PROPOFOL AND THE DEATH OF MICHAEL JACKSON
A Pharmacist's Perspective
Now that a verdict of involuntary manslaughter has been decided against Conrad Murray in the death of Michael Jackson, I decided I would comply with several requests to comment on this case.
As a pharmacist, I am used to writing about medications. I am not used to writing about entertainers, Hollywood or homicides. However, the death of Michael Jackson and the potential relationship of the drug "propofol" have forced me to venture into unfamiliar territory. I have been asked by several individuals for my perspective, as a pharmacist, on the pop star's death. Whether the death was self-inflicted or the result of gross neglect...it was clearly a tragedy and my sympathies go out to those who feel the loss most dearly.
In this article I just want to focus on giving some details about the drug "Propofol" as this information does not always appear to be clearly articulated in the media. I will begin with a chronology related to Michael Jackson's death and end with a few quick comments by way of professional opinion. Therefore, the structure of this article is as follows:
- Chronology of Michael Jackson's Death
- Propofol - What it is and what happened
- Summary - Concluding remarks
One brief note about the "facts" related in this article. I have tried to accurately gather what information is available about this case from the online media sources. I am, however, painfully aware of the potential inaccuracies that abound, even when the best efforts are used to compare stories and use reliable sources. If any facts presented here go awry from the truth, allow me to apologize in advance. I have tried to stick with the best evidence and facts I could find.
Just to briefly review the relevant chronology:
May 2009 - Cardiologist Conrad Murray hired as personal physician to Michael Jackson (reportedly for a salary of $150,000 per month).
June 24, 2009 - 9:00PM-Midnight Jackson rehearses at the Staples Center
June 25, 2009 - Michael Jackson dies of cardiac arrest in his leased Bel Air mansion in the Westside of Los Angeles, CA.
August 28, 2009 - Jackson's death ruled a homicide by the L.A. coroner.
September 27, 2011 - Trial of Conrad Murray, Jackson's personal physician, begins.
Propofol - What is it?
Although Michael Jackson was likely on a variety of prescription medications for anxiety, depression and insomnia, the attention has come to be focused almost entirely on something called "propofol."
Propofol is an injectable anesthetic used almost exclusively in a hospital setting on patients prior to certain surgical procedures. The brand name (Diprivin) was introduced into the U.S. market back in 1986.
Propofol comes in a 10mg/ml vial for IV administration and is available by prescription only from the following U.S. sources:
- A.P.P. pharmaceutics (brand name Diprivan)
- Hospiria (generically as propofol)
- Teva (generically as propofol)
Uses: Propofol is indicated ONLY to induce and maintain sedation for surgical procedures. For example, a patient on a breathing machine needs to be sedated (not something you want to go through while awake) and would be given an infusion of this drug by an IV line. Propofol might also be given to sedate a patient prior to a colonoscopy.
Propofol and Michael Jackson: From the above description, you might be asking "Why was Michael Jackson using Propofol?" Good question. Michael Jackson suffered from insomnia. Although many prescription drugs are available to effectively treat insomnia, he apparently had been introduced at some point to the powerful effects of propofol. Propofol knocks you out, and apparently was the only thing consistently effective to help Michael Jackson sleep.
It appears that Michael Jackson hired Dr. Conrad Murray, a cardiologist, to be his personal physician and, when necessary, to administer propofol to him at home so that he could sleep. According to what Dr. Murray told LA detectives, he had been regularly administering 50mg of propofol every night to Michael.
June 25, 2009 Drug Administration Schedule:
1:30AM: Early on the morning of June 25, 2009 (around 1:30AM) Dr. Murray administered a dose of Valium to help Michael Jackson sleep. Valium (generically available as Diazepam) is a commonly prescribed benzodiazepine used for seizures, anxiety, insomnia and muscle spasms.
2:00AM: When still awake at 2:00AM Dr. Murray then administered an IV injection of Ativan (generic name lorazepam), another strong benzodiazepine.
3:00AM: When still awake at 3:00am, Dr. Murray decided to administer a drug called midazolam, an injectable drug also used for anesthesia in hospital settings.
3:00AM - 10:40AM: Other prescription drugs, not propofol, were apparently administered to try and help Michael Jackson fall asleep. These may include additional doses of lorazepam and midazolam.
