What killed the king?: As testimony continues in the case against Michael Jackson's physician Conrad Murray, an anesthesiologist explains the dangers of the drug implicated in his death at age 50.
Image: Wikimedia Commons/Georges Biard
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In the first week of the trial of Conrad Murray, Michael Jackson's physician, Los Angeles jurors heard audio recordings of the late pop star's slurred speech, in addition to the litany of prescription drugs he had taken in the hours and weeks prior to his June 25, 2009, death.
It will be up to them to decide if they agree with the Los Angeles County coroner's office, which labeled Jackson's death a homicide.
According to the 2009 autopsy report (pdf), "the cause of death is acute propofol intoxication," which caused the singer to stop breathing. In addition to propofol (a hypnotic drug used for general anesthesia, sedation and in veterinary medicine) the examiner also found traces of lorazepam (a benzodiazepine drug used to treat anxiety and insomnia); midazolam (another benzodiazepine, indicated for insomnia and medical sedation); lidocaine (a local anesthetic often included with propofol to relieve injection pain); diazepam (a benzodiazepine to treat anxiety, insomnia and alcohol withdrawal); and nordiazepam (a benzodiazepine-derived sedative, often used to treat anxiety) in Jackson's bloodstream.
To support the weighty pronouncement of homicide, the medical examiner concluded that: "circumstances indicate that propofol and the benzodiazepines were administered by another. The propofol was administered in a nonhospital setting without any appropriate medical indication. The standard of care for administering porpofol was not met."
Prosecutors are following this line of evidence, arguing that Murray should be held responsible for Jackson's death because he lacked adequate justification, expertise and equipment for giving this powerful drug to his client (who was reportedly aiming to stay rested in preparation for a comeback tour). Although Murray was using a device to keep tabs on Jackson's vitals, as is recommended while using a general anesthetic, the fingertip pulse and blood-oxygen monitor he used is "specifically labeled against continuous monitoring," said an executive from Nonin Medical, Inc., which makes the $275 device, CNN reported Friday. And according to testimony from a paramedic that responded to the 911 call and found Jackson without a pulse, Murray did not mention giving Jackson anything other than the lorazepam.
Given Jackson's apparently substantial admixture of meds and oft-discussed medical conditions, why was propofol the most likely candidate for his death—and can it be used more safely? To find out, Scientific American spoke with Beverly Philip, a professor of anesthesia at Harvard Medical School.
[An edited transcript of the interview follows.]
Propofol is not your run-of-the-mill sleeping aid. How does it differ from more commonly used sedatives?
It's not a sleeping aid at all. What it is is a general anesthetic. This puts people into general anesthesia—a sleeping aid doesn't do that.
This is not meant to be used at home. This is meant to be used by anesthesiologists in a clinical setting. So the use as a sleep aid is way off the mark.
How does propofol work in the body?
We don't know exactly how general anesthesia works. This works as other general anesthetics work, acting on receptors in the brain—possibly the GABA [gamma-aminobutyric acid] receptors, because that is a mechanism for a lot of sleepiness in the brain.
Are there negative side effects that propofol can have—even when it is used as directed and in a proper setting?
Yes. Unlike other sedatives, this drug has an extraordinarily narrow safety margin. It changes the body's state very rapidly so that the patient will go unconscious and stop breathing. It can affect the breathing even before unconsciousness. So even in trained hands, it is very difficult to titrate just where you want. We can do it, but that's what we're trained and educated to do—it's not easy. If I'm inducing anesthesia, it will act inside of 60 seconds.
So as a cardiologist and personal physician to Michael Jackson, is it likely that Conrad Murray did not have the proper training to administer this type of drug safely?
I have heard nothing about how he had had training to use the drug. How it was used here, we call it recreational use. This had nothing to do with the medical care of a patient, which is a situation in which you have things to make it safe, so it's not even in the ballpark of normal use.
The drug also has some reportedly pleasant side effects, such as euphoria. Is that common among sedatives?
When it first came out it was very obvious that it causes euphoria. It's not that dissimilar to alcohol. It reduces inhibition, people get giddy, and whatever thoughts they have on their mind, they tell you. It can also cause hallucinations, because whatever is in a person's head is more likely to be seen. We see it as they go off to sleep and as they wake up.
Recreationally, a lot of people die from this. It's very difficult to administer safely even in the most controlled settings.
The FDA [U.S. Food and Drug Administration] is in the process of making this a restricted drug, recognizing its euphoric property.
Are there other anesthetics that are used off-label as sleep aids?
There are other things that are quite in a different class. For example, Valium and its cousins: In very, very high doses, someone could sleep, but you have to give lots of it, and it works very slowly to cause sleep.
Drugs in the Valium class and painkillers have a reversing agent that's commercially available. There's no reversing agent for propofol.
