Michael Jackson used to propofol to sleep - it ended up killing him. Photo / AP
Michael Jackson used to propofol to sleep - it ended up killing him. Photo / AP
Doctor Love introduced me to the wonder drug propofol. I was in for electric shock treatment - a cardioversion, an attempt to correct the fast, haphazard rhythm of my trembling heart - at North Shore Hospital. It required a general anaesthetic. "People call it Jackson juice," said the anaesthesiologist, Dr Andrew Love, a reassuring and kindly man from South Africa. He explained that was the nickname for propofol, the anaesthetic Michael Jackson craved so badly and so recklessly that it killed him. Jackson wanted it to put him to sleep. In fact it would given him shocking levels of sleep deprivation.
REM sleep, that deep, mysterious slumber where we enjoy our most vivid dreams, is reduced in the brief coma of propofol. If his life had turned into a nightmare, then propofol took away his dreams. He was shot up almost every night for two months until he stopped breathing on June 25, 2009. Cause of death: acute propofol intoxication. His cardiologist, Dr Conrad Murray, found guilty of involuntary manslaughter, had ordered four gallons of the stuff.
"He didn't know what he was doing," said Dr Love. "We do. Don't worry." Perhaps I looked alarmed. In fact I was depressed. I regarded the electric shock with a dread that was profoundly exhausting. I didn't want to know about it, didn't want it to happen, and had the distinct feeling it was somehow going to kill me. I kind of lost interest in the world. But Dr Love's propofol chatter inspired a sudden interest in something - the drug that was going to knock me out, used every day to knock out everyone who has surgery. Countless patients have experienced it; propofol is the anaesthetic of choice, the most common sedative in elective surgery and intensive care. If you've had the knife, you've had Jackson juice.
Pania Stevens (Bree Peters) administers a fatal dose of propofol in a recent episode of Shortland Street. Photo / South Pacific Pictures
An injection will put you under; an infusion will keep you under for hours, days, longer. Propofol works. It's the world leader, the active ingredients isolated in 1973 in Cheshire, England, first trialled in 1977 in Ghent, Belgium, and put on the market in 1986. It's fast, passing through the blood-brain barrier at fantastic speeds - 10 seconds, or thereabouts. It's pleasant, with no side-effects, unlike the drowsiness, nausea, and hangover commonly brought on by thiopental, which propofol replaced. It's cheap, at only $3 for a vial of 200mg. As little as 20mg is enough to induce unconsciousness. Because the electric shock would otherwise feel like I'd been kicked by a horse, I was given 100mg. "You might have to double the dose with me," I told Dr Love. "I'm as resistant as an ox."
I didn't hear the "hurt". The next thing I knew I was talking in my sleep. In not exactly medical terms, I was talking in a subconscious miasma where the truth roams free. I heard a sentence rise from the depths of my soul and make its way around the room. It was a dreadful sentence and I deeply regretted saying it. There was a Chinese nurse standing by the bed. He didn't seem offended. He was calm, and there was a gentle smile on his face - I don't mean to say he was inscrutable.
I felt very confused. I said, "What's going on? Has it started yet?"
He said, "It's finished. We've done it. You're awake now." Five minutes had passed in oblivion. Where had I gone, and how did propofol get me there? What does it do in the brain?
"Nobody knows," says Auckland anaesthesiologist Dr Michael Kluger. "There's lots of theories why anaesthetics work, but we don't know. Which is kind of weird, because it's what we do as a profession, and yet nobody can tell for sure."
Milk of amnesia
The active ingredient of propofol (2,6-diisopropylphenol) is held in a white liquid, cutely known in anaesthesia as "the milk of amnesia". Auckland anaesthesiologist Dr Manoja Kalupahana has another fetching description of the drug, which is emulsified in soya bean oil and egg yolk: "It's like salad dressing."
Propofol disperses quickly. The blood pressure drops. The patient also stops breathing.
"Airways, airways, airways," chants Dr Ted Hughes, president of the New Zealand Society of Anaesthetists. His mantra underlines the crucial need to keep the patient's airways open, and monitor their breathing. While Michael Jackson gasped his last, Murray was busy gassing on the phone to his girlfriend.
Joan Rivers died last year of brain damage due to lack of oxygen after she was given propofol - by her gastroenterologist, who posed for pictures with her famous patient during anaesthesia. "I'm actually profoundly grateful to Joan Rivers and Michael Jackson," says Hughes. He means their deaths have served to stress the absolute need for anaesthesiologists to administer the drug. Its margin of safety is exquisitely narrow. The slightest increase can kill.
