Many people are aware that ketamine is increasingly used recreationally, with a growing status as a popular ‘party drug’, especially among younger people. You might also have heard ketamine described as a ‘horse tranquiliser’. The drug has indeed been used in veterinary settings but did you know that ketamine was first introduced into clinical practise for humans in the 1960s.
Under certain circumstances it can be a very effective anaesthetic and can be used ‘off label’ for the treatment of severe or chronic pain. Evidence-backed ketamine-assisted therapy can also enhance the therapeutic process to help people who are experiencing treatment-resistant depression, anxiety, PTSD, alcohol addiction and other mental health challenges.
So what exactly is ketamine’s legal status and how is it legitimately used in the UK?
Ketamine’s licenced Uses in the UK
Ketamine is currently controlled as a Class B substance, which means that the maximum penalty for supplying and producing it is up to 14 years in prison, an unlimited fine, or both. The government is also currently seeking expert advice on reclassifying ketamine to become a Class A substance, after illegal use of the drug reached record levels in the year ending March 2023.
Ketamine can certainly be potentially harmful if used recklessly but it has several legitimate medical uses. Ketamine is currently licenced for use as an anaesthetic. In the UK, licences are granted by the Medicines and Healthcare products Regulatory Agency (MHRA) and confirm the health condition the medicine should be used for and the recommended dosage.
Off-label Prescription: Mental Health and Depression
Off-label prescription is when a medication is being used in a way that is different to that described in the licence. For example, ketamine also has an ‘off licence’ use as an analgesic for the treatment of severe or chronic pain. The Christie NHS Foundation Trust, the largest single-site cancer treatment centre in Europe – says that when used correctly under medical supervision, ketamine ‘has been shown to be safe and effective for many years’.
The government provides a list of healthcare professionals who can prescribe unlicenced or off-label medicines, including doctors, psychiatrists, dentists, independent nurse and pharmacist prescribers and other supplementary prescribers.
It says that there are clinical situations when the use of unlicensed or off-label medicines ‘may be judged by the prescriber to be in the best interest of the patient on the basis of available evidence’.
One growing area of interest is the use of ketamine for mental health issues including depression. Led by the Eulas Clinics in Scotland and London, a number of facilities have been offering ketamine-assisted treatment for severe depression and other treatment-resistant mental health conditions.
Why ketamine Can’t Yet be Widely Prescribed for Psychiatric Use
The licencing process is very involved and hugely expensive, including extensive clinical trials. The Oxford University Hospitals NHS Foundation Trust points out that due to this expense, ‘once a medicine is on the market, the company may decide not to complete extra clinical trials if the medicine is found to treat other illnesses’.
It adds that unlicenced and off-label medicines are only prescribed after careful consideration of other options available and that clinicians ‘will have reviewed medical publications supporting its use, and may have taken advice from other experts’.
As mentioned, the MHRA grants licences for medicines and approved uses in the UK, but the National Institute for Health and Care Excellence (NICE) also needs to recommend the product and use before it can be prescribed on the NHS in England. This takes into account a cost-benefit analysis, which means that a product may not be approved if it is not considered cost-effective across the service as a whole – even though it may be the most effective treatment for some individuals.
For example, a ketamine-like nasal spray called esketamine, which is licensed as a therapy for people with hard-to-treat depression, was rejected by NICE largely on grounds of cost. The decision was challenged by the by the Royal College of Psychiatrists but upheld as NICE said it was ‘unlikely to be an acceptable use of NHS resources’.
The Scottish equivalent to NICE is the Scottish Medicines Consortium (SMC). The SMC did approve esketamine (branded Spravato nasal spray) for use within NHS Scotland.
Ketamine itself is not generally available through the NHS on prescription, but private providers may run therapy sessions with the drug and some NHS Trusts also provide ketamine-assisted therapy, and access depends on clinical need, eligibility, and local NHS funding decisions.