MATTHEW PERRY DEAD AT 54

[tezi]

One of my friends is an MD who specializes in pain meds. She has told me quite a few things about how they handle patients who are drug dependent.

My friend and I just watched the report on the national news broadcast. We both said that people die from drug overdoses every day in the city near where we live. Unless the person is wealthy or well known the deaths aren’t investigated. Just another drug addict dying from an overdose.

RBBM: Exactly, I totally agree. Those people just get written off as junkies who died of an overdose. I just want the law applied equally to every death like Matthew Perry's has been. I realize that is probably not going to happen, but we can hope it will. Currently, where I live there is a huge investigation of a death involving an overdose. The guy climbed in a dumpster and died. It was good that there was a video camera on the dumpster, so LE knows exactly what happened to the guy. I just hope that there are charges against the people who sold him the drugs that he "allegedly" overdosed on.

JMO, IMO, and all other disclaimers.

PS: Thank you IceIce9.

 

[SpanishInquisition]

I totally understand why it was investigated as it was. I just have a hard time believing that the law was applied "equally." Because of things I've experienced, I can say I have a hard time believing it was applied equally in this case. If MP was on skid row do you really think the LAPD would have expended the resources to investigate his case? I don't. We wouldn't have seen a quarter or an eighth of the resources used to investigate the case if he was some degenerate living on skid row. He would have been written off as another junkie, maybe gotten an oh, well...And that would have been the last we would have heard of it.

JMO, IMO, and all other disclaimers.

What you are describing actually seems to be part of the implicit social contract. If someone voluntarily goes homeless for drug addiction they are basically allowed to do many things where the rules aren't enforced. Loni Willison for instance is openly and publicly a celebrity who is now a homeless drug user. If Loni Willison was housed and getting drugs from a doctor, the rules would be different even though we're talking about the same person.

 

[Cedars]

Actually, we prescribe controlled substances to recovering addicts all the time. Look at Suboxone or methadone. And yes, even Ketamine shows promise, though still too early to say definitively. This is called replacement therapy.

"Ketamine has been shown to effectively prolong abstinence from alcohol and heroin in detoxified alcoholics and heroin dependent individuals, respectively."

Ketamine for the treatment of addiction: Evidence and potential mechanisms - PubMed

Ketamine is a dissociative anaesthetic drug which acts on the central nervous system chiefly through antagonism of the n-methyl-d-aspartate (NMDA) receptor. Recently, ketamine has attracted attention as a rapid-acting anti-depressant but other studies have also reported its efficacy in reducing...

pubmed.ncbi.nlm.nih.gov

The thing is, these are less addictive and dangerous than the drug they're recovering from, so that's the reasoning behind it.

Also, most people who are using drugs are not doing it because of #funtimes. They're doing it to self-medicate. So the question is, self-medicate what? Is another controlled substance helpful in treating the underlying illness or abstain from using the addicted substance?

I keep going back to ADHD because most people are familiar with it. Many cocaine users have underlying ADHD. It used to be that you wouldn't prescribe a stimulant to ANYONE with a cocaine addiction. But that thinking changed and now we know that treating the underlying problem is the key to abstinence. So that may also be applied to Ketamine (I don't prescribe Ketamine, so I'll say MOO here).

I don't think this case is as black and white as it may seem right now. I might eat those words later if it turns out these were drug dealers who happened to be doctors. But doctors are sometimes villianized because the media doesn't understand the treatment protocols. MOO. It's not intuitive, certainly and before I read the research, I would have reacted the same way.

I'll be very interested to see how this case unfolds.

Links provided to stimulant treatment for cocaine abusers just to justify what I said above.

"Substitution pharmacotherapy is an effective approach for treating opioid and nicotine dependence, and accumulating evidence indicates that stimulant pharmacotherapy for cocaine dependence is a promising strategy."

Psychostimulant Treatment of Cocaine Dependence

Cocaine dependence continues to be a significant public health problem and no clearly effective pharmacotherapy has yet been identified. Substitution pharmacotherapy is an effective approach for treating opioid and nicotine dependence, and accumulating ...

www.ncbi.nlm.nih.gov

"While stimulant medications have the potential for abuse and must be used cautiously in patients with substance use disorders, the available evidence suggests that stimulant medications administered under monitored conditions can be safe and effective in patients with substance use disorders."

Treatment Strategies for Co-Occurring ADHD and Substance Use Disorders

Attention-deficit hyperactivity disorder (ADHD) is a common co-occurring mental disorder among patients with substance use disorders (SUD). Clinicians must be cognizant of the complicated nature of diagnosis and treatment of ADHD when comorbid with SUD. ...

www.ncbi.nlm.nih.gov

Is your patient using cocaine to self-medicate undiagnosed ADHD?