10:40AM: Still unsuccessful, Dr. Murray injected 25mg of Propofol to induce sleep.
At some point following this dose of propofol, the Dr. left to use the restroom for 10 minutes, upon returning he found Michael not breathing. After performing CPR and eventually making phone calls for help, emergency medical personell arrive and Michael Jackson is taken to the UCLA Medicaid Center where, after further efforts to revive him, he is pronounced dead at 2:26PM.
Comments & Perspectives
Propofol, in itself, is not a bad drug. When properly used in the right setting it is remarkably effective and useful as a surgical anesthetic. In developing my own opinion on this case (not that my opinion is of any significance here) I have focussed on 3 specific questions to help me.
The 3 (three) significant questions related to Michael Jackson's death which require an answer are:
1. Was it the administration of propofol (or any drug for that matter) that caused Michael Jackson's death?
The autopsy report, which I read, states that the cause of death (according to the medical examiner) was acute propofol intoxication, contributed to by benzodiazepines. Dr. Murray admits that both propofol and other benzodiazepines were being given to Michael Jackson that night.
These drugs work by depressing the central nervous system. Any medication capable of CNS depression is capable, if given in too great a quantity, of causing a patient to stop breathing. When this happens, oxygen can no longer reach the brain or the heart. The heart, without a supply of oxygen eventually stops working (as do our other organs).
Although cardiac arrest can occur for many different reasons, the medical examiner did not notice evidence that would point to any other cause. Respiratory depression and cardiac arrest are known risks associated with propofol (see picture below), which would even be more likely when benzodiazepines were also on board. In my professional opinion, it was propofol (in combination with the other benzodiazepines) that caused Michael Jackson's cardiac arrest and death. As a pharmacist who has seen some extremely high doses of medications used in the treatment of insomnia and anxiety, I have personally never encountered dosages of this magnitude.
The Dangers of Propofol
2. Could Michael Jackson have injected himself with additional propofol, or taken other drugs which Dr. Murray was unaware of?
In my opinion this question and the answer is not especially significant. On the one hand, sure, I believe Michael Jackson could have taken additonal doses of medication (even self-injecting propofol) without Dr. Conrad's knowledge. But I believe that only aggrevates the negligence of the doctor. If Michael Jackson were in a hospital setting this would have been almost impossible. And if propofol were not being used, the potential for a fatality would have been much less.
3. Was Dr. Murray negligent in his prescribing and administration of these drugs?
This question is a bit more difficult and the answer may require more information than we, as the general public, have had full access to. I know that on one level it seems pretty obvious that Dr. Murray was at fault for these reasons:
- Propofol was never intended to treat insomnia.
- Propofol is never indicated for home use.
- Propofol should never be administered without adequate and continuous observation.
These facts alone create an enormous body of evidence against Dr. Murray in my opinion.
However, another set of facts may also need to be considered by the jury in this case. Dr. Murray may have inherited this patient, Michael Jackson, with a drug problem already. Patients come with baggage. The doctor may not have introduced Michael to this drug, but having gotten used to it, Michael may have gotten to the point where virtually nothing else worked. In an ideal world a doctor can just treat a patient according to standard medical therapy. But this isn't an ideal world, and Michael Jackson's case appears to have been an unusually resistant case of insomnia. The use of any drug for puposes other than what it is approved for is known as "off label" prescribing. It happens ALL the time. Many drugs work for things which they have not been "officially" approved for. Ever taken Benadryl for hives? That would be an "off label" use, but it works. Dr. Murray made a professional decision to use propofol for an "off label" indication with Michael Jackson.
So what is my opinion as a pharmacist? On the one hand I can sympathise with Dr. Murray and the challenges associated with a (possibly) demanding patient who may already have problems that he was now forced to deal with. On the other hand, medical professionals are bound to a code of ethics and required to use sound judgment in their decisions. At the present time, and based on the information available to me, I am convinced Dr. Murray was guilty of unintentional manslaughter. Although Michael's case was clearly unique, Dr. Murray consented to continue very questionable and dangerous treatments for which he was paid handsomely. This case is a sobering reminder to all professionals in health care of one of the very fundamental principles of medicine: Primum non nocere (first, do no harm.)