Results tagged “popular culture” from Pathophilia
A newly released affidavit reveals the last hours of Michael Jackson's life, as told to an LAPD homocide detective by Jackson's personal physician, Conrad Murray. The affidavit, which was used to support a search warrant of Conrad's storage locker in Houston, Texas, also reveals the preliminary and not-so-surprising cause of Jackson's death: a lethal dose of propofol, aka Diprivan. Contrary to popular speculation (and common sense), Jackson did not receive the anesthetic until the mid-morning hours on the day of his death, June 25th (at least that's what the doctor reportedly claimed).
Here's what allegedly went down on that day at Jackson's rented home in Los Angeles:
@ 01:30—Murray gives Jackson a 10-mg tablet of diazepam (Valium) for insomnia. Jackson is unable to sleep.
@ 02:00—Murray gives Jackson lorazepam (Ativan) 2 mg by slow IV push. Jackson is unable to sleep.
@ 03:00—Murray gives Jackson midazolam (Versed) 2 mg by slow IV push. Jackson is unable to sleep.
@ 05:00—Murray gives Jackson another 2-mg dose of lorazepam by slow IV push. Jackson remains awake.
@ 07:30—Murray gives Jackson another 2-mg dose of midazolam by slow IV push. Jackson remains awake.
@ 10:40—After repeated demands by Jackson, Murray administers propofol 25 mg IV after lidocaine pretreatment.
@ 10:50—Murray leaves Jackson's bedside to go to the restroom.
@ 10:52—Murray returns to find that Jackson is not breathing. (Murray stated to investigators that Jackson had been continuously monitored throughout this time with pulse oximetry.) Murray begins CPR (presumably while Jackson remains on the bed) and administers 0.2 mg of flumazenil (Anexate), a benzodiazepine antagonist. Using his cell phone, Murray also calls Jackson's personal assistant and requests that security personnel be sent upstairs for an emergency.
A few minutes later, Murray runs downstairs to the kitchen and (inexplicably) asks the chef to send up Jackson's oldest son. Murray returns to Jackson to continue CPR. Jackson's son responds and summons security detail.
11:18-12:05—Phone records reveal that Murray was on his cell phone for approximately 47 minutes with 3 separate callers; although Murray did not reveal these calls to investigators at the time of the interview.
@ 12:21—Michael Jackson's bodyguard, Alberto Alvarez, goes to Murray and calls 911 on his cell phone.
@ 12:22—An LA Fire Department ambulance responds to Jackson's home. Murray informs the paramedics that he is Jackson's personal physician and that he had continuously administered CPR, for respiratory arrest, until their arrival. Murray also divulges that he had given Jackson lorazepam before his respiratory arrest.
While continuing resuscitation efforts, the paramedics transport Jackson and Murray to the UCLA Medical Center.
@ 14:26—After a protracted effort to revive Jackson at UCLA, Jackson is pronounced dead. Murray allegedly did not reveal to emergency physicians that he had given Jackson propofol. He also refused to sign Jackson's death certificate.
Early in the course of their death investigation, the LAPD evidently could not locate Murray. At Jackson's home, "numerous" bottles of medications were found, which had been prescribed by Murray for Jackson—including the benzodiazepines diazepam, lorazepam, and temazepam (Restoril). Bottles of clonazepam (Klonopin) and the antidepressant trazodone (Desyrel) were also found, which had been prescribed by internist Allan Metzger. And a bottle of the muscle relaxant tizanidine (Zanaflex) had been prescribed to Jackson by his dermatologist, Arnold Klein.
Four days later, investigators, armed with a search warrant, discovered vials of lidocaine, propofol, lorazepam, midazolam, and flumazenil at Jackson's home. None of these medications were associated with an identifiable prescription. The affidavit also reveals that the Drug Enforcement Agency (DEA) could not find a record of Murray purchasing, ordering, or obtaining propofol with his medical license number or DEA number.
