August 2009

The Nation Reviewed

Croakers

By Gail Bell
Illustration by Jeff Fisher.

When Michael Jackson’s heart stopped beating on 25 June, he was lean, only 50 years old, and sufficiently fit to lay down enough of his trademark stage moves to refute rumours about advanced physical deterioration. Even before the first ambiguous cause-of-death reports hit the headlines, we caught a chemical scent in the air. The early forensic tickertape punched out words we knew from other celebrity deaths: Xanax, Demerol (pethidine), OxyContin, needle tracks.

Then came a surprise addition to the death-scene pharmaceutical checklist: Diprivan, a drug no one knew a lot about. A coma-inducing anaesthetic that needed a specialist hand to drip it in and, on occasion, another drug to reverse its consciousness-cancelling authority. If claims about Jackson’s use of this drug are true, then it would seem in his case that an ethical boundary line has been crossed; one that has implications for our interpretation of the words ‘acceptable medical practice’. Diprivan does not kill pain or anxiety per se; it renders the brain incapable of receiving or sending messages.

This country governs its powerful drugs by a system of checks and balances. Tablets are signed in and out, counted and double-counted. Returned and out-of-date opiates must be destroyed in the presence of a witness, who needs to be either a medical professional or a police officer. And yet, the boat leaks. With so many units in circulation (an average packet of these controlled pharmaceuticals contains 20 pills), and many more in holding areas (warehouses, pharmacy shelves, hospitals, nursing homes), there is plenty of good stuff to go around.

Small-scale diversion for personal use has been identified in both the professions (doctors, dentists, nurses, pharmacists) and the home sector (carers, family members), but the quantity being siphoned here pales beside the volume flowing across the pharmacy counter. How much of this traffic is patient-driven and how much doctor-driven is one of the hardest measurements to make given the confidentiality of the patient–doctor pact.

About 18 million legal prescriptions for drugs to treat pain, anxiety and sleep disorders are written in Australia each year, and of these the most prescribed by the total volume of all drugs are, in order: the codeine/paracetamol combination best known as Panadeine Forte (sixteenth on the PBS list); temazepam, the most popular sleep aid (twenty-third on PBS); and the opiate OxyContin (thirty-first).

Are we to read an assertion of moral ambiguity into the workings of a system designed to minister to the sick when it also acts, on occasion, to prop up the sickness of addiction?

Currently in the US, doctors are in the dock. Physicians who prescribed for Jackson are being traced through a controlled-substances database, and most (except Deepak Chopra, who refused to write a narcotic script) are ducking for cover. Those who were blinded by proximity to enormous wealth are recalling the rules about supplying scripts to aliases of their sequined clients.

In the parallel universe of street dealing, the elevation of the medico over the guy in the alley became an issue when wild morphine dried up and street-drug addicts were forced to find an obliging prescriber. William S Burroughs called these narcotic-prescription-writing doctors “croakers”. As he wrote in his autobiographical book Junky (1953): “Some will write only if they are convinced you are an addict, others only if they are convinced you are not.” Sourcing a good croaker was a game with rules. “You need a good bedside manner with doctors or you will get nowhere.” Playing a role mattered. On the streets of New York after the end of World War II, Burroughs and his fellow users mastered the routine. One croaker liked to see an addict with a gentlemanly front; another reveled in having an audience for his tales of former glory days. “Even though they do not believe your story, nonetheless they want to hear one.”

Of course, we don’t denigrate doctors with the croaker epithet anymore. Michael Jackson’s former lawyer used a softer term, straight out of the co-dependency counselling dictionary, calling these narcotic script-writers “enablers”. While this word conjures up the image of a carer helping a spoon to a twitching mouth, it is most often applied in the maladaptive sense.

‘Enabling’ occurs between implicitly unequal partners. Jackson might have had the fame and money, but his doctor had the right to prescribe and the power to break open the drug cupboard. Michael Jackson’s private physician reportedly kept his clinical eye on the singer’s wellbeing for a retainer of US$150,000 per month. I imagine that there wasn’t a lot of ‘just say no’ in this doctor–patient relationship.

William S Burroughs wrote in his 1997 journal, Last Words: “Morphine is for people with pain. So who should get it? People with pain.” Looking at Jackson’s drug call sheet (such as it is known), it is obvious that he began low and slow with tranquillisers and painkillers, until he had a couple of nasty accidents. As he moved into midlife, beset by legal battles and bad publicity, it is not surprising to read that his drug consumption reached new heights: 10, 30 – some say 60 – Xanax a day, on top of OxyContin and shots of pethidine.

Jackson was believed to have a sleeping disorder. We could apply the Burroughs rationalisation to his case and assert that the end (sleep) justified the means (hard drugs). Sleep obsession has been implicated in past celebrity overdoses: Marilyn Monroe (Nembutal and chloral hydrate); Elvis (barbiturates, opiates, Valium); and Judy Garland, who woke in the middle of the night, staggered to the bathroom and took an additional dose of Seconal to get herself back down again. Only last year, it was Heath Ledger – alone, ill and sleep-deprived in a Manhattan apartment.

Sleep is at the hungry heart of the drug beast. What is different in Jackson’s case is the jump from hypnotic drugs to anaesthetics.  One nurse close to him spoke publicly about his request for Diprivan: “You just don’t understand,” Jackson is supposed to have said. “I just want to be knocked out and go to sleep.”

Samuel Taylor Coleridge wrote of that same intense yearning for temporary oblivion in 1797, while incubating his opium habit. “I should much wish, like the Indian Vishnu, to float about along an infinite ocean cradled in the flower of the Lotus, and wake once in a million years for a few minutes – just to know that I was going to sleep a million years more.” Coleridge’s suspension of consciousness, while romantic, belongs to a time when opium cost a few pennies and every house had some on hand for toothaches.

Was Jackson’s heart stopped by a drug? Was his doctor’s hand on the needle? The answers matter to those who want a scapegoat for his death. There is a larger question at stake. Should anyone be able to enjoy the ‘special privileges’ of induced coma simply because they can afford it? We need only remember there was once a fashion for deep-sleep therapy in a now notorious Sydney clinic.

Gail Bell
Gail Bell has worked as a pharmacist, educator and writer. Her books include The Poison Principle and Shot: A Personal Response to Guns and Trauma.

Cover: August 2009

August 2009

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