A little known but long-running push by China to make ketamine a controlled substance worldwide will likely culminate this week in a United Nations vote that health experts say could leave much of the developing world without access to a vital anesthetic.
A decision from the 53 members of the UN's Commission on Narcotics (CND) is expected on Friday in Vienna during its annual session. Such meetings are notoriously opaque, with pretty much no recordings or transcripts made public after their conclusion beyond details disseminated by participating states and researchers.
Despite some tentative optimism that China will have trouble mustering the two-thirds majority required to schedule the drug, the government in Beijing has immense clout with many members, and the proposition's defeat is anything but assured.
In industrialized countries, ketamine is mostly used in veterinary medicine outside of emergency situations, but the drug is commonly dispensed in poor and rural areas of developing nations to alleviate pain and prepare patients for surgery. Considered a dissociative anesthetic, ketamine acts quickly to alter sensory perception and can produce a trance-like state. Unlike other drugs that are used to dull pain and sedate a patient, ketamine poses less potential danger to respiratory and cardiovascular systems, meaning that it can be injected or administered orally with none of the monitoring equipment required for gas anesthesia.
The same dissociative properties that prove helpful in medical settings also make ketamine — or Special K, as it's known in clubs — popular among users seeking worldly detachment, or, in high doses, to fall into a K-hole. China, which is one of the world's largest producers of legal and illicit ketamine, has for years argued that the dangers of the drug's recreational use must be addressed by scheduling it under UN drug conventions.
In China and other parts of Asia, ketamine diverted from pharmaceutical supplies is often combined with methamphetamine to create knock-off ecstasy tablets. Raids on two alleged clandestine Chinese laboratories in 2013 yielded nearly 200 kilograms of the drug. According to the US State Department, ketamine is, after methamphetamine, "the second most important drug issue for China."
Many countries, including China, already control its sale despite not being required to do so under international law. In the US, ketamine is a Schedule III controlled substance — grouped together with anabolic steroids and Tylenol with codeine — and is considered by the Drug Enforcement Administration to be less dangerous than marijuana.
Last year, the World Health Organization, at China's urging, undertook its third study of the drug to determine if it should be scheduled under the 1971 UN Convention on Psychotropic Substances. The WHO's Expert Committee on Drug Dependence (ECDD) found, yet again, that the drug "currently does not appear to pose a significant global health-risk."
"If ketamine were placed under international control, this would adversely impact its availability and accessibility," wrote the committee. "This in turn would limit access to essential and emergency surgery, which would constitute a public-health crisis in countries where no affordable alternative anaesthetic is available."
Such a recommendation by the WHO would normally stall efforts to impose restrictions on a drug, but China has persisted. After originally proposing the assignment of a draconian Schedule I status, China backpedaled and requested that the CND hold a vote to place it in the less restrictive Schedule IV.
Despite the softening of China's request, drug policy and public health experts have echoed the WHO in saying that the scheduling push would still have disastrous effects, particularly in Africa, where the drug has been administered to countless patients and is commonly used to treat women undergoing cesarean sections.
"In order to fight misuse in China and southeast Asia, you are forcing countries in Africa that have no known misuse of the medication to comply with a regulatory regime that for poorer countries with weak health care systems is very burdensome," Diederik Lohman, an associate director at Human Rights Watch who focuses on access to medicines, told VICE News.
Developing countries already face drastic and chronic shortages of pain medication, in part due to international scheduling.
"We've seen this with morphine — in some countries it's almost impossible to find a company that's willing to supply the medication because there are so many headaches attached to being in that business," said Lohman.
Though UN treaties distinguish between eight schedules of drugs, in many countries controlled substances are lumped into as few as two. "In such cases, the nuances of control intended by international scheduling are lost, and it is easy for the practical outcome in country settings to be more restrictive than is appropriate," wrote Willem Scholten, former secretary of the ECDD, in an extended consideration of scheduling ketamine.
Scholten pointed to the case of phenobarbital, an anti-epileptic drug that is already in Schedule IV of the 1971 convention. Despite its low cost and effectiveness, some 80 percent of epileptic patients in low-income countries do not have access to sufficient supplies of the drug.
"If the Commission votes to place ketamine in in Schedule IV of the drug control conventions, the same thing will happen with ketamine," wrote Scholten.
The WHO recommends that medical professionals include both morphine and ketamine in emergency health kits. However, because morphine is an internationally controlled substance — considered Schedule I under the 1961 Single Convention on Narcotics — doctors often leave it behind to avoid bureaucratic delays. As a result, particularly in disaster zones, doctors rely heavily on ketamine.
Martin Jelsma, coordinator of the Transnational Institute's Drugs and Democracy Programme, says a vote flouting the advice of the WHO is a dangerous move.
"Even if the vote is defeated, it would still set a precedent," Jelsma told VICE News. "Next year a country could push for a vote on Tramadol without any WHO advice," he added, referring to the mild opioid painkiller that has been targeted in recent years by countries such as Russia.
Jelsma and other drug policy experts have argued that the CND has no legal grounds to consider scheduling a drug without WHO approval, but that has thus far not stood in the way of a vote.
Under Schedule IV, countries would be required to license ketamine's dispensation and track the production, importation, and exportation of the drug. Such regulations would be easily incorporated into established health bureaucracies in wealthy nations, but in developing countries without sufficient public health administrations, it could lead to the drug disappearing in all but a handful of central hospitals.
"The amount of paperwork that the pharmaceutical industry has to deal with increases their costs, and it becomes harder for physicians to prescribe and health centers to stock," said Lohman.
The CND is the governing body of the UN's Office on Drugs and Crime (UNODC), which is based in Vienna. Many poorer countries, including some from Africa, do not have dedicated missions in the Austrian capital. Diplomatic teams in Vienna often hail from government law enforcement and foreign ministries, and are not necessarily familiar with public health. As a result, negotiations at CND sessions can be more conservative than the global consensus among drug policy experts.
"Basically the African voice in this discussion has been mostly absent," said Lohman. "China has enormous influence in Africa, and there's concern to what extent China will try to use its influence there to try to force this through."
According to reports from Monday's session, Namibia, speaking on behalf of the CND's Africa group, said it was concerned about both ketamine and tramadol and asked that the commission to consider scheduling ketamine. That statement led one drug policy researcher to wonder whether China had "bought the Africa group's statement."
Though China has a significant population that abuse ketamine, advocates say it's difficult to see what practical effect international scheduling would have in a country that already puts drug traffickers to death.
"In the case of China, what is consumed domestically is diverted from their national pharmaceutical industry," said Jelsma. "International trade is not a big deal for China. It's not clear what they hope to gain from international control."
In addition to ketamine, the CND will consider scheduling several other drugs this week, including mephedrone, at the request of the United Kingdom. Jelsma believes that controlling the stimulant, which is often sold in place of ecstasy, is a reasonable request in light of its limited medical value. But ketamine, despite its use as a party drug, is much more widely employed as a medicine.
"Even if there are places where it becomes a more serious problem, at a national level you can do whatever you want and add it to your national schedule, but don't force all those countries that don't have problems with its recreational use to do so," said Jelsma. "In cases where electricity is not easily available, this is the only anesthetic that can be used."