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Ketamine is a dissociative anesthetic used in veterinary and human medicine since the 1970s. Its clinical use has expanded to control of seizures, pre-hospital emergency medical services (EMS), and is finding new purpose as an analgesic alternative and antidepressant. Ketamine brings hope for effective management of chronic pain in the absence of opioids, and decreasing suicidal ideations, however, its persistence as a recreational drug for its hallucinogenic properties remains. In the wake of expanding medicinal purposes, the diversity of New York City’s population was explored to better understand its misuse. This retrospective study looks at the prevalence of ketamine in driver fatalities over a period of 18 years (2003–2020) and cases involving suspected driving under the influence of drugs (DUID) over a period of 6 years (2015–2020). Ketamine was identified in 6 driver fatalities and in 47 DUID cases. None of the driver fatalities were suspected of ketamine misuse, due to administration either in hospital or EMS administration. In the DUID cases, an increasing trend was observed over the 6-year study period with 100% (N = 47) of the cases confirmed as non-hospital/non-EMS administered ketamine. Of the DUID cases, 94% were male, with the majority between the age of 21–39 years (85%) and were predominantly Hispanic (36%) and Asian (34%). Blood concentrations of ketamine ranged from 27 to > 2000 ng/mL with polydrug use prevalent. The most common drug classes detected in addition to ketamine were cannabinoids (38%), ethanol (32%), benzodiazepines (26%), cocaine (19%), and amphetamines/MDMA (15%). In 2019, 2-fluoro-deschloroketamine (2F-DCK) was identified in two cases for the first time. Despite its increased acceptance for mental health disorders, ketamine’s persistence and misuse as a recreational drug remains and should continue to be monitored by relevant toxicological, clinical, and law enforcement communities along with emerging illicit ketamine analogs.

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Introduction: Deaths due to drug intoxications in the United States have increased. Public health agencies track the specific intoxicants using death certificate data in order to develop and focus prevention strategies. Criteria used to decide what deaths need toxicological investigation and how these deaths are certified will affect this data. Methods: We retrospectively reviewed the investigative, autopsy, and toxicology reports of 118 fatal intoxications that were certified as "acute opiate intoxication." Results: Of the 113 decedents in whom morphine was detected, 84 were determined to involve heroin. For 61 of 84 heroin deaths, the heroin diagnosis was based upon the detection of diacetylmorphine, 6-acetylmorphine, and/or a lower blood codeine to morphine concentration. For 23 of 84 deaths, the determination was based upon morphine detection and illicit substances and/or paraphernalia at the scene. Of the 61 of 84 heroin deaths diagnosed by direct toxicology results, 33 of the 61 (54%) did not have illicit substances or paraphernalia at the scene. Toxicology identified 33 of 84 (39%) heroin fatalities that would not have been distinguished from morphine intoxication by the scene investigation. Conclusions: The majority of deaths due to opioids can be further classified based upon the toxicological analysis and scene investigation. As heroin deaths may have no illicit substances/paraphernalia at the scene, investigators should not solely base their decision to perform an autopsy/toxicology on the scene absence of illicit drugs/paraphernalia. In our study sample, if toxicology testing were to be only performed when illicit substances/paraphernalia were found at the scene, a high portion of heroin deaths (39%) would have been missed.