Robert Supenaw, PhD
16 ROBERT SUPERNAW,
17 CALLED BY THE DEFENDANT, HAVING BEEN DULY
18 SWORN, WAS EXAMINED AND TESTIFIED AS FOLLOWS:
19 DIRECT EXAMINATION
20 BY MR. STIRBA:
21 Q. DOCTOR, WOULD YOU PLEASE STATE YOUR FULL NAME AND SPELL
22 YOUR LAST NAME FOR US?
23 A. ROBERT B. SUPERNAW. S-U-P-E-R-N-A-W.
24 Q. AND ARE YOU PRESENTLY EMPLOYED?
25 A. YES, I AM.
3520
1 Q. AND TELL US WHAT YOU DO.
2 A. I AM A PROFESSOR AND ASSOCIATE DEAN AT THE TEXAS TEACH
3 SCHOOL OF PHARMACY AT THE MEDICAL CENTER IN AMARILLO, TEXAS.
4 AND I'M EDITOR IN CHIEF OF THE AMERICAN JOURNAL OF PAIN
5 MANAGEMENT.
6 Q. AND AS ASSOCIATE DEAN AND PROFESSOR AT THE SCHOOL OF
7 PHARMACY, COULD YOU TELL US GENERALLY WHAT YOUR
8 RESPONSIBILITIES ARE?
9 A. PRIMARILY I TEACH THIRD YEAR AND FOURTH YEAR DOCTOR OF
10 PHARMACY STUDENTS PRINCIPLES OF PAIN MANAGEMENT AND THIRD
11 YEAR MEDICAL STUDENTS AND THEIR INTERNAL MEDICINE ROTATION
12 PRINCIPLES OF PAIN MANAGEMENT.
13 Q. AND WITH RESPECT TO YOUR RESPONSIBILITIES FOR THE
14 PAIN -- I'M SORRY. I FORGOT THE ASSOCIATION THAT YOU
15 REFERENCED.
16 A. THE AMERICAN JOURNAL OF PAIN MANAGEMENT.
17 Q. WOULD YOU PLEASE TELL US WHAT YOUR RESPONSIBILITIES ARE
18 IN THAT REGARD?
19 A. I'M EDITOR IN CHIEF OF THE AMERICAN JOURNAL OF PAIN
20 MANAGEMENT AND HAVE BEEN FOR THE LAST NINE YEARS. I REVIEW
21 MINUTES AND MAKE FINAL DECISIONS AS TO WHICH MINUTES WILL BE
22 PUBLISHED AND WHICH WILL NOT.
23 Q. AND WOULD YOU PLEASE TELL US YOUR EDUCATIONAL
24 BACKGROUND?
25 A. I RECEIVED MY DOCTORATE IN PHARMACY AT THE UNIVERSITY OF
3521
1 THE PACIFIC IN CALIFORNIA IN 1972.
2 Q. AND HAVE YOU HAD ANY TRAINING OR EXPERIENCE AS A
3 PHARMACIST SINCE THAT TIME?
4 A. NO. WELL, UPON GRADUATION I HAD PRACTICED FOR TWO
5 YEARS, BUT THEN WHEN I WENT INTO ACADEMICS AND I GAVE UP MY
6 PRACTICE.
7 Q. TELL ME WHAT TEACHING POSITIONS YOU'VE HAD IN THE FIELD
8 OF PHARMACOLOGY SINCE YOU GRADUATED FROM SCHOOL.
9 A. IN 1974 I BECAME DIRECTOR OF POST-GRADUATE EDUCATION FOR
10 THE UNIVERSITY OF THE PACIFIC AND ROSE TO THE RANK OF
11 PROFESSOR OF PHARMACY AT THE UNIVERSITY OF THE PACIFIC IN
12 CALIFORNIA. IN 1998 I MOVED FROM THE UNIVERSITY OF THE
13 PACIFIC TO THE TEXAS TECH MED CENTER, AMARILLO AND HAVE
14 SERVED THERE FOR THE LAST TWO YEARS AS PROFESSOR. I WAS
15 TENURED AT BOTH INSTITUTIONS.
16 Q. DO YOU HAVE ANY CLINICAL EXPERIENCE IN THE FIELD OF
17 PHARMACY WORK?
18 A. YES, I DO.
19 Q. TELL US WHAT THAT IS, PLEASE.
20 A. I HAVE CONSULTED FOR WHAT WE CALL TREATMENT FAILURES IN
21 PAIN MANAGEMENT FOR MANY YEARS. ADDITIONALLY, I SERVED AS A
22 STAFF REPRESENTATIVE TO A CHRONIC PAIN PROGRAM AND THEN
23 LATER I BECAME DIRECTOR OF THE CHRONIC PAIN TREATMENT
24 PROGRAM AT THE UNIVERSITY OF THE PACIFIC IN CALIFORNIA.
25 Q. DO YOU HAVE ANY PROFESSIONAL AFFILIATIONS WITH RESPECT
3522
1 TO YOUR WORK EITHER AS A TEACHER OR A CLINICIAN IN THE FIELD
2 OF PHARMACY?
3 A. YES.
4 Q. COULD YOU JUST DESCRIBE SOME OF THEM FOR US, PLEASE?
5 A. I'M A DIPLOMATE OF THE AMERICAN ACADEMY OF PAIN
6 MANAGEMENT.
7 Q. WHAT IS THAT?
8 A. THAT IS A NATIONAL INTERDISCIPLINARY ASSOCIATION OF PAIN
9 MANAGEMENT PRACTITIONERS.
10 Q. AND DO YOU HAVE ANY OTHER PROFESSIONAL AFFILIATIONS OF
11 SUCH A DISTINCTION?
12 A. WELL, I'VE SERVED AS PRESIDENT THE AMERICAN ACADEMY OF
13 PAIN MANAGEMENT. ADDITIONALLY I'M A MEMBER OF THE AMERICAN
14 ASSOCIATION OF COLLEGES OF PHARMACY. I HAVE THREE TIMES
15 BEEN NAMED FACULTY FELLOW AT THE UNIVERSITY OF THE PACIFIC.
16 AND I'M A MEMBER OF THE AMERICAN PHARMACEUTICAL ASSOCIATION,
17 THE AMERICAN SOCIETY OF HEALTH SYSTEMS PHARMACISTS AND MANY
18 REGIONAL ORGANIZATIONS. AMERICAN PAIN SOCIETY,
19 INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN.
20 Q. CAN YOU TELL US WHAT THE ACADEMY OF PAIN MANAGEMENT IS?
