The Longest Rest

June 25, 2009.  I was rapidly scanning BBC News when I shouted “No” at the monitor and gasped before recognizing why.  Michael Jackson was so young.  How could he die?

I gasped again when my webmaster told me CNN Headline news was calling Dr. Conrad Murray, Jackson’s personal physician at the time of his death the “rest doctor.”

Whatever Michael Jackson was getting before he died, it wasn’t rest.

Propofol

I was not surprised when I heard propofol had been used by Jackson as a sleep aid – I was shocked.  I’ve never administered propofol, but I’ve had it myself  – for colonoscopies.  After these procedures I recalled – precisely nothing.  Amnesia is part of what anesthetics do. A major purpose of propofol is to induce unconsciouness.

And propofol is an exclusively intravenous anesthetic. Most doctors like myself associate it with surgical suites and anesthetist observed anesthesia – only.  That you would use it to “help” someone sleep is simply bizarre. Who wants an IV pole by their bed every night? Plus propofol has a short half-life – it’s cleared quickly out of the body – and an ever shorter time of effect.  Stop infusing it and the anesthesia quickly goes.

Anesthesia is not sleep but something much closer to coma.  Anesthesia short circuits parts of the brain that communicate with each other and create what we call consciousness.  Some parts of the body may still rework and repair themselves, but the endlessly regenerative functions of sleep do not happen.

Had Jackson misidentified unconsciousness with sleep?

Later autopsy results identified much else in Jackson’s body.  There was lorazepam, midazolam, diazepam.  Yes, they sound alike for a reason – they are all benzodiazepines, drugs whose profound effect on receptors in the brain and elsewhere include decreases in anxiety, impairment of cognition (though often the subjective sense that it’s improved) and muscle relaxation. And they are often used as sleeping pills.

Yet not midazolam. It’s main use is, not unlike propofol, intravenous.  Intravenous midazolam “knocks you out,” obliterating memory – not a bad result if you’re trying to avoid the pain of the knife.  But to inject midazolam for insomnia?  No doctor I know uses it that way. And the potentially lethal respiratory depression provoked by benzodiazepines are far more likely when given intravenously – and in the form of multiple different benzodiazepines.

Also found in his body was lidocaine and ephedrine.  Lidocaine is often used a topical anesthetic – sometimes cutting the pain that comes with propofol injections. Ephedrine however is a real outlier – a pharmacologic version of epinephrine, our potent flight or fight hormone.

Anesthetics, multiple “downers” – and ephedrine.  Had Jackson been part of the “Up-Down Syndrome”?  Many entertainers get hooked on medications to rest or sleep, like benzodiazepines, and then take uppers like ephedrine to “get up in the zone.”   Sadly that zone often derails, destroys, or shortens their lives (see my “Celebrity Rehab 101″ in the blog archive). Legal versions of the Up Down trap are common – many teenagers get “up” with “energy beverages” – really anti-relaxation drinks – and then “down” with so called “relaxation drinks” – whose cocktails of  “calming natural substances” include neurohormones like melatonin.

Later it was reported in the New York Times that Jackson had walked into the Bellevue Emergency Room in 1994 and requested propofol for “sleep.”  The incredulous docs talked instead of sending him to the police.

Sleep Is Not Turning Off a Switch

Sleep is many things, but coma is not one of them.  My guess is that Jackson was using propofol to get “knocked out,” after which the multiple benzodiazepines would start to work to provide their version of artificial sleep – with sleep staging and architecture quite different from normal. For naps, he might have used propofol and/or midazolam as continuous infusions.

The American version of sleep, often described as “lie down and die,” sadly equates unconsciousness with sleep.  You lie down.  Then you wake up.  Sort of like turning the electricity on and off on your computer.

Except we’re not machines.

We’re alive.  We survive through regeneration.  The internal processes of human life work so fast that we use up most of the materials in our body quickly.  Subtract skeletal elements like bones and teeth plus bits of DNA and you’re pretty much new in about a month – different from what you were before.

That is if you get enough rest.  Rest is critical to that regeneration – like food.  Even passive, undirected rest like sleep is critical to life – animals deprived of it die.

Michael Jackson was getting decreased consciousness with propofol and benzodiazepines, but it’s doubtful it was the kind of rest that normally regenerates your body.  We don’t just renew ourselves constantly – we learn.  We see hair and teeth grow, not our brains.  But our brains and bodies are constantly growing, shifting, changing, adapting, learning – or we’re not around anymore.

A jury will decide if Dr. Conrad Murray was culpable in Jackson’s death.  But you don’t get life renewing rest through an IV pole spewing coma inducing anesthetics.

You get something far, far worse.