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12 Comments
Add CommentMurray ....Just a normal brain dead medical professional
Reply | Report Abuse | Link to thisThere is nothing "normal" about Dr. Murray's care of Michael Jackson. It is grossly below the standard of care for use of propofol, which is just another way of saying that no "normal" doctor would dream of doing what he did.
Reply | Report Abuse | Link to thisA very disappointing article. Almost no real science of Propofol. Just tabloid standard coverage. Pity.
Reply | Report Abuse | Link to thisThis is a much more scientifically informative link, though still not up to the normal standard of SciAm scientific analysis:
Reply | Report Abuse | Link to thishttp://liambean.hubpages.com/hub/Propofol-Diprivan--what-is-it
"Propofol binds to GABAA receptors in the central nervous system. These receptors, once blocked, are known to cause a reduction in anxiety and also induce sleep. Propofol is known to bind to these sites and in sufficient quantities can induce a dreamless, near coma-like state in those given the drug.
Like many drugs Propfol is cleared from the body by the liver. However, since it is known that Propofol's effects are reduced or eliminated within minutes of cessation of administration and a close study reveals that it's impossible for the liver alone to eliminate that much of the drug, it is also thought that the drug is taken up by surrounding tissues such as vein walls, muscles, and fatty tissue. Once a drip of the drug has stopped patients can re-awaken in as little as two minutes and be fully aware and able to drive or resume work activities within a short period of time (one to three hours for most).
Propofol can be administered for very short or long durations depending on the procedure it is needed for. From minutes to hours."
And here:
"Proposed Mechanisms of Propofol-Related Infusion Syndrome"
http://www.medscape.com/viewarticle/572673_4
"Propofol is known to bind to these sites and in sufficient quantities can induce a dreamless, near coma-like state in those given the drug."
Reply | Report Abuse | Link to thisWell....that explains a lot of what is going on in DC!!!
The author brushes over the fact that Michael took four Benzodiazapines, each of which would have individually suppressed his respiration, combined they truly wuold have caused a severe, catastrauphic event without the propofol, add to it a serious anesthetic and it is easy to see how he went into arrest and died.
Reply | Report Abuse | Link to thisI think he should definitely lose his license, I'm not sure about jail though. He didn't deliberately killed him; he was making 150 thousand dollars a month off Michael. He chose money over ethic, he knew Michael was abusing the drugs, but what you gonna do, huh? Michael had his mind made up and this is what he wanted to take and he paid for his life with the choice he made. And now people are demonizing this doctor, the black Rasputin, putting him under the microscope, hoping to find sth that will show... haha... he did it, you see I found the smoking gun! There is a bigger picture, the iatrogenic death in the Usa/World. The pharmaceutical/medicine industry is the biggest fraud. Say no to drugs! It's everyone's responsibility! Everybody wants a piece of Michael, he is worth more dead than alive. Joe Jackson is launching a cheesy line of perfumes with a French scam-artist Julian Rouas. Prince and Paris jackson are posing with the perfumes. See the sickening photos at, http://jacksontributefragrances.blogspot.com
Reply | Report Abuse | Link to thisWith Benzodiacepines, you need giving tenths of times the ordinary dose to start having any kind of problem, and without another drug, for example alcohol, even a high benzodiazepine overdose is not probably going to cause serious problems, just an sleep longer than usual, ordinarily no more, even if you mix several of them. It's quite difficult to die just on benzodiacepines, another more powerful drug or toxicity adding drug uses to be involved in such cases.
Reply | Report Abuse | Link to thisSounds as if Michael was an accident ready to die. Too bad for his so-called personal physician that he was nearby at the time of death.
Reply | Report Abuse | Link to thisDr. Murray was there only to provide the drugs. Michael probably knew more about the drugs than he did but didn't have a license to write prescriptions.
Murray has a problem with his "accident" defense! Why, if he did nothing wrong, did he feel motivated to tape record Micheal "demanding" the drug?
Reply | Report Abuse | Link to thisMost accidents are not pre-taped for play at trial.
A few years ago while being prepped for a colonoscopy I asked the anesthesiologist what drug he would be administering and the reply was Propofol.
Reply | Report Abuse | Link to thisI wonder if I'll question the use of that drug when next I need to be tested. Too much controversy makes for a nervous patient.
There is no requirement for anesthesia during a colonoscopy. There are better outcome without anesthesias, primarily due to less perforations. Sometimes if polyps are found, the patient is later informed, permission for removal sought and the money earning exercise is repeated. Ensure that all permission are given and signed for before the procedure starts.
Reply | Report Abuse | Link to thisIts (anesthesia's) main purposes is to reduce culturally learned embarrassment for all parties and reduce the witnessability to negligence.