21 A. THE AMERICAN ACADEMY OF PAIN MANAGEMENT?
22 Q. YES.
23 A. THAT'S AN INTERDISCIPLINARY ORGANIZATION DEDICATED TO
24 THE EDUCATION OF PAIN MANAGEMENT PRACTITIONERS.
25 Q. AND WHO COMPOSES THIS BODY?
3523
1 A. ABOUT 80 PERCENT OF THE MEMBERS ARE PHYSICIANS. ABOUT
2 FIVE TO SEVEN PERCENT ARE DENTISTS. SEVERAL ARE
3 PHARMACISTS, PHARMACOLOGISTS, PAIN RESEARCHERS, NURSES,
4 ANYBODY THAT HAS A PRINCIPAL DUTY OR RESPONSIBILITY FOR PAIN
5 MANAGEMENT.
6 Q. IS THERE A DIFFERENCE BETWEEN A PHARMACIST AND
7 PHARMACOLOGIST?
8 A. WELL, A PHARMACOLOGIST IS SOMEONE WHO STUDIES THE
9 MECHANISM ACTION OF DRUGS. A PHARMACIST IS ACTUALLY A LEGAL
10 TERM MEANING A REGISTERED PRACTITIONER.
11 Q. AND WHAT ARE YOU?
12 A. WELL, I WOULD SAY I'M BOTH.
13 Q. AND IN TERMS OF THE MECHANISM OF THE REACTION OF DRUGS,
14 COULD YOU EXPLAIN IN WHAT RESPECT YOU ARE REFERRING TO THAT?
15 A. WELL, IT'S ESSENTIALLY A STUDY OF WHAT HAPPENS TO THE
16 DRUG ONCE IT'S EITHER CONSUMED OR INGESTED INTO THE SYSTEM.
17 THAT IS, WHAT HAPPENS IN THE BODY PHYSIOLOGICALLY TO
18 MANIFEST ANY CHANGE THAT'S ASSOCIATED WITH THAT DRUG, HOW
19 DOES IT WORK, HOW LONG DOES IT WORK, HOW IS IT ABSORBED,
20 METABOLIZED, EXCRETED, HOW LONG DOES IT HANG AROUND AND WHAT
21 ARE ASSOCIATED ADVERSE EFFECTS OF THAT DRUG.
22 Q. AND HAVE YOU BEEN ASKED TO MAKE A STUDY OR AN ANALYSIS
23 WITH RESPECT TO CERTAIN MEDICATIONS IN THIS CASE?
24 A. YES, I HAVE.
25 Q. AND YOU HAVE BEEN RETAINED AS AN EXPERT TO RENDER AN
3524
1 OPINION WITH RESPECT TO THOSE MATTERS?
2 A. YES, I HAVE.
3 Q. FIRST OF ALL, COULD YOU TELL US, PLEASE, IN TERMS OF AN
4 ANALYSIS OF THE PHARMACOLOGY OF A DRUG, FOR EXAMPLE, A
5 MEDICATING DRUG IN THIS CASE, CAN YOU JUST ORIENT US
6 GENERALLY ON HOW YOU GO ABOUT LOOKING AT THE EFFECT THAT
7 THAT MEDICATION MAY HAVE HAD?
8 A. WELL, PROBABLY TO MOST IT'S CERTAINLY SMOKES AND MIRRORS
9 AS TO HOW MEDICATIONS WORK, BUT WHAT I LOOKED AT WAS WHEN
10 DID THE DRUGS ENTER THE BODY, HOW LONG DID THEY TAKE TO TAKE
11 EFFECT, HOW LONG DID IT TAKE FOR EACH OF THE DRUGS TO REACH
12 ITS PEAK EFFECT AND WHAT HAPPENED TO THAT DRUG ONCE IT
13 REACHED ITS PEAK EFFECT; THAT IS, HOW RAPIDLY DID IT
14 DISAPPEAR FROM THE SYSTEM AND AT WHAT POINT WAS THAT DRUG
15 REDOSED SO THAT WE COULD DO AN ANALYSIS OF WHAT THE -- WHAT
16 WE CALL PEAKS AND TROUGHS; THE PEAKS BEING THE HIGHEST LEVEL
17 IN THE BLOOD STREAM OF THAT DRUG AND A TROUGH BEING THE
18 LOWEST LEVEL, BLOOD LEVEL OF THAT DRUG.
19 Q. WHAT IS A PEAK EFFECT?
20 A. A PEAK EFFECT IS WHAT KIND OF REACTION THE BODY IS GOING
21 TO ASSUME ONCE THAT BLOOD LEVEL REACHES ITS ABSOLUTE
22 MAXIMUM. ONCE IT REACHES THAT ABSOLUTE MAXIMUM IT IS SLOWLY
23 DEGRADED BY THE BODY, AND DEPENDING UPON THE NAME OF THE
24 DRUG, SOME GO OUT OF THE SYSTEM RATHER RAPIDLY AND OTHERS
25 TAKE QUITE A WHILE TO LEAVE THE SYSTEM.
3525
1 Q. HOW DOES A PHARMACOLOGIST DETERMINE THE PEAK EFFECT OF
2 ANY PARTICULAR DRUG?
3 A. WHAT THEY WOULD DO WOULD BE OVER THE YEARS TO TAKE BLOOD
4 LEVELS OF AN INDIVIDUAL YOU HAVE BEEN GIVING THE DRUG AND
5 THEN DO AN ANALYSIS OF WHAT THE RANGE WOULD BE AND THEN COME
6 UP WITH AN AVERAGE OVER MANY, MANY PATIENTS.
7 Q. AND DID YOU DO THAT IN THIS CASE?
8 A. YES, I DID.
9 Q. AND CAN YOU TELL US, PLEASE, WHAT RELEVANCE IN THIS
10 PARTICULAR CASE PEAK EFFECT HAS?
11 A. WELL, THE RELEVANCE OF THE PEAK EFFECT WITH RESPECT TO
12 MORPHINE SULFATE IS VERY PROFOUND BECAUSE I BELIEVE THE
13 ALLEGATION IS THAT RESPIRATORY DEPRESSION COULD HAVE BEEN
14 THE CAUSE OF DEATH IN SOME OR ALL OF THESE PATIENTS. WHAT'S
15 IMPORTANT TO UNDERSTAND IS THAT RESPIRATORY DEPRESSION WILL
16 BE MANIFESTED MOST PROFOUNDLY AT THE PEAK EFFECT OF THE
17 DRUG. BEFORE THE DRUG REACHES ITS PEAK, WE WON'T HAVE AS
18 MUCH RESPIRATORY DEPRESSION, AND AFTER THE DRUG IS ON ITS
