August 26, 2009

Michael Jackson Died Of Overdose

But the question is, an overdose of what?

According to CNN, this is the timeline of drugs he received on the day he died:

1:30 am.: 10 mg Valium

2 am:  2 mg IV Ativan

3 am: 2 mg IV Versed.

5 am: 2 mg of IV Ativan.

7:30 am: 2 mg of Versed; placed on pulse ox (measures amount of oxygen in blood-- used in these cases when you worry they may be too sedated to breathe)

10:40 am: "after repeated demands/requests from Jackson," Dr. Murray administered 25 mg of propofol.

I.

We can say that this is enough drugs to kill a horse, but look at 5am: Jackson is still awake.  And at 7:30.  And at 10:40.  It may seem like a lot of drugs to you, but regardless, they were too weak to put him down.  Therefore, you can't say these were lethal levels of medications; half a bottle of rum is lethal to some people.

So when CNN does that idiotic segment where they give a reporter propofol to show how strong it is, you should take that for what it is: pornography.


II.

Farily safe to assume: this isn't the first time Jackson's taken these drugs, at these doses.

III.

It's extremely unusual for a doctor to be charged criminally in such cases, unless there was malice; they are usually dealt with in civil court (malpractice) and/or by a medical review board.

It is going to be impossible for a prosecutors to prove, beyond a reasonable doubt, that Dr. Murray killed Jackson.

  • First, the amount of drugs Murray administered was not only not lethal-- it wasn't even effective.  Jackson was wide awake, all night.
  • That amount of benzodiazepine drugs is not at all unusual for a benzo addict.  If Jackson was used to that amount, it's going to be very hard to show why that amount, on that day, killed him.
  • Which brings us to the second point: we have no way of knowing whether Jackson was giving himself extra oral, or even IV doses of the same drugs, that Murray didn't know about.   Apparently, Jackson had 8 other bottles of propofol in the house, along with other Ativans, etc.  It wouldn't be surprising if Jackosn was taking extra Valiums throughout the night.
  • Third: "What about the propofol?  The coroner said high blood levels of propofol killed him."  If the coroner said this, he is a fool. Picking out one drug as the cause of death is like blaming one section of the ocean water for a drowning.   The effect of propofol only lasts 5-10 minutes. If it was a single injection, it would have stopped working after that long.  Propofol rarely accumulates to high blood levels because it clears so quickly; a high level would suggest either supplementation, or Murray was lying.  Then the prosecution's case falls apart: either Murray told the truth about the 25mg, and therefore Jackson was supplementing; or he was lying, which... good luck proving that.
  • Unless Dr. Murray gave him a propofol drip and forgot to turn it off.  That would be...
  • In any event, unless you give a high dose all at once, in order to die you would have to maintain the propofol infusion, i.e. not turn it off.  That wouldn't be negligence, that would be retardation or murder.   But that would be the only way propofol could have killed him. 
  • Fourth: administering propofol along with benzodiazepines is not unheard of, nor is using it outside a hospital with nothing more than a pulse ox. (e.g. used commonly in a doctor's office for a colonoscopy.)


IV.  There is one way this could be an easy case of negligent homicide: if Dr. Murray administered the propofol but, contrary to what Dr. Murray said, he didn't have any monitoring equipment.  This is the part of the story that makes no sense to me.  A pulseox is a simple machine to measure blood oxygen levels, you clip it on the patient's finger and watch the readout display numbers from 0-100%

In order to die, you must first fall asleep, and then your breathing slows and stops. This takes minutes, not seconds.   Wasn't it on after Jackson fell asleep?  If so, why didn't Murray hear the first alarm that goes off when the oxygenation fell below a certain, non lethal level?  Did he have it off?

It seems crazy to me that you would have a pulseox, put it on the patient, but ignore the readout for the crucial hour after the guy falls alseep?  Especially after all those benzos?

Of course, having a pulse ox to detect low oxygenation is pointless if you don't have supplemental oxygen on hand.

