29 July 2009

MJ: doped to death?

Deadly array of dangerous drugs in MJ's home: a psychiatrist comments.

That there was a long pattern of abuse of prescription drugs by Michael Jackson has been clear for years, from many sources including police, family statements and friends.

Whatever evidence emerges about the actual blood levels of drugs found in Michael Jackson's blood post-mortem, a pattern is emerging: stories first emerge as rumours, and gradually become confirmed by later statements by authorities or even family and other spokesmen.

When local Sheriff's deputies raided Neverland back in 2003, they're reported to have found powerful narcotics, vials, IV bags containing a milky fluid (Propofol and a number of other drugs could look like this) and a syringe, and reports mention Versed (Dormicum) a very short-acting sedative; Promethazine (a very sedative anti-histamine ); Alprazolam/Zanax, a sedative anxiolytic; Percocet (a pain-killer containing paracetamol with Oxycodone, a narcotic analgesic which can produce dependence) ; a vial of Demerol (Pethidine - see below) ; a bottle of the steroid Prednisone, oxygen tanks, IV stands, and many loose pills. A normal home does not contain oxygen tanks and IV stands.

Unjustifiable medication use
Many of the drugs reported to have been used are justifiable as proper treatment of any disorder or symptoms he may have had. Benzodiazepines like the Alprazolam are not suitable for long-term use over many years.

There's talk of chronic pain complaints, possibly related to injuries or to the head burns received during the filming of a commercial, but no mention of a proper diagnosis or assessment by genuine pain experts at a real pain clinic.

Having worked in such a clinic, I know that no competent pain expert would ever recommend the use of the sort of drugs that have been mentioned, let alone at the doses mentioned, in managing chronic pain. There's a peculiar theme of the use of very short-acting medications for chronic symptoms, which is never advisable.

Comment on specific reported drugs

MJ is said to have had a habit of receiving injections of Demerol (Pethidine), calling them "health tonic"; but that he had a doctor or nurse inject him, because he didn't like handling needles. Pethidine is a commonly used opiate analgesic, but totally unsuitable to treat chronic pain from any cause. It is short-acting. Fine for situations such as brief medical or surgical procedures where analgesia is only needed for an hour or two - but not for chronic pain.

It is definitely addictive, and can produce psychological and physical dependence. It may be more so than morphine, due to its rapid onset of action and an early "rush" many users find pleasant. It is not very powerful, and has a number of toxic effects - including fits, delirium, confusion, and other problems, because it is rapidly broken down into another substance which is toxic. It can interact badly with alcohol, benzo's and some antidepressants. It is best not given intravenously. Providing it to anyone for long-term use in a situation like this is malpractice, and simply a crudely ignorant way of dealing with chronic pain problems.

This is the most sinister drug reported to have been found in the house. It is a general anaesthetic, usually used in hospitals to start or maintain anaesthesia during surgery, and by vets operating on small animals. It is an dangerous drug which should never be used except by an experienced anaesthetist in hospital with full resuscitation equipment at hand.

There is a narrow margin between a dose that works and a dose that can kill. A slight overdose can cause someone to stop breathing, and later lead to cardiac arrest.

No possible excuse for its home use
Let me be clear. With regard to this drug, there is no possible respectable medical indication for the prescription or administration of these drugs to someone at home, let alone for pain problems or insomnia. Or for it to be administered to a patient anywhere outside of a hospital with full resuscitation equipment immediately at hand. Its use for insomnia is so ridiculous that I'd suggest hospital admission for a full psychiatric assessment, for any doctor who prescribed or used it for that indication.

Yet there are reports that significant amounts of the drug were found in his home on the day of his death, and, from his former nurse-nutritionist, that she refused Michael's calls for this as a sedative, because he wanted to sleep. Even asking a nurse for such a hazardous drug, suggests a pattern of expecting various people to supply whatever drug he asked for, and an expectation that the usual regulations controlling use of such drugs, would be ignored.

Uses and abuses
Diprivan/Propofol is short-acting and must be given intravenously. It's fine to use carefully in casualty when you want to perhaps set a dislocated shoulder, and to render someone unconscious for a really short period of time, or in an operating theatre to put you to sleep just before other and safer longer-acting anaesthetics are used. It is also used inside an intensive care unit where it can be given intravenously and with every precaution available, for someone who is temporarily intubated and on a respirator which is breathing for them.

