This doc should walk. Who knows what other shit MJ was using on the side, with some other source or dealer.
It's the mixing that counts.

So says dr kill.

Okay, that's funny.

Thank you for the interesting description of propofol that I've not read elsewhere. It's not like the mainstream media is going to write a balanced treatment of a drug like that.

As far as the Michael Jackson case having any effect on the outside world: Michael Jackson was sui generis. As was his death. There is nothing about this case that has any lessons for anybody anywhere about anything.

I will only allow it to be considered funny if dr kill thinks it's funny!

I don't know about whether Murray should walk, but I think it might be tough to get a conviction. Still, it just strikes me as violative of the Hippocratic Oath to be giving a dangerous anesthetic drug like propofol to someone at home.

Had I been Jackson's doctor and he asked me for it, I'd have explained that I could not give it to him unless he entered the hospital. (I'm sure Jackson would have been wanted one elective procedure or another.)

Very nice job connecting the dots. I've been looking for a description of what sort of high propofol induces. Very hard to find. And the commonality of childhood trauma among addicts, particularly sexual abuse.... chilling.

Michael Jackson spent periods of his childhood in the sexually liberated, gay friendly drug-abusing environment of Studio 54. One can only guess what he might have encountered there, and how those era might have shaped his appetites, both pharmacological and sexual.

I hope for an end to the war on drugs, but that doesn't extend to making something like propofol available over the counter.

Let the Darwin dropouts have their fun. More room for normal people.

Eric -

I hope you aren't in favor of a blanket removal of prescriptions. Do that and you get Mexico - where resistant strains of bacteria are legion due to overuse and improper use of antibiotics.

I wonder if this would generalize to fugu eaters - the Japanese pufferfish delicacy that can kill you if prepared wrong, and that often causes numbness.

What's puzzling, experts said, is the strength of the connection. "I don't know of any other drug where the perceived incidence of trauma, particularly of sexual trauma [in abusers], is so high," Dr. Manejwala said. "It's really quite remarkable."

I guess he never heard of heroin.

Heroin

This is long, but I wrote it to the FDA four years ago:
A petition is now before the FDA that has the potential to put patient safety at unwarranted risk. On June 28, 2005, the American College of Gastroenterology (ACG) filed a petition to modify the warning label of the sedative drug, Propofol. The organization is requesting that the section pertaining to administration by individuals trained in general anesthesia be removed (see below). In the hands of trained professionals, Propofol can be a very safe and efficient drug, but patient reactions can at times be very unpredictable during surgery. Because there are no reversal agents for this anesthetic, it is crucial that a formally educated and trained anesthesia provider, with primary and sole responsibility for advanced airway support and resuscitative support, be responsible for its administration. Experience administering this medication, as well as observing and treating common and rare untoward events, is a long process?it comes from thousands of cumulative hours spent monitoring subtle clinical clues, cardiac rhythms and observing patterns of clinical response. These comprehensive skills can not be marshaled after a two or three day program such as the NAPS (Nurse Administrated Propofol Sedation) training course. Nor are they gleaned after similar weekend seminars for gastroenterologists or other physicians who may leave with a false sense of security that they are as familiar with potent anesthetics as anesthesiologists. There is absolutely no question that physician anesthesiologists and certified nurse anesthetists have undergone the extensive training required for administration of this anesthetic. Today?s anesthesiologists complete four years of formal postgraduate training, which includes one year of clinical medicine and three years of clinical anesthesiology. Nurse anesthesia programs consist of two to three years of didactic and clinical training in the techniques of administration of anesthetics. There are several professional organizations that recognize the risks involved with Propofol: ? The American Society of Anesthesiologists? (ASA) position on Propofol is: ?Whenever Propofol is used for sedation; it should be administered only by persons trained in the administration of general anesthesia who are not simultaneously involved in the surgical or diagnostic procedure. In addition, these persons must monitor patients continuously for oxygen saturation, respiration, heart rate and blood pressure.? ? The Joint Commission on Accreditation of Health Organizations (JCAHO) Standard PC 13.20 requires: ?The person administering the medication must be qualified to manage the patient whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally.? (Revised Jan.1, 2004). Further, ?these standards require that individuals who administer moderate or deep sedation must also be competent to perform the rescues described in these standards,? i.e. the ability to manage an airway, administer reversal agents and provide ACLS care. ? The American Association of Accreditation for Ambulatory Surgical Facilities (AAAASF) states: ?Propofol is a very potent drug capable of rapidly producing a state of general anesthesia even when a state of sedation is the intended effect. If this should occur, the patient?s protective reflexes- for example, control of the airway, breathing, and circulation are lost or dangerously depressed. A life-threatening condition would exist in the absence of proper supportive care. Anesthesia professionals are best qualified to provide such supportive care for the sedated or anesthetized patient. Outpatient Surgery Magazine conducted a survey and found that 74.8% of its readers felt that RN-administered Propofol is a patient safety risk and