The simple explanation is that he either didn't use the pulse ox (negligence) or he did use it but paid it no mind (negligence and stupidity); or he did use it, heard the alarm but was unable to save Jackson despite his attempts.  This is all assuming he did give only a single injection of propofol, not a propofol drip. 

Murray says he did administer CPR and flumazenil (the antidote for benzos, but not propofol) but the timeline is hazy. Maybe Murray was scared of getting in trouble, so he lied about the times; but if he did use the pulse ox and diligently tried to save him, then there's really no criminal case here.

V.

A small clinical aside, I neither expect Dr. Murray to know this, or even the majority of the doctors.  There's a difference between time of onset and peak blood level.  Just because the pill doesn't work in 30 minutes, doesn't mean there isn't another 70% of the pill coming in an hour.

This is how famous people die: they take stimulants to party all night, and sleep very little.  Finally, on day 3 they're too wired to fall asleep naturally, so they take a few extra sedatives (because they feel so wired.)  However, the full dose of the pills doesn't happen until after they fall asleep; the sedation is worsened even further by stimulant withdrawal; and, of course, the natural exhaustion that comes with partying for three days and not sleeping.

Smaller doses, more time.  That's the secret to not being ruled a suicide.







Comments

1) Not all pulse oximeters ... (Below threshold)

August 26, 2009 3:17 AM | Posted by Anonymous: | Reply

1) Not all pulse oximeters "beep" when they reach a critical low level. It is possible the type Murray was using was this sort. It's also possible he was BSing about it.

2) Assuming it was noted that the o2 had fallen critically low, supplemental O2 is not going to help much when your patient's respirations are critically low as a result of CNS depression secondary to grotesque amounts of benzos (to overcome even the mightiest of tolerance).

3) I'm an RN and I understand the difference between time of onset and peak blood level. I think even a non medical professional understands this, if they ever cared to think about it.

4) I think the real issue is that Dr Murray was used to dealing with the elephant-seal like drug tolerance level of MJ... combined with MJs demands to push the envelope further and further... and this time he pushed too far. When you're dealing with that insane amount of benzo intake, it's hard to judge what is and is not "too much" because it totally defies normal prescriptive boundaries/indications. I suspect Murray approached MJs drug seeking as sort of an "art" because this was such a unique situation, and art is imprecise... too bad imprecision equals death here.

5) I agree this is not homicide but "Dr" Murray won't ever be able to practice again, and there must be some kind of legal accountability for a professional who violates ethics in this way... beyond the obvious no-brainer of denial of right to practice. This was ridiculous, really. He was nothing more than a back alley drug dealer using his MD as a cover.

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"... and art is imprecise..... (Below threshold)

August 26, 2009 4:43 AM | Posted by Lt. Horatio Kane: | Reply

"... and art is imprecise... too bad imprecision equals death here."

I hope you don't mind, but I'll be using this line in the next season of CSI: Miami.
yeeeeeeaaaaahhhhh!!!

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I hope Murray is charged fo... (Below threshold)

August 26, 2009 5:49 AM | Posted by David Johnson: | Reply

I hope Murray is charged for murder. I don't particularly care whether or not the legal system would or could convict. The upside to a murder charge is as follows: 1. Guarantee Murray never practices again, 2. Cause him extreme emotional and economic pain (the punishment part of "the system") and 3. Force other board certified drug dealers to think twice about knowingly and willfully dealing drugs to their addicted clients for profit.

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Of course...the other possi... (Below threshold)

August 26, 2009 7:31 AM | Posted by nohope: | Reply

Of course...the other possibility is that Jackson begged his doctor to put him out of his misery and spare him from having to embark on his upcoming tour.

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America's "In God we trust"... (Below threshold)

August 26, 2009 8:24 AM | Posted by Anonymous: | Reply

America's "In God we trust" should be changed to "In drugs we trust".

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Is insomnia a life threaten... (Below threshold)

August 26, 2009 8:43 AM | Posted by Anonymous: | Reply

Is insomnia a life threatening illness or disease? No? What makes the doctor different than a illegal drug dealer? A piece of paper on the wall?

