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Supreme Court Upholds Use Of Midazolam, But How Does The Drug Work Outside Executions?

Dr. Ervin Yen holds a prescription for Midazolam
Kate Carlton Greer
Dr. Ervin Yen holds a prescription for Midazolam

The Supreme Court upheld Oklahoma’s lethal injection protocol Monday. The case centered on a single drug, midazolam, that’s now used as part of a three-drug cocktail. Critics claim it is unreliable during executions and cannot produce a “deep, coma-like state” on a regular basis.

But in hospitals across Oklahoma, the drug is being used by anesthesiologists very frequently.

Families crowd a surgical floor waiting room at St. Anthony Hospital in Oklahoma City. Just down the hall, there’s an overflowing private room where Dr. Ervin Yen squeezes between family members, a hospital bed and an older male patient.

“I'm Dr. Yen, how you doing? It's nice to meet you,” Yen says. “I will be your anesthesiologist. You ever had any problems with anesthesia as far as you know?”


The patient is minutes away from going into his second heart surgery. Yen explains that after the procedure ends, he’ll likely feel groggy, and his memory could be hazy. He’ll still have tubes connected to monitor his vitals for a while.


“One of the medicines that kind of keeps you sleepy and relaxed afterwards and kind of messes up your memory for the rest of the day is a drug called midazolam,” Yen says.

Dr. Ervin Yen picks up a prescription for midazolam at St. Anthony Hospital in Oklahoma City.
Credit Kate Carlton Greer / KGOU
Dr. Ervin Yen picks up a prescription for midazolam at St. Anthony Hospital in Oklahoma City.

Midazolam: a ‘minor tranquilizer’


That drug – midazolam – has been at the center of a heated debate since Clayton Lockett writhed and moaned on the gurney during his execution in April 2014.

Lockett’s case was the first time Oklahoma used the medicine for lethal injections, but Yen says it’s a pretty common prescription for anesthesiologists.


“It's been around for a gazillion years. It's just new to executions. It's in the family of drugs called benzodiazepines, and those are minor tranquilizers, meaning they make you tranquil, make you quiet and calm,” Yen says.


Think Valium or Xanax. Both are benzodiazepines. Yen is using midazolam as a sedative for today’s heart surgery. He’ll put the patient to sleep with it and then use a combination of that and other drugs to make sure the man stays asleep.

The making of midazolam

Midazolam hasn’t quite been around for a gazillion years, but it has been around for about 40.


That’s where Armin Walser comes in. He’s one of the drug’s original synthesizers, or developers.

Walser is a retired organic chemist from Switzerland who worked and lives in the United States.

When he invented midazolam in the 1970s, he was working for Hoffman La-Roche, now Roche, at the company’s New Jersey office. He was on a team with two other synthesizers, Rodney Fryer and Louis Benjamin.

Walser developed midazolam after Valium was around. But his version was stronger, and it didn’t sting when injected like Valium does.


“It's usually not used for deep narcosis, it's just for pre-narcosis. It's mainly for minor surgeries they use it, just to put people at ease,” Walser says.


Some anesthesiologists like Yen use it for major surgeries, like heart procedures. It’s really up to each individual doctor.

Midazolam given through an IV doesn’t depress the heart as much as inhaled anesthesia, Yen says, so he prefers to use the drug during procedures dealing directly with the heart.


Warding off recall

During the drug’s development, Walser noticed another property in midazolam that he thought could benefit anesthesiologists and patients.


“Another advantage is midazolam has some amnestic properties, so people don't remember any unpleasant effects,” Walser says.


Yen says some patients have experienced recall during a heart surgery. In other words, they remember parts of the procedure. He likes to use midazolam to prevent that from happening, even though not all physicians or patients like the amnestic effect.

“I had patients tell me they lost one to three days of memory that they never got back because of the medication,” says Dr. Barry Perkins, a gastroenterologist at St. Anthony Hospital.

In the hospital’s operating room pharmacy, Perkins says he used to use midazolam all the time, but he switched over the Propofol – the drug Michael Jackson overdosed on – about three years ago.

Differing doses

Perkins says Propofol is just more predictable.

“Whereas with midazolam, there was a lot of variability with every patient on how much you had to give, and how good the sedation was. Some patients, you'd give them very little and they'd be dangerously sedated. Some patients, you could give them a whole lot, enough to put a horse down, and they wouldn't go to sleep.”


Yen agrees there is variability, but he says that’s what he’s in the operating room for. He can monitor the patient’s sedation and adjust any drugs as needed. It’s important to be flexible.


“The average dosage, sometimes we use 2 milligrams for a case and sometimes we use 20 milligrams.”


But never, he says, anywhere near 500 milligrams, the amount used during Oklahoma’s most recent execution in January.

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