Expensive, dangerous and very ‘en vogue’

When Los Angeles County medical examiners worked last year to determine how Matthew Perry died, they discovered something startling.

The amount of ketamine in Perry’s bloodstream was about the same as what would be used during general anesthesia, his autopsy showed.

Perry’s death—now the subject of an investigation by the Los Angeles Police Department and the Drug Enforcement Administration—is putting a spotlight on the growing use of ketamine. There are more prescriptions, dedicated clinics and a burgeoning black market that medical and law enforcement professionals say is being fueled by the wealthy.

Far removed from its club-drug days, when ketamine was known as “Special K” or “Super Acid,” the drug’s newest users include the rich and famous.

“These kinds of en vogue, money-making drugs have just exploded with certain strata of society,” said Dr. David Goodman-Meza, an addiction-medicine and infectious-disease specialist at UCLA.

Part of the drug’s new boom, medical experts say, is being driven by clinics and online services offering intravenous treatments and prescriptions for in-home use—such as tablets and nasal sprays—for ailments including depression, post-traumatic stress disorder and substance abuse.

It doesn’t come cheap. A single intravenous session can cost from $350 to more than $700. Many clinics bundle treatments, which can cost thousands of dollars.

But an even bigger concern is those taking the drug without close medical supervision.

“I think that’s a recipe for disaster,” said Dr. Caleb Alexander, an epidemiologist and professor at Johns Hopkins Bloomberg School of Public Health.

Ketamine is legal and commonly used as an anesthetic, but it also is used recreationally to create a sense of disconnect and sedation—and, at times, hallucinations.

Elon Musk posted on X that he has a prescription for ketamine “for when my brain chemistry sometimes goes super negative.” Sharon Osbourne told People she underwent three months of ketamine therapy. “Saturday Night Live” alumni Pete Davidson revealed during a comedy set in Atlantic City that he had taken ketamine daily for four years before he checked himself into rehab.

The drug is offered off-label to treat depression and other mental health disorders. The Food and Drug Administration has not approved its use for those treatments, and while prescribing drugs for off-label use is not uncommon, some medical experts worry that the risks are being ignored.

“There has been an explosion of ketamine usage with these kinds of online direct-to-consumer marketing practices,” Goodman-Meza said. “If enough people use a drug, you are going to see a certain proportion that is going to start seeing adverse side effects.”

When Dr. David Mahjoubi opened Ketamine Healing Clinic of Los Angeles in 2014, the board-certified anesthesiologist said the treatment was still largely unknown to the general public.

That changed about five years ago, he said. Demand increased. He opened a second location in Orange County in March 2022.

“There’s been a blow-up of ketamine clinics,” he said, adding that he’s also seen an increase in online sites offering telehealth services that deliver ketamine prescriptions to a patient’s home.

Mahjoubi is president of the American Board of Ketamine Physicians, a new organization of medical professionals that, according to its website, vets providers who use the drug “for the treatment of mood and chronic pain.”

For $700, his clinic provides a one-hour ketamine infusion personally monitored by Mahjoubi. Memberships for six and 12 sessions are also offered—for $2,580 and $4,650, respectively.

But he said he worries ketamine’s profitability has prompted some companies to put financial gains ahead of patients’ health.

“Someone would just open [a clinic] up and stick an untrained nurse in there and have them give [the patient] whatever dose in whatever duration,” he said. “It was quite distressing to see that being done incorrectly.”

Because he supports off-label ketamine use for those with mental health issues, Mahjoubi said he also offers a cheaper treatment at his clinic. For $350, patients can receive the same one-hour infusion, monitored by a nurse. The discounted price, he said, is to “provide it to people who can’t afford to see me.”

For most patients, their primary concern is whether ketamine is going to work and how long it will last, Mahjoubi said.

Since Perry’s death, however, many more have asked about the risks.

“I say Matthew Perry was someone who was struggling with addiction way before he started dealing with ketamine,” Mahjoubi said, noting that he thinks other factors, including buprenorphine, a medication used to treat opioid-use disorder, also contributed to the actor’s death.

Perry was found dead in a hot tub at his Pacific Palisades home Oct. 28 with trace amounts of ketamine in his stomach and a much higher concentration in his bloodstream. In December, the L.A. County Department of Medical Examiner determined the actor died from acute effects of ketamine.

While Perry had been receiving ketamine treatment every other day for some time, the medical examiner’s report noted that he had reduced his intake, and his last known infusion had been more than a week before his death. Detectable amounts of ketamine from those types of treatments normally disappear from a person’s system in three to four hours, the coroner said.

Investigators are now trying to determine how Perry got the drug.

His autopsy noted that Perry had no other drugs in his system, and while he had been open about his struggles with addiction in the past, he had been 19 months sober at the time of his death. There was no evidence of illicit drugs or paraphernalia at his home.

The risks of off-label ketamine use are not fully understood by medical professionals.

“There is little data to support these uses, and it’s a really risky proposition to be using this drug willy-nilly to treat these sorts of conditions,” said Alexander, the John Hopkins professor. “The evidence just isn’t there.”