Effective treatment modalities tend to prioritize management of substance abuse, but the patient’s age may dictate the overall assessment plan.

www.mdedge.com

Interesting and complex topic.

With all due respect for your expertise, in this case of Matthew Perry, he has said he became addicted to alcohol at age 14. From what I've read from addiction research, that would have changed/damaged his brain so much, that any underlying disorders such as ADHD, or depression, would be long past trying to address with drugs. Would it not be his severe problems with becoming addicted to substances that would need priority consideration in any treatment plan?

JMO

 

[Inthedetails]

What you are describing actually seems to be part of the implicit social contract. If someone voluntarily goes homeless for drug addiction they are basically allowed to do many things where the rules aren't enforced. Loni Willison for instance is openly and publicly a celebrity who is now a homeless drug user. If Loni Willison was housed and getting drugs from a doctor, the rules would be different even though we're talking about the same person.

And then there is the complication of "regular folk" who get addicted, but not by choice. I'm thinking of people who are prescribed pain killers by their doctor and their life spirals into illegal purchases and ruin when the Rx runs out.

Did they "voluntarily" use the illegal drugs and "voluntarily" become addicted, to the point of losing perhaps their family, their home, their job, their dignity? Is the doctor to blame, the patient, the supplier on the street? This is a reality for some people leading decent and productive lives, who had no intention on becoming drug users, let alone addicts.

jmo

 

[MissMalowe]

It's been happening for a while.

https://www.cnn.com/2017/07/31/health/opioid-doctors-responsible-overdose/index.html

In most cases, it's justified, IMO. But I won't lie, I feel like I have to write a novel in the chart defending my decision every time I prescribe or renew a controlled substance, even Ritalin. This is going to have a greater negative impact on patients in the coming years. MOO.

It would be excellent if we could find a happy medium somewhere.

I was floored a few months ago when I went to urgent care at 7pm for a horrific toothache/jaw pain- the doctor who saw me took one look at my mouth and prescribed me an opioid, and then noted that "this was only the 2nd time since he's worked here that he prescribed that to someone." TWO! He didn't mention how long he had worked there, and I was in too much pain to bother asking or to even care; but once I got home and felt better, I thought about what he said and wondered how many poor people who had been there with a toothache like mine or anything else causing that level of pain had NOT been given adequate pain relief?! I'm so thankful that the level of pain I was in was able to be visibly confirmed otherwise I can't imagine how I would have faired that night.

I 100% understand why non-addict patients and reputable Doctors hate the hoops they have to jump through as a result of Doctors who over-prescribe and patients who over-indulge.

I hope we, as a country/society can somehow get a better handle on this.

 

[Cedars]

RBBM: Exactly, I totally agree. Those people just get written off as junkies who died of an overdose. I just want the law applied equally to every death like Matthew Perry's has been. I realize that is probably not going to happen, but we can hope it will. Currently, where I live there is a huge investigation of a death involving an overdose. The guy climbed in a dumpster and died. It was good that there was a video camera on the dumpster, so LE knows exactly what happened to the guy. I just hope that there are charges against the people who sold him the drugs that he "allegedly" overdosed on.

JMO, IMO, and all other disclaimers.

PS: Thank you IceIce9.

I will repeat my earlier reply, that billions upon billions of dollars are spent in the US to try to eliminate/control street drugs. It would be atrociously ineffective to approach the issue on a case by case basis. Instead, every police department has many dedicated drug officers who spend all day, every day trying to get drugs out of their community and the DEA receives over $3 billion in annual funding. They arrest and charge dealers constantly, investigate and arrest trafficking rings constantly, they have enacted numerous laws to force airports, border guards, transportation companies and foreign countries to stop the supply reaching the US, they fund addiction treatment centres and research, etc.

The 'war on drugs' is a real thing and has been relentless for 50 years. Yet people speak about it with contempt, 'just legalize drugs and quit trying', they say.

Obviously, the media are only interested in Matthew Perry, because the public is only interested in him. The media/public are bored by stories of the massive and complex war on drugs, they prefer stories about celebrities.

JMO

 

[Cedars]

It would be excellent if we could find a happy medium somewhere.

