A Drug Market Growing in the Shadows

Ketamine has long occupied an unusual position in medicine. Developed in the 1960s as a safer anaesthetic alternative to phencyclidine (PCP), it earned a place on the World Health Organization’s (WHO) list of essential medicines thanks to its reliability, affordability and effectiveness in settings where conventional anaesthesia is not possible. Today it is also being used as a treatment for depression.

But a parallel story has been unfolding. Across Europe, ketamine health harms are rising sharply, driven by growing non-medical use among young adults who increasingly view the drug as both affordable and safe. New data presented at a recent webinar hosted by the EU Drugs Agency (EUDA) shows the situation is more serious than many people realise, and that the worst may still be ahead.

The Market: From €350 a Kilo to Street Level in Days

Between 2016 and 2024, ketamine seizures across Europe increased from under 200 kilograms to 3.5 tonnes annually, according to EUDA data. The number of individual seizures also rose substantially during this period. At the same time, wholesale prices fell, with the kilo price in the Netherlands showing a clear downward trend over recent years.

Dr Rita Jorge, a scientific analyst at EUDA and the lead author of the agency’s Ketamine in Europe: EMPACT Situation Report, explained how the substance is reaching illicit markets. Legal active pharmaceutical ingredient (API) imports, predominantly from India and primarily entering via Germany, are being diverted before they ever reach licensed pharmaceutical manufacturers.

“Legal API importers normally sell to a legal third party to transform these active pharmaceutical ingredients into the finished medicine,” Dr Jorge told the webinar audience. “What seems to be happening is that, from these legal API importers, the material sometimes gets passed to an illegal third party instead.”

The financial incentive is substantial. A kilogram of ketamine API imported legally may cost between €350 and €500. By the time it reaches street level in the Netherlands, it can sell for the equivalent of €20,000 per kilo or more, representing a return of up to 40 to 60 times the original purchase price.

Criminal networks, particularly those operating out of the Netherlands, appear to be exploiting inconsistencies in how different EU member states classify and regulate ketamine. In some countries it is scheduled as a narcotic; in others it remains an unscheduled medicine. This creates what Dr Jorge described as “jurisdiction shopping,” where criminal groups exploit legal grey areas across borders to reduce their exposure to law enforcement.

Why Young People Are Using It

Non-medical ketamine use has been documented since the late 1970s, but the European market remained limited for decades. That picture has changed significantly. Use has tripled in certain areas of the United Kingdom between 2006 and 2023, and EUDA data points to increasing prevalence in nightlife settings and urban hotspots across the continent.

Dr Wouter van der Sanden, a urologist at Jeroen Bosch Hospital in the Netherlands and one of Europe’s leading specialists in ketamine-related urological damage, described the narratives he hears most often from his patients.

“People tell me, ‘It’s also used in hospitals, so how bad can it be?’ They say you cannot really overdose on it, it’s much safer than other drugs, and they’ve heard it’s used for depression so it can’t be that addictive,” he said. “These are the real narratives on the streets.”

Ketamine is fast-acting, produces dissociative and euphoric effects and, unlike many other substances, carries a comparatively low risk of acute overdose. It is also genuinely cheap: in the Netherlands, Dr van der Sanden noted, delivery can arrive faster than a pizza. For young people looking for a party drug that feels manageable and affordable, the appeal is not hard to understand.

The Ketamine Health Harms Nobody Talks About

The most serious ketamine health harms are not the acute ones. They develop slowly, over months and years of intensive use, by which time the damage can be profound and, in some cases, irreversible.

Ketamine is metabolised in the liver, and the resulting metabolites are excreted through the kidneys and into the bladder. There, they can trigger a chronic chemical inflammation of the bladder lining, causing ulceration, scarring and fibrosis. A healthy bladder can hold around 400 to 500 millilitres of urine before the urge to void becomes pressing. A severely damaged ketamine bladder may hold as little as 40 to 50 millilitres.

Dr van der Sanden described the clinical picture bluntly: “Think of a very small espresso cup. Now imagine the inside of the bladder covered with sandpaper and the outside with barbed wire, while acidic urine constantly passes through it.”

