Although it is a legitimate medication, ketamine is also often used illegally as a recreational drug and smuggled into the country, as can be seen in this police bust where the drug was packed in Chinese tea packages. — Photos: Filepic
The finding by the Los Angeles County medical examiner in the United States that TV sitcom Friends star Matthew Perry died from “acute effects” of ketamine is generating interest in the drug.
Ketamine is generally safe when taken under medical supervision, experts said, but the Perry case also underscores potential risks.
Here are some basics about the drug.
Autopsy results
Perry was found dead in his hot tub at home on Oct 28 (2023).
The medical examiner concluded the death was an accident.
The high levels of ketamine found in his blood could cause “lethal effects” from cardiovascular (heart) overstimulation and respiratory depression, the Los Angeles County medical examiner said in a report.
Other contributing factors in the actor’s death included drowning, coronary artery disease and the effects of buprenorphine, a medication used to treat opioid use disorder.
Perry was undergoing ketamine infusion therapy every other day for a period of time, but had reduced that intake more recently.
His last known infusion was a week and a half before his death.
The medical examiner noted the ketamine could not have been from that session, as it typically disappears from the system in detectable amounts within three to four hours.
What is ketamine?
A legal medication commonly used medically as an anaesthetic, ketamine has been increasingly offered “off label” at private clinics in the US in an effort to treat depression and other mental health disorders, said University of California, Los Angeles (UCLA) addiction medicine and infectious disease specialist Dr David Goodman-Meza.
In 2006, the US National Institute of Mental Health concluded that an intravenous (IV) dose of ketamine had rapid antidepressant effects.
About 300 clinical trials have been held and they have broadly found that ketamine is extremely fast-acting, compared with traditional antidepressants, and can relieve depression for a period that can last days or weeks.
A prescription version of ketamine, known as esketamine, which is given through a nasal spray, was approved in 2019 by the US Food and Drug Administration (FDA) for treatment-resistant depression.
The number of ketamine clinics in the US has risen from a few dozen to several hundred in the last few years.
Ketamine is “generally really safe,” said Keck Medicine of USC clinical operations chief and pain services medical director Dr Michael Bottros.
Side effects such as dissociation aren’t as worrisome in a medical setting when ketamine is infused, because “healthcare professionals will be ensuring that patients are not moving around unsupervised”.
But he said that based on the autopsy findings, which indicated ketamine was found in his stomach, Perry may have taken ketamine orally and the risk is that “there was too much taken at once”.
The physician cautioned that he did not know what the prescription dose for Perry was, but that “the level in his blood is higher than it would be” for what is considered an “appropriate” oral dose.
And “the problem here is that he was in a hot tub,” Dr Bottros said.
In a dissociated state, he said, someone could sink into a tub without realising it.
He said the tragedy should not dissuade people from being treated with ketamine under the supervision of medical professionals.
“There has to be a healthy balance between the concerns, along with the known benefits,” he said.
What are the risks?
Perry (left), most well-known for his role as Chandler Bing in the TV sitcom Friends, died due to the acute effects of ketamine.
Some people also snort or inject ketamine recreationally to experience euphoric or “dissociative” effects that cause someone to feel separated from their own body, Dr Goodman-Meza said.
At very high doses, it can make people feel immobilised and spur hallucinations – an experience called a “K-hole”.
The drug can complicate breathing and increase demands on the heart, he added.
If someone already has coronary artery disease and is taking high doses of ketamine, “that could then speed up your heart, create more demand, but then your arteries don’t have the ability to supply that demand,” the physician explained.
Tucker Avra, a UCLA medical student who works with people recovering from ketamine addiction, said that people using ketamine can also be at risk of passing out or falling down.
“If you’re in water,” he said, there’s “a risk of drowning by basically putting yourself under anaesthesia by using it.”
He said those using ketamine should test their drugs for the synthetic opioid fentanyl, have naloxone on hand to reverse an opioid overdose in case the drug is contaminated with opioids, and avoid using the drug alone.
He hopes the tragedy of Perry’s death might encourage doctors to learn more about the side effects of recreational use.
Physicians also urged people not to write off ketamine for medical treatment in light of the tragedy.
When doctors turn to ketamine for patients with depression, “these are patients who might not have anything else left for them” because typical treatments have failed, Dr Bottros said.
“Ketamine could be literally lifesaving for them.”
Overdosing on ketamine
“Ketamine overdose by itself is exceedingly rare,” said LA County Public Health Department Substance Abuse Prevention and Control Division prevention associate medical director Dr Siddarth Puri.
In general, much of the overdose concern around ketamine surrounds mixing it with other substances that can also affect breathing or heart rate, such as alcohol or opioids, he said.
People are also at higher risk of bad outcomes if they have underlying conditions such as high blood pressure or breathing problems, he said.
In medical settings, Dr Puri said that “your doctor is making sure your heart can manage and respond to ketamine appropriately, your breathing is OK, you’re not having any kind of allergic reaction,” and that other medications will not compound its effects. – dpa