19 WAY DOWN, THAT IS, LEAVING THE SYSTEM, WE WON'T HAVE AS
20 NEARLY AS PROFOUND RESPIRATORY DEPRESSION EFFECT. THAT HAS
21 BEEN STUDIED AND WELL-DOCUMENTED.
22 Q. NEVER QUITE KNOW WHERE TO PUT THIS THING BUT START HERE.
23 WHAT IS RESPIRATORY DEPRESSION?
24 A. IS IT OKAY IF I MAKE IT VERY SIMPLE?
25 Q. YES. NOT ONLY OKAY, HOPED FOR.
3526
1 A. WELL, THE BRAIN STEM HAS BUILT INTO IT WHAT YOU MIGHT
2 WANT TO THINK OF AS A SMOKE ALARM JUST LIKE YOU WOULD HAVE A
3 SMOKE ALARM IN YOUR KITCHEN, ALTHOUGH THE BRAIN STEM SMOKE
4 ALARM IS SUBJECT TO CHANGES IN CARBON DIOXIDE. ESSENTIALLY
5 INSTEAD OF MONITORING FOR SMOKE, WHAT THE SMOKE ALARM IN THE
6 BRAIN STEM DOES IS MEASURE THE AMOUNT OF CARBON DIOXIDE THE
7 BODY IS THROWING OFF, AND AS SOON AS IT REACHES A CRITICAL
8 LEVEL, THE ALARM GOES OFF, C02 ALARM GOES OFF IN THE BRAIN
9 STEM.
10 AND WITH THAT, WHEN THAT GOES OFF, IT TELLS US, THE
11 BODY, IT'S TIME TO BREATHE AGAIN. SO THIS HAPPENS
12 APPROXIMATELY 15, 16, 17 TIMES PER MINUTE IN THE AVERAGE
13 INDIVIDUAL. YOU'LL HAVE A WIDE VARIATION, SO THERE'S A
14 RANGE MAYBE ANYWHERE FROM 10 TO 20 TIMES A MINUTE. BUT EACH
15 TIME YOUR BODY SENSES CARBON DIOXIDE, THE ALARM GOES OFF AND
16 SAYS BREATHE AND SO WE BREATHE AGAIN.
17 RESPIRATORY DEPRESSION SECONDARY TO MORPHINE IS A
18 LESSER SENSITIVITY OF THAT SMOKE ALARM TO THE CARBON DIOXIDE
19 IN THE SYSTEM. SO AS WE GET INCREASING LEVELS OF MORPHINE
20 SULFATE, POTENTIALLY THAT ALARM WON'T BE AS SENSITIVE SO
21 WE'LL TEND TO BREATHE LESS; THAT IS, NOT AS MANY TIMES PER
22 MINUTE.
23 Q. NOW, CAN YOU TELL US, PLEASE, WHY MAXIMUM RESPIRATORY
24 DEPRESSION IS ASSOCIATED WITH A PEAK IN THE DRUG?
25 A. WELL, THE DRUG ITSELF IS TELLING -- IS TELLING THE SMOKE
3527
1 ALARM -- AND I HOPE I'M NOT MAKING THIS TOO SIMPLE -- BUT IS
2 TELLING THE C.D. ALARM IN THE BRAIN STEM, YOU KNOW, DON'T BE
3 SO CRITICAL. IT'S ALMOST LIKE TAKING YOUR SMOKE ALARM IN
4 YOUR KITCHEN AND TURN IT DOWN A COUPLE OF NOTCHES. SO THE
5 PEAK IS VERY IMPORTANT BECAUSE THAT'S WHEN YOU WILL HAVE THE
6 MAXIMUM DISCUSSION BETWEEN THE DRUG AND THE ALARM ITSELF;
7 THAT IS, AT THE PEAK THE MORPHINE IS TELLING THE ALARM,
8 DON'T BE SO SENSITIVE. JUST BEFORE THE PEAK AND JUST AFTER
9 THE PEAK IT ISN'T AS CRITICAL.
10 Q. HOW DID YOU GO ABOUT CALCULATING PEAK EFFECT IN THIS
11 CASE RELEVANT TO MORPHINE?
12 A. WELL, IT'S WELL-DOCUMENTED AS TO HOW MORPHINE GETS INTO
13 THE SYSTEM AND HOW LONG IT TAKES TO REACH AN EFFECTIVE DOSE
14 AND HOW LONG IT TAKES TO REACH ITS PEAK.
15 Q. WHAT IS THE DIFFERENCE?
16 A. WELL, YOU'LL GET AN EFFECT DEPENDING ON THE PAIN
17 THRESHOLD AFTER ABOUT 15 MINUTES. NOW, IN EACH OF THESE
18 CASES WHERE WE'RE TALKING ABOUT AN INJECTED DRUG AS OPPOSED
19 TO AN ORAL MEDICATION, AN ORAL MEDICATION, IF WE WERE GOING
20 TO TAKE A TABLET OF MORPHINE, WILL TAKE JUST A BIT LONGER TO
21 GET INTO THE SYSTEM AND GIVE US A THERAPEUTIC EFFECT. SO
22 WE'RE GOING TO BE IN PAIN A LITTLE BIT LONGER WITH AN ORAL
23 MEDICATION. BUT WITH AN INJECTABLE -- AND I BELIEVE ALL OF
24 THESE WERE GIVEN INTRAMUSCULARLY -- WE'LL TAKE EFFECT A
25 LITTLE BIT SOONER. AND IT REACHES ITS PEAK A LITTLE BIT
3528
1 SOONER. SO WE KNOW, BASED UPON STUDIES OVER THE YEARS,
2 EXACTLY HOW LONG IT'S GOING TO TAKE FOR THIS DRUG TO GET
3 INTO THE SYSTEM AND ALSO WE CAN CALCULATE ACCURATELY HOW
4 LONG IT WILL TAKE BEFORE THAT DRUG REACHES ITS PEAK.
5 Q. AND WHAT SIGNIFICANCE IN THIS CASE IS IT THAT YOU ARE
6 ABLE TO CALCULATE THE PEAK EFFECT OF MORPHINE?
7 A. WELL, THE SIGNIFICANCE IS, IS ESSENTIALLY IF WE ARE
8 GOING TO SAY THAT MORPHINE CAUSED RESPIRATORY DEPRESSION --
9 AND THAT'S DEBATEABLE, WE CAN GET INTO THAT LATER -- BUT IF
10 WE WERE GOING TO SAY MORPHINE CAUSED RESPIRATORY DEPRESSION,
