The chemical formula of ketamine, a powerful anesthetic that was used to allegedly sedate Elijah McClain during an arrest. He died days later. (Getty Images)
One of the many disturbing police brutality cases to be revisited during the national groundswell of Black Lives Matter support has been that of Elijah McClain the 23-year-old massage therapist and violinist from Aurora, Colo., who was minding his own business and walking home last year when his quirky manner and appearance inspired someone to call the cops on him, leading to his death.
And one of the most alarming details of his case was that it involved the administering of a powerful anesthetic, ketamine, by Aurora Fire Rescue, who allegedly arrived on the scene at the behest of police and injected McClain who reasonably panicked when police officers became aggressive and put him in a chokehold with 500 mg of the drug. The injection, which was enough to sedate a man twice his size, may have played a part in the death of McClain, who went into cardiac arrest on his way to the hospital and later died.
So how did ketamine, a drug used in high doses as a medical sedative and in low doses to combat depression (and, illicitly, as a party drug) get involved in this arrest? While it also played a prominent role in Minneapolis where police allegedly directed EMTs to inject ketamine into dozens of suspects in 2018, leading to an investigation that further revealed suspects were being enrolled in a ketamine study by Hennepin Healthcare without their consent overall, its an uncommon situation. Thats according, at least, to Maria Haberfeld, co-director of the NYPD Police Studies Program at John Jay College of Criminal Justice in New York, who tells Yahoo Life that using ketamine to sedate suspects is practically unheard-of.
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But, she notes, There is nothing general about American law enforcement, with over 18,000 different depts., 97 percent of which are small police departments with less than 50 police officers Im not surprised to find anything and everything, because there are no standards.
And while the use of ketamine on suspects is reportedly legal in Colorado, Haberfeld, who has studied police standards and misconduct for over 20 years, notes that it is not an accepted or legal practice in New York or in any major city. I have no knowledge of any authority, whatsoever, on the part of police to require the EMTs to engage in any specific medical intervention [or] if this is legal or not in a given jurisdiction.
But it is clearly happening, at least in Aurora and Minneapolis. So, what is ketamine anyway? What is it used for, typically, what are the risks and how might it have contributed to the death of McClain? We asked some experts on the drug to explain.
Ketamine was originally developed as an anesthetic agent in the 1960s, and gained popular use starting in the 70s as a field anesthetic during the Vietnam War and others because its very safe to administer in terms of having adverse effects on respiration, explains ketamine expert Gerard Sanacora, a professor of psychiatry at Yale University and director of the Yale Depression Research Program. Its officially in the class of dissociative anesthetic drugs. And, yes, all three versions of ketamine also known as ketamine racemic mixture or ketamine hydrochloride are one and the same.
In addition to being a general go-to anesthetic in operating rooms and emergency rooms, Sanacora says, more recently, its become very commonly used for pediatric emergencies. And its gained a lot of attention in the past decade or two because its been shown to have rapid onset of antidepressant properties. In 2019, the FDA approved a derivative of ketamine esketamine, in the form of a nasal spray to treat depression. Further, adds Sanacora, referring to the McClain case, its come under real interest as a rapid induction sedative. And, notes Alan Schatzburg, a professor of psychiatry at Stanford University who has urged caution in the use of ketamine for depression, Its also been used in certain clinics for severe chronic pain treatment. The main difference for each use lies in the dosage, as well as the route of administration intravenously, orally or, as in McClains case, by intramuscular injection. (As a party drug, it is typically cooked into a powder form and then snorted.) For antidepression use, for example, small, controlled doses are administered, while larger ones are needed for sedation.
Its not a straightforward drug, notes Sanacora, explaining that the main effects come from how it seems to bind to the brains major neurotransmitter of glutamate, blocking the activity, and initiating a whole cascade of events, depending on the dosage. At lower doses, the drug can be excitatory it can excite brain regions and cause an increase in metabolism. Animals tend to move around a lot more people become a little bit more disinhibited, he explains. But at higher doses, it becomes much more sedating, decreasing activity in the brain and taking on sedative and anesthetic properties. It is fast-acting, he says, and has a short half-life and is metabolized quickly, so most of the time its gone within a couple to a few hours of taking it. Schatzburg adds that the dose for agitation is high, at 4 mg to 5 mg per kilo, with which a patient will fall asleep in six minutes.
Short-term risks can be either physiological usually a transient increase in heart rate or blood pressure with a lower dose, or, with higher doses, a relatively low risk of respiration problems or psychological. So, in some patients, [low doses] could create a feeling of anxiety, and really change your perceptions and cognition so you may not be thinking clearly. Long-term risks come more with the high-level abuse of ketamine and can include bladder or gastrointestinal problems.
There are higher risks involved in an out-of-hospital setting, when the individuals medical history or current situation is unknown, as with McClain. There is definitely a higher risk, and there are many studies showing a higher risk of intubation when drugs are given in the field [where] youre not able to do blood work or an EKG to try to understand the situation. But the flip side, he says, is that by doing nothing in a situation when someone is highly agitated, theres a real risk too. Schatzburg says that before learning of the McClain incident, I never knew that it was used this way. The 500 mg, he adds, is a whopping dose.
That depends. This is a really difficult thing ... and the true definition of a dilemma, the worst thing for a clinician or EMS, when youre called to someone who is highly agitated and you cant figure out what is going on, says Sanacora. When someone is in a state of acute agitation, sometimes referred to by police and EMTs as excited delirium, he says, there is a relatively high mortality and morbidity risk, so people in those states run a risk of 5 percent to 10 percent of having a really bad outcome ... [so] there is some pressure to take care of that quickly.
Physical restraint, Sanacora explains, is not necessarily the best thing, because part of the physiology thats actually going on during this is called autonomic dysfunction, which is the way the body is normally keeping things in control. Your temperature, your blood pHm, your heart rate is in many cases out of control, so a person can become hypothermic [or suffer from] metabolic acidosis, a serious acid-base imbalance in the body. Pushing against restraints can cause muscle breakdown, which in turn can release a lot of potassium, which can be damaging to the heart. So, there is a real urgency to treat someone like that, and just leaving them in that state is quite dangerous. Its complicated. The standard sedative injection to be used in these situations, he says, has been an antipsychotic along with a benzodiazepine, but that comes with risks to heart and respiratory function. Ketamine research, meanwhile, is suggesting it may be one of the safest things you can give in that situation. So its not crazy.
Schatzburg agrees that people can have excited delirious states where theyre nonresponsive to intervention. Thats real. And theres a relatively high mortality associated with it. But he personally believes that a benzodiazepine might bring less risk in these out-of-hospital situations, and worries that if use of ketamine continues in this way, We are going to have a number of untoward events, if I were to predict. Referencing what hes read about McClain, he notes, With somebody in a manic frenzy, theres risk. But if hes just walking along doing nothing, well, theres not much risk there.
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