As a response to rising levels of use, particularly in South East Asia, recent years have witnessed a growing debate surrounding the placing of ketamine within the schedules of the international drug control treaties. The United Nations Commission on Narcotics Drugs (CND) has passed resolutions urging member states to employ national control systems to restrict the use of ketamine to medical and scientific purposes within their own jurisdictions. Several states called for its scheduling, countries such as China, Thailand and Japan arguing that the inclusion of the substance in national controls is insufficient, and that it should be listed with substances controlled by the 1971 Convention. The advocates of this measure, however, should take fully into account the unique role played by ketamine as an anaesthetic in the developing world.
The publication of the 2012 Annual Report of the INCB saw the Board sharpen the tone of its advocacy for the international scheduling of ketamine. From at least 2004, INCB has flagged up the issue, and in three Reports has urged countries to schedule it in their national control systems. This year, the Board went further, stating that:
'The Board shares the opinion of the Governments concerned that national control measures alone may not be sufficient to enable law enforcement cooperation between the countries involved...'
This statement reminds us that a set of problematic themes continue to dominate INCB thinking. Firstly, the above passage- in which the Board presents its opinion alongside those of certain member states- arguably exceeds the limits of its mandate. It is CND and the member states that make it up, that should determine policies. Secondly, INCB fails to account for the broader health implications of its proposal. As so often, INCB fails to give equal weight to the positive aspect of its duties: focused obsessively on the restriction of non-medical drug use (the law enforcement aspect), it ignores the urgent medical considerations at stake in the question (the vital role ketamine plays as an anaesthetic in the developing world).
The scheduling of a substance requires the advice of the World Health Organisation (WHO). WHO has recently undertaken a 'critical review' (taken prior to a decision on scheduling or re-scheduling). It found insufficient evidence to show that ketamine produces a withdrawal syndrome in humans; illicit consumption rates are generally low and the drug is highly useful in therapeutic terms, providing an inexpensive anaesthetic in developing countries where no affordable, technically feasible alternative exists. WHO therefore recommended against scheduling, which would be liable to result in greater harm by reducing availability and access to this essential medicine.
WHO's recommendation is clear and sane, taking into account the wider context of public health and balancing drug control objectives against a recognition of medical need. It remains to be seen whether CND will ultimately accept this advice: WHO's own recommendation notes that, 'the Conventions allow CND to decide differently from a WHO recommendation, based on considerations other than the medical and scientific ones' used by the WHO's experts. Just what those ‘considerations’ are remains to be seen.
Christopher Hallam, IDPC researcher
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