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The question must be asked:... (Below threshold)

August 26, 2009 8:52 AM | Posted by Rosiecee: | Reply

The question must be asked: why did MJ develop such a weird, off-the-wall personality that he needed all these meds to function and sleep?

Could it have been the Zoloft and Paxil, both SSRI antidepressants, that he had taken for many, many years.

MJ started off as fairly normal for a Hollywood-type singer, dancer, actor but then, after he was burned during the Pepsi commercial, he was started on the SSRIs and his personality was never the same. This happens to many people. I have had people say to me, "Well, she/he started on Prozac and now I don't even know who they are anymore"

All so tragic.

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Jackson's timeline was 9 ho... (Below threshold)

August 26, 2009 11:47 AM | Posted by V: | Reply

Jackson's timeline was 9 hours long. Are you saying that he should have waited longer to fall asleep, or if he hadn't been impatient earlier he wouldn't have built up this resistance?

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Maybe Jacko wanted to die a... (Below threshold)

August 26, 2009 1:57 PM | Posted by Anonymous: | Reply

Maybe Jacko wanted to die and asked Murray to put him out of his misery.

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Okay, it would be difficult... (Below threshold)

August 26, 2009 2:04 PM | Posted by BHL: | Reply

Okay, it would be difficult to convict Dr. Murray. However, what about his professional and personal obligations in this situation? What do you think should happen to doctors who keep handing addictive (and mostly unnecessary) drugs to drug addicts who are rich or lucky enough to avoid suffering the usual criminal consequences visited upon drug addicts in our society?

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"The question must be as... (Below threshold)

August 26, 2009 2:20 PM | Posted by Anonymous: | Reply

"The question must be asked: why did MJ develop such a weird, off-the-wall personality that he needed all these meds to function and sleep?"

To any practicing psychiatrist there's nothing weird or off the wall about this. If you've any experience with blind driven black out drinking for days on end, the story's all too familiar.

Us kind just want the same end. We just can't afford the good stuff. :)

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I think maybe the media is ... (Below threshold)

August 26, 2009 2:52 PM | Posted by L: | Reply

I think maybe the media is trying to revive their cash cow?

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The rich, they are not like... (Below threshold)

August 26, 2009 3:09 PM | Posted by Ben Zod: | Reply

The rich, they are not like you and me.

"Epic" does not begin to describe the extent of MJ's prescription drug and doctor abuse. He stands as a god among men. OK, stood.

A few morsels, culled from the affidavit posted at TheSmokingGun.com (which comes highly recommended--primary sources, people!)

--Jackson referred to propofol as his "milk" and lidocaine as the "anti-burn". When you have pet names for your injectables, you know you're hardcore. (Milk is presumably a cute allusion to the notion that warm milk will help you sleep, as well as a reference to propofol's cloudy appearance).

--Jackson's stable of doctors included a GP (Metzger), cardiologist (Murray), TWO anesthesiologists (Adams and Rosen), dermatologist (Klein), plastic surgeon (Kopler) and a nurse practitioner (Lee, possibly the wisest of the lot, and who can prescribe in CA). Aside: several of these docs work or live in OJ Simpson's old stomping grounds.

--Not only did MJ use names of his family and entourage for Rx purposes, but he also used at least a dozen other script aliases. They include Jack London (!), Frank Tyson, Omar Arnold, Josephine Baker (!), Fernand Diaz, Peter Madonie, Paul Farance and of course the pedestrian Mic/Mick/Mike Jackson.

--As if the phantom scripts weren't enough, searches of MJ's residence also turned up loads of unlabelled (as in unprescribed, straight from the pharmacy shelf) Versed and Ativan. Pills and injectable style, too. Because po is for pikers.

Most haunting revelation:

On father's Day this year, nurse-practitioner Lee received a phone call from MJ's bodyguard, saying he was sick. In the background, she could hear Jackson complaining "one side of my body is hot and the other side is cold". (Lee diagnosed CNS issues, and said get him to the hospital pronto).