I was floored a few months ago when I went to urgent care at 7pm for a horrific toothache/jaw pain- the doctor who saw me took one look at my mouth and prescribed me an opioid, and then noted that "this was only the 2nd time since he's worked here that he prescribed that to someone." TWO! He didn't mention how long he had worked there, and I was in too much pain to bother asking or to even care; but once I got home and felt better, I thought about what he said and wondered how many poor people who had been there with a toothache like mine or anything else causing that level of pain had NOT been given adequate pain relief?! I'm so thankful that the level of pain I was in was able to be visibly confirmed otherwise I can't imagine how I would have faired that night.

I 100% understand why non-addict patients and reputable Doctors hate the hoops they have to jump through as a result of Doctors who over-prescribe and patients who over-indulge.

I hope we, as a country/society can somehow get a better handle on this.

IMO, normally, people showing up in emergency in extreme pain will be admitted and treated for the cause of their pain (and perhaps given pain medication as part of that treatment).

Your case was different, because they can't do dental surgery. Hopefully, you went to a dentist as soon as possible to get the cause of the pain treated. If I had severe dental pain, I'd contact a dentist, not go to emergency.

If people could just go to emergency, claim to be in severe pain, and the doctors made no attempt to cure them, just prescribed strong pain medication and sent them home, do you think that would be a good system?

JMO

 

[Herat]

IMO, normally, people showing up in emergency in extreme pain will be admitted and treated for the cause of their pain (and perhaps given pain medication as part of that treatment).

Your case was different, because they can't do dental surgery. Hopefully, you went to a dentist as soon as possible to get the cause of the pain treated. If I had severe dental pain, I'd contact a dentist, not go to emergency.

If people could just go to emergency, claim to be in severe pain, and the doctors made no attempt to cure them, just prescribed strong pain medication and sent them home, do you think that would be a good system?

JMO

People with opiate dependence go to ER's and Urgent Cares all the time to try to get prescription narcotics. The ER's know well how to spot this. They evaluate them on a case-by-case basis in case there is something acutely wrong with them, but do not give them narcotics and give them a number to call for an appointment to a clinic or primary care physician that could be able to organize their care.

 

[Cedars]

People with opiate dependence go to ER's and Urgent Cares all the time to try to get prescription narcotics. The ER's know well how to spot this. They evaluate them on a case-by-case basis in case there is something acutely wrong with them, but do not give them narcotics and give them a number to call for an appointment to a clinic or primary care physician that could be able to organize their care.

Yes. The irony is, the most relentless kind of pain is often the pain of withdrawl from a substance that was supposed to keep you from feeling pain.

JMO

 

[MissMalowe]

IMO, normally, people showing up in emergency in extreme pain will be admitted and treated for the cause of their pain (and perhaps given pain medication as part of that treatment).

Your case was different, because they can't do dental surgery. Hopefully, you went to a dentist as soon as possible to get the cause of the pain treated. If I had severe dental pain, I'd contact a dentist, not go to emergency.

If people could just go to emergency, claim to be in severe pain, and the doctors made no attempt to cure them, just prescribed strong pain medication and sent them home, do you think that would be a good system?

JMO

I went to a Walk-In/ Urgent Care Clinic, not an Emergency room as I was 3 states away from home/my own dentist and ALL calls in an attempt to be seen by any local dentist were unsuccessful/no one would see me.
Thankfully, the same doctor who saw me at the Urgent care clinic was able to get me an appt first thing the next morning at, ironically, one of the places I had called prior to showing up at Urgent care.

And no, I dont feel your suggestion would be an ideal system, hence the reason my post began with how my saying some sort of happy medium would be excellent.

 

[BeginnerSleuther]

IMO it's fairly easy to distinguish the good guys from the bad guys here: was the person actively working towards freeing MP from his addictions, by reducing and ultimately eliminating his dependencies, or were they driving him further into his addictions by giving him increasing doses, ie exploiting his addiction for their own benefit.

JMO

That isn't how you treat addiction or other mental health conditions though, for the most part. The guidelines on opiate addiction are very clear that Suboxone will likely need to be increased time and again and that taper and discontinuation should not be rushed if the patient isn't ready. While it sounds logical to say the goal should have been lowering the dose, increasing the dose does not equal malpractice. In fact, the opposite is sometimes true. Decreasing the dose can lead to relapse and malpractice in some cases. It's very, very trick. The details of this case really do matter, IMO.

 

[Herat]

Yes. The irony is, the most relentless kind of pain is often the pain of withdrawl from a substance that was supposed to keep you from feeling pain.

JMO

And that pain is exactly what many of the unrecognized everyday addicts are desperate to avoid.

I went to a talk on Addiction by two prominent Pain and Addiction Specialist Physicians in our area.

