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The Nebraska Department of Corrections recently notified convicted death row killer Jose Sandoval of the four drugs that will be used as a lethal injection protocol to carry out his execution. This notification is in accordance with state regulations, which is required at least 60 days before the Attorney General can request an execution warrant from the Nebraska Supreme Court.
The four drugs that will be used by the state have been used medically for decades. Their mode of action, onset of activity, and clinical effects are well known and documented. Each is currently used in a wide variety of medical applications in practices across the state. It is highly likely you or a family member have been administered one or more of the compounds during routine anesthesia. Nevertheless, death penalty opponents have mischaracterized the combination as “untested” and “unproven” in an attempt to create doubt about their use. Regardless of one’s opinion about the death penalty, distorting the pharmacological facts about approved, widely used anesthetics to achieve a political end is unethical.
The four drugs in the protocol are diazepam, fentanyl, cisatracurium besilate, and potassium chloride. Diazepam is a sedative medication that is commonly known by its trade name, Valium. It has a wide variety of clinical uses, including for anxiety, seizure control, resolution of muscle spasms, and as a sedative before administration of general anesthesia. It is included on the “List of Essential Medicines” compiled by the World Health Organization (WHO), which is considered the standard of care for safe and effective medicines in a healthcare facility. Approved in 1960, an article in the journal ACS Chemical Neuroscience on diazepam states it “set the standard for pharmacotherapy in terms of potency, onset of action, and safety”.
Fentanyl is also a widely used and well known opioid. Also introduced in 1960, fentanyl is available in a wide variety of formulations for uses as a potent pain medication. In addition to its use as an injection and tablet, fentanyl is available in patches, which administer the drug through the skin. Fentanyl patches are also included on the WHO List of Essential Medicines. Fentanyl lollipops are used by the US military as an effective way of delivering pain relief to injured troops in the field. Its onset of action is within five minutes, and a single therapeutic dose provides over 30 minutes of effect. The effects of fentanyl overdose are well documented. Illegal use of fentanyl as a street drug by opioid addicts has led to the deaths of tens of thousands in the U.S. since 2000.
Cisatracurium is a paralytic agent used by anesthesiologists in addition to general anesthesia during routine surgery. Paralytics are required when using a mechanical ventilator, such as heart surgery. Some anesthesia protocols also routinely use cisatracurium to relax the muscles of the head and neck to allow placement of an endotracheal tube in the airway. Atracurium is its parent compound, and has been in use since 1974. A 2014 study published in the Journal of International Medical Research details a double-blind randomized trial that demonstrated cisatracurium effectively prevented pain associated with the injection of propofol, a common injectable anesthetic agent. The pain prevention was as effective as administering lidocaine, the commonly used local anesthetic.
Potassium chloride is a salt that is added to intravenous fluids to treat low blood potassium. At high doses the potassium causes paralysis of the heart muscle and cardiac failure. Potassium chloride has been used as the third drug in lethal injection protocols that have satisfied judicial review. Accidental overdose of undiluted or improperly calculated potassium chloride via intravenous fluids is a well-documented medical error leading to sudden death in hospitalized patients. The journal Pharmacy and Therapeutics published an article in 2011 titled “Potassium Chloride Injection Still Poses Threats to Patients”, documenting steps health care facilities needed to adopt to address “lingering problems associated with concentrated KCl”.
It is true that the combination of these four drugs has not been used in an execution. That does not mean their clinical effects, when used alone or in combination, are unknown. Their use at therapeutic levels is common and well-studied. The fatal effects of overdose of each of these compounds, either accidental or intentional, has been documented.
Misrepresenting the science of the drugs for a political end has far reaching implications. Both diazepam and fentanyl are WHO Essential Drugs, as is another anesthetic, sodium thiopental. Activism and misrepresentation of sodium thiopental has virtually eliminated the drug from the global market, at the cost of untold lives. Accurate, evidence based information and reporting will hopefully prevent a similar fate for these medications.