Investigators are focusing on at least five doctors who prescribed drugs to Michael Jackson as they try to unravel the circumstances surrounding the pop star's death, according to law enforcement sources.
Authorities removed drugs and other medical evidence from the Holmby Hills mansion where Jackson was stricken and are trying to determine whether the medications were properly prescribed and whether they played any role in his death.
The names on some of the prescriptions were Jackson pseudonyms, and in some cases, the drugs had no prescription labels on them at all, the sources told The Times.
One of the most significant clues so far is the discovery of what one source described as "numerous bottles" of the powerful sedative Diprivan at the home. The source, who spoke on the condition of anonymity because it is an ongoing investigation, said some of the bottles were full and others were empty. None had prescription labels, and investigators are trying to determine how Jackson got the drugs.
Diprivan is an extremely potent drug that is supposed to be dispensed by a person trained to administer anesthesia, such as an anesthesiologist or a certified registered nurse anesthetist, and it is typically used in hospitals. Experts expressed alarm that it would be used at a private home.
"It's a very dangerous drug if self-administered or administered by someone not trained in airway management and cardiac life support," said Ethan Bryson, an assistant professor of anesthesiology at Mt. Sinai School of Medicine in New York. "You need to have someone who knows what they are doing when they administer it."
Diprivan, the market name for propofol, is one of the most widely used IV drugs for general anesthesia. The product label from the U.S. Food and Drug Administration says a patient being given the drug should be monitored at all times for early signs of abnormally low blood pressure, low oxygen levels and stopped breathing. Problems with the heart or breathing are more likely to occur after rapid administration of the drug. The label states that equipment to provide artificial ventilation, supplemental oxygen, and cardiopulmonary resuscitation "must be immediately available."
It's unclear whether any of this equipment was found in Jackson's home.
Abuse of Diprivan is a growing problem, said Paul Wischmeyer, an anesthesiologist at the University of Colorado.
Wischmeyer co-wrote a 2007 study of Diprivan abuse for the journal Anesthesia & Analgesia. The study found that in an e-mail survey of 126 academic anesthesiology training programs nationwide, 18% of departments reported one or more incidents of Diprivan abuse in the previous 10 years. Of the 25 individuals who abused propofol, seven died as a result, including six who were residents, according to the journal study.
"A lot of people do it because it makes you completely blotto. It totally takes away all anxiety, all fear," Wischmeyer said. "It's incredibly relieving of pain, anxiety and stress. People do it to escape."
He said that he has seen people take the drug to relieve anxiety and that many people he has interviewed at rehab centers who are trying to kick an addiction "experienced trauma earlier in their life and are using it to escape."
It remains unknown whether prescription drugs played any role in Jackson's death. The Los Angeles County coroner's office is awaiting the results of toxicology testing before determining a cause of death.
The coroner and the Los Angeles Police Department are being aided in their probe by the Drug Enforcement Administration. The California attorney general's office has also offered assistance. Both agencies have expertise in investigating doctors suspected of improperly prescribing drugs.
The attorney general's office investigated doctors who were charged earlier this year with supplying model Anna Nicole Smith with addictive prescription drugs in the years before she died. The DEA is expected to investigate whether doctors who prescribed medication for Jackson had a face-to-face relationship with him and provided a diagnosis, as required by law.
Diprivan surfaced in the Jackson case last week when a nurse, Cherilyn Lee, said the singer complained to her earlier this year about having insomnia and asked her to get Diprivan for him.
Lee said she told Jackson, "This medication is not safe." She said she never saw him take the drug.
J. Randy Taraborrelli, a Jackson biographer, said the singer was in pain in recent years and had trouble sleeping. "This was a person who would have paid anything -- done anything -- to get a decent night's sleep," he said. "I'm not sure Michael Jackson got a decent night's sleep without medicinal aid."
But experts said Diprivan should never be used for insomnia. John F. Dombrowski of Baltimore, a member of the American Society of Anesthesiologists, said that in a hospital setting, he has EKG equipment, a blood pressure cuff and a blood-oxygen monitor in order to watch a patient's status. Also on hand in a hospital is supplemental oxygen, he said.
"But unless you have a trained physician to rescue that patient, all of the monitors in the world mean nothing. Machines are great, but this is where you need the skill set of a physician."
Times staff writers Kimi Yoshino, Harriet Ryan and Andrew Blankstein contributed to this report.