UPDATED: SWALLOW Featured Post: Little Slices of Death

Heath Ledger as "The Joker" in 2008's "The Dark Knight"

Sleep Deprivation and the Unholy Trinity of Celebrity Death
by Maxim W. Furek, MA, CAC, ICADC
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“Sleep, those little slices of death; Oh how I loathe them.” —Edgar Allen Poe (1809-1849)

The common denominator connecting the deaths of celebrities Heath Ledger, Anna Nicole Smith and Michael Jackson was prescription drug abuse triggered by chronic sleep deprivation.

Sleep deprivation is a serious condition that can become deadly. It is one of the most common health complaints, caused by insomnia or sleeplessness, and can lead to impaired mental and physical health. After periods of reduced sleep, brain neurons may begin to malfunction, visibly affecting a person’s behavior. In sleep-deprived subjects, there is no activity in the temporal lobe of the cerebral cortex, which is associated with the processing of language (Ledoux, 2008). Thus, in these individuals, there are signs of slurred speech, stuttering, speaking in a monotone voice or speaking at a slower pace than normal.

Other behavioral changes may include mood changes, such as anxiety, depression, fatigue, or lack of interest or motivation, social or vocational dysfunction, including increased errors or accidents, decreased attention span and tension, headache, or stomach symptoms (Peters, 2009). Extreme anxiety caused by poor sleep patterns may contribute to irrational and dangerous behaviors. The National Highway Traffic Safety Administration (NHTSA) estimates conservatively that each year drowsy driving is responsible for at least 100,000 automobile crashes, 71,000 injuries, and 1,550 fatalities (Breus, 2009).

Heath Ledger
Actor Heath Ledger suffered from chronic sleep deprivation. Ledger won critical acclaim for The Patriot, Monster’s Ball and a best actor Oscar nomination for Brokeback Mountain. Success, however, began to take its toll as a cluster of life stressors contributed to his eventual unraveling. His personal life was also unraveling. Ledger had just ended his relationship with actress Michelle Williams and was involved in a fierce custody dispute over their daughter Matilda.  Ledger, who suffered from chronic insomnia and anxiety, was forced to deal with the additional pressures of success and demands for increased creative output. Too many sleepless nights were coupled with exhausting film shoots, red-carpet events and grueling press campaigns. He told the New York Times in 2007, “Last week I probably slept an average of two hours a night. I couldn’t stop thinking. My body was exhausted, and my mind was still going.” (CNN,2008). Prior to his tragic overdose the sleep-deprived and physically exhausted actor is believed to have been fighting off effects of walking pneumonia. Ledger died on January 22, 2008, his 28-year-old body discovered in a loft on Broome Street in New York’s SoHo district. The actor died from an accidental overdose of prescription medications, including painkillers, anti-anxiety drugs and sleeping pills. The New York City medical examiner’s office determined that “Mr. Heath Ledger died as the result of acute intoxication by the combined effects of oxycodone, hydrocodone, diazepam, temazepam, alprazolam, and doxylamine. We have concluded that the manner of death is accident, resulting from the abuse of prescription medications.”

The prescribed medications included painkillers Vicodin (hydrocodone), and OxyContin (oxycodone); anti-anxiety drugs, Valium (Diazepam), Xanax (Alprazolam); sleeping agents Restoril and Euhypnos (Temazepam), and an over the counter antihistamine, used as a sleep aid (Doxylamine). But according to a cover article in Vanity Fair, Ledger’s drug use may have been more extensive than what has been generally reported. “Some press accounts blamed Ledger, [for his relationship difficulties] citing heavy drinking and hard-drug use including cocaine and heroin.” (Biskin, 2009).  Curiously Ledger, who had so much more to give, will most likely be remembered for receiving a posthumous Oscar as the maniacal Joker in The Dark Knight.

Anna Nicole Smith
Because traditional sleep medications such as ambian were ineffective, TV reality star and former Playboy Playmate of the Year Anna Nicole Smith was prescribed the sedative chloral hydrate. That proved to be her undoing. The combination of chloral hydrate and a number of benzodiazepines contributed to the death of the reality star on February 8, 2007 (CNN.com, 2007).