11 WE'LL KNOW CATEGORICALLY THAT THE MAXIMUM RESPIRATORY
12 DEPRESSION WILL OCCUR AT PEAK. SO THAT'S THE RELEVANCE IN
13 THIS CASE AND WHY WE STUDY MORPHINE DOSING AND PEAK EFFECTS.
14 Q. DID YOU ALSO, IN TERMS OF THIS CASE, ANALYZE THE EFFECTS
15 OF OTHER CENTRAL NERVOUS SYSTEM DRUGS?
16 A. YES, I DID.
17 Q. SPECIFICALLY PSYCHOTROPIC MEDICATIONS?
18 A. YES, I DID.
19 Q. AND TELL US WHAT YOU DID IN THAT REGARD IN TERMS OF YOUR
20 ANALYSIS.
21 A. WELL, THE FIRST THING I DID WAS CATEGORIZE ALL THE DRUGS
22 THAT WERE ALSO GIVEN. AND THESE WERE GERIATRIC PATIENTS WHO
23 WERE IN A PSYCHIATRIC CARE AND IT REALLY GOES WITHOUT SAYING
24 THAT THESE KIND OF PATIENTS ARE ON LOTS OF DRUGS, LOTS OF
25 MEDICATIONS, WHO HAD SOME PAIN, SOME FOR PSYCHOTROPIC EFFECT
3529
1 AND SOME FOR BOIL CARE. YOU NAME IT. THE FIRST THING I DID
2 WAS SECTOR OUT ALL OF THOSE THAT WOULD HAVE NOTHING TO DO
3 WITH CENTRAL NERVOUS SYSTEM DEPRESSION AND THE EFFECT SUCH
4 AS LAXATIVES, BULK FORMING LAXATIVES, THINGS THAT MIGHT
5 CORRECT A PROBLEM IN THE G.I. TRACT. ANYTHING THAT WOULD
6 NOT HAVE ANY ADMINISTRATIVE C.N.S. DEPRESSANT.
7 Q. YOU ARE GOING TO HAVE TO TELL US WHAT YOU MEAN BY
8 ADDITIVE C.N.S. DEPRESSANT EFFECTS.
9 A. THE CLASSIC EXAMPLE OF ADDITIVE EFFECT WOULD BE TO TAKE
10 A TRANQUILIZER AND ALCOHOL. BOTH THE TRANQUILIZER AND THE
11 ALCOHOL HAVE CENTRAL NERVOUS SYSTEM DEPRESSANT ACTIVITY. IF
12 WE TAKE THEM SEPARATELY, WE'LL GET A LITTLE BIT OF C.N.S,
13 CENTRAL NERVOUS SYSTEM DEPRESSION. IF WE TAKE THEM TOGETHER
14 WE'LL HAVE A CUMULATIVE OR ADDITIVE EFFECT OF THE TWO OF
15 THEM. THE SAME THING IS TRUE -- ALCOHOL IS NOTHING MORE
16 THAN A DRUG. SO THE SAME THING IS VERY TRUE OF DRUGS THAT
17 HAVE CENTRAL NERVOUS SYSTEM DEPRESSANT EFFECTS.
18 Q. IS THERE A RELATIONSHIP BETWEEN CENTRAL NERVOUS SYSTEM
19 ADDITIVE EFFECTS AND RESPIRATORY DEPRESSION?
20 A. SOMETIMES THERE'S AN ADDITIVE RESPIRATORY DEPRESSION
21 EFFECT, NOT ALWAYS. FOR SOME DRUGS THAT CAUSE CENTRAL
22 NERVOUS SYSTEM DEPRESSION -- ATIVAN IS A VERY GOOD
23 EXAMPLE -- WE'LL NOT SEE ADDITIVE RESPIRATORY DEPRESSION.
24 OTHER DRUGS, NAMELY THE ANTIDEPRESSANTS, YOU SEE ADDITIVE
25 RESPIRATORY DEPRESSION. SO IT'S NOT A -- WE CAN'T SAY
3530
1 CATEGORICALLY ONE WAY OR THE OTHER.
2 Q. NOW, I THINK I INTERRUPTED YOU WERE -- YOU WERE SAYING
3 YOU WERE CULLING OUT ESSENTIALLY THE NON-CENTRAL NERVOUS
4 SYSTEM DEPRESSANT MEDICATIONS AND CONTINUE ON WITH WHAT YOU
5 DID IN TERMS OF THE NON -- THE OTHER DRUGS OTHER THAN
6 MORPHINE.
7 A. OKAY. IT MADE MY JOB MUCH SIMPLER ONCE I CONCENTRATED
8 ON DRUGS WHERE -- THOSE DRUGS THAT HAD A POTENTIAL FOR
9 CENTRAL NERVOUS SYSTEM DEPRESSANT ACTIVITY, I CONCENTRATED
10 ON JUST THOSE AND LOOKED AT WHEN THEY WERE DOSED. AND I DID
11 THE SAME THING AS I DID WITH THE MORPHINE SULFATE. I LOOKED
12 AT HOW LONG IT WOULD TAKE FOR THOSE C.N.S. DRUGS TO GET INTO
13 THE SYSTEM, HOW LONG IT WOULD TAKE THEM TO GET TO THEIR PEAK
14 EFFECT AND WHEN THEY WOULD BE ELIMINATED FROM THE SYSTEM
15 BASED UPON THEIR HALF LIVES.
16 Q. WERE YOU ABLE TO DETERMINE IN THESE CASES WHETHER THERE
17 WAS AN ADDITIVE EFFECT AS YOU'VE DESCRIBED IT RELEVANT TO
18 MORPHINE?
19 A. THERE WERE MINOR ADDITIVE EFFECTS. FOR THE MOST PART
20 THE DRUGS THAT WERE GIVEN WERE GIVEN SO EARLY -- THE
21 NONMORPHINE DRUGS THAT WERE GIVEN WERE EITHER NOT GIVEN THE
22 DAY BEFORE THE PATIENT EXPIRED OR GIVEN VERY EARLY IN THE
23 COURSE OF THAT DAY SUCH THAT ALMOST INVARIABLY THEY WERE
24 CLOSE TO BEING ELIMINATED FROM THE SYSTEM. A COUPLE OF THE
25 DRUGS HAD VERY LONG HALF LIVES. SO I HAD TO GO BACK 48
3531
1 HOURS AND LOOK AT WHAT DRUGS WERE GIVEN THE PREVIOUS DAY TO
2 DETERMINE HOW FAR ALONG THE DOWNWARD CURVE THEY WERE. WHEN
3 I SAY DOWNWARD CURVE, HOW LONG WOULD IT TAKE THEM TO BE