Patients experience severe pelvic pain, sometimes so debilitating they arrive in wheelchairs. They may need to urinate every 10 to 15 minutes, day and night. Many pass blood and blood clots. Sexual dysfunction is common in both male and female patients. In approximately 10% of cases, the damage extends to the ureters and kidneys, with the risk of kidney failure and, in extreme cases, the need for dialysis. Where the bladder cannot recover, surgical removal becomes necessary, leaving patients in their twenties or thirties with a permanent urostomy.

“When you’re 25, you don’t want to live like this for the rest of your life,” Dr van der Sanden said.

There are also emerging concerns around fertility. While the evidence remains limited, he noted that many patients using ketamine show high rates of infertility, and that some men do not recover fertility even after stopping use.

A Self-Reinforcing Trap

One of the most troubling aspects of non-medical ketamine use is the cycle it creates. Ketamine is a painkiller. As bladder inflammation develops and worsens, many users increase their intake to manage the pain, accelerating the very damage that is causing it.

“Patients completely know that using ketamine is bad for their bodies,” Dr van der Sanden said. “They suffer the consequences every 10 to 15 minutes. But they tell me, ‘With ketamine, I can have an hour of sleep. I don’t feel that much pain. I can get my kids from school.’ That is the real world these people are living in.”

Breaking this cycle is the central challenge of his clinic, which opened in 2022 at Jeroen Bosch Hospital and now serves as a national referral centre, with patients travelling internationally for treatment. The clinic takes a fully integrated approach, combining urology, addiction medicine, pain management and psychosocial support in a single outpatient pathway. Of the more than 500 patients treated so far, three quarters achieved abstinence within six months of starting the programme. In that group, the vast majority experienced adequate relief of symptoms without requiring major surgery.

The data also tells the other side of the story: among those who did not stop using ketamine, most saw no improvement or experienced progression of their symptoms.

A Delayed Epidemic

Perhaps the most important message from both speakers was about timing. Ketamine health harms are not immediate. Dr van der Sanden’s data shows that patients typically begin intensive use around one year after first trying the drug, and that they present at the clinic on average 41 months later, after roughly three and a half years of heavy use at a mean consumption of around 22 grams per week.

“The patients I see today started using ketamine years ago,” he said. “The increase in ketamine use we see today will likely become the healthcare problem of the coming years. What we see now is probably only the beginning.”

Roughly 25% of recreational ketamine users report urological problems, based on older epidemiological data. Applying that figure to the rapidly expanding user base in Europe suggests a substantial clinical burden is being stored up. Healthcare systems are not yet prepared for it, and awareness among both users and clinicians remains low.

Stigma compounds the problem. “We have young patients getting addicted to ketamine and developing devastating symptoms, and then there is the silence,” Dr van der Sanden said. He drew a pointed comparison with tobacco and alcohol, both of which have generated significant public health investment and relative social acceptance around treatment-seeking, while drug-related harm remains a source of shame that delays diagnosis and access to care.

Closing the Gaps

EUDA’s report identifies several areas where the European response needs to strengthen. Cross-agency information sharing between law enforcement, health ministries and medicines regulators is inadequate. Data collection across member states is inconsistent. The legal supply chain for ketamine APIs lacks transparency, and there is no EU-wide system for monitoring legitimate import volumes.

The agency recommends engaging with source countries, particularly India, to map the full supply chain and close the gaps being exploited. It also calls for greater attention to prevention, harm reduction and monitoring, and flags the risk of displacement effects if pressure on the ketamine market pushes users or suppliers towards other substances.

Dr Jorge noted that ketamine should also serve as a case study for other psychoactive medicines whose supply chains may be similarly vulnerable. “We should be looking to other critical supply chains for other psychoactive medicines to ensure that monitoring gaps do not result in a lack of knowledge about the situation,” she said.

Both speakers emphasised that there remains a window of opportunity. The rise in non-medical ketamine use is recent enough, and the delayed nature of ketamine health harms long enough, that early action, whether through prevention messaging, clinician education or supply-side enforcement, could still make a meaningful difference to the scale of harm that follows.

Source: dbrecoveryresources