The Disturbing Case of the Street Drug Ketamine
The UK’s Medicines & Healthcare Products Regulatory Agency (MHRA) is refusing to respond to the concerns of psychiatrists, parliamentarians, patients and other experts about the impending licensing of the street drug ketamine as a treatment for depression.
In March this year, the USA’s Food and Drug Administration approved Spravato (esketamine), on the basis of just one efficacy study.
On 17.10.19 the European Medicines Agency (EMA) issued a ‘positive opinion’ recommending the granting of marketing authorisation for esketamine for depression in adults and sent it to the European Commission, which has 67 days to make a final decision (December 23).
The MHRA (UK) has deferred a decision, pending the EMA/EC ruling. However, during the 67 days, member states can submit new information not addressed by the EMA opinion.
On 31.10.19 twelve experts, including eight psychiatrists, wrote to the MHRA and EMA.
Dr June Raine
Chief Executive Officer
Medicines & Healthcare Products Regulatory Agency
London E14 4PU
October 31, 2019
Dear Dr Raine
We are writing to express grave concern about the possibility that the dissociative anaesthetic agent, and known street drug of abuse, ketamine, might be approved for use in this country in the marketed form of ‘esketamine’.
There have been no trials of the efficacy of esketamine in the medium or long term. The majority of the studies of this drug (almost entirely conducted by the drug company attempting to license the drug, Janssen) are only four weeks in duration. Most of these studies find no benefit for esketamine versus placebo, and multiple adverse effects. The one positive efficacy study finds a difference between esketamine and placebo that is small and not clinically meaningful. Esketamine is the only antidepressant that has been approved by the FDA with only one successful efficacy trial.
The longest study to date is a 16-week trial using a discontinuation design, which is almost certain to confound withdrawal effects with relapse of depression. This trial design also increases the likelihood of patients breaking blind in the drug condition. As noted in the FDA statistical review, “perception of their treatment assignment may have been influenced by acute side effects (dissociation, sedation, etc.). FDA’s exploratory analysis suggested that changes in these side effects were associated with time relapse.”
Notably, there were six deaths in the esketamine studies, including three suicides, all in the esketamine group, with none in those assigned to placebo. Although these deaths were dismissed as unrelated by Janssen we do not believe that this worrying signal of danger should be ignored. It may well be consistent with a severe withdrawal reaction from the medication, known to occur in other medications such as antidepressants and opiates.
Short term apparent benefits of using esketamine are unsurprising, given its similarities to drugs of abuse, and no basis for approving a drug. One could achieve similar results, short term euphoria or dissociation, with various other street drugs. Indeed, we are as shocked by this recent development as we would have been had es-cocaine been submitted for approval.
If esketamine is approved for public use in the UK next month, there is no impediment to doctors prescribing this drug for weeks, months and beyond, which is precisely what we now see occurring in the US since FDA approval.
We trust that an evidence-based approach will be taken to your decision and, therefore, that no approval will be granted until multiple independent trials (i.e. not industry-sponsored) of at least a year, and preferably longer, have been conducted.
Dr John Read, Professor of Clinical Psychology, University of East London.
Dr Pat Bracken, Consultant Psychiatrist, Ireland
Dr James Davies, Medical Anthropology, University of Roehampton
Dr Peter J Gordon, Consultant Psychiatrist for Older Adults, NHS West Lothian.
Dr Rex Haigh, Consultant Psychiatrist in Medical Psychotherapy, Berkshire NHS
Dr Peter Kinderman, Professor of Clinical Psychology, University of Liverpool
Dr Irving Kirsch, Associate Director, Program in Placebo Studies, Harvard Medical School;
Professor Emeritus, Psychology: University of Connecticut (USA) & University of Hull (UK)
Dr Hugh Middleton, Psychiatrist, University of Nottingham
Dr Clive Sherlock, Psychiatrist, Oxford
Dr Derek Summerfield, Consultant Psychiatrist; Hon. Senior Clinical Lecturer – Institute of Psychiatry, Psychology & Neuroscience, King’s College, London
Dr Philip Thomas, Formerly Professor of Philosophy, Diversity & Mental Health, University of Central Lancashire; Formerly Consultant Psychiatrist
Dr Sami Timimi, Consultant Child and Adolescent Psychiatrist
Despite many subsequent emails, no meaningful response to the concerns raised, and research evidence provided, has been received from the MHRA. Efforts, with both the MHRA and the EMA, to obtain minutes of meetings, committee memberships and conflict of interest statements of individuals involved in esketamine decisions, have failed.