4 METABOLIZED OUT OF THE SYSTEM AND THEN DID AN ANALYSIS OF
5 HOW THAT CURVE COULD BE SUPERIMPOSED UPON THE MORPHINE CURVE
6 TO DETERMINE WHETHER OR NOT THERE WOULD BE ANY ACCUMULATIVE
7 EFFECT OF THE C.N.S. DEPRESSANT DRUG AND MORPHINE SULFATE.
8 Q. YOU SAID EARLIER YOU DESCRIBED WHAT ARE CALLED PEAKS AND
9 TROUGHS.
10 MR. STIRBA: AND PERHAPS, YOUR HONOR, MAY THE
11 WITNESS APPROACH THIS PAD. IT MIGHT BE HELPFUL TO
12 ILLUSTRATE HIS TESTIMONY?
13 THE COURT: YOU WANTED HIM TO DRAW SOMETHING?
14 MR. STIRBA: YES.
15 THE COURT: YES.
16 Q. (BY MR. STIRBA) PERHAPS IF YOU'LL ILLUSTRATE FOR THE
17 JURY PEAKS AND TROUGHS AND HOW THEY ARE RELATED TO THE
18 PHARMACOLOGICAL ANALYSIS.
19 A. OKAY. ACROSS THIS BASIS -- AND WE'RE GOING TO PLOT
20 TIMES. AND ACROSS THIS IS AXIS WE'RE GOING TO PLOT BLOOD
21 LEVEL.
22 MR. STIRBA: CAN EVERYBODY SEE ALL RIGHT?
23 A. SO IF WE SECTOR OFF THE TIME IN TERMS OF HOURS, THIS IS
24 TIMES ZERO. THIS WOULD BE ONE HOUR, TWO HOURS, THREE HOURS,
25 FOUR HOURS, FIVE HOURS. AND USING MORPHINE SULFATE AS AN
3532
1 EXAMPLE.
2 Q. (BY MR. STIRBA) SURE.
3 A. IF WE WERE TO GIVE MORPHINE SULFATE AT TIMES ZERO BY
4 INJECTION, THAT IS AN I.M. INJECTION, INTRAMUSCULAR
5 INJECTION, IT'S GOING TO GET INTO THE SYSTEM RATHER RAPIDLY.
6 SO WITHIN ABOUT 15 MINUTES THE PATIENT IS GOING TO FEEL
7 RELIEF TO A CERTAIN EXTENT OF THE PAIN. SO LET'S SAY THAT
8 WE ARE GIVING A 10-MILLIGRAM DOSE OF MORPHINE SULFATE, WE'LL
9 START TO SEE THE BLOOD LEVELS INCREASE AND HIT A PEAK RIGHT
10 AT ABOUT ONE HOUR; THAT IS, IT WILL TAKE APPROXIMATELY ONE
11 HOUR FOR THE DRUG TO GET INTO THE SYSTEM AND REACH ITS PEAK
12 EFFECT.
13 THEN AS SOON AS IT REACHES ITS PEAK EFFECT, IT
14 IMMEDIATELY -- WHAT'S HAPPENING IS AS IT'S COMING INTO THE
15 SYSTEM, THE LIVER IS GRABBING IT. IT'S GRABBING IT AND IT'S
16 SAYING, YOU ARE NOT PART OF OUR SYSTEM, I'M GOING TO
17 METABOLIZE YOU OUT, JUST AS WE WOULD DO ANYTHING ELSE LIKE
18 ALCOHOL, TYLENOL, YOU NAME IT. THE LIVER IS TAKING IT OUT.
19 IT IS SENSING ANYTHING THAT COMES INTO THE SYSTEM AS A TOXIC
20 SUBSTANCE TO PROTECT OURSELVES. AND SO IT'S GOING TO START
21 METABOLIZING THAT DRUG INTO TWO OTHER DRUGS. ONE DRUG IS
22 ACTIVE. THE OTHER DRUG IS NOT ACTIVE.
23 SO IN DETERMINING HOW LONG IT TAKES FOR THE DRUG TO GET
24 OUT OF THE SYSTEM WE HAVE TO ADD THE MORPHINE SULFATE TO
25 WHAT WE CALL ACTIVE METABOLITE; THAT IS, THE LIVER HAS
3533
1 CHANGED THE CHEMICAL ENTITY INTO A SECOND ENTITY THAT'S
2 STILL A POTENT ANALGESIC DRUG. SO WE'LL ASSUME THOSE TWO
3 AND WE KNOW THAT THEY WILL PEAK THE LEVELS OF THOSE TWO
4 DRUGS, THE ORIGINAL DRUG AND THE DRUG THAT HAS BEEN
5 METABOLIZED. THE ACTIVE ONE WILL PEAK AT ONE HOUR. THEN WE
6 KNOW THAT SLOWLY THE LIVER IS CONTINUING TO METABOLIZE THESE
7 DRUGS TO GET THEM OUT OF OUR SYSTEM. AND OVER A PERIOD OF
8 ANYWHERE FROM ONE AND A HALF TO UP TO 4.5 HOURS IT WILL TAKE
9 FOR THAT DRUG TO REACH HALF OF THE CONCENTRATION THAT WAS
10 INJECTED INTO IT AND THAT'S WHAT WE CALL A THERAPEUTIC HALF
11 LIFE. THAT IS THE TIME IT TAKES HALF THE DRUG TO BE
12 SWITCHED OUT OF THE SYSTEM.
13 NOW, THERE'S A WIDE RANGE -- I CAN'T GRAPH A RANGE --
14 WHICH WHEN I SAY THE HALF LIFE IS BETWEEN ONE AND A HALF AND
15 FOUR AND A HALF HOURS, WHAT KIND OF A PERSON WOULD IT TAKE
16 TO HAVE A HALF LIFE OF THIS DRUG OF FOUR AND A HALF HOURS.
17 IT WOULD BE AN ALCOHOLIC OR SOMEONE WHO NO LONGER HAS A GOOD
18 LIVER TO METABOLIZE THE DRUG OR SOMEONE WHO HAS ALMOST
19 COMPLETE KIDNEY SHUTDOWN SO THAT THEY CAN'T EXCRETE THE
20 DRUG. SO ON AVERAGE WE USE TWO HOURS AS THE HALF LIFE OF
21 THIS DRUG, BECAUSE THE MAJORITY OF THE PATIENTS DON'T HAVE A
22 SEVERELY COMPROMISED LIVER AS AN ALCOHOLIC WOULD AND DO NOT
23 HAVE SIGNIFICANT RENAL SHUTDOWN, MEANING THAT YOU STILL HAVE
