Q&A with Dr. John Dombrowski: Michael Jackson's bungled pain management may have killed him
Four days after Michael Jackson died of an unexpected heart attack on June 25, Dr. John Dombrowski,an anesthesiologist and pain management specialist, posted a letter on his Web site, demanding better pain management for all patients and a recognition that pain care is an important specialty.
Unfortunately for Michael Jackson and his immediate family, he was treated long-term with long-acting narcotics. In this "medical cocktail" the physician provided, Mr. Jackson was given muscle relaxants, Valium-like medications, and more narcotics. All these medications, unfortunately for Mr. Jackson proved to be lethal. It was a shocking finding on his autopsy report that the only "contents in his stomach was present that of pills". ...
We, in the United States, have come to a level of excellence with respect to our health care. No one would accept a patient having a heart attack not being seen by a proper specialist such as a cardiologist for appropriate interventions. We, the Pain Medicine Community, Anesthesiologists, and Physical Medicine Rehabilitation doctors believe the same. If a patient is suffering with a "pain attack," the patients should be referred to the appropriate pain specialist for care.
Dombrowski, one of five members of the American Society of Anesthesiology's administrative affairs committee, talked with Good Morning America this week about Jackson's death and the role that the anesthesia drug propofol, sold under the brand name Diprivan, may have played in combination with the other drugs that Jackson was taking to manage what appears to have been chronic back pain.
I reached him at his home in the Washington D.C. area. Here is a recap of the first part of our conversation. I will post more next Friday. It has been edited for space and clarity.
Q: The American Society of Anesthesiologists and the American Association of Nurse Anesthetists issued joint guidelines about propofol in 2004, 15 years after it had been approved for sale by the FDA, what prompted the groups to take a second look at the drug?
A: A lot of practitioners outside of our profession and paraprofessionals, like anesthesia nurses and anesthesiologist assistants, were using propofol without proper oversight or supervision. These could be ER physicians who wanted to set an arm in the ER or an endoscopist doing a colonoscopy. Because the medication looks so easy to use, people say, "I could do that." We really wanted to take a stand for patient safety and say, "If you do that, these are a couple of things you need to think about in advance. And these are some of the things you need to worry about."
Q: What made propofol so easy to use?
A: The anesthetics we've always used in the past had to be the gases. You had to put a breathing tube in, and put a mask on their face. You have to monitor the machine. Who the hell knows how to do that? With propofol, it's general anesthesia in an IV bottle. Every doctor knows how to pick up a syringe and insert an IV.
Q: Did you think at the time that something very bad was going to happen in the future if you didn't step in?
A: Bad things already were happening. People were having a respiratory arrest in the ER or in the endsoscopy suite. These incidents never made the headlines because the patients weren't famous.
Q: And I imagine, too, that people go into these procedures signing waivers saying that they understand that they are going under anesthesia and that there are potential side effects, including death.
A: Right. If you are the provider you would say to the patient or the patient's family, "These things always happen with these medications. This is the risk that you took, and you ended up getting too much anesthetic." What they probably don't say is that, whether they are an ER physician or an oncologist or any other type of doctor it's hard to actually do the procedure and give the sedation at the same time. It seems easy. You're just using an IV. But it's hard to do both jobs well. Right now, I'm talking and you're listening and writing things down. What if you were trying to talk, listen and write at the same time. You could do it, but not very well.
Q: So more doctors outside of anesthesia have been using propofol in the OR and in their offices. But what about outside of those settings. Is it getting more popular as a sleep remedy, as appears to be the case with Michael Jackson?
A: I don't think there's going to be another person on the planet who is using this in their home. I'll eat my hat if I'm wrong. Michael Jackson lived a very unique life that not many other people live.
Q: Then why did the American Society of Anesthesiologists feel prompted to issue a statement about propofol after the news of Michael Jackson's death broke?
