The stimulant khat--another door in the wall? A call for overcoming the barriers.

AIM In this article, we comment on the current international discourse on khat, we highlight pitfalls and and suggest balanced national international regulatory actions. METHOD A brief an focussed review of the available literature on khat and health and examples from our own research are provided. RESULTS The use patterns of catha edulis (khat) have changed throughout the last decades. During this period khat has had a remarkable economic boom and developed from a niche crop to the backbone of the regional economy. Now it contributes to the livelihoods of millions of people. Today, khat use is often the proverbial "Door in the wall" for large parts of the populations in African and Arab countries beyond the traditional user groups. Its use is often excessive and not restricted by social regulation mechanisms. Under such conditions, problematic khat use patterns develop rapidly, exemplified by the growing group of binge users, and it gets even prevalent among especially vulnerable groups such as children, people with mental disorders or pregnant women. The currently existing scientific evidence suggests that problematic use patterns not the use per se can be linked to numerous health consequences. CONCLUSION This paper argues that changed patterns of khat use are a burden for some of the most underdeveloped countries in the world. But the debate around khat is stuck between extreme poles arguing for prohibition or for de-regulation. Here, we call for a balanced action of governments and international organizations leaving behind the decades of debilitating debate pro vs. contra scheduling and banning khat leaves. Instead, regulation and harm-reduction measures are urgently needed. We suggest a number of steps that should be taken immediately to better understand current khat use patterns, to address noxious excesses and to relieve suffering.