After a seven-week investigation, the official death report acknowledged that Smith’s death was caused by an accidental drug overdose. Dr. Joshua Perper, Broward County Medical Examiner and Forensic Pathologist, stated that Smith died of “combined drug intoxication,” with the sleeping medication chloral hydrate being the “major component” in her death. There were also a total of seven prescription drugs, usually prescribed for anxiety, depression and insomnia, found in her bloodstream.

According to Perper, Smith had developed an increased tolerance to the sedative chloral hydrate and took more than the average prescribed doseage. Smith ingested about three tablespoons, whereas the normal dosage is between one and two teaspoons. Synthesized in 1832, chloral hydrate, also known as “Mickey Finn” or “knockout drops” was developed for the specific purpose of inducing sleep. When used properly, and without the introduction of alcohol or other depressants, chloral hydrate is effective in easing sleeplessness due to pain or insomnia. Unfortunately the effective dose and lethal dose of chloral hydrate are so close that the sedative should be considered dangerous (Avis,1990). Today, the use of chloral hydrate has declined as other agents, including barbiturates and benzodiazepines, have largely replaced it. In the death of Anna Nicole Smith, chloral hydrate became increasingly lethal when mixed with four prescription benzodiazepines: Klonopin (Clonazepam), Ativan (Lorazepam), Serax (Oxazepam), and Valium (Diazepam). In addition, Smith had taken Benadryl (Diphenhydramine) and Topamax (Toprimate), an anticonvulsant GABA agonist, which likely contributed to the tranquilizer effects of the chloral hydrate-benzodiazepine combination (Furek, 2008).

Although the individual levels of any of the benzodiazepines in her system would not have been sufficient to cause death, their combination with a high dose of chloral hydrate led to her fatal overdose. The autopsy report indicated that chloral hydrate was the “toxic/lethal” drug, but it is difficult to know if chloral hydrate ingestion would have killed her alone. On October 12, 2007 the Drug Enforcement Agency and California authorities served eight search warrants in connection with Smith’s death. Detectives collected over 100,000 computer images, files, patient profiles and other important documents associated with Smith’s death probe according to CA State Attorney General Jerry Brown. The investigation revealed that Dr. Khristine Eroshevotz, Smith’s personal psychiatrist, had written all eleven prescriptions, later called “pharmaceutical suicide” by a pharmacist who refused to fill one of Eroshevotz’s prescription order (Duke, A, 2009).

Smith’s former boyfriend Howard K. Stern and physicians Eroshevotz and Sandeep Kapoor were charged with “illegal conspiracy to prescribe, administer and dispense controlled substances to an addict.” Stern faces eleven felony counts, while the doctors were charged with six each. The trio had been charged earlier this year with conspiring to give Smith drugs, but prosecutors later revised the counts. The three defendants previously entered “not guilty” pleas to those charges (2009).

Michael Jackson
Michael Jackson, the “King of Pop,” was the most recent celebrity in this tragic cluster. His death — reckless, senseless, irresponsible — has been ruled a “homicide” by the Los Angeles County coroner. According to court documents, Dr. Lakshmanan Sathyavagiswaran concluded that Jackson, 50, died of an overdose of propofol, a powerful sedative given to help him sleep. Michael Jackson’s personal physician, Dr. Conrad Murray, administered Jackson the propofol prior to the singer’s death on June 25, 2009 (Duke and Simon, 2009).

Propofol, with the brand-name of  Diprivan, is an extremely dangerous drug. Used as a general anesthetic Propofol is administered intravenously in operating rooms according to manufacturer AstraZeneca. The sedative is used in office procedures such as urology, dentistry and gynecology and is the most common anesthetic for colonoscopies. The drug works as a depressant on the central nervous system, however, once the infusion is stopped, the patient wakes up almost immediately. Due to propofol’s milky appearance, Jackson referred to the drug as his “milk.”