So, how does it look for Murray, the cardiologist who performed CPR on a mattress? The downside includes his initial failure to mention anything but the lorazepam on the night of the death, and his disappearing act from the hospital on the same night ("I didn't think I would be needed..."), along with a trio of frantic cell calls that he tried to keep hushed up. The upside? Well, Murray's residence and practice(s) are out of state (Nevada, Texas), which may gum things up.... And also... well, pretty much everything mentioned above. MJ was in deep--really deep. He was living in a pharma netherworld, and ultimately that should help Murray. Except...

Consider what may have happened. Murray was with Jackson all night, doing the right thing. Holding back the propofol, spreading out the benzos. Starting with long-lasting diazepam in the hope it would keep MJ out all night. Smaller doses, more time, no Ledger-de-main. We can assume basic competence; after all, Murray had the pulse ox and the flumazenil. Besides, the successful parasite does not kill its host.

But say, after his night vigil, Murray was tired and went for a nap--after being a good doc and standing by for the crucial half-hour or hour after he finally relented and gave MJ the good stuff. While Murray sleeps, MJ wakes--remember, he only got a half-dose of his milk (25 mg). Where's the doc? Not nearby. So MJ does it himself, or gets someone to do it. A full cup of milk this time. Because it's been a long night, and MJ wants some sleep, damnit. Except now the good doctor is not standing by. Nobody is. A last dose of warm milk, and Peter Pan flies off on his final trip to never-never land.

Murray awakes after a short nap, maybe roused by the pulse ox, maybe not. Either way, he checks on the patient, and uh-oh! Panics, does his thing. Injects the antidote, does the half-assed CPR, calls the crew. But it's too late. And now Murray's real trouble begins. He should tell the truth. The truth would exonerate him if only he told it, because he *was* careful, he *was* competent... But instead, Murray starts to lie. He fails to mention the Valium, the Versed, the Diprivan. Says he was there the whole time. He doesn't quite realize that by claiming he was present, he is unwittingly taking the rap for whoever did screw up, whether it was MJ or someone else. After doing everything right, he sets himself up.

And therein lies a lesson.

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"But the question is, an ov... (Below threshold)

August 26, 2009 3:24 PM | Posted by Jbower: | Reply

"But the question is, an overdose of what?"

Narcissism!

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One- I think the doctor sho... (Below threshold)

August 26, 2009 5:00 PM | Posted by Paula: | Reply

One- I think the doctor should be spared jail, and be suspeded for a year. I would rather he give addicts Rx rather than the nurse steal it from my dose to sell it to him for major money. Smart right? But I beleive a person has the right to kill themselves. He had all the resources in the world and non mattered. He liked drugs. They are great for avoiding suffering- like life mostly is.

I want to knoe what is diagnosis is. I think body dysmorphic, and axis II, pedaphile absolutly. Poor kids.

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Before we get the lynch mob... (Below threshold)

August 26, 2009 6:03 PM | Posted by Meat Robot: | Reply

Before we get the lynch mob together, I'd be very interested to see how this problem evolved to its lethal climax over time.

It's pretty shocking to see Versed and Propafol being used outside a setting of conscious sedation, but we can't immediately leap to the conclusion that there was no indication, even a fuzzy one.

Don't get me wrong. There probably isn't one, but let's see the whole story first.

My first question is, pulse-ox or not, why is there no mention anywhere of basic resuscitation equipment like a bag and mask or oral airway??? Pulse-ox alone is about as useful as a "check engine" light out in the desert.

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Purposly or not, that DR kn... (Below threshold)

August 26, 2009 6:50 PM | Posted by Angie: | Reply

Purposly or not, that DR knows he should not of administered the variety of medicines he did, never mind the amounts, without being on monitors. It shouldn't matter how much MJ begged or pleaded. Apparently at the time his paycheck was speaking louder than his brain! Also if I'm not mistaken, Propafol will put you to "sleep" but must continue to be infused to keep you "sleeping" Besides it was 10:40 AM time to get up! He should of given MJ's body a break from all those drugs. Finally, if he knew MJ was addicted to benzo's then he should of been trying to help him with his addiction not feed it! Apparently he hasn't heard "first do no harm" Maybe he's not guilty of murder but certainly manslaughter is appropriate in this case. He should of known better as a Medical Doctor. He was playing with fire and now he's going to get burnt!

