Dependence and urinary symptoms among recreational ketamine users

Authors


Sir,

The recent study by Winstock et al.[1] provides strong evidence of the prevalence and natural history of ketamine-induced urinary symptoms; however, a common thorny problem was also mentioned: 17% of ketamine users in the study were found to be dependent on the drug. This problem has been frequently reported since 2007, with Wang et al. [2] stating that ‘management for ketamine dependence seems more difficult than treating ketamine-associated bladder dysfunction’. In the present paper, we would like to share our experience of this thorny issue by reporting on a retrospective case of ketamine-induced vesicopathy.

The representative case was a man aged 25 years, with a secondary modern school education, who had > 3 years' recreational ketamine use. He had a reduced bladder capacity and bladder wall thickening without upper urinary tract lesions, confirmed by ultrasonography, and sought emergency help from urologists for his typical LUTS. He was advised to cease using ketamine. A few weeks later, he presented again with aggravated symptoms: bilateral hydronephrosis, ureteric dilatation and ureteric wall thickening on CT. He admitted he had tried his best several times but could not completely cease ketamine use. He was subsequently referred to psychiatrists for help with this drug addiction and was assessed using the Eysenck Personality Questionnaire-Revised Short Scale (EPQ-RS) [3] and the Self-Rating Depression Scale (SDS) [4], which have been widely used in research and in clinical practice in the fields of psychiatry and psychology. The EPQ-RS scores were as follows: extraversion (E) score T 51, pschoticism (P) score T 85, neuroticism (N) score T 71, lie (L) score T 33, which indicated neither introversion nor extroversion, emotional instability and neuroticism. His SDS score was 57.5, indicating mild depression. He was forced to stay in a drug rehabilitation centre for several months with no access to ketamine, as he had a history of intermittent secret use of the drug, had fallen into ketamine and could not move himself.

Ketamine cessation is the only effective treatment to prevent deterioration of renal function and to offer the possibility of symptom resolution [5]. Winstock et al. [1] also concluded that 51% of ketamine users experienced improvement in their urinary symptoms upon cessation of ketamine, and that cessation with early referral was needed to manage ketamine-associated urinary tract symptoms and to avoid progression to severe and irreversible urological pathologies. A dose– and frequency–response relationship has been shown between ketamine use and urinary symptoms [1, 6], therefore, continued abuse would aggravate LUTS and cause renal dysfunction, even uraemia. Various surgical procedures, such as augmentation enterocystoplasty, would be implemented to alleviate urinary symptoms or improve renal function [7], so the importance of ketamine cessation to treat ketamine-associated urinary tract symptoms and prevent long-term deterioration of disease is obvious. Recently, ketamine-associated neuron damage has also been reported in vivo [8] and in vitro [9]; however, ketamine dependence and personality are linked as in the above-mentioned case. It is not certain whether the particular type of personality and depression are linked to ketamine-associated central nervous system damage, or are the cause of the ketamine dependence. It is hard to confirm the relationship and a series of case–control studies are needed to elucidate this interesting phenomenon.

Ancillary