24 KIDNEYS THAT ARE HELPING YOU EXCRETE THE DRUG.
25 Q. AND THE DRUG YOU ARE TALKING ABOUT IS MORPHINE?
3534
1 A. MORPHINE IS THE DRUG.
2 Q. SO YOU ARE ADOPTING A TWO HOUR HALF LIFE?
3 A. THAT'S CORRECT.
4 Q. IF YOU CONTINUE ON IN SHOWING HOW YOU CONDUCT THE STUDY,
5 FOR EXAMPLE, IN THIS CASE.
6 A. WE CAN THROW THIS INTO THE COMPUTER. WE CAN SAY, THIS
7 IS ABOUT HALF THE DRUG HERE. REMEMBER, THIS IS THE BLOOD
8 LEVEL AND IT REACHES ITS PEAK HERE IS HALF WAY BETWEEN THOSE
9 TWO, IS HALF OF THE DRUG. AND SINCE WE KNOW AT TWO HOURS --
10 SINCE WE KNOW AT TWO HOURS HALF OF THE DRUG IS GOING TO BE
11 GONE, WE CAN DRAW THIS CURVE DOWN HERE. AT TWO HOURS HALF
12 OF THIS IS GOING TO BE GONE. SO BY FOUR WE GET A CURVE THAT
13 LOOKS LIKE SOMETHING LIKE THAT. SO THAT BY ABOUT FIVE OR
14 SIX HOURS THERE'S VIRTUALLY NO MORPHINE IN THE SYSTEM THAT'S
15 GOING TO CAUSE ANY HARM OR BY THE SAME TOKEN IS IT GOING TO
16 DO ANY GOOD IN TERMS OF RELIEF OF PAIN.
17 Q. SIMILARLY, CAN YOU DO A GRAPH ANALYSIS LIKE THIS WITH
18 OTHER, FOR EXAMPLE, THE PSYCHOTROPIC MEDICATIONS IN THIS
19 CASE?
20 A. YES, WE CAN.
21 Q. AND HOW WOULD YOU GO ABOUT DOING THAT?
22 A. WHAT WE WOULD DO WOULD BE DETERMINE WHAT THE HALF LIFE
23 IS OF THE DRUG AND DO THE SAME THING AS WE DID HERE. THE
24 ONLY DIFFERENCE HERE WOULD BE HOW LONG DOES IT TAKE THAT
25 DRUG TO REACH A PEAK BEFORE IT TROUGHS.
3535
1 Q. NOW, THIS LINE, THIS LINE THAT IS GOING DOWNWARD LIKE
2 THAT, IS THAT THE TROUGH LINE?
3 A. THE TROUGH IS CONSIDERED DOWN HERE. THIS IS A PEAK.
4 THIS IS A TROUGH.
5 Q. AND WHERE WOULD MAXIMUM RESPIRATORY DEPRESSION OCCUR?
6 A. DEFINITELY WITHOUT A DOUBT WOULD HAPPEN RIGHT HERE AT
7 THE PEAK, WHEN THE DRUG IS AT ITS HIGHEST LEVEL.
8 Q. NOW, IN TERMS OF YOUR GRAPH, HOW WOULD YOU INCORPORATE
9 OR INCLUDE OTHER CENTRAL NERVOUS SYSTEM DEPRESSANT
10 MEDICATIONS?
11 A. OKAY. WE WOULD HAVE TO DO IT ON A DIFFERENT GRAPH, BUT
12 WE COULD SUPERIMPOSE TIME BECAUSE TIME IS CONSTANT,
13 IRRESPECTIVE OF WHAT THE GRAPH SHOWS. THE BLOOD LEVEL'S
14 GOING TO BE COMPLETELY DIFFERENT. SO IF WE USE A COMPLETELY
15 DIFFERENT GRAPH, LEAVING TIME AS A STANDARD, BUT THE BLOOD
16 LEVEL IS TO BE COMPLETELY DIFFERENT, WE CAN GRAPH IN OTHER
17 DRUGS THAT MIGHT CAUSE C.N.S. DEPRESSANT EFFECTS.
18 Q. IS THAT WHAT YOU HAVE DONE IN THIS CASE?
19 A. YES, IT IS.
20 Q. ALL RIGHT. YOU MAY RESUME THE WITNESS STAND. THANK
21 YOU.
22 NOW, DOCTOR, IN TERMS OF YOUR STUDY, DID IT HAVE A
23 PARTICULAR PURPOSE? WERE YOU TRYING TO ANSWER A PARTICULAR
24 QUESTION?
25 A. YES, I WAS.
3536
1 Q. AND WHAT WAS THAT QUESTION?
2 A. I WANTED TO SEE IF THE TIME OF DEATH OF EACH OF THESE
3 INDIVIDUALS COINCIDED WITH A SUFFICIENTLY LARGE DOSE AND A
4 SUFFICIENTLY HIGH PEAK.
5 Q. AND WHY WOULD THAT BE IMPORTANT FOR PURPOSES OF
6 EXAMINING THE CIRCUMSTANCE OF THIS CASE?
7 A. WELL, JUST TO GET AT THE ULTIMATE CAUSE OF DEATH; THAT
8 IS, IF WE COULD SHOW THAT A GIVEN PATIENT HAD A SUFFICIENTLY
9 HIGH DOSE AND THAT THAT DOSE, COUPLED WITH A PREVIOUS DOSE,
10 MAY HAVE CAUSED AN EXAGGERATEDLY HIGH PEAK, THEN WE COULD
11 SAY THAT THERE MIGHT BE A POSSIBILITY THAT THE PEAK OR THE
12 BLOOD LEVEL OF THE DRUG COULD HAVE, IN FACT, CAUSED THE
13 RESPIRATORY DEPRESSION.
14 Q. WOULD THERE BE A CORRESPONDENCE BETWEEN A PEAK AND THE
15 TIME OF DEATH?
16 A. THERE SHOULD BE, IF IT WAS THE CAUSE OF DEATH.
17 Q. AND WHY DO YOU SAY THAT?
18 A. BECAUSE WE KNOW THAT MAXIMUM RESPIRATORY DEPRESSION
19 OCCURS AT A PEAK.
20 Q. NOW, CONCERNING THE SPECIFIC CASES THAT YOU REVIEWED IN
21 THIS PARTICULAR MATTER, STARTING WITH ELLEN ANDERSON, DO YOU
22 HAVE AN OPINION BASED UPON YOUR PHARMACOLOGICAL ANALYSIS AS
23 TO WHETHER OR NOT MORPHINE CAUSED HER DEATH?
24 A. YES, I DO.
25 Q. AND WHAT IS YOUR OPINION?