Murray admitted that he had been treating Jackson's insomnia with propofol 50 mg IV every night for the last 6 weeks. According to the affidavit, he had successfully reduced the propofol dose to 25 mg on June 22nd, while also administering lorazepam and midazolam to Jackson. The following night, Murray claimed that he was able to induce sleep with only lorazepam and midazolam.
In a mind-blowing report, today's Los Angeles Times indicates that Dr. Conrad Murray, Michael Jackson's personal physician, left the singer alone on the morning of his death, June 25th, while Jackson received IV propofol (aka Diprivan) as a sleep aid in his home. The Times cites 3 unnamed sources who are "familiar with the investigation."
Murray allegedly left Jackson for an unknown period of time to make calls on his cell phone, and when he returned, Jackson was not breathing. Murray's evidently cavalier attitude toward this highly renegade use of the anesthetic agent, which he reportedly acquired legally from a Las Vegas pharmacy (possibly Applied Pharmacy Services), suggests that the doctor had administered propofol in this manner on more than one occasion. One law enforcement source told the Times that Murray admitted to giving IV propofol repeatedly to Jackson since May.
Although Jackson's autopsy results have not been officially released, leaked information indicates that propofol and an anxiolytic (possibly alprazolam [Xanax]) were present in Jackson's system.
Image of Diprivan formulations from APP.
Not sure which is more shocking: The report that at least 20 non-OTC drugs were recovered from Michael Jackson's home or the fact that ABC News is sourcing The Sun on this one. Maybe ABC's reporters were impressed by alleged autopsy information printed last week by the tabloid—namely that Jackson's arms were riddled with needle marks. Yesterday ABC reported the same ("Jackson's arms were scarred with track marks"), citing "investigators."
On the basis of reportage from ABC and The Sun, the partial, cobbled-together list of drugs (save propofol [Diprivan]) found in Jackson's home includes the following (in alphabetical order):
- Demerol: Generic names, meperidine and pethidine. A fast-acting opioid available in injectable and oral formulations. Legitimate use has become unpopular during the last 2 decades, owing to the drug's potential neurotoxicity and abuse potential. Jackson allegedly took Demerol daily and possibly several times a day.
- Dilaudid: Generic name, hydromorphone. A morphine derivative available in injectable and oral formulations. Typically used for pain management.
- Fentanyl: A highly potent synthetic opioid available in injectable, transdermal patch, and "lollipop" formulations. Typically used in anesthesia induction and pain management.
- Lidocaine: Presumably in the form of low-concentration vials to produce local anesthesia. Possibly used in conjunction with propofol to reduce injection-associated pain.
- Methadone: A synthetic oral opioid. Most commonly used as a maintenance medication when kicking opioid addiction.
- OxyContin: Generic name, oxycodone. A wildly popular, semi-synthetic oral opioid. Jackson allegedly took the medication daily.
- Paxil: Generic name, paroxetine. An orally administered, selective serotonin-reuptake inhibitor (SSRI). Indicated for the treatment of depression, OCD, panic disorder, anxiety disorders, and PTSD.
- Percocet: Generic ingredients, oxycodone (same as OxyContin) and acetaminophen (eg, Tylenol). Typically prescribed short term for pain relief.
- Soma: Generic name, carisoprodol (a metabolite of meprobamate, aka Miltown). An orally administered, centrally acting muscle relaxant that potentiates opioid-induced analgesia.
- Versed: Generic name, midazolam. A very-short-acting benzodiazepine in oral and injectable formulations. Typically used as a premedication before surgical or medical procedures.
- Vicodin: Generic ingredients, hydrocodone and acetaminophen. Orally administered and should be prescribed short term for pain relief. (N.B.—I've witnessed physicians dispense this drug like Pez candy.)
- Xanax: Generic name, alprazolam. An orally administered, short-acting benzodiazepine. Prescribed for anxiety and/or sedation.