According to the affidavit Murray had been treating Jackson for insomnia for six weeks. Murray said he nightly gave Jackson 50 mg of propofol diluted with the anesthetic lidocaine via an intravenous drip. Murray, a Houston cardiologist, said he attempted to wean Jackson from it, putting together combinations of other drugs that succeeded in helping Jackson sleep during the two nights prior to his death. Murray was worried that Jackson may have been becoming addicted to the anesthetic drug.

The 32-page warrant noted “Jackson finally went to sleep and Murray stated that he remained monitoring him. After approximately 10 minutes, Murray stated he left Jackson’s side to go to the restroom and relieve himself. Murray stated he was out of the room for about two minutes maximum. Upon his return, Murray noticed that Jackson was no longer breathing.”

The document cited reports from staff at the University of California at Los Angeles Medical Center, where Jackson’s body was taken, who said Murray “admitted” to having given Jackson flumazenil, an antagonist benzodiazepine, to counteract the Ativan. The statement added, “other conditions contributing to death: benzodiazepine effect.” In the nine-hour period, prior to Jackson’s death, Murray administered the following dosages to Jackson: 10 mg of Valium, 2 mg of Ativan, 2 mg of Versed, 2 mg of Ativan, 2 mg of Versed and 25 mg of propofol.

Dr. Conrad Murray was not the only physician to treat the troubled rock star. Another five doctors and a nurse practitioner are believed to have also attended to Jackson’s medical needs. “Detectives … believe that the miscellaneous prescriptions, from multiple doctors … could have contributed to his death,” the official affidavit stated. It added that “it cannot be determined whether the cause of death is due to the actions of a single night and/or a single doctor, or the grossly negligent treatment of several doctors over an extended period of time.”

The childlike Peter Pan creation that was Michael Jackson strived to be forever young. His ageless, androgynous persona was labeled “arrested development.” But, after extensive plastic surgery and skin bleaching, the radical procedures left him a pathetic disfigured creature  who was, according to sources, drug addicted. “Jackson had health problems for years. Drug problems, too, apparently. In 2007, according to the Associated Press an L.A. pharmacy sued him, claming he owed $100,000 for two years’ worth of prescription meds…” (Gates, 2009).

In his response to Jackson’s death, Ronald W. Manderscheid, PhD, reflected, “On the face of it, it seems to me that Michael had been crying out for our help for a very long time. It is tragic that none of us responded to his call… Why did we not do more to treat this as a teachable moment? Perhaps we could prevent another unfortunate death from prescription drug addiction.” (Manderscheid, R.W., 2009).

The tragedy is multi-layered. We have lost a talented individual capable of inspiring young and old across cultural divides with “We Are The World” as a prime example. That musical collaboration raised more than $60 million for famine relief in Africa and Jackson’s 1982 Thriller, stands as the bestselling album of all time.  “But, unquestionably,” and sadly, as pointed out in a recent Time Magazine article, “Jackson is worth more dead than alive.” (Corliss, 2009).

Spanning three unique demographic groups the careers of Michael Jackson, Anna Nicole Smith and Heath Ledger touched our lives in unusual ways. All were gifted and talented, but, in the end, their lives intersected at the juncture where sleep deprivation and drug overdose defined their final days.

Like a perverse reality show this tragic saga continues. Each decade we observe our iconic celebrities self-destructing in full view of their fans and a curious public. The slaughter persists — note the deaths of Elvis Presley, Marilyn Monroe, Janis Joplin, Kurt Cobain and countless others — as does our vicarious fascination. We need to stop the madness and view this as a “teachable moment” where we renew our commitment to treatment and carry the message of recovery to those who need it most.

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Maxim W. Furek, MA, CAC, ICADC, is Director of Garden Walk Recovery, an organization “promoting wellness through drug prevention and education.” His i-Universe book, The Death Proclamation of Generation X: A Self Fulfilling Prophesy of Goth, Grunge and Heroin, was published in 2008. He can be reached at www.maximfurek.com

Tags: abuse of prescription medications, alprazolam, Anna Nicole Smith, Diazepam, doxylamine, drugs, Euhypnos, Heath Ledger, hydrocodone, Michael Jackson, oxycodone, OxyContin, painkillers, Prescription drug abuse, Restoril, sleep deprivation, sleeping pills, temazepam, Valium, vicodin, xanax