On 29.11.2019, the twelve wrote to the MHRA again, saying:
‘It is incumbent upon the MHRA to exercise their obligation, within the permitted 67 day period, to raise the various safety and efficacy issues clearly not dealt with in the EMA ‘opinion’ and insist that the procedure be referred back for further examination. We believe that failure to do this would represent a blatant failure to fulfil its remit to act in the public health interest of the citizens of the UK.’
No meaningful response has been received.
The MHRA has also failed to respond to multiple letters from the All-Party Parliamentary Group (APPG) for Prescribed Drug Dependence asking when MHRA would be discussing the drug. In October, the APPG’s chair, Sir Oliver Letwin MP, wrote to the UK regulator outlining his objections to esketamine as a drug likely to cause ‘dependence, addiction and withdrawal’. He asked MHRA not to approve esketamine, ‘at least until long-term trials have taken place and the long-term risks are fully understood’.
Members of the UK online support group, Let’s Talk Withdrawal, which represents people negatively affected by antidepressants, antipsychotics and benzodiazepines, also wrote to the MHRA requesting longer-term studies before esketamine is licensed. Their letter was not even acknowledged.
In October, the evidence for esketamine was scathingly critiqued in the Lancet, by prominent U.S. psychiatrist Dr Erick Turner (a member of the USA’s Food and Drug Administration’s Psychopharmacologic Drugs Advisory Committee).
The role of drug companies
In the U.S. it costs more than £25,000 to treat one patient for a year with esketamine.
The lack of transparency of these agencies is a serious matter. If they approve esketamine, on the basis of such inadequate research, it will suggest they are more interested in keeping the drug company happy than keeping the public safe.
89% of the EMA’s funding, and 100% of the MHRA’s funding, comes from drug company fees.
Both the members sent by MHRA to represent the UK on the EMA, Dr Nithyanandan Nagercoil and Dr Marie-Christine Bielsky, are ex-employees of drug companies.
The two most prominent promoters of esketamine in the UK, psychiatrists Professor Allan Young and Dr Rupert McShane, both have significant financial links with Janssen-Cilag, the maker of esketamine.
Consultant Psychiatrist, Dr Rex Haigh, a co-signatory to the 31.10 letter, commented:
‘The evidence is that ketamine is the most dangerous of the psychedelics and dissociants. We remain hopeful that unlike the USA’s FDA, our MHRA will take an evidence-based approach, ignore the drug company hype, and decline the application’
Professor Peter Kinderman (Liverpool University), another co-signatory, added:
‘This drug has been widely criminalised to protect people from the harms associated with it. While we certainly need new ways of helping people in distress, prescribing party drugs is unlikely to be the answer.’
Another co-signatory, Dr James Davies, a spokesman for the Council for Evidence-Based Psychiatry, has stated:
‘We are deeply concerned about the proposed approval of esketamine. It works via an opioid mechanism and is likely to cause serious problems of addiction and withdrawal.
‘No one should forget the troubled history of psychiatric medication, where supposedly safe and effective medicines turn out to be addictive and damaging when used long term. We urge the MHRA to deny this drug a licence at least until long-term trials on safety and efficacy have been completed.’
Professor John Read, University of East London
This is, indeed, seriously worrying not only v specifically, but also generally re attitudes.
This is, indeed, very worrying. Not only specifically – but generally, re attitudes re drug companies and their freedom….
Dear folks at CEP:
Why am I not surprised by this? Perhaps because I worked for pharmaceutical companies for 13 years as a scientific writer.
When working for these companies I was appalled at their attitude regarding clinical research studies where upper management emphasized speed and profit over patient safety.
They also emphasized spending money on marketing rather than on scientific integrity.
So, as I said, I’m not surprised about what you posted about ketamine/esketamine.
