Diprivan risk well-known to doctors - CNN.com

On Friday, The Associated Press quoted an unnamed law enforcement source saying investigators found Diprivan in Jackson's Holmby Hills home.

[From Diprivan risk well-known to doctors - CNN.com]

I really hate to play armchair pathologist, but this case is just strange. It also allows me to speak to two aspects of modern medicine that are quite concerning. The first is boutique medicine, the second is the state of narcotics use in the United States.

First, boutique medicine and again, I will approach this from the perspective that we don't know *exactly* what was going in, but some of the stories are shocking. At first we heard that Mr. Jackson was suffering from chronic pain that required, presumably, narcotics to treat. This has been apparently been happening for a number of years. To first put this in perspective, let me quote from a generic "narcotics contract" that many physicians use for their chronic pain patients:

It is not appropriate to expect total relief of the pain with opioid. To do so places you at increased risk of respiratory depression, sedation, nausea, constipation, and tolerance. A 50% reduction in pain is a realistic goal. The goal in prescribing pain medications is to reduce the need for them in a reasonable amount of time. For example, the underlying pain may decrease over time, and you should attempt to learn safer ways to manage your pain (e.g., relaxation techniques, self hypnosis, biofeedback, etc. all available through pain rehabilitation clinic). Approximately every 6 months, the need for this medication will be re-evaluated and you agree to periodically attempt to reduce or discontinue the pain medication altogether under your physician’s supervision.

Certainly delivering daily, weekly, monthly *INJECTABLE* opioid medication is not consistent with keeping the safety and health of your patient in mind. Primum non nocere. Oh, but right, I forgot one important aspect of the business of boutique medicine. The patients are not patients, they are "consumers" of health care. As such, the customer is always right. We see this all of the time. You have a sniffle, probably viral, but you want antibiotics, sure. What could possibly go wrong. You have chronic back pain and you want oxycodone, oxycontin, methadone, hydromorphone, fentanyl etc....., ad infinitum.

Another thing to mention is this alleged use of propofol for sleep. It is completely beyond me why one would use this medication for the purpose of sleep. Firstly, it is not without side effects...

• anaphylactic/anaphylactoid rxns, incl. fatal


• propofol infusion syndrome (PRIS), incl. fatal


• bradycardia


• asystole


• cardiac arrest

PRIS seems unlikely as I think the duration of treatment was not adequate, and there would have been findings on autopsy. That said, I recently read a quote that said:

This is only meant for use in anesthesia and [administering it as a sleep aid] it's like giving someone chemotherapy so they don't have to shave their head," said veteran anesthesiologist Dr. John F. Dombrowski

I think that about sums it up. The medication is used in the OR, it is used in the ICU for management and sedation of intubated patients. It is rapid onset and rapid offset. It is not super-Ambien. It is anesthesia. It is not an analgesia, and as such should not be compared to oxycodone or other pain medications like I have seen recently in the MSM. Enough about that.

The second point I will spend some less amount of time with, just some statistics.

The number of all poisoning deaths increased 54 percent to 30,308 over the 1999-2004 period, while the number of poisoning deaths mentioning methadone increased 390 percent to 3,849.

Age specific rates of methadone death are higher for persons age 35-44 and 45-54 years than for those younger or older.

Following are examples of 1999-2004 ratios in states with “large” numbers of methadone–related deaths (greater than 50 for at least 3 of the 6 years): West Virginia (25:1), Kentucky (15:1), Florida and Oregon (14:1), North Carolina and Texas (7:1), Virginia (6:1) and Washington (5:1). New York showed no overall change during the 6 years (1:1).

The number of unintentional poisoning deaths increased from 12,186 in 1999 to 20,950 in 2004. The annual age-adjusted rate increased 62.5%, from 4.4 per 100,000 population in 1999 to 7.1 in 2004. The increase among females, from 2.3 to 4.7 per 100,000 population (103.0%), was twice the increase among males, from 6.5 to 9.5 per 100,000 population (47.1%) (Table 1). Among males, rates among whites, American Indians/Alaska Natives, and Asians/Pacific Islanders all increased approximately 50%. Rates among black males were highest in 1999 but did not increase. Among females, rates among whites more than doubled, whereas nonwhites had smaller increases or decreased. Overall, rates increased 75.8% among whites, 55.8% among American Indians/Alaska Natives, 27.4% among Asians/Pacific Islanders, and 11.2% among blacks. Rates among non-Hispanics increased more than rates among Hispanics for both sexes. Among all sex and racial/ethnic groups, the largest increase (136.5%) was among non-Hispanic white females. Among all age groups, the largest increase occurred among persons aged 15--24 years (113.3%). In 2004, the highest rates were among persons aged 35--54 years, who accounted for 59.6% of all poisoning deaths that year.

Unintentional drug poisoning mortality rates increased substantially in the United States during 1999--2004. Previous studies, using multiple cause-of-death data, have indicated that the trend described in this report can be attributed primarily to increasing numbers of deaths associated with prescription opioid analgesics (e.g., oxycodone) and secondarily to increasing numbers of overdoses of cocaine and prescription psychotherapeutic drugs (e.g., sedatives), and cannot be attributed to heroin, methamphetamines, or other illegal drugs (3,5).

At the end of the day, common things being common, I would not be unreasonable to assume Mr. Jackson consumed too much of some unknown medication which caused respiratory depression, this in turn caused Mr. Jackson to develop hypoxemia which lead to cardiac arrest and his subsequent death. Make no mistake, if this is the case, this death is 100% preventable.