to resemble those of healthy individuals. These predominantly modulate dopamine, serotonin, glutamate, GABA or noradrenaline signalling.

AREAS COVERED

This review summarizes the therapeutic potential of each drug as evidenced by clinical and preclinical studies. It also discusses their utility in terms of bioavailability and half-life.

EXPERT OPINION

Amphetamine salts and topiramate clearly stand out in terms of their potential efficacy in treating cocaine addiction. The efficacy of topiramate was closely associated with regular cognitive-behavioural therapy (CBT), which highlights the importance of a combined effort to promote abstinence and enhance retention via CBT. Cognitive/psychological screening appears necessary for a more symptom-based approach with more reasonable outcomes other than abstinence (e.g., improved quality of life) in treating cocaine addiction.

Initiation into prescription drug misuse: differences between lesbian, gay, bisexual, transgender (LGBT) and heterosexual high-risk young adults in Los Angeles and New York

OBJECTIVE

Prescription drug misuse is an important public health problem in the U.S., particularly among adolescents and young adults. Few studies have examined factors contributing to initiation into prescription drug misuse, including sexual orientation and childhood abuse and neglect. The purpose of the present study is to investigate the relationship between initiation into the misuse of prescription drugs (opioids, tranquilizers, and stimulants), sexual identity, and individual and family determinants.

METHOD

Results are based upon data from a cross-sectional survey of 596 youth (polydrug users, homeless youth, and injection drug users) aged 16 to 25 who reported current prescription drug misuse. Participants were recruited in Los Angeles and New York City between 2009 and 2011. We compared initiation behaviors between sexual minority and heterosexual youth and examined factors modifying the relationship between sexual identity and earlier initiation into prescription drug misuse.

RESULTS

Sexual minority youth were more likely to report histories of initiation into misuse of prescription opioids and tranquilizers. Further, they were more likely to report various types of childhood abuse than heterosexual youth. However, multivariate analyses indicated that age of first prescribed drug was the most significant factor associated with initiation into misuse of all three categories of prescription drugs.

CONCLUSIONS

The correlates of initiation into prescription drug misuse are multidimensional and offer opportunities for further research. Identifying additional factors contributing to initiation into prescription drug misuse is essential towards developing interventions that may reduce future drug use among young adults.

Ketamine use: a review

AIMS

Ketamine remains an important medicine in both specialist anaesthesia and aspects of pain management. At the same time, its use as a recreational drug has spread in many parts of the world during the past few years. There are now increasing concerns about the harmful physical and psychological consequences of repeated misuse of this drug. The aim of this review was to survey and integrate the research literature on physical, psychological and social harms of both acute and chronic ketamine use.

METHOD

The literature on ketamine was systematically searched and findings were classified into the matrix of Nutt et al.'s (2007) rational scale for assessing the harms of psychoactive substances.

RESULTS

A major physical harm is ketamine induced ulcerative cystitis which, although its aetiology is unclear, seems particularly associated with chronic, frequent use of the drug. Frequent, daily use is also associated with neurocognitive impairment and, most robustly, deficits in working and episodic memory. Recent studies suggest certain neurological abnormalities which may underpin these cognitive effects. Many frequent users are concerned about addiction and report trying but failing to stop using ketamine.

CONCLUSIONS

The implications of these findings are drawn out for treatment of ketamine-induced ulcerative cystitis in which interventions from urologists and from addiction specialists should be coordinated. Neurocognitive impairment in frequent users can impact negatively upon achievement in education and at work, and also compound addiction problems. Prevention and harm minimization campaigns are needed to alert young people to these harmful and potentially chronic effects of ketamine.