Friday, July 25, 2014

Once Again, Real Life Takes Away My Material. I Also Call Out Some Chicken Shit Compounding Pharmacists

Those of you who've picked up a copy of my awesome first book no doubt remember how I opened it with reminiscences of how I used to mock healthcare professionals who couldn't poison someone.  A doctor who tried to kill his mistress with strychnine for example, or a nurse who might use morphine to off a patient or two. It worked as humor because you'd assume that anyone who spent a few years studying the combination of how the body works and the chemicals the world of medicine puts into it oughta be pretty good at figuring out the poison thing. Basic stuff, right? Right in these people's wheelhouses and they screwed it up.....ha ha ha.....

Yeah....ha ha fucking ha.

The execution of a convicted murderer in Arizona lasted for nearly two hours on Wednesday, as witnesses said he gasped and snorted for much of that time before eventually dying. 
This drawn-out death of Joseph R. Wood III in Arizona prompted the governor to order a review and drew renewed criticism of lethal injection, the main method of execution in the United States, just months after a high-profile botched execution in Oklahoma.

And another one before that in Ohio. Right in the people's wheelhouses and they screw it up. Time after time. Once again I have underestimated the incompetence of others, and once again, real life robs me of comedic material.

Midazolam is the common denominator in all these fuckups, used with the narcotic hydromorphone in Ohio and Arizona and with a muscle relaxant (vecuronium) and potassium chloride (to stop the heart) in Oklahoma. So let me tell you a little bit about midazolam. It's what's known as a benzodiazepine, related to the Xanax and Valium so many people have made friends with. All in all they're a pretty good class of meds, gaining popularity in no small part because they are safer, particularly in overdose, than the class of meds they replaced, known as barbiturates.

Now, I'm gonna pause here, and place a large bet that even if you haven't had a day of any kind of medical training in your life, you can read that last paragraph and figure out the problem here, and offer a possible solution.

Some 6th grade dropout probably just said something like "um...maybe they shouldn't be using the safer one if they want to kill someone, and maybe go with that barbiturate stuff instead"...and that person... would be smarter than the Ohio, Oklahoma, and Arizona Departments of Correction.

 How many of you have had to have a pet put down? How long did it take? Seconds, not hours, yes? Guess what they use? Read that paragraph again and just take a wild-ass guess.

"Um......a barbiturate maybe?" the dumbest person on earth might say. And he would be right. Pentobarbital to be specific.

The olive in the martini here is that some states have figured this out. You won't hear about botched executions in Texas or Missouri because pentobarbital is exactly what they use.

So let's recap here. There is a successful model of a lethal drug that has a proven track record in both animals and humans. Yet some people in power think it's a good idea to go their own way and come up with a plan that uses a drug that is popular in medical practice in part because it is safer in overdose than the drug that is successfully used to kill lots and lots of living creatures.

And this is the world in which I try to satirize. Which probably says something about my intelligence.

Not that a midazolam/hydromorphone combination is completely inappropriate in theory. Pump someone full of enough of it and yeah, they should kick the bucket you would think. You know, assuming the meds were of the correct potency and actually were what they said on the label. Who knows? Maybe that was the problem here. Let's just check with the manufacturer and clear this right up....

...oh....wait. We can't do that. because no one quite knows who the manufacturer is. The prison people claim they're getting their goods from compounding pharmacies. Which means, if true, there's a colleague or two out there of mine who's a spineless, chicken-hearted, weak, cowering, thumbsucking, lily-livered, yellowbellied coward of a human.

That's right bubs. I'm calling you out. Signing a contract of death with the state is one thing, but doing so while insisting on the protection of anonymity is a whole other level of pussydom. Come out come out where ever you are deathdruggist, because if you can't stand the heat you're generating, you never should have gone into that kitchen and started cooking.

And just in case you are ready to point a finger back at me, I'll point out that I ended my awesome first book by telling the world how to get an abortion using a common anti ulcer medication, and I'll put the backlash whackadoodle anti-choice zealots are capable of generating up against anything you'll face any day of the year.

That part of the book still holds up by the way. No doubt because there I wasn't trying to mock an increasingly unmockable world.


Mike said...

I do wonder if cost was a factor here. States will do whatever they can to pinch a penny, especially when it comes to corrections. Could they have been procuring their midazolam/hydromorphone from whatever pharmacy cheaper than commercial pentobarbital?

Also, the wiki article for lethal injection says that as of late, the injection procedure is still sodium thiopental, and then midazolam/hydromorphone as a safeguard if the first doesn't kill you. Not sure if that's what happened in Arizona.