- Zoloft: Generic name, sertraline. An orally administered SSRI. Indicated for the treatment of depression, OCD, panic disorder, anxiety disorder, PTSD, and premenstrual dysphoric disorder (which Jackson presumably did not have).
There are a number of permutations for lethal combinations of these drugs, some of which can kill all by themselves. Perhaps more surprising than Jackson's death is his survival—given the duration of his alleged polypharmacy use and dependence.
OCD = obsessive-compulsive disorder; OTC = over the counter; PTSD = posttraumatic stress disorder.
Props must be given to TMZ. Multiple news sources have been citing the entertainment news-gossip web site in the widespread coverage of Michael Jackson's suspect death.
The latest: Edward Chernoff, criminal defense lawyer for Conrad Murray (Michael Jackson's doctor), won't confirm or deny that Murray gave Jackson propofol (trade name, Diprivan). In a phone interview last night, Chernoff reportedly told TMZ, "I have no statement on whether the Dr. prescribed or administered Propofol." Although the lawyer was apparently willing to repeat that Murray did not administer Demerol or OxyContin to Jackson.
In its update, TMZ implies that Chernoff is now backtracking somewhat on last night's statements and "can't speak for anything that was in the [Jackson] home."
Image of Diprivan formulations from APP.
Sources are now implicating propofol (Diprivan; sanofi-aventis) in Michael Jackson's death. TMZ reports that police recovered the anesthesia inducer at Jackson's rented home. And ABC News interviewed Jackson's nutritionist, Cherilyn Lee, who stated that the singer asked her for Diprivan, by trade name, 3 months ago. Jackson's alleged intention, bizarre as it may sound, was to be put to sleep at home under the guidance of an anesthesiologist.
In use for more than 2 decades, Diprivan is a rapidly acting (within 40 seconds) IV sedative-hypnotic that is FDA approved for the induction and maintenance of anesthesia and for sedation in an intensive care unit (in both cases, patients are mechanically ventilated). According to the prescribing information, the induction dosage for ICU sedation begins at 5 microg/kg/min and should be titrated (by increments of 5-10 microg/kg/min) to the desired clinical effect. Maintenance rates are generally 5-50 microg/kg/min or higher for adults.*
For anesthesia induction, the typical dosage is 40 mg every 10 seconds in healthy adults younger than 55 years of age; maintenance of anesthesia can be achieved by intermittent boluses of 20-50 mg. However, slow infusion or injection techniques are recommended to avoid apnea and hypotension. Diprivan dosages should be reduced in patients who have received large doses of narcotics.
Common adverse events with Diprivan use include bradycardia or other arrhythmias, hypotension, and apnea. Burning pain or stinging at the injection site, which is also common, may be reduced by preinjecting the vein with a 1% lidocaine solution (1 mL).
Subanesthetic doses of Diprivan may have the potential for abuse by inducing euphoria. Diprivan's abuse potential is particularly high among physicians who have access to the drug—namely, anesthesiologists. An e-mail survey in 2007 indicated that Diprivan abuse has increased substantially in academic anesthesia departments during the last 10 years. Among the 25 reported abusers in the survey, 16 (64%) were resident physicians. Seven (28%) abusers died; 6 of the deceased were resident physicians. In academic centers where abuse occurred, none had established pharmacy protocols to account for the drug (as is done routinely with opiate medications).
In 2008, an anesthesia nurse was convicted of killing a University of Florida student, with whom he was infatuated, by injecting her with propofol in her home. The victim's propofol blood level was 4.3 microg/mL. The expected propofol concentration after a bolus induction dose of 2.5 mg/kg (175 mg for a 70-kg man) is 1.3-6.8 microg/mL.
If a vial or vials of Diprivan were indeed recovered from Jackson's home, it seems almost certain that the medication was palmed by someone who had access, rather than formally prescribed.
