The long awaited toxicology report has been released for the sudden death of "Friends" star Mathew Perry. He was found face down in his hot tub at home and the autopsy states he died of "acute effects of ketamine" with drowning, coronary artery disease and buprenorphine contributing. That's a lot to unpack so let's see if we can make medical sense out of his tragic death.
What we know. Mr. Perry was open about his struggle with addiction and being in-and-out of treatment programs for over half of his life. He felt well enough to play pickle-ball the day he died and he was undergoing supervised ketamine infusions by a physician. His last treatment was 1-1/2weeks before he died. Buprenorphine is a prescribed sublingual pill taken daily and widely used to treat opiod use disorder (OUD).
Ketamine is a controlled substance widely used for decades, in surgery and in emergency departments, as an analgesic (pain treatment) and amnestic (you don't remember much). It is rapid acting with less cardiovascular and respiratory depression seen with other anesthetics. It is especially effective and safe to use with children in the emergency department. It is also used "off-label" for acute and chronic pain.
More recently, ketamine has been found to be effective for treatment-resistant depression, that is, severe depression that has not been relieved with other medications and treatments. Relief with ketamine happens rapidly, unlike SSRI anti-depressants that can take weeks to have an effect. Ketamine clinics have popped up all over the place and are generally high-profit centers owned by private equity or business folks and staffed by anesthesiologists and nurses. I presume Mr. Perry was getting Ketamine at such a clinic, hopefully under the supervision of a psychiatrist. You can find a ketamine clinic on every corner in LA.
Ketamine is administered IV and can be very effective for people who have failed other treatment for their depression and especially people who are considering suicide, as its effects are immediate. Nasal ketamine can be prescribed for home use and is much more affordable. I won't go into the mode of action but it is considered a dissociative psychedelic type drug.
It is highly unlikely the ketamine found in his system (at levels of anesthesia) were remaining from his clinic infusions 1-1/2 weeks before his death. Ketamine is around on the "street" as a popular recreational drug and mixed with buprenorphine can cause serious respiratory depression, hypertension, arrhythmias and sedation. It would appear he had an overdose, passed out and drowned in the hot tub. Hot tubs themselves can cause increased heart rate and taking any sedating drug or alcohol and getting into a hot tub is dangerous.
Pharmaceutical drugs can be life saving or life ending, depending upon set and setting. Ketamine for depression may have been a good thing for him. Buprenorphine is life saving for people with opiod addictions and it was also a good choice for him. In fact, it should be more widely prescribed to treat the current opiod epidemic. (Thanks Sacklers, Big Pharma and Government!)
Unfortunately, the combination of recreational ketamine, mixed with his prescribed buprenorphine and the hot tub was the wrong set and setting for Matthew Perry. May he RIP. He has a lot of fans and people who cared very much for him in this life.