There is an elevated prevalence of participation in risky behaviors among criminal justice populations. In the United States, about two-thirds of state prisoners reported regular drug use at some time during their lives (Mumola and Karberg 2006
). Over half (53%) of state prisoners met DSM-IV criteria for drug dependence or abuse during the past 12 months, which is well above the 2% prevalence of drug dependence or abuse in the general U.S. population during the same timeframe as indicated by the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC) (Mumola and Karberg 2006
). The use of psychoactive drugs places individuals at greater risk for engaging in unprotected sex (Kelly 2005
; Kurtz 2005
; Maxwell 2005
; Patterson et al. 2005
); however, participation in risky sexual behaviors varies by type of substance used. One under-explored drug that could place individuals at risk for contracting infectious diseases such as human immunodeficiency syndrome (HIV) is ketamine, a liquid pharmaceutical anesthetic.
The purpose of this study is to examine the relationship between illicit ketamine use and engagement in high-risk sexual behaviors prior to incarceration among a sample of drug users undergoing prison-based drug abuse treatment in the United States. Drug using criminal offenders whose repertoire includes having ever used ketamine at least once in their lifetime will be defined as ‘ketamine users.’ It should be noted that while the extent and context of ketamine use is unknown, this study is a first step in understanding the association between ketamine use and unprotected sexual behaviors in a criminal offending population.
Ketamine, a dissociative drug, was developed by the pharmaceutical company Parke-Davis in the United States in the 1960s (Corssen and Domino 1966
). Originally it was developed as a rapid-acting general anesthetic that was a medical alternative to phencyclidine (PCP) because PCP had adverse side effects such as irrationality and violence (Dotson et al. 1995
). Ketamine has been used as a surgical anesthetic for children, elderly, and wounded military personnel on the battlefield (Dotson et al. 1995
). Currently, the clinical use of ketamine is not commonplace because its side effects can produce vivid dreaming, hallucinations, and confused states; however, ketamine is still regularly used as a veterinary anesthetic (Curran and Morgan 2000; Fine et al. 1974
; Lankenau and Clatts 2002
; Perel and Davison 1976
). Ketamine also has analgesic actions and has been used in radiation therapy as well as in the treatment of severe burn victims or individuals with chronic pain (Dotson et al. 1995
; Fine 1999
). It should be noted that lower doses of ketamine are used recreationally, as compared to higher doses used in medical settings, and the use of an anxiolytic before medical treatment with ketamine can help control adverse psychological effects (Krystal et al. 1994
Non-medical use of ketamine was first observed in the late 1960s. Users included medical professionals, educated individuals, and recreational drug users who were seeking altered states of consciousness (Jansen 2001
; Lankenau and Clatts 2002
). Recreational drug users obtained ketamine through underground ‘medicinal chemists’ (Jansen 2001
) and most illegal ketamine on the streets was diverted from veterinary offices. The abuse potential of ketamine was noted in the 1970s (Reie, 1971
) and the National Institute on Drug Abuse responded by publishing pamphlets, reports, and manuscripts on ketamine as a drug of abuse (NIDA 2001
; Mathias 2003
). In 1999, ketamine was classified as a Schedule III drug under the Controlled Substances Act making ketamine possession for non-medical purposes illegal in the United States.
Ketamine has various street names including Special K, vitamin K, K, Special LA Coke, Super Acid, Super C, green, and cat Valium (Dotson et al. 1995
; NIDA 2001
). It is a unique drug because it is manufactured as an injectable liquid but is available on the street in liquid, powder, or pill forms (Lankenau and Clatts 2005
). There are various modes of ketamine administration in that it can be swallowed, smoked, drunk, snorted, injected intra-muscularly, or injected intravenously (Mathias 2003
). Some drug users take ketamine to achieve a psychological and physical state called the ‘k-hole,’ which is more easily achieved by injection (Mathias 2003
). Being in the k-hole lasts less than an hour and produces hallucinations and an intense distortion of time and space (Mathias 2003
). In reference to the k-hole, the use of ketamine may impede sexual functioning and/or make a user vulnerable to engaging in unprotected sex since judgment may be impaired. Other users, such as infrequent recreational users, may try to avoid the k-hole (Mooney 2008).