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You people need to stop the... (Below threshold)

August 27, 2009 1:05 AM | Posted by Anonymous: | Reply

You people need to stop the nonsense. Doctors are just human beings, and they are prone to greed. Dr Murray was nothing but a drug dealer who happened to be in a profession that made it easier to obtain drugs. Why should Murray feel any special guilt just because he is a doctor? He should feel the same shame/guilt any person should feel for behaving in a way that is socially destructive and harmful to people. If Murray tried to get MJ off the benzos, Murray would lose his MJ money. MJ would easily find another physician to take his place. Murray just wanted the money. Duh. That's why hes a cardiologist ;). You don't risk your professional license without a financial incentive which is even greater than that. No one steals when they can make more at work.

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Please cut your scientology... (Below threshold)

August 27, 2009 7:06 PM | Posted, in reply to Rosiecee's comment, by Anonymous: | Reply

Please cut your scientology crap. SSRI treatment saved my mother's life by helping her chronic depression. Her personality has changed, but it changed for good! She is happier, more outgoing, and recently started taking a class. All thanks to Paxil that started her recovery!

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Do you do requests?<p... (Below threshold)

August 28, 2009 10:54 AM | Posted by gjhgjg: | Reply

Do you do requests?

Please write about this film:
http://en.wikipedia.org/wiki/Into_the_Wild_%28film%29

The main character is a serious narcissist and it's a true story.

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"Could it have been the Zol... (Below threshold)

August 28, 2009 6:51 PM | Posted by Anonymous: | Reply

"Could it have been the Zoloft and Paxil, both SSRI antidepressants, that he had taken for many, many years."

Answer - No, obviously not.

My guess is he got more propofol than he was meant to have got. Medication error. The doctor, remember, hadn't had any more sleep than M.J.

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wow...finally I thought thi... (Below threshold)

August 28, 2009 9:31 PM | Posted by Thomas Jones: | Reply

wow...finally I thought this was going to take forever to figure out..! MJ you WILL be missed.!

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After all the armchair anal... (Below threshold)

August 29, 2009 2:17 AM | Posted by David Johnson: | Reply

After all the armchair analysis and without benefit of the coroner's complete toxicology report:
Aug 28, 2009 14:50 EST

LOS ANGELES (Reuters) - Pop star Michael Jackson's death has been ruled a homicide from an overdose of propofol and other drugs, and police will refer the case to prosecutors for possible criminal charges, officials said on Friday.

And further on: "Warrants used to search Murray's office have said he is the subject of a manslaughter investigation."

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Anon 10:54: after reading t... (Below threshold)

August 30, 2009 3:47 AM | Posted, in reply to gjhgjg's comment, by Anonymous: | Reply

Anon 10:54: after reading the synopsis of that plot I would disagree the main character is a narcissist (he is college age; such identity confusion/self discovery is normal at that time). However, the film looks absolutely fascinating. It has always been a fantasy of mine to live in the woods and just observe nature. It has always been a fantasy of mine to die. There is some sort of relationship between physical death (suicide) and self isolation. Just the other day I came to the conclusion that, psychosis excluded, hermitic isolation is a non-violent person's suicide. Suicide is the ultimate withdrawal.
I can't believe this movie exists. Must watch.

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See, what did I tell you - ... (Below threshold)

September 5, 2009 9:17 AM | Posted by Neuroskeptic: | Reply

See, what did I tell you - accidental propofol overdose (more than 25mg), at least according to his doctor...

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not sure I am reading y... (Below threshold)

September 5, 2009 2:44 PM | Posted, in reply to Neuroskeptic's comment, by Alone: | Reply

not sure I am reading you right-- that article says two things: first, that he administered a drip, and second that it was more than 25mg. My point here is that it is impossible for him to have been given 25mg and then died; he had to be given more (either by doc or MJ himself taking extra) or the guy didn't use the pulse ox like he said he did, left the drip on, etc.

