all from the same class (the other two drugs were a local anaesthetic, lidocaine, and a vasoconstrictor that raises heart rate, ephedrine). If he was tolerant to one kind of benzo, then giving him another was not going to help much.

These drugs in the long run can make insomnia worse because first one can’t sleep without them and then one can’t sleep with them either. Did his doctors not try any other class of sleeping pill?

In addition, two of those drugs – midazolam and lorazepam – are very short-acting so they wouldn’t keep you asleep for long even if you weren’t tolerant to their effects. For this reason they’re not normally used as sleeping pills. Midazolam is only used in Britain for inducing sedation during operations and lorazepam for anxiety. (Midazolam is eccentrically used, and abused, in parts of the developing world as a sleeping pill.) Lorazepam is widely used in Britain as “something to calm you down” but not for sleeping. Valium is longer-acting so can be used for sleep.

Incidentally, I wonder if the quantities of propofol stated – 50mg and in the end 25mg – are accurate. Dr John Dombrowski, a member of the American Society of Anesthesiologists, says that sounds too low. “It doesn’t make any sense,” he says in the LA Times. “I cannot believe that was the number that was given. Such a small amount won’t tip anyone over in terms of respiratory depression.”

Lastly, the Chicago Tribune helpfully provides a slide-show of the pills, capsules and vials reportedly used at one time or another by the singer, who died aged 50.

A note on that photo-gallery: one of the medicines is modafinil, brand-name Provigil, used to treat daytime sleepiness associated with narcolepsy. One hears of students using this relatively new medication to stay awake for exam cramming, but it’s not recommended for that. In Jackson’s case, given that his regular nightcap was 50mg of intravenous anaesthetic, it’s not surprising if he tried to balance it out with something that promotes wakefulness, but he’d have been better advised to leave out the heavy-duty anaesthetic in the first place.

http://blogs.telegraph.co.uk