It is handy in such situations, because one recovers and wakes up quickly afterwards - and utterly useless when someone wants to sleep through the night. Given intravenously, its sedative effects typically wear off in minutes. So, if more prolonged sedation is needed, it would have to be given continuously, in a drip. And then there would always be a danger of overdose, with a need for a trained anaesthetist to be present and awake at all times to monitor the process.

It is not an analgesic, pain-killing drug, and has no place whatsoever in treating chronic pain. Indeed, it tends to cause significant pain in the vein where it was injected. It also tends to wipe out short-term memory, so you wake without any memory of what happened when it was being given to you.

Some find it produces a mild degree of euphoria, and disinhibition and sexual hallucinations have been reported.

Abuse and death
It has seldom been abused recreationally, and where this happens, it has usually been among doctors like anaesthetists who have readier access to it. So many precautions are needed to use it safely, that abuse is understandably rare, and would be considered very dangerous. At least 9 deaths from self-administration have been reported in recent years.

As the drug is hardly known among the general public, one wonders what bizarre doctor might have ever suggested it to MJ. Maybe he experienced it during some brief plastic surgery procedures, but who would have ever enabled him to use it needlessly at home? Most pharmacies outside of a hospital would probably not carry stock of this drug.

Delay in announcing results
The delay in announcing the autopsy and test results may seem puzzling, but one hopes that in this case, the Californian authorities, who have a lousy record when it comes to dealing with possibly criminal matters involving major celebrities, may, wisely, be being cautious and thorough. If investigations include the records of many different doctors and aliases, they would unavoidably take time.

The absent brain
There's a report on the web that MJ was buried without his brain, which was kept for tests, and a coroner's office spokesman has confirmed "neuropathology" testing.

If they wish to closely examine and test a brain, there may be a need to wait a couple of weeks for the brain, preserved in formaldehyde, to be hardened enough to be sliced and properly examined as to its structure. When this happens, families may choose to delay the burial, bury the brain later and separately, or have it cremated by the laboratory. Weirdly, in the 1978 musical film of The Wiz ( a version of the Wizard of Oz, starring Diana Ross ) MJ played The Scarecrow, a character who says: "I haven't got a brain... only straw. "

It may sound peculiar, but there are many precedents for this. I remember when the brain of genius Albert Einstein was found in a University lab, and a paper published when it was examined to see if the structure gave any hint of why he was so unusually brilliant. It didn't, by the way.

False names
There are increasing reports, including in the LA Times, that MJ had for years used false names to get prescriptions. Among the names said to have been used are Omar Arnold (his favourite), Michael Armstrong, Jack London, Peter Midani, Dan Wilson, Joseph Scruz, and Bill Bray. His wish to remain anonymous is understandable, but it would be illegal under state and federal laws intended to prevent drug abuse.

A doctor may not write a prescription in any name but that of the actual patient, and previously doctors who have done so have lost their license to practice, and faced criminal charges. For instance, when actress Winona Ryder was arrested for shoplifting and found to have medications prescribed under six aliases, from 20 doctors, at least one of them lost his license.

Other reports, such as TMV, describe him as "an anaesthesia addict" going round doctor's and dentist's offices to get anaesthesia for minor outpatient procedures which might not ordinarily need such medication. They refer to cosmetic procedures, Botox, and even acne treatments, receiving sedation or anaesthetic. This is highly irregular practice, though such "doctor shopping" is common in prescription drug addicts. It is said that his dermatologist occasionally prescribed Demerol for him, which would be unusual, and that he has said he knew of MJ using Diprivan/Propofol, and warning him of its dangers. He is said to have at times sent MJ to a "Pain Medical Clinic" for procedures done under general anaesthetic.

Financial implications
There are major financial implications that will depend on the results of the autopsy. The insurance policy taken out on him by the promoter of his last planned concerts could be rendered void, perhaps especially if the death is found to be in some way caused by the doctor the company hired.

Obviously if any doctors, pharmacists or others are found to have been involved in the illicit procuring of drugs which were not medically necessary, there could be serious consequences for them. It can be excusable for doctors to at times use some drugs for purposes not included in the official listed indications for their use, but only if there is a widely accepted rational reason for expecting them to help, and for alternative methods not to be used. This cannot apply to any home use of Diprivan, or Pethidine for chronic pain.

If any of the doctors have broken the applicable law with regard to prescription and administration of such drugs, may face major criminal as well as civil charges.

Yet again, this case seems to illustrate the perils of being rich enough to afford really bad doctors, some of whom seem to operate as medical call girls, available, at a price, to provide whatever you want, rather than what you might actually need.


Professor M. A. Simpson, 2009


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