As an addiction medicine physician, I have cared for scores of patients with various substance use disorders: alcohol, cocaine, opioid, tobacco, cannabis use disorder and many others. Several articles about Matthew Perry’s death have focused on ketamine, and justifiably so as it was the ultimate cause of the actor’s death (drowning also contributed). But what I think is just as important to point out is what was NOT found in Perry’s system: opioids such as heroin, oxycodone and the highly potent, synthetic fentanyl.
Some of you might be thinking, ‘Wait, an opioid WAS found in Perry’s system.’ You would be right. Buprenorphine was detected at therapeutic levels. While the medical examiner concluded that buprenorphine might have contributed to Perry’s death through respiratory depression, I believe that the high, toxic levels of the powerful anesthetic, ketamine, overrode the low, safe amount of bupe.
While the exact reason for Perry’s use of buprenorphine is not known, we know that the medication has three primary FDA-approved clinical indications: treatment of opioid use disorder (OUD); detoxification from opioids; and pain management. In the past, Perry disclosed a history of opioid use disorder. Regardless of Perry’s reason(s), we also know that bupe is highly effective at binding opioid receptors, preventing other opioids like heroin or fentanyl from binding, and thereby reducing the risk of an opioid-related overdose.
So, why am I discussing buprenorphine? The primary reason is that bupe is a lifesaving medication that is still mostly unknown, both among the public and medical professionals. In fact, I didn’t learn about bupe until years after my formal medical training when I attained addiction medicine board certification upon discovering in 2013 that the leading cause of death among my patients—Boston’s homeless population—was drug overdose.
Because so few people know about bupe, it is both misunderstood and grossly underutilized. We are very much in the midst of a public health crisis. Opioid-related overdose deaths, primarily driven by illicit fentanyl, surged during the COVID pandemic, nearly doubling from 42,000 to 80,000 from 2016 to 2021. In 2022, nearly 110,000 people in the United States died from an overdose, mostly driven by the synthetic opioid, fentanyl. The death toll does not include the multiple collateral consequences including job loss, hospital stays, sick days and criminal justice costs.
Tom Arnold, actor, comedian and friend of Perry’s, has been outspoken about his long-term recovery from addiction. He recently told me that he has benefited from using buprenorphine.
“I saw bupe help my peers, too,” said the former writer for Roseanne. “Addiction is different for everyone. The first few days of rehab are the most important because a lot of people want to leave. They worry they’ll never feel right. We say they have no intention of using again but our addiction brain has other plans.”
Despite the staggering morbidity and mortality, on average, less than 20% of people with an OUD are receiving evidence-based treatment, which includes one of three FDA-approved medications for OUD (MOUD): methadone, buprenorphine or naltrexone. People of color are less likely to receive treatment.
For all these reasons, I feel compelled to remind the public of bupe’s key role in treating people with OUD. Unfortunately, the vast majority of people in the U.S. with OUD do not access any recommended medication. Stigma and lack of education are major barriers to treatment. Even Perry himself held stigmatizing views of buprenorphine. In Friends, Lovers, and the Big Terrible Thing: A Memoir, Perry perceived bupe as only a “detox med.” In an interview, he said bupe was “the hardest drug to get off of.” The Friends star’s views perpetuate a common myth associated with bupe: it’s still an opioid, and people taking bupe are simply replacing one addiction for another. (Perry might have had other reasons for discontinuing bupe but none that would have been clinically warranted).
So, how effective is buprenorphine? Pretty damn effective. A Yale study published just a few days ago showed that “detox” and long-term rehab treatments that don’t include buprenorphine or methadone (i.e. the key features of abstinence-based programs) are no more effective at preventing overdose deaths than no treatment at all. Multiple studies have shown that buprenorphine as well as methadone—a tightly regulated medication that can only be administered in specialized opioid treatment programs—are associated with reductions in overdose, recurrence of opioid use and mortality. Other public health benefits of MOUD: a reduction in transmission of HIV and hepatitis C, and increased treatment retention among justice-involved individuals.
As with individuals with other chronic conditions such as diabetes and heart failure, people with OUD need to be treated long-term. Unfortunately, people who are tapered off buprenorphine after 1 or 3 months experience relapse rates greater than 90%. We don’t prematurely stop a patient’s metformin or amlodipine. So why are we cutting off lifesaving bupe or methadone, particularly in the midst of an overdose crisis?
“Recovery can be a struggle,” confesses Tom Arnold. “Addiction is different for everyone. My friend Matthew tried everything—12-step, ketamine, Suboxone—and suffered terribly. But he ultimately made the mistake a lot of us make: he became his own doctor and it killed him.”
At the end of the day, the talented and kindhearted Perry left this world far too soon. I am heartbroken over my fellow Canadian-American’s passing, but it was NOT in vain. The beloved actor knew that addiction was a chronic disease of the brain and NOT a moral failing. He spent years helping others get the treatment and support they needed and deserved. Perry wanted to humanize people with addiction and inspire them to get help. He has certainly inspired me to continue this important work.