71.2% responded with it being outside of an RN?s scope of practice In the interest of patient safety and quality of care, it is my opinion that your committee denies this petition for a label change.

Overall I agree with your sentiments. Where I see a problem (with the facts as known) isn't that a person (Jackson) wanted to use a specific substance - propofol, for whatever reason.

The problem arises because he asked a licensed physician, someone who had specific knowledge and a professional duty to use a pharmaceutical product (propofol injection, manufactured for medical use) in manner consistent with the products intended use and within the guidelines of his profession, and that physician utterly failed in this duty thereby harming his patient.

As a libertarian I believe that if Jackson wanted to use propofol, and someone was willing to make it and provide it, that should be entirely between the two of them.

But I also believe that if a manufacturer makes a product that they specifically intend for professional use and do not want used in any other manner, they have a reasonable expectation that society will sanction those who do not abide by those terms of use.

Eric...You were wondering about the effects of this drug. I have had the occasion to take this drug during a colonoscopy this year and maybe I can give you an idea.

Upon awakening, I felt high and started joking with my doctor. The only way to describe the feeling is that it is a bit like being on cloud 9 or the feeling of being in love. The feeling wore off over the next 18 hours or so.

Have had this 3 times this year (I think that's what it was) for epidural steroid injections. I have no idea what the anesthetic actually was, but it was unique to any other anesthesia I've received, so after reading your description of how it works, I can now guess it contained propofol. When I asked the nurses about it, they told me that my anesthetist had a special cocktail injection, and others had reported the same "DO IT AGAIN, PLEASE" response as mine.

It was the best power nap EVER.

The procedures lasted less than 20 minutes or so (so I wasn't out that long), but it felt like I'd slept for 10 hours and the euphoria lasted for days.

After the first one, I looked forward to the remaining ones, just to get that great nap. It felt like I was catching up on all the sleep I'd ever lost/missed, and sleep without any pain/disturbance.

If this was legally available at a walk-in clinic and they added a pedicure/manicure, followed up with a massage, I'd start budgeting to have it once a month. Oh, and add a bag of saline/sugar fluids to flush out a month of toxins/dehydration, too, please!

After reading this, I think that was what I was given a few years ago for outpatient surgery for a soft, benign cyst on my neck.

I did not feel euphoric after coming around. I was missing about 3 hours of time. All my life I have awakened knowing about what time it is. If I decide to wake at, say, 7AM, at 6:55AM my eyelids pop open.

In this case, nothing. Three hours had been cut out of my life. It took the better part of two days to get my 'time sense' back in synch.

I didn't like that even a little.

I'm a physician.

You don't give someone a potentially dangerous anesthetic drug like propofol without:

a. Considerable training in monitoring their vital signs (since as already mentioned these drugs are potentially lethal), and just as important knowledge and training in what to do if there is a complication, and

b. Actual equipment in place to do these things, including equipment to deal with possible immediate life-threatening side effects, and

c. A good medical indication for it.