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Finally, a voice of reason ... (Below threshold)

September 8, 2009 5:52 PM | Posted by Kellen: | Reply

Finally, a voice of reason in this madness. As a therapist I've had clients with high drug tolerances, especially for benzodiazepines and opiates. It's amazing the amount of medication that the human body can adapt itself to handle. And if MJ was obtaining that many medications from that many different doctors it would have been easy for Dr. Murray to not know what he was mixing the medications with. (For this reason alone, caution would have been called for on the part of Murray.) I don't entirely buy Murray's story, especially since he failed to call EMS upon discovering that MJ wasn't breathing, but it's very clear that there MJ had a dependence and a tolerance of astronomical proportions.

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Well for one, I think that ... (Below threshold)

September 19, 2009 11:35 AM | Posted by scott: | Reply

Well for one, I think that the doctor shouldnt be charged with anything at all. I am lead to beleive that mj did it to himself not suicide. maby not caring how much of the drug/drugs he took in. but speaking as an addict for many years if he could talk the doctor into giving him more than recomended he did. If he could jack the amount up himself from the iv thing he would. Is there any report of what else they found in his drug screen results? and even with a drug screen it still doesnt rule out it wasnt mjs fault or stupidity/by doing something to himself. i have od'ed before. and out of the many times that i did. a few time when they took my blood and urine they could find no traces of drugs at all. or they didnt find the main drugs that caused it. i dont know if it was from sometihng like the kidneys shutting down and no toxins getting threw but i do know that it happend so maby they need to do some more digging before they point fingures.

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You can't OD from benzodiaz... (Below threshold)

September 21, 2009 9:30 PM | Posted by db: | Reply

You can't OD from benzodiazepines alone. And from my understanding IV benzos are much shorter acting than those orally administered. I mean it looks to me like the he took equivelant of what ~6mg of Xanax over a 9 hour period. While a lot, it's not unheard of and certainly not lethal. I don't know how the propofol plays into this and certainly the pain meds could have played a role.

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This dr Murray is becoming ... (Below threshold)

October 27, 2009 9:59 PM | Posted by excarina11: | Reply

This dr Murray is becoming an uncelebrity-celebrity with every step he takes down.His a sheepish smile is just about the only public photo seen,so what about the paparazzi?One thing is for sure he was out of his depth and therefore acted or did not act right.He has for example stated that he did not know MJJ was an addict. In medical practice one takes a history and performs a physical examination.Also he has stated that he is óldschool´and does not care for modern med .teh cnicali
ty like ecg´s, or was thera one?It is the first time i hear about a possibility of an oximeter having been used.-Then sure the benzo amounts where relat small,somewhere it was mentioned that he may also have been on an SSRI, Zoloft, i believe, though this was not
mentioned among the drugs given the fateful night.Druginteractions may be tricky and surprising if you do not know your parmacology well.-It is as important to know what you do not know as what you do.-Dr murray does not appear to be the the most reliable person. He was not boardcertified in anything.What i have garnered was that MJJ was restless and agitated through that night.And i do believe a psychiatrist would have had a better knowledge how to deal with his medical and mental state.Also dr murray behaved strangely when the paramedics were finally summoned .Then there are many discrepancies with time. Did dr Murray play for time to save his skin-well that was wilful denial of givinf aid.I hope they have some doctors on the investigative team, a pharmacologist, a specialist in forensic medicine.Well a good doctor should at least have turned to a qualifies college or sent him to the ER before it became too critical and too late..

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Why did michael use benzodi... (Below threshold)

July 27, 2012 8:15 AM | Posted by Anonymous: | Reply

Why did michael use benzodiazepines? Did he have anxiety?

I just don't get it, and such doses while not unusual, because a patient with anxiety will build tolerance to benzos quite fast, he will need more and more.

What was Michael Suffering from?

http://www.lyme.ws/

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