Murray Trial Day 19 October 27, 2011

Morning Session 

Dr. Robert Waldman Addiction Specialist

Chernoff Direct

RW states that addiction specialists help patients to stop using alcohol and/or drugs. RW states that if a person came to him looking for help, he would first do an interview and a complete history; repetitive use, age of onset, history of all substances of abuse, history of adverse consequences of use such as legal, social consequences. RW states that a complete medical history but also to focus on the consequences.

RW states that there are different types of treatment programs depending on the substance that a person is addicted to. RW states he asks the person if the addiction has caused legal issues, problems in their marriage, etc. RW states that he has treated professional athletes and celebrities with addictions to prescription pain pills. RW states that the signs of withdrawal can be performance changes, behavior changes, use beyond the regular use can come from a dependence.

RW states that demerol is an older drug, and since then, there have been newer drugs that have surfaced. RW states that opioids are prescribed for pain. RW states that people who stop using prescription pills they have been abusing, the situation is not safe, nor is it comfortable. RW states that people in denial of their addiction, telling everyone surrounding them that they don't have a problem. RW states that interventions are necessary at times, because addicted people don't want to give up their daily lives, or live by the rehab's rules. RW states that addicted people hide the use, and do everything in their power to maintain their privacy and discretion, including patients who hide their addictions from a variety of doctors and pharmacies (referred to as doctor shopping) RW states that to keep their addiction from family or friends, addicts use drugs away from them. 
RW states that there are two ways to help a opioid addict, one is a opioid substitution drug such as methadone, but one has to enter withdrawal first before they can use the opioid substitution drug. The second method is given through lots of benzodiazepines for sedation through the withdrawal process. Symptoms of opioid withdrawal consist of sweating, tachycardia, muscular aches, bone pain, abdominal cramps, vomiting, severe anxiety, hot and cold chills, diarrhea. RW states that an addict's greatest fear is that they are going to be uncomfortable going through withdrawal. RW states that both lorazepam and ativan can be used for opioid withdrawal. RW states that withdrawal time is variable, and often the addict will say they do not need the rehabilitative drugs anymore because they are now comfortable.

RW states that anesthesia can be used to withdraw from opioid addiction, and while under anesthesia, other drugs can be given to alleviate drug withdrawal symptoms. 

RW states that he reviewed the medical records of Michael Jackson from Dr. Arnold Klein, statements/testimony from witnesses. RW states that MJ's medical records begin in January and end on June 22, 2009. RW states that on March 12, a page from the medical records shows that a patient named Omar Arnold (MJ alias) was treated with Restylne/Botox and received Demerol injections for those treatments. RW states that Restylne and Botox are fillers for wrinkles, but he is not familiar with the drugs. RW states that he asked his colleagues whether the REstylne or Botox would be painful enough to call for demerol, and his colleagues said no. RW states MJ also received Midazolam on this day, and that the doses of demerol were above average, meaning it was a large dose.
RW states that he reviewed MJ's medical records for March 17, and that the treatment was similar to March 12, but no botox, and similar demerol injections. RW states that the recommended top limit for demerol is 600 mgs in 24 hours; MJ received 100 mg at 10:45 am and another 100 mg injection of demerol at 11:45 am. 

RW states that on April 6, MJ's medical records reveal that at 8 pm, demerol was given at 200 mg and 1 mg midazolam, in one shot. On April 9, MJ received at 3:30 pm an injection of demerol at 200 mg, and midazolam 1 mg. On April 13, MJ received 200 mg of demerol and 1 mg of Midazolam at 11:15 along with Restylne for both the 13th and the 9th. April 5th MJ received 200 mg demerol and midazolam 1 mg injection. April 17th MJ received Botox in the armpit for perspiration, 200 mg demerol 1 mg midazolam, then another demerol 100 mg injection 1 mg midazolam for a total of 300 mg demerol. April 21, MJ received Botox to groin, demerol 200 mg midazolam 1 mg, an hour later demerol 100 mg. RW states that the progression from 200 mg of demerol to 300 mg demerol is significant in that he believes MJ was developing a tolerance of demerol. April 22 11:30 am 200 mg demerol 1 midazolam an hour later, 100 mg of demerol, an hour later 75 mg demerol for total of 375 mg demerol along with Botox. RW states he has never given 375 mg of demerol to a patient. April 23, MJ received 100 mg demerol, 1 mg midazolam, so the total for the 3 days (April 21,22,23) demerol injection was 775 mg. 

