Shortage of Assisted Dying Meds Leads to Experimental Combos

After watching a documentary on assisted dying recently, I started really thinking about how important it is for patients who choose it (and prisoners who don't choose execution but will face it anyway) to have access to tested & proven methods of bringing about death in a fast & painless manner.  This is not a debate about the morality of assisted dying or the death penalty--there's plenty of those discussions to be had elsewhere.  

While researching this topic I found that, surprise surprise, there's a shortage of the drugs used in euthanasia & assisted dying--namely barbiturates like pentobarbital & secobarbital.  These meds already weren't ideal, as 90-100 pills are required to consistently bring about death in a somewhat timely manner.  Drinking a thick sludge with that much bitter material in it can lead to gagging, choking & aspiration, especially in patients with GI issues.  But at least those drugs were relatively predictable.  

Now for some reason I cannot fathom, assisted dying patients in the U.S. are being given a bizarre cocktail of (cheap, old, dirty) drugs:  digoxin, Diazepam, morphine & amitriptyline (DDMA) or alternately, DDMP the "p" being propranolol.  Aside from being an entirely experimental mixture, each drug you add to this cocktail increases the risk for horrific side effects like "anesthesia awareness," vomiting, seizures, or simply waking up and not dying at all.  While some may not see the importance of this issue, I find it cruel, unusual & scandalous for a developed nation to engage in this sort of human experimentation simply because wealthy private pharmaceutical companies refuse to produce ample supplies of the right medications.


A Closer Look at This Cocktail

Many opioids are stronger than morphine.

In the absence of barbiturates, all that's needed for assisted dying is a one-two punch of a sedative (i.e. a non-opioid tranquilizing drug that acts on GABA) and an opioid, plus an anti-nausea medication 30 minutes beforehand to keep it down.  But why choose morphine when there are stronger opioids like oxycodone, Dilaudid, oxymorphone & fentanyl?  And diazepam, like all benzos, is not fatal even in high doses, merely causing blackouts & amnesia but not respiratory depression like barbiturates.  Yes, the risk of OD goes up when it's combined with other depressants but that's not a risk I'd be willing to take.  And many of these patients have existing depressant tolerances due to their painful terminal illnesses.  I'll get into which drugs I think would be superior choices later, but for now let's take a closer look at the ones states have actually chosen to use on desperate terminally ill and condemned patients.

Digoxin is a cardiac toxin.  What do you suppose that feels like as it brings about death?  Symptoms of OD include vertigo, vomiting, rapid irregular heartbeat, abdominal pain & delirium.  Now if the morphine & diazepam do their job, the patient shouldn't feel anything.  But as stated above, these drugs aren't all that potent compared to other drugs in their respective classes and there are other factors like stomach contents, other medications present & GI conditions that can interfere with absorption.  If the digoxin should kick in FIRST you're in trouble. 

Both amitriptyline and propranolol have atypical sedative effects and a whole host of side effects.  Propanalol is a blood pressure drug that slows heart rate.  It may cause seizures in overdose & cannot be used by asthma patients because it can cause severe shortness of breath.  Amitriptyline is a tricyclic antidepressant with anticholinergic (drying) effects throughout the body.  It has so many side effects it's rarely prescribed nowadays--a few of these include weight gain, rapid heart rate, suicidal thoughts & drowsiness.  In assisted dying patients it has been known to cause severe burning of the mouth and esophagus.  Remember, these pills have to be opened up & emptied or otherwise dissolved into a solution so the contents come into direct contact with the lips, tongue, throat, mouth & esophagus.   

Better Alternatives

The 1 thing fentanyl analogues are good for (but they're not being used).