The non-medical use of ketamine can place the user at increased risk for contracting and transmitting blood borne pathogens, such as HIV. However, the existing literature on the relationship between ketamine use and engagement in HIV risk behaviors raises three additional questions. The first question surrounds the classification of ketamine as a club drug and users are described as youth who attend raves (Curran and Morgan 2000; Dillon et al. 2003
; Dotson et al. 1995
) or men who have sex with men (MSM) (Clatts et al. 2005
; Patterson et al. 2005
; Rusch et al. 2005); however, there are no known studies of ketamine use among individuals under criminal justice supervision despite that fact that criminal offenders are frequently the first to try ‘new’ illicit drugs (Yacoubian et al. 2002
). Consequently, it is also important to examine prisoners because their risky drug using behaviors before incarceration have lead to a high prevalence of HIV. In fact, the most recent Bureau of Justice Statistics report indicates that the overall rate of confirmed AIDS among prisoners was more than three times the rate in the general U.S. population (Maruschak 2006
). Moreover, there is a gender disparity in the prevalence of HIV among prison inmates with 2.6% of female inmates being HIV seropositive as compared to 1.8% of male inmates (Maruschak 2006
The second area in need of further examination is the role of injecting ketamine as a risk factor for contracting or transmitting blood born pathogens. It is common for ketamine injectors to share vials of liquid ketamine or injection equipment such as cookers (Lankeau and Clatts 2002; Lankeau et al. 2007). It should be noted that in a study of young ketamine users, the majority injected ketamine intramuscularly which is not as high risk as intravenous injections because the user is not drawing blood into the syringe barrel (Lankenau and Clatts 2004
). Nonetheless, the effects of ketamine are short-lived. Therefore, ketamine users may have to inject multiple times within a short period of time to maintain euphoria (Maxwell 2005
). This places the injecting ketamine user at risk for contracting or transmitting infectious diseases because users who are under the influence of ketamine may be less likely to engage in safe injection practices. Ketamine injectors may also underestimate their risks for HIV because injecting ketamine is viewed with less stigma because it is manufactured by pharmaceutical companies and is available in sterile vials (Lankenau and Clatts 2004
According to the Centers for Disease Control and Prevention (CDC), in 2005 injection drug use accounted for approximately 26% of the HIV/AIDS transmission cases for females and 18% of the HIV/AIDS transmission cases for males in the U.S. (Department of Health and Human Services, 2007
). Unfortunately, the Bureau of Justice Statistics (BJS) doesn’t collect information on the number of diagnoses of HIV/AIDS among individuals in the criminal justice system by transmission category.
A third under-explored area in the ketamine literature is on the relationship between ketamine use and participation in risky sexual behaviors. For example, the current literature focuses on ketamine use for men who have sex with men at circuit parties (Kurtz 2005
; Kurtz and Inciardi 2003
; Mattison et al. 2001
). However, there are no known studies that explore the relationship between ketamine use and sexual behaviors among criminal offenders despite research that suggests that individuals under criminal justice supervision are known to have engaged in risky sexual behaviors (Braithwaite and Stephens 2005
; Cotten-Oldenburg et al. 1999; Oser et al. 2006
; Oser et al. 2006
). In the U.S., sexual contact accounts for the majority of HIV transmission. In fact, the two most common transmission categories for HIV/AIDS for U.S. males are heterosexual contact with a person known to have or to be at high risk for HIV (13%) and men who have sex with men (61%) (Department of Health and Human Services, 2007
). In addition, the high risk heterosexual contact transmission category accounts for almost three-fourths (72%) of female U.S. HIV/AIDS cases (Department of Health and Human Services 2007
). As such, the combination of risky drug use and sexual practices places criminal offenders at higher risk for contracting and transmitting HIV and other infectious diseases.
This study contributes to the literature because it is the first known study to examine the relationship between ketamine use and participation in unprotected sex behaviors among a high risk group – criminal offenders. Using data from the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative’s Transitional Case Management (TCM) protocol (Prendergast, Cartier, & Hall, 2007
), bivariate analyses were used to identify differences in sociodemographic characteristics, substance use history, criminal justice history, and HIV sexual risk behaviors between ketamine users (n=44) and non-ketamine users (n=672). In addition, three Poisson regression models were used to identify the significant correlates of high-risk sexual behaviors in the 30 days prior to incarceration -- (1) number of times had unprotected sex while high, (2) number of times had unprotected vaginal sex, and (3) number of times had unprotected anal sex.