RW states that April 27, MJ received 11:30 200 mg demerol 1 mg Midazolam an hour later 100 mg demerol and 1 mg midazolam. On April 30, MJ received 200 mg demerol 1 mg midazolam, two hours later 100 mg demerol 2 mg Midazolam. May 4, MJ received 200 mg demerol, 1 mg midazolam, an hour later 100 mg demerol 1 mg midazolam. RW states that he believes MJ was dependent on demerol and possibly/probably addicted to opioids. RW states that six weeks of very high opioid use would provoke a dependence for anyone.

RW states May 5, 200 mg demerol, 1 mg midazolam, then 100 mg demerol 1 mg midazolam. May 6, total 300 mg demerol in two separate doses, 2 mg midazolam in two separate doses. RW states that there are not any notes in the medical records from Dr. Klein, because there are no signatures or initials from Klein. RW states that total demerol given to MJ in three days (May 4,5,6) is 900 mg.
RW states that between May 6 and May 19, there was no interaction between MJ and Dr. Klein. RW states that on May 19, MJ received 200 mg demerol and 1 mg midazolam (versed generic name). RW states that on May 20, MJ received 200 mg demerol and 1 mg versed. May 21, MJ received 100 mg demerol, 1 mg midazolam. RW states that on June 1, MJ received 200 mg demerol, 1 mg of midazolam, june 3 200 mg demerol, 2 mgs of midazolam, June 9 200 mg demerol, 2 mg midazolam, June 16 100 mg demerol 1 mg of midazolam, June 22 100 mg demerol 1 mg midazolam. 

RW states that opioid withdrawal entails anxiety, restlessness, insomnia. RW states insomnia is very common, nearly universal with opioid withdrawal. RW states that the simplest way to end withdrawal from demerol would be to provide benzodiazepines. 

Walgren Cross

RW states that it is possible to be addicted to benzodiazepines, including lorazepam. RW states that he did not review Conrad Murray's statement as to what happened the night before and the morning of MJ's death. RW states that he was unaware that Murray was shipping lorazepam and midazolam to his girlfriend's apartment, but he was aware that Murray was giving them to MJ. RW states that the shipping of benzodiazepines was not pertinent.

RW states that opioid and benzodiazpine withdrawal do not have the same symptoms. RW states that he based his opinion that MJ was physically dependent on demerol on the medical record from Klein, but would be highly suspicious of diagnosing MJ as an addict based on the same record. 

RW states that he is not board certified in drug addiction. RW states that he is involved in dialysis professionally. RW states that this involves a process by which a machine provides kidney function for those patients whose kidneys do not function properly. RW states that he requests a urinalysis for patients who he feels have been lying to him, but not for every patient.

RW states that he works in his office and a number of facilities that are confidential. RW states that he works at Visions Treatment Facility, Clearview Treatment Facility, Authentic Recovery Center, Cliffside Malibu and his office. RW states that he is a consultant and he sees patients at all the above facilities, and also does dialysis but cannot pinpoint how many hours he works a week. 

RW states he has determined that some of his patients have not received adequate care prior to treating those patients. RW states that the easy part of his job is getting patients off the drugs, the hard part is keeping them off the drugs.

RW states that the Botox/Restylne injections from Dr. Klein were given in the cheekbones, chin and facial tissue

RW states he has not used demerol in his practice for two decades, as there are much better and safer drugs to use.

RW states that with demerol, withdrawal symptoms would appear within a day. RW states that there are significant lapses of demerol shots in June, 2009. 

RW states that most common withdrawal symptoms of benzodiazepine: anxiety, insomnia, crawly skin. RW states that he would agree with the CA State Medical Board's requirement that controlled substances should be in a locked cabinet, to prevent theft. RW also agree with CA State Medical Board's requirement that medical records are kept by all physicians. RW states that doctors and patients decide what kind of medical care that is best for the patient. 