I'm no pharmacologist, but I can think of a couple drugs off the top of my head that would be far better options than the dirty ones they've chosen.  Propofol comes to mind, as it works almost instantly & produces total amnesia.  If you must use a benzo, go with a potent short acting one like rohypnol or midazolam.  Better yet, why not use Xyrem, aka GHB?  It's been known to kill people all on its own.  You don't want a long-acting gentle one like Diazepam which is likely the worst candidate.  Phenobarbital--a barbiturate in the same class as Seconal & Nembutal--is also still available last time I checked.  Any one-two punch of a sedative + an opioid would work, but you shouldn't just randomly choose ANY two.  On the opioid side, the fentanyl analogues would be great candidates.  Plain fentanyl, acetylfentanyl, butyrfentanyl & the big one: carfentanil would all get the job done in short order with or without a sedative.  The nitazenes would be another reliably potent option as they're roughly 20x stronger than fentanyl.  Just don't forget the anti-nausea meds.  Brain death is said to happen as soon as 8 minutes after a fentanyl overdose, which is far faster than even the barbiturate meds which can take hours.

Ideally you would go around the GI tract and use an IV, but many states sadly don't allow this because it would require a medical professional to be involved with the injection process.  It's a shame because that would totally avoid the vomiting and having to choke down tons of bitter pills.  Bypassing first-pass metabolism also ensures a speedier, more potent effect.  (Oral bioavailability is generally much lower than IV, which is around 100%).  This whole "first do no harm" thing among medical professionals is also why so many inmates endure botched executions--lethal injections are administered by total laypeople with little to no experience giving IV's or the like.  It seems by refusing to do harm, these doctors ARE doing it, even if indirectly. 

As for other possible options, there are also inhalants like nitrogen & xenon gas, which are known to cause euphoria at the end & work much faster than the pill solution, but the whole 'bag over the head' aesthetic scares some people.  I say follow the science:  if there's no carbon dioxide inhalation involved, there's nothing to fear.  I believe one state has tried the nitrogen inhalation method to execute at least one inmate.  

Benzos compared to Diazepam, one of the 4 weakest drugs in the whole class.

Because it's unethical to put people to death to study the lethal effects of euthanasia methods, this will always remain an inexact science to some degree.  There will never be a 100% pain-free, instant option that works for everyone.  But we don't need perfect; just reasonably reliable.  100 barbiturate pills is better than the experimental DDMP/DDMA cocktails, which are better than a shotgun blast to the face.  I suppose a shotgun blast is much quicker & less painful than a protracted battle with bone cancer.   That doesn't mean we can't do better than all of these.  An intravenous shot of fentanyl + propofol would likely be even better than the pills.  Cost & drug availability shouldn't factor into it, especially in developed nations.  We don't make terminally ill animals slurp down a hundred Nembutals through a straw at the vet's office, and we damn sure shouldn't expect our loved ones to endure such indignities.

Governments need to step up and make Pharma companies produce a certain (small) amount of essential drugs like these each year so we're not in this situation.  If they refuse, it's time to admit this privatized medicine setup isn't working.  These companies have taken so much from society with all the drug epidemics they've created; the overpriced medications they hold hostage from critically ill people, the scandals like knowingly shipping blood infected with HIV overseas... it's the least they could do. 

For those concerned about assisted dying becoming the law of the land and taking someone you love, keep in mind that only 1/3rd of patients who obtain the drugs end up using them.  Simply having them on hand provides a sense of peace & control for these desperate suffering folks.  We treat our beloved pets better than our human loved ones in this regard.  If you don't agree with it, don't choose it for yourself.  That's where your rights end.  Patients in hospice care are often overdosed on pain medications at the end, which is merciful compared to the alternative, which may include starvation/death by dehydration if a "Do Not Resuscitate" order is in play.  If you choose life-sustaining measures, you may spend your final weeks or months under the glow of fluorescent hospital lights with a breathing tube shoved down your throat and a feeding tube up your nose, comatose & unable to speak despite horrid pain and/or sickness.  If you're lucky you'll have doctors and nurses who are attentive to your needs.  If not, you'll spend your final days suspended in a kind of purgatory unable to scream while being neglected by jaded healthcare workers who not only don't belong in the profession but the free world.  

These things are not pleasant to think about by any means, but it's a part of life we'll all face at some point.  Better to think and plan for it now than to be caught unprepared.  Raging at people who choose a different ending than you will not change your outcome one bit.  It behooves us all to ensure that our legal & medical systems employ humane & scientifically sound methods of sustaining life as well as ending it.  💚