3537
1 A. MY OPINION IS IT COULD NOT HAVE CAUSED THE DEATH.
2 Q. AND COULD YOU EXPLAIN TO US WHY YOU SAY THAT?
3 A. THE TIME OF DEATH OF THIS INDIVIDUAL WAS FIVE AND A HALF
4 HOURS AFTER THE LAST DOSE OF MORPHINE SULFATE. WE KNOW THAT
5 MORPHINE SULFATE IS GOING TO PEAK IN ACTUALLY A LITTLE LESS
6 THAN AN HOUR AND IT'S GOING TO TROUGH WELL IN ADVANCE OF THE
7 TIME OF DEATH. SO I CANNOT -- I DON'T THINK IT'S REASONABLE
8 TO ASSUME THAT THERE WAS AN ASSOCIATION BETWEEN THE TWO.
9 Q. NOW, WERE THERE ANY OTHER MEDICATIONS YOU HAD TO ANALYZE
10 IN TERMS OF YOUR STUDY OF ELLEN ANDERSON?
11 A. NO. SHE HAD NO OTHER MEDICATIONS THAT WERE GIVEN TO HER
12 WHILE SHE WAS IN THE FACILITY.
13 Q. AND DID THAT ASSIST YOU IN TERMS OF YOUR ANALYSIS?
14 A. WELL, IT MADE IT MUCH SIMPLER.
15 Q. AND WHY IS THAT?
16 A. WE ONLY HAD TWO DOSES OF MORPHINE SULFATE THAT WERE
17 GIVEN, THOSE TWO DOSES WERE GIVEN SUFFICIENTLY FAR APART TO
18 WHERE THERE WAS NO ACCUMULATIONS; THAT IS, THE SECOND DOSE
19 DID NOT SUPERIMPOSE A PEAK ON TOP OF THE PREVIOUS DOSE.
20 THAT THEY WERE DOSED FAR APART. AND THEN THE TIME OF DEATH
21 WAS FIVE AND A HALF HOURS AFTER THE SECOND DOSE. SO WE'RE
22 ONLY TALKING ABOUT TWO DOSES SPACED FAR APART. ONLY
23 10 MILLIGRAMS, VERY MODEST DOSE, AND A LONG TIME BETWEEN THE
24 LAST DOSE AND THE TIME OF DEATH.
25 Q. CAN YOU DEMONSTRATE YOUR TESTIMONY ON THE PAD AGAIN AND
3538
1 WOULD THAT ASSIST IN TERMS OF ILLUSTRATING WHAT YOU FOUND
2 CONCERNING ELLEN ANDERSON? YOU NEED TO ANSWER THAT QUESTION
3 BEFORE I GIVE YOU A MARKER.
4 A. YES.
5 Q. GO AHEAD, DOCTOR, IF YOU WOULD.
6 A. I CAN'T REMEMBER EXACTLY. I THINK THAT THE FIRST DOSE
7 WAS GIVEN AT --
8 Q. 7:30.
9 A. 7:30. OKAY. AND THE SECOND DOSE WAS GIVEN --
10 Q. 3:30?
11 A. 3:30. OKAY. 7:30 TO 3:30, WE'RE TALKING ABOUT SEVERAL
12 HOURS SO THAT THERE WOULD NOT BE ANY -- IF WE DOSED EARLIER
13 SAY AT TWO HOURS AFTER THE FIRST DOSE, YOU CAN SEE WHERE --
14 Q. WHY DON'T DO YOU THIS, DOCTOR, IF YOU WOULDN'T MIND.
15 WHY DON'T YOU GET A NEW PIECE OF PAPER AND IF YOU COULD JUST
16 ILLUSTRATE THE GRAPH OF ELLEN ANDERSON, THAT WOULD BE
17 HELPFUL.
18 A. FIRST, I'LL SHOW YOU WHY -- HOW IT COULD HAVE BEEN
19 COMPLICATED IF WE WOULD HAVE GIVEN ANOTHER DOSE HERE.
20 MS. BARLOW: YOUR HONOR, I OBJECT TO THE
21 HYPOTHETICAL ABOUT HOW IT COULD HAVE BEEN COMPLICATED.
22 THE COURT: SUSTAINED.
23 THE WITNESS: OKAY. WITH ELLEN, WE HAVE TWO
24 DISTINCT PEAKS AND TWO DISTINCT TROUGHS. SHE EXPIRES OVER
25 HERE. HAD MY ANSWER BEEN DIFFERENT TO MR. STIRBA'S
3539
1 QUESTION; THAT IS, IF I THOUGHT THAT MORPHINE SULFATE WOULD
2 HAVE BEEN DIRECTLY RELATED TO HER DEMISE, I WOULD HAVE
3 EXPECTED THE TIME OF DEATH TO BE HERE OR HERE.
4 Q. (BY MR. STIRBA) NOW, DOES THE ACTUAL DOSING INTERVAL
5 TIME-WISE IN HER CASE, IS THAT SIGNIFICANT FOR PURPOSES OF
6 YOUR ANALYSIS AS TO CAUSATION?
7 A. YES, IT IS.
8 Q. AND WOULD YOU EXPLAIN TO US WHY THAT IS?
9 A. THE REASON THE SPREAD OF THE DOSE IS PARTICULARLY
10 IMPORTANT IN THIS CASE IS THAT THE FIRST DOSE HAS NOTHING TO
11 DO WITH THE SECOND DOSE; THAT IS, THE FIRST DOSE IS OUT OF
12 HER SYSTEM. THERE ARE PROBABLY TRACE AMOUNTS OF MORPHINE AT
13 THE TIME OF THE SECOND DOSE, BUT SUFFICIENT TIME HAS GONE BY
14 TO WHERE WE'RE TALKING ABOUT A VERY LOW LEVEL OF MORPHINE IN
15 HER SYSTEM WHEN THE SECOND DOSE IS GIVEN. SO THE FIRST DOSE
16 DOES NOT SUPERIMPOSE ANY EXAGGERATED PEAK ON TOP OF THE
17 SECOND DOSE.
18 Q. IS THERE ANY ADDITIVE EFFECT, THEN, IN YOUR OPINION IN
19 THE DOSING CIRCUMSTANCES OF MS. ANDERSON?
20 A. ONE MORE TIME, PLEASE.
21 Q. SURE.
22 IS THERE ANY ADDITIVE EFFECT IN TERMS OF YOUR
23 UNDERSTANDING OF THE DOSING CIRCUMSTANCES OF ELLEN ANDERSON?
24 A. NONE WHATSOEVER.
25 Q. CAN YOU -- BY THIS PARTICULAR GRAPH, IS THIS SOMETHING