In October, noting an uptick in use, the FDA issued a warning about ketamine, saying the drug is not approved for the treatment of psychiatric disorders.

“FDA is aware that compounded ketamine products have been marketed for a wide variety of psychiatric stress disorders (e.g. depression, anxiety, post-traumatic stress disorder … and obsessive-compulsive disorder); however, FDA has not determined that ketamine is safe and effective for such uses,” the statement read.

Use of ketamine for those treatments without monitoring, the agency warned, “may put patients at risk for serious adverse events.”

The drug’s proliferation, Alexander said, has been compounded by events that helped make it easier to obtain.

The Drug Enforcement Administration in 2020 allowed doctors to prescribe controlled medications online in response to the COVID-19 pandemic. The DEA has since extended that rule, allowing companies to continue marketing ketamine with online consultations.

Its off-label use also has placed ketamine in a medical and legal gray area, Alexander said.

Manufacturers are not allowed to advertise or promote the drug for unapproved uses, but clinics and some doctors have done so freely. The result: Some patients are self-seeking these clinics instead of primary doctors prescribing the medication.

Alexander said he worries about the long-term effects of repeated use in an untested setting. The FDA says ketamine use could lead to abuse, psychiatric events, increased blood pressure and slowed breathing.

Bill Bodner, former special agent in charge of the DEA’s Los Angeles field division, said ketamine use is increasing.

“People are hearing about the medicinal uses for it … [and] are sort of self-prescribing on the black market,” he said.

But the fact that ketamine has therapeutic usage and is being prescribed—even off-label—makes it difficult to police, Bodner said.

“It would be almost impossible to go after a doctor,” he said, unless there were issues regarding prescriptions, such as fraudulent scripts or an effort to hide the amount prescribed to a patient.

Cases like Perry’s, where he used ketamine at home and then died, would certainly draw scrutiny, Bodner said.

Still, for most law enforcement agencies across California, ketamine has remained a low priority, said Devin Chase, an instructor and board member of the California Narcotics Officers Association.

Ketamine doesn’t have the “street” presence of opioids like fentanyl and methamphetamine, which are cheaper and more prevalent, he said.

But there are concerns with ketamine use, especially for those who take large doses, said Chase, a narcotics officer with decades of experience.

“You can get addicted to ketamine, and there are people that use large amounts a day,” he said.

Bodner thinks the black market is also feeding an interest in ketamine.

During fiscal year 2023, Customs and Border Protection officers seized more than 8,000 pounds of ketamine being transported into the U.S. The year before, they nabbed 14,000 pounds. This year, CBP officers have seized 2,500 pounds through April.

It’s unclear how Perry obtained the ketamine cited in his death, but if it was provided by a doctor, investigators will likely want to know why, Bodner said.

“People are going to look at it and say, was that prescription justified?” he said.

Cases against doctors for providing drugs are difficult for law enforcement to pursue, Bodner said. In the Perry investigation, he said, detectives likely will seek to determine whether there was any effort to conceal the ketamine or who it was going to. If the drug was obtained through the black market, it would likely be an easier case.

Deaths connected to ketamine are “infrequent,” but not unheard of, said Rosa Valle-Lopez, a spokesperson for the DEA in Los Angeles.

In Los Angeles County, ketamine was listed as a primary or secondary cause of death in just 14 cases in 2022, the spokesperson said, citing information the agency obtained from the Los Angeles County Department of Medical Examiner.

That would link ketamine to 0.4% of all 3,220 drug-related deaths in L.A. County for that year, the most recent data available.

But the fact that ketamine has therapeutic uses makes it complicated for law enforcement to pursue a case against a distributor, especially if they are a licensed medical professional, said Dmitry Gorin, a defense attorney who handles drug cases.

Still, federal officials have filed criminal charges in some cases. In January, two doctors from St. Louis were indicated after DEA investigators alleged they were illegally distributing ketamine.

While Bodner said no charges have been brought in connection with any ketamine fatalities in L.A., other high-profile drug-related celebrity deaths have increased pressure for criminal charges.

Two years after Michael Jackson died in 2009, Dr. Conrad Murray would be convicted of involuntary manslaughter. Prosecutors portrayed him as a reckless physician paid $150,000 a month to treat the pop star’s insomnia with a nightly drip of propofol.

Two years after model Anna Nicole Smith’s accidental overdose in 2007, two of her doctors and her boyfriend were charged with orchestrating her array of prescriptions. Then-Attorney General Jerry Brown called their conduct “damn serious.” One doctor was acquitted, a psychiatrist was convicted of a misdemeanor and a judge later dismissed the charges against her boyfriend.

When rapper Mac Miller died in 2018 as a result of unwittingly taking fentanyl-laced pills, three drug dealers were convicted and sentenced to prison for selling him the drugs.

Mahjoubi, who said his clinical use of ketamine follows all medical protocols, worries that other clinics and online services are not as careful and whether that could mean more serious consequences, like Perry’s death.

“I’m really surprised that nothing has been done,” he said.

2024 Los Angeles Times. Distributed by Tribune Content Agency, LLC.