Addendum: It also appears that Diprivan can be purchased through online pharmacies. For instance, drugdelivery.ca offers a 50-mL prefilled syringe for $122.99 USD. The completion of a patient questionnaire is necessary (along with payment); it is not clear that a valid prescription is required.
* So for a 70-kg man (~154 lbs), 0.35 mg/min would be administered for induction, and the maintenance dosage ranges from 0.35 to 3.5 mg/min. Vials of Diprivan contain 10 mg/mL and come in 20-, 50-, and 100-mL vials.
Image of Diprivan formulations from APP.
07/04/09 update: Yesterday the AP, citing an anonymous law enforcement official, confirmed that Diprivan was found in Jackson's rented home. CNN also reported that Neil Ratner, an anesthesiologist, traveled with Jackson during his HIStory tour in the mid-90s. Ratner's NY medical license was suspended in 2002 after being convicted of insurance fraud.
The 911 call for Michael Jackson revealed that the singer's hired physician, Conrad Murray, performed CPR (ie, chest compressions) on a bed. Because anybody who's familiar with CPR knows that the procedure should be performed on a hard flat surface (so that chest compressions can be effective), the doctor's resuscitation technique has been called into question.
Now Murray's criminal defense lawyer, Edward Chernoff, offers at least 2 explanations to "Good Morning America" for why the doctor performed chest compressions on a bed. Neither explanation is particularly satisfying. The first is that the bed was "firm," ostensibly serving as a hard, flat surface. The second is that Murray "braced Michael Jackson's back with his hand and compressed his chest with his other hand." This explanation obviously begs the question: If the bed was sufficiently firm, then why was it necessary to brace Jackson's back?
Chernoff goes on to state that Murray checked to determine that his compressions were producing "blood flow." In CPR, typically a second party will determine, by assessing the pulse (eg, the femoral pulse), if chest compressions are mechanically pumping the heart. This assessment can only be done, of course, while chest compressions are being administered. So if Murray was performing CPR with 2 hands, it'd be impossible for him to assess (by himself) the effectiveness of his compressions without an additional hand or two.
Then Chernoff relates that Murray, at some point, moved Jackson off the bed and continued CPR. At what time this action was performed is unknown; it logically took place after the 911 call. But, if Murray believed that his CPR technique was effective on the bed, then why did he later move Jackson onto the floor?
Last, Chernoff states that "it [Murray's CPR] went on for 25, 30 minutes"—suggesting that Murray attempted to revive Jackson on his own for quite some time, before attempting to call 911.
CPR = cardiopulmonary resuscitation.
N.B.—Chernoff denies that Murray ever administered Demerol to Jackson. He states to GMA, "I can't go into any specifics about drugs that Michael Jackson might have taken the night before, by agreement. I can tell you this: Whatever was taken by Michael Jackson at any time wouldn't have caused his death."
Michael Jackson overdosed on Demerol (meperidine), according to numerous posts on the web, including those at TMZ—the go-to site for bottom-feeders of entertainment news. The web site also reports that Jackson received daily shots of the morphine analog, possibly for years, and that a physician who was at Jackson's home yesterday is "nowhere to be found." The physician possibly administered the dose, which must be given IM or IV.
According to other news sources, Brain Oxman, a Jackson family spokesperson and lawyer, and Liza Minnelli (no stranger to addiction) suggest that Jackson's abuse of prescription opiate medications is longstanding. The speed with which Jackson's speculated cause of death has been transmitted is evident in the fact that the news has already been incorporated into a Wikipedia entry for the drug.
While favored as a treatment for acute pain in the 1980s, Demerol has become considerably less popular among physicians as a short-term analgesic during the last 2 decades, largely because of its toxicity profile and abuse potential.
An autopsy on Jackson's body is to be performed today, with results expected this afternoon, reports MTV.com. Although some toxicology tests are reported to take weeks, measures of opiate medications can be obtained within a day, if not hours.
AoNW returns, if only intermittently.
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