I was really astonished how they described the problems for the "inadvertently addicted" ordinary working people in the community who became addicted to narcotics as the result of generous physician prescribing for post-surgical pain. Many of these people are your neighbors, your colleagues, just people with ordinary lives who are addicted and desperate to avoid withdrawl. Either they can't afford rehab or cannot yet face the social consequences of needing to explain their addiction and why they would want time off to go to rehab for weeks-to-months.

The physicians described that it would take about half an hour to get a fix in this community and that these underground networks are not hard to find at all. They have a Buprenorphine clinic that supplies the necessary opiates to these people, under a medication contract, precisely so they can continue to function as regular wage workers, maintain a household, and be adequate wives, husbands, or childcare givers. They don't want the high. They just don't want to go into withdrawl and expose themselves.

Not at all Perry's problems, but a very real part of addiction in our society and the lack of adequate mental health and substance rehab in communities.

 

[Cedars]

I went to a Walk-In/ Urgent Care Clinic, not an Emergency room as I was 3 states away from home/my own dentist and ALL calls in an attempt to be seen by any local dentist were unsuccessful/no one would see me.
Thankfully, the same doctor who saw me at the Urgent care clinic was able to get me an appt first thing the next morning at, ironically, one of the places I had called prior to showing up at Urgent care.

And no, I dont feel your suggestion would be an ideal system, hence the reason my post began with how my saying some sort of happy medium would be excellent.

So that was a good plan in your situation, I'm glad it worked out. I guess everyone is suspicious that strangers are just trying to 'barge into the front of the line', so it does make sense to get the clinic to confirm it was a priority.

JMO

 

[BeginnerSleuther]

Interesting and complex topic.

With all due respect for your expertise, in this case of Matthew Perry, he has said he became addicted to alcohol at age 14. From what I've read from addiction research, that would have changed/damaged his brain so much, that any underlying disorders such as ADHD, or depression, would be long past trying to address with drugs. Would it not be his severe problems with becoming addicted to substances that would need priority consideration in any treatment plan?

JMO

Absolutely not. In fact, a doctor could be successfully sued for malpractice for not treating mental health conditions due to long history of substance use. Substance use is very, very, very, very rarely (almost impossible) to occur outside other mental health conditions and if the goal is long-term sobriety, then you need to treat the underlying condition too. What is true is that you can't adequately assess for ADHD or other mental health conditions in someone acutely intoxicated or in very early remission. So for example, if I see someone in the hospital who is going through alcohol withdrawal or has been sober for one week, it would be nearly impossible to tease out what's abstinence related versus an organic mental health process. However, someone who's been sober for weeks or months, must be evaluated just like anyone else. So while sobriety is the first step in an evaluation of someone actively using, substance use HISTORY is not the primary consideration in patients with mental health concerns. The other thing is that sometimes medications are prescribed in those actively using as replacement therapy. For instance, we start Suboxone on those using opiates within days.

If Matthew Perry was clean and sober when seeking help, then there's no reason his history had to take precedence. If he was actively using, then I wonder if someone thought Ketamine would be helpful as replacement therapy or in treating underlying issues. MOO.

 

[BeginnerSleuther]

IMO, normally, people showing up in emergency in extreme pain will be admitted and treated for the cause of their pain (and perhaps given pain medication as part of that treatment).

Actually, most people who go to the ER in pain are sent home for outpatient workup and treatment. It depends on where the pain is and the labs/x-rays and whether or not it's a chronic condition. For example, pain exacerbation for cancer is usually admitted for pain management. However, abdominal pain in someone without any history with good labs and x-ray or CT is sent home. Pain on its own is not an admission. Most workup is outpatient, not inpatient.

Your case was different, because they can't do dental surgery. Hopefully, you went to a dentist as soon as possible to get the cause of the pain treated. If I had severe dental pain, I'd contact a dentist, not go to emergency.

If people could just go to emergency, claim to be in severe pain, and the doctors made no attempt to cure them, just prescribed strong pain medication and sent them home, do you think that would be a good system?

JMO

Just so you know, that is what happens. We don't have enough beds to admit every pain patient. People are going to experience pain sometimes. It's part of life. If labs and tests are normal, they are sent home to follow up with either primary care or specialist. Even people with chest pain are sent home unless an EKG and labs show an acute issue.

 

[TDoc72]

This sounds like yet another variation of Elvis and "Dr. Nick."

Also, Michael Jackson and Dr. Conrad Murray.

Agree with both. In all cases, if proven the doctors or assistant did something illegal/wrong and should be punished. But honestly, if it wasn’t that specific doctor or assistant, it would’ve been another and the end result (dead celeb) would probably be the same. Addicts would’ve found other people to help get them what they wanted.