Its potential as a lethal injection is in demand; Missouri tried to introduce it two years ago, but the EU threatened to withdraw propofol from the US altogether.
Rampage of villainy
There are only three recorded instances of propofol homicides. In 2005 and 2008, two anaesthesia nurses in the US killed their victims with stolen vials of the drug. The third murder was on Monday, in New Zealand, on television, when the monstrous Pania Stevens stole a vial of propofol and gave a lethal injection to her comatose husband Caleb on Shortland Street. "As so often happens with villains," says the show's producer, Simon Bennett, "they explode into a rampage of villainy."
Strange that it should happen just as I was researching this story, but Shortland Street has a long and distinguished history of life imitating its villainous rampages. "We thought, 'What might she use to kill Caleb?'" said Bennett. "We were given a list of possibilities by our advisers. Propofol was one of them, and we thought, 'Well, that would probably do the trick.'" (I alerted Kalupahana to the episode. She watched it at TVNZ OnDemand. "Quite realistic," she reported, although she thought Pania's method of injecting it directly into the intravenous tubing would have gone in "too slowly". Ideally, she added, Pania should also have used potassium and a paralysing agent.)
Bennett continues, "The other thing is that propofol's not easily accessible, so it's unlikely to give people copycat ideas. That's always a consideration at seven o'clock."
He's right. Propofol is really only accessible to anaesthesiologists and surgical staff. That's just the problem.
"When an anaesthetist decides to commit suicide, they do it very well," says Dr Rob Fry. They choose propofol. They have the access, and they know exactly how it works. Fry is a member of the Welfare of Anaesthetists Special Interest Group, and has conducted surveys of substance abuse among anaesthetists in New Zealand and Australia. The most recent findings were published this year. Propofol was identified as the most commonly abused substance - higher than opiates or alcohol. The most chilling statistic records, "Death was the eventual outcome in eight cases of substance abuse (18 per cent), with three identified as suicide and five as overdose. All eight deaths involved propofol."
Every anaesthetist I spoke to for this story knew anecdotally of a case of propofol abuse or suicide: the woman who was so sure her propofol infusion would kill her that she laid out the dress she wanted to wear in the casket; the man who cut open the femoral artery on his leg, and bled out during a propofol drip; the surgeon who was busted in an operating theatre with a needle feeding steady little doses of propofol in her foot; she later posed as a midwife at another hospital to hunt for her favourite drug. In 2006, Christchurch anaesthetist Dr Darren Cathcart died of a propofol overdose. The coroner's report stated Cathcart had been abusing the drug for at least six months before his death, and had obtained it from discarded syringes.
And in Hamilton, 53-year-old former Waikato Hospital nurse Peta Lee Millar will be sentenced on October 6 for her massive theft of more than 5000 propofol vials. Court documents show that at the time of offending, she was employed in the post-anaesthesia care unit. Like Michael Jackson, she said she wanted it because she had difficulty sleeping. Even after she lost her job, and was ordered to hand in her uniform and swipe card, Millar returned to hospital wearing her work scrubs and used her swipe card to steal more propofol - on 16 occasions. She pleaded guilty to burglary charges.
Like working in lolly shop
"It's like working in a lolly shop," says Hughes. There are a wide range of drugs available to anaesthesiologists. Propofol, though, is the most desired. It kills, and it does the job of any narcotic - it gets you out of it. It's an altered state and a sweet surrender, spacey, numbing, dissociative.
In line with international trends, Fry's welfare study revealed a high mortality rate of propofol abuse, at 45 per cent. "It's a very high concern," he says. "We do a lot of educating about it. I run education meetings several times a year telling the juniors about it, and the risks involved."
Studies in the US show a high percentage of users have suffered childhood trauma. They're often unable to sleep, and they want to block out the world. A doctor at an addiction treatment centre in Virginia told an anaesthesiology journal, "I don't know of any other drug where the perceived incidence of trauma, particularly of sexual trauma [in abusers], is so high. It's really quite remarkable." They want to forget. They want the milk of amnesia.
Dr Steve Low, an anaesthesiologist in Nelson, is a kind of propofol online superstar. He wrote and performed a satirical song called Propofol, and posted it on YouTube. It's got a funky, driving riff, and syringes swing from his ears in the video. "I get requests from professors in Germany and England to use it as part of their teaching programme," he says. "I also get inquiries about the drug itself from people who are obviously thinking of using it. That's a bit disturbing."