A: Obviously, all the patients that we take care of are going to be getting propofol. It is ubiquitous to the practice of anesthesiology. People will say, "You're going to give me that? That's what killed Michael Jackson." This way, we're doing a bit of public relations, a little damage control. He wasn't getting a procedure done. He was trying to get 40 winks at his house. This is completely beyond the pale. This does not occur in common everyday living. Only in the world of Michael Jackson does it occur.
Q: But do we really know that? Jackson was eccentric, but his drugs of choice were no different than the drugs that addicts of all income levels use. Why would propofol be any different?
A: For one, because it doesn't give you a high the way those other drugs do. We did a study in 2003 with respect to abuse of propofol by physicians who were in their medical residency. We found that a small number, probably three in 10,000 resident physicians, were using propofol recreationally. One of the bigger risks of an anesthesiologist is the possibility of dependency on the drugs that you are administering. The other medications like Demerol, morphine and fentanyl are all easily abused and have been abused for years by anesthesia nurses as well as physicians. They are the more common ones that you see. Propofol just isn't abused in the same way. You feel asleep. There's not much bang in that buck.
Q: Why were you studying drug abuse among medical residents?
A: Because we know it can be a problem. We wanted to look into what could do in terms of educating our membership, especially the young people. We emphasize stress management. The job can be very high pressure, so you need to learn how to manage your stress without drugs. Is there a risk of abuse in your family? Have you had trouble with alcohol or other drugs in the past? We tell them, "Don't experiment." It only takes one chance, and you can be hooked and could ruin your career. Our society has kicked off a wellness campaign for all our 40,000 members. We realize that we have multiple stressors in our lives, from the hours that we have to put in, to the kind of care that we are giving.
Q: In Michael Jackson's case, it might not have been the propofol that was the culprit, right? It might have been a bad batch of propofol. The drug had been the subject of an FDA recall, and then the CDC, after Jackson's death, issued a warning about generic versions of propofol, and the drugmaker voluntarily recalled two lots of the drug. How likely is it that Jackson just had a bad dose?
A: For Dr. Murray's sake, he hopes that was the case. That CDC warning was for an infectious contamination of the drug. There were some bacteria in the propofol. Propofol is in a protein, like egg whites, and egg whites are a great culture medium for bacteria. So obviously if you have some break in sterility at the factory, and then the bacteria gets into the mix, it is going to grow. But I don't think that would have led to his death. This looks like a case of too much of the drug being administered without the proper monitoring.
Q: You also think his pain wasn't being properly managed, a situation that you think is fairly widespread. Why doesn't pain care get the respect that other specialties get?
A: I think we as physicians don't really realize the resources at our fingertips. Fifty years ago if you had a heart attack they would say, "Take some nitroglycerine and go home and rest. There's nothing we can do." Now you automatically go see a cardiologist. A lot of internists and family care physicians don't realize there is a similar resource for pain care. There are anesthesiologists and pain specialists who are there to help. We can say, "I bet if we did an injection or changed the medication he would get better." Versus, "Here's another Percocet." Saying, "here's another Percocet" doesn't help anyone get better. What about, "Tell me about your pain? How's your sleep been? What makes the pain better and what makes it worse?" Again, the guy on the front line can write a scrip that says, "Pain consult." And that's just as easy as writing "Percocet." Once you write a prescription, you are in a box. You feel comfortable giving them two a day and now you're up to six a day and you wonder, "How did I get here?" And that's even assuming that opiates are an appropriate response.
Q: What's wrong with opiates?
A: I think opiates are inappropriate for long-term pain management. We know for non-malignant pain, you're just going to go on giving more and more and more. Some patients we know have a great problem with diversion of these medications. I gave it to you but you decide to give it to someone else. A lot of kids now aren't abusing alcohol or marijuana. Their drug of choice is Schedule II narcotics. How did they get their hands on those drugs? They stole it from their parents or they got it on the internet. There has to be a better way to help people get better without contributing to a much bigger societal problem.
Coming next week: Part 2 of my conversation with Dr. John Dombrowski