Chernoff Redirect

RW states that he read the testimony of both Faheem Muhammad and Michael Amir Williams.
RW states that although there are blocks of time that MJ did not receive demerol, it was concerning. 

Walgren Recross

RW states that a chart he created was made only for his own use representing MJ's doctor visits with Dr. Klein. Walgren and RW go back and forth over what each area represents. RW admits that he has made mistakes in the chart, including April 20, 2009. On April 20, MJ was not seen by Klein, but RW entered data into his chart that reflect that date. RW states that the chart does not reflect a June 4 entry, in which MJ did receive injections from Klein.

RW states that he was not personally aware that Conrad Murray was MJ's personal doctor during April, May and June of 2009. RW states that he was aware that CM was MJ's personal doctor through the media when MJ died.

Chernoff Re-redirect

RW states that he reviewed a summary from Chernoff of MJ's medical records and the medical records themselves of Dr. Klein's. RW states that the medical records were very difficult to read and therefore, there were charts made for RW's personal use.


Murray Trial Day 19 October 27, 2011

Afternoon session

Dr Paul White Testimony

Flanagan Direct

White is an anesthesiologist that’s currently retired. He’s still consulting and involved in research projects. White lists his education, his board certification, his articles, books, his awards and research. 

White says he was introduced to propofol by a European doctor and at that time emulsion of Propofol created allergies. White suggested a fatty emulsion to avoid allergies. 

Flanagan asks about Shafer and the research they did together.

Flanagan called White in January 2011. White heard about CM and didn’t want to be a part of this case about the death of an icon and he says he doesn’t like the public attention. After his wife’s encouragement White agrees to review the docs. 

Flanagan asks and White agrees that he cannot justify the elephant in the room that CM infused propofol to MJ and abandoned him. 

White says his initial report was based on CM’s police interview and autopsy report with 13 expert opinions. White was surprised and says if CM did what he says in his interview MJ wouldn’t have died. White asked to meet with CM. Flanagan tries to ask if he met CM but sustained. White flies to LA to meet with Flanagan and Chernoff and was given the transcripts of the preliminary hearing. 

White wrote a letter that had his conclusions but he currently doesn’t think the same way. In his letter he wrote oral consumption as a speculation based on other expert’s testimony and says that he was not aware of the studies about oral bioavailability. White says he learned about them from Dr. Shafer’s report.

Flanagan asks about the Chilean study. White says he felt bad that Dr. Shafer himself drank Propofol. White mentions his concerns with that study there was no blind test and one subject had similar levels to MJ. He had done a study on beagles and agrees that there was no absorption by the stomach. White and Shafer think that one subject might have absorption through the mouth esophagus and they thought of doing a Propofol lollipop to sedate patients non-invasively.

White mentions the variations in blood levels from the same dose and he says its 5 fold. For example from the same dose of propofol , you could get a blood level from 1mg/ ml to 5 mg/ml.

They show some examples from articles that show patients with different blood levels.

Mid afternoon break

White says most centrally active drugs have the same variability in the blood levels such as lorazepam. Again example articles and graphs are shown to demonstrate variability in the levels. 

White mentions Propofol as sedative hypnotic. Low doses cause sleepiness, reduces anxiety. Medium dose means deeper sedation and higher dose means that patient is not responsive to pain and anesthesia. Benzos have the same variability. 

Flanagan asks about off label use. Sleep in a ICU is on label and sleep at home is off label.

Flanagan asks about the Chinese study about Propofol and insomnia. White says that he found the study interesting and the authors should be given a chance. He says he understands Shafer’s concerns but those could be corrected with a review.

Flanagan asks if White has read the toxicology report for MJ. White says he has. 

Flanagan asks about polypharmacy. White explains that it’s combining drugs. It’s reducing the side effects by combining lower doses of drugs. White gives the example of pain management and mixing opiates and non opiates to reduce opiates side effects. White says that it’s common in their area and that midazolam + propofol is a standard technique. 

Flanagan shows a graph done by Dr Shafer that shows 2 doses of 2 mg Lorazepam given at 2AM and 5AM. The graph has 2 lines of responsive and non responsive to pain levels. White says Lorazepam is not an analgesic, doesn't understand these line. 

Flanagan tries to find the graph for midazolam but he can’t. Court ends 15-20 minutes early.