“The two most prominent promoters of esketamine in the UK, psychiatrists Professor Allan Young and Dr Rupert McShane, both have significant financial links with Janssen-Cilag, the maker of esketamine.”
This fact alone should be enough to completely discredit and shut this endeavor down completely!
How interesting that the MHRA would push forward with a drug that has proven serious problems with it, as well as suicides, while other agents are much better candidates. By the way I don’t necessarily promote any drug usage as non-drug therapies such as Somatic Experiencing can be much more effective. However drugs such as MDMA (“E”) have shown a lot of promise over the years with zero suicides as far as I know, see https://michaelzfreeman.org/study-that-proved-mdma-e-causes-brain-damage-mistakenly-gave-animals-meth/
The Ketamine thing also seems to be an emphasis of psychiatry’s obsession with the mind/body split. Ketamine severely dissociates, whereas things like Somatic Experiencing (and the whole Somatic field) show that people with trauma need to got more in contact with their bodies. There is somewhat of a paradigm shift going on towards these much more effective body work therapies. See just one article on my site about this – https://michaelzfreeman.org/the-ordinary-miracle-of-healing/
It seems that the very mechanisms of oversight are corrupt by design, it is not surprising then that those tasked with making such weighty decisions who have arrived at that responsiblity via the revolving door of profit interest groups will act therefore in the best interests of corporate and financial gain and not In the public interest.
This is indeed terrifying. I wonder how closely related esketamine is to ketamine, which is used as an anaesthetic for horses and cattle. It renders them utterly incapable.
It sounds as though this would be yet another drug which turns the heads of patients experiencing difficult life syndrome into blocks of wood, preventing them from understanding and resolving their difficulties and leading fulfilling lives and from being active participants in their own lives. Would prescribing it by any chance be cheaper than talking therapies and minimise inconvenience to others? It seems that the population is being gaslighted; told that it has a plethora of disorders which are really disorders of society, often resulting from poverty and ignorance, rather than diseases of the body which can be diagnosed scientifically and treated with drugs.
Perhaps the Royal College of Veterinary Surgeons would be able to advise?
Ketamine is a racemic mixture of the drug. Whereas Esketamine is the s-enantomer of Ketamine. The distinction simply relates to how the different components of the racemic mixture of Ketamine (the s-enantomer vs the r-enamtomer) rotate light.
For a further understanding of the differences between Ketamine and Esketamine visit “Uptodate.com”. The main topics presented on the site about the two drugs are listed below. Take care.
MECHANISM OF ACTION
Single intravenous infusion
Treating suicidal ideation
Repeated intravenous infusions
SOCIETY GUIDELINE LINKS
Intravenous anesthetic induction agents
Please also realize that Ketamine is usually taken via injection (intravenously) and Esketamine is administered nasally and requires a prescription……If that really makes a difference?
Clearly and based on evidence of repeated ignoring of letters and appeals – it is useless to waste time writing to MHRA. I have had similar experience in the past. The thing that should now be done urgently is to write to the Health Minister – Matt Hancock. Also from personal experience, he will listen to your appeals and use his parliamentary authority to put a stop to this blatantly corrupt behaviour. He has declared publicly on the Radio 4 Today Programme that he is tackling addictiion, in all its forms, which includes opioids and antidepressants. I appeal to CEP to stop wasting time on tackling the criminals who are without conscience or morals, “the monkeys,” – and go right up to the top – the government The NHS is the priority of this new government. PM Boris Johnson can withdraw funding from MHRA – crush them once and for all. Money is all they care about, so take away the money. BE strong and determined – give the government the evidence and your support and go very, very public. l
I endorse everything Rosemary has said. The time has come to put people before profit.
Drug companies have become too powerful. They have too much influence within some parts of the medical profession and I suspect they have used financial incentives to people in government too. I honestly do not know how these people who advocate the use of this dangerous drug can live with their selves.
“mantra of “just get the drugs into the patient” to the extent that we now in the UK even have policies for lying to patients and hiding medicine in their food or drink.”
I knew that doctors were allowed to lie to their patients about psych drugs in the UK but “hiding medicine in their food and drink”
Anyone know any more about this ?
When a psychiatrist describes a movement disorder as “a habit”. then be afraid. Be very afraid.