Insomnia, childhood trauma ... in 2009, a 50-year-old Bel Air, Los Angeles man reportedly stood on his bed at 4.30am, and hollered, "I told you I couldn't sleep all night!" He remembered that propofol had put him out during surgery. He demanded it. He got it. He was dead 65 days later with wooden beads and a tube of toothpaste at the foot of his bed, and a bottle of urine on top of a chair. The propofol IV was hooked up to his left leg. RIP the King of Pop.
The operation was a success. I got zapped, and the joules brought my heartbeat down from a frantic 100 beats per minute to a boring 60. I should have felt elated, and not only because of my increased chances of a long life. Propofol is a clean drug. Many patients climb out of its abyss in terrific spirits. There's a sense of well-being, euphoria, sometimes amorousness. There was the case, famous among a certain generation of male anaesthetists in New Zealand, when a patient woke from her sedation but had not yet crossed into full consciousness. Staff on the other side of the surgical curtain heard the piteous cries of her anaesthetist: "Help me! Help me!" They flung open the curtain. The woman had grabbed him by the front of his shirt and pulled him on to the bed.
The magic of propofol casts so many happy spells. "It's just unbelievably good," said Dr Hughes. "It makes us look a lot better than we are, really. It's a wonder drug. It works so much better than thiopental."
That general anaesthetic was introduced in 1932, and is still in use. There are also rare occasions when the infamous tranquilliser ketamine is infused instead of propofol.
Dr Fry remembers the first propofol trials in New Zealand in the 1980s. "It was a remarkable drug," he said. "There was a demand for a new anaesthetic that was quicker than thiopental and with less side-effects. I'd been through trials as a house surgeon with a whole lot of other drugs to get away from thiopental. Propofol was the ideal agent. It's amazing, it really is. And it's the reason why nothing else has really been developed. Propofol is just so good at what it does."
New trials with etomidate, though, indicate it works even better than propofol. "But it's very experimental, and very expensive. It costs so much to make it and purify it. So the likelihood of it being adopted and put out by the pharmaceuticals industry ... There just isn't any money in it."
Propofol rules supreme. But its properties turned me into a wretch. I felt terrible. The dreadful sentence I threw at the nurse hung in the air - and what else had I said in my unconscious state? Propofol releases our inhibitions.
Dr Kruger once anaesthetised an SAS officer. "He had a minder. I said to him. 'What happens if he wakes up and say things I'm not supposed to hear? What will you do to me?' He just smiled."
Although hardly a truth serum, propofol does have ways of making you talk. I said to the nurse, "I can't believe I just said that. I didn't mean anything by it." He said not to worry about it. I said, "Did I say anything else?" He said not to worry about it, and then he recounted our dialogue.
As I first emerged from the propofol's black, deep space, I turned to the nurse, and said, challengingly, "I know you."
I said, "Devonport. Milford. Takapuna. Albany. One of those."
He said, "I used to live on the Shore."
I said, "Aha!" Then the conversation took a turn. Suddenly I was an expert in matters of society and the mood of the times. I said, "Tell me. Do you regard New Zealand as essentially violent?"
The nurse was a reasonable man. He said, "No, not really."
And this is when I heard myself dredge up that sentence from a black lagoon of my racist mind, and announced, "I have to tell you that I don't think you've adjusted to the New Zealand way of life."
I'd missed out on the pleasures of an illicit narcotic to reveal myself as boorish, argumentative, idiotic, and a dreary xenophobe. The nurse said he'd heard worse from anaesthetised patients, and one clown took a lazy swing at him in the twilight zone of waking from propofol.
So why do we respond in different ways to the same drug? How does it work inside our thick skulls?
Dr Jamie Sleigh at Waikato Hospital is the co-author of numerous papers on propofol's affect on the brain.
"The main philosophical problem is it's hard to define and understand the mechanisms of consciousness," he says. "You can't really say how material stuff gives rises to subjective sensations.
"We know so much and understand so little. We're kind of like before Copernicus, or before Newton. We've got a lot of observations and accumulated a lot of facts, but we need to be able to find the underlying laws of the brain."
I asked how far away we were before a genius emerged as the Copernicus of the consciousness.
"We're edging closer! I don't know. Five or 10 years? But that could be wildly optimistic"
I went to see my GP a few weeks after my cardioversion. It hadn't held. "You're all over the place again," said the quack. The beats per minute were now 105. I could always go back for another jolt. It might work. I wouldn't mind. I'd like another chance, another opportunity to experience propofol's mysterious spell.