If a, b, and c aren't met, administering the drug is BY DEFINITION malpractice. (EG deviation from the generally accepted standards of medical practice with likelihood to harm a patient).

The treatment for insomnia isn't propofol.
The treatment for post-traumatic stress disorder isn't propofol.
The only really accepted medical indication for the use of propofol is to induce anesthesia.

Administering mind-altering drugs to patients solely to get them "high" is not only malpractice, its usually grounds for permanent revocation of a physicians license to practice medicine.

Propofol can't be self-administered. . .well, it can, but not with any real margin of safety. Which means that in practice, the only way you CAN get it is if a physician gives it to you.

In short, its hard to characterize administration by a physician of a dangerous anesthetic drug like propofol by a physician outside of an operative setting as anything other than gross professional negligence. If someone were to die in that setting, I think that would satisfy the definition of manslaughter, which is to say a death caused by gross negligence.

Speculating, in the case of Michael Jackson, he probably *would not* (and *could not*) have been abusing this drug without the direct participation of a physician or other health professional. So if indeed the drug killed him, its probably fair to say that "but for" the physicians actions, he's dead.

Further, MJ was likely proceeding under the belief that since "a doctor" was giving him the drug, it was safe. He probably did not fully appreciate the risks involved.

In short, libertarian arguments probably don't fly here. If consenting adults want to abuse drugs, MAYBE they should be allowed to, but I can't see how physicians should be given license to participate in substance abuse.

Further, the situation here is NOT one of classical informed consent, since informed consent implies a risk/benefit ratio. As there is no medically accepted use for propofol outside of a medical anesthesia setting, there was no potential benefit to Jackson and his consent (assuming he gave it) was effectively meaningless.

[i]"I wonder if this would generalize to fugu eaters - the Japanese pufferfish delicacy that can kill you if prepared wrong, and that often causes numbness."[/i]

Its an apt analogy.

I've been told by a sushi lover who has tried it that fugu itself takes like crap, and that nobody eats the stuff for its taste. The fugu eaters do so because:

a. Eating the "deadly" fish gives the thrill of taking risk, and shows off that the eater is "brave", and
b. The stuff is "deadly" expensive. . .giving some "conspicuous consumption" type status in ordering/eating it, and
b. Supposedly small amounts of the toxin residual can give an interesting numbing sensation. . .its not quite getting "high" but maybe analogous.

To extend the analogy, every fugu eater knows there is a risk involved, and the fugu chefs are required to undergo careful meticulous training and certification before they can serve it.

Serve it without that license and you can go to jail.

If a fugu chef were to skirt the rules and include more toxin than the acceptable guidelines (either deliberately or by negligence), they may fairly be held liable for negligence if their client dies.

Supposedly many of the fugu-related deaths occur for EXACTLY this reason. Some super-wealthy client requests a little more of the "good stuff" to feel the drug effect and the fugu-chef complies a bit too much by mistake, leading to overdose.

The difference between the fugu thing and the Jackson story is that outside an operative setting there is *NO* accepted "safe" dose of propofol. Again, it would be a breach of professional ethics to administer *ANY* propofol to a patient who didn't need it medically.

"I'd hate to see this case being used to intimidate doctors, and frighten them away from giving their patients whatever pain medication they need."

Don't worry, it will be. The Feds already make it extra-hard to properly treat intractable pain. :-(

Dr. Anonymous, MD:
Since you are a doctor you know that propofol is always administered with lidocaine.
That's because it burns. Doesn't that fact ring some kind of bell?
Also, allegedly because of the short supply of anesthesiologists and the use of propofol for every day procedures like colonoscopies, plain old RN's are used to administer this drug, often NOT in a proper hospital setting where oxygen, paddles, and someone able to bag and intubate are handy.
I just went through this nightmare with someone dear to me who was overdosed on this crap. Fortunately it was a hospital, and he ended up in Shock Trauma on a ventilator instead of plastic bag.

THIS DRUG SHOULD BE ONLY GIVEN BY TRAINED ANESTHELOGISTS, PERIOD!