DrugMonkey, Master of Pharmacy said...


In both the Ohio and Arizona attempts, only a 2 drug midazolam/hydromorphone combo was used.

Robin said...

You are aware, aren't you, that the manufacturer of pentobarbital have limited the sale of it, so that it cannot be purchased or transferred to any prison for use in executions?

While I understand your point that this means that prisons are now forced to get the drugs used in their new execution protocols from compounding pharmacies, I'm not sure if compounding pharmacies can produce pentobarbital. Can they?

I'm wondering if anybody has considered just buying the solution that vets use to euthanize animals, which is pentobarbital and phenytoin. One of the brand names is Euthasol. The dosage is calculated by body weight, 1 ml of solution per 10 lbs. Wonder if some prison or other has looked to a friendly neighborhood vet for their execution drug needs.

Anonymous said...

The manufacturer (European) threatened to stop supplying pentobarbital if it was used in executions, so I think the states ran out and had to come up with a new plan.

I know that because I remember when sodium thiopental went on shortage. My pharmacy director was a disorganized chicken shit. She didn't know that the drug was no longer available. She wouldn't take any responsibility for telling the anesthesiologists about it when we finally ran out. I had to tell this monster of an anesthesiologist (probably the last guy in the US who still used it for non-execution purposes) that he couldn't have it and then inform the anesthesiology group. He got them really worked up about it and the group had an email with my contact information on it, so for the next couple of weeks they'd call the pharmacy to rage at our incompetence and about the death penalty and Denmark.

DrugMonkey, Master of Pharmacy said...


You are aware, aren't you, that I said in the post you supposedly read that 2 states currently use pentobarbital in their executions?

And you are aware, aren't you, that one of those states I mentioned in the post you supposedly read was Texas.

And you are aware, aren't you, that Texas tends to be a bit active in the execution game.

I doubt they're shitting pentobarbital out their ass. Which means it's out there somewhere, maybe....

Wait, you actually come out and say one place to get it. Right in your comment.

Why exactly did you write in? Christ.

Miss Margo said...

Hi! Layperson here (though I have pretended to execute someone at work, as part of a roleplay)!

Is it against some pharmacy code of ethics to sell the drugs to the state for purposes of execution...? I was just wondering. Could the pharmacist who made it and sold it to the state have their license taken away?

Once you brought up pets and euthanasia, I started thinking about it, and damned if you aren't right: I've heard of two horror stories where the vet botched it in my entire life. Otherwise, everyone I know who's had an animal PTS said that the poor thing (mercifully) went out like a light. I know my two dogs did, when it had to be done...poor babies.

Great blog post. Very readable and informative. It was even a little bit funny, which is something, given the really depressing subject matter. I mean, Jesus, the guy would have been dispatched more mercifully with a firing squad.

DVM.Pat said...

As a vet, we've been hearing rumours of impending Euthasol backorders for a few months now. Hard to not connect the dots with this, and paranoid companies concerned about diversion (not that they are wrong to be).

Generally speaking, though, folks working in human med are very reluctant to admit vets ever do anything potentially better than they do, even though we cause humane death in our patients all the time.

Miss Margo said...

@DVM Pat;

I used to date an Avian vet, a really excellent physician and a scholar, and he also mentioned how belittling human med people would be towards him. It's frustrating because vet school is even harder to get into than med school and vets have to learn medicine for a diverse scope of animals. And vets practice for less money.

Regarding execution: I wonder if any of the death penalty states has actually consulted a pharmacist about how to successfully administer executions. I never thought about it till now, but really, pharmacists would be the professionals in the know.

Hirka T'Bawa said...

All these talks of drugs, all these problems procuring them... The best and most humane form of execution, a gas chamber full of N2. The prisoner will end up passing out, and suffocating, without any biological panic of impending death... Hell, Put them in a dining room for their last supper, and slowing replace the air with a 100% N2 mix, and they will be happy, pass out, and die, with no panic or distress from the prisoner.

Alice said...

I believe my last two elderly cats were sent to the great big litterbox in the sky with a mixture of ketamine and potassium, with buprenorphine already on board. Seemed rapid and peaceful, except for my prolonged wailing. Not sure if that's standard or just my vet's personal favorite death mix.

Is there perhaps some regulation saying "this is the maximum allowed dose" of lethal meds? You know, for safety reasons.

Angry Psychiatrist said...

Insane. Lol. I am reminded of Mencken when he said no one ever lost money underestimating the intelligence of (insert favorite punching bag here)