High levels of ketamine in his blood stream. Last time he was given a treatment by his doctor was a week and a half before his death. It wouldn't have still been in his bloodstream. So he was probably also using recreationally.
amp.cnn.com
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Matthew Perry’s autopsy report shows he died of ‘acute effects of ketamine’ | CNN
Friends star Matthew Perry died as a result of “acute effects of ketamine” and subsequent drowning, an autopsy report shows.