3540
1 MAYBE YOU CAN PUT IN TIME JUST SO WE CAN ORIENT OURSELVES TO
2 THE PARTICULAR GRAPH THAT YOU'VE DRAWN?
3 A. OKAY. THE FIRST DOSE WAS GIVEN YOU SAY AT 7:30.
4 Q. YES.
5 A. SO THE PEAK HERE WOULD HAVE BEEN APPROXIMATELY 8:30 AND
6 HALF THE DOSE, 10:30, 12:30, WE'RE TALKING ABOUT THREE
7 QUARTERS OF THE DOSE BEING ELIMINATED.
8 Q. DISSIPATED FROM THE SYSTEM?
9 A. YES.
10 Q. THAT'S A LIVER PROCESS?
11 A. LIVER TAKES IT, CHANGES IT AND IS EXCRETED OUT IN THE
12 URINE. THE TIME OF THE SECOND DOSE?
13 Q. 3:30.
14 A. OKAY. SO WE HAVE THREE HOURS FROM THE TIME OF THREE
15 QUARTERS OF THE DRUG BEING ELIMINATED TO THE TIME OF THIS
16 DOSE. SO AT 4:30 WE WOULD SEE A SECOND PEAK. AT 6:30 HALF
17 THE DRUG IS ELIMINATED AND BY 8:30 THREE QUARTERS OF IT IS
18 ELIMINATED. AND WHAT WAS TIME OF DEATH?
19 Q. 8:55.
20 A. OKAY. SO AT 8:55 I WOULD SAY PROBABLY 80 PERCENT OF THE
21 DRUG IS OUT OF THE SYSTEM.
22 Q. AND IN TERMS OF A RESPIRATION DEPRESSION, HOW WOULD YOU
23 CHARACTERIZE THE IMPACT OF THE DRUG AT 8:30 A.M. ON THE 30TH
24 OF DECEMBER?
25 A. PRACTICALLY NONEXISTENT. STUDIES HAVE SHOWN THAT AFTER
3541
1 PEAK WE DON'T GET RESPIRATORY DEPRESSION.
2 Q. HOW WOULD YOU CHARACTERIZE THE RESPIRATORY DEPRESSION
3 EFFECT AS OF 1 O'CLOCK A.M. ON THE 30TH OF DECEMBER?
4 A. 1 O'CLOCK?
5 Q. YES.
6 A. NONEXISTENT.
7 Q. WHY DO YOU SAY THAT?
8 A. BECAUSE THE FIRST DOSE IS OUT OF THE SYSTEM AND THE
9 SECOND DOSE HAS NOT BEEN GIVEN YET.
10 MR. STIRBA: ALL RIGHT. THANK YOU, DOCTOR. YOU
11 MAY RESUME THE WITNESS STAND.
12 THE COURT: I ASSUME YOU HAVE SOME MORE QUESTIONS
13 FOR THIS WITNESS?
14 LADIES AND GENTLEMEN, IT IS NOON. WE'LL TAKE OUR BREAK
15 TO 1:30 TODAY. DURING THIS TIME IT'S YOUR DUTY NOT TO
16 CONVERSE AMONG YOURSELVES OR TO CONVERSE WITH OR OUR ALLOW
17 YOURSELVES TO BE ADDRESSED BY ANY OTHER PERSON ON ANY
18 SUBJECT OF THE TRIAL. IT'S YOUR DUTY NOT TO FORM OR EXPRESS
19 AN OPINION UNTIL THE CASE IS FINALLY SUBMITTED TO YOU.
20 REMEMBER NOT TO LISTEN TO ANY RADIO, TELEVISION OR NEWSPAPER
21 REPORTS ABOUT THE TRIAL. AND WE'LL SEE YOU BACK AT 1:30.
22 I THINK WHAT THE SITUATION IS, IS THAT WE HAVE THIS
23 WITNESS AND ONE MORE AND COUNSEL HAS TOLD ME THAT THEY
24 THOUGHT ALL THESE COULD BE DONE BEFORE 4:30. SO WE WON'T GO
25 PAST 4:30 TODAY? WE'LL SEE YOU BACK AT 1:30.
3542
1 (WHEREUPON, THE JURY LEAVES THE COURTROOM)
2 (WHEREUPON, MORNING SESSION ENDS.)
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
3543
1 (WHEREUPON, THE AFTERNOON SESSION BEGINS.)
2 THE COURT: OKAY. PLEASE BE SEATED. THE RECORD
3 WILL REFLECT THAT IT IS 1:30 AND EVERYONE IS RIGHT ON TIME.
4 MR. STIRBA, I BELIEVE YOU ARE --
5 MR. STIRBA: YES, YOUR HONOR.
6 THE COURT: -- EXAMINING THIS WITNESS.
7 MR. STIRBA: THANK YOU.
8 DIRECT EXAMINATION, CONT'D
9 BY MR. STIRBA:
10 Q. DOCTOR, I WOULD LIKE TO DIRECT YOUR ATTENTION TO THE
11 STUDY AND ANALYSIS DONE WITH MR. ENNIS ALLDREDGE, THE
12 PATIENT ENNIS ALLDREDGE. DO YOU REMEMBER HIS SITUATION?
13 A. YES, I DO.
14 Q. AND WOULD YOU TELL US PLEASE WHAT YOU RECALL ABOUT HIS
15 CIRCUMSTANCE AND WHAT YOU DID WITH RESPECT TO YOUR ANALYSIS
16 CONCERNING HIM?
17 A. WELL, I DID THE SAME THING AS I DID FOR ELLEN ANDERSON;
18 THAT IS, PLOT THE MORPHINE DOSES, AND THEN I ALSO LOOKED AT
19 HIS OTHER MEDICATIONS THAT COULD HAVE BEEN CONSIDERED
20 CENTRAL NERVOUS SYSTEM DEPRESSANTS.
21 Q. AND CONSIDERING HIS OTHER MEDICATIONS, DID YOU ATTEMPT
22 TO CALCULATE ANY KIND OF ADDITIVE EFFECT OF THESE OTHER
23 MEDICATIONS?
24 A. THE ONLY DRUG THAT WOULD HAVE STILL BEEN IN THE SYSTEM
25 WAS THE DRUG ATIVAN, WHICH IS A BENZODIAZEPINE. THIS
3544
1 PARTICULAR MEDICATION IS USED WIDELY. IT'S RECOMMENDED BY
2 THE WORLD HEALTH ORGANIZATION TO BE USED AS WHAT IS CALLED
3 AN ANALGESIC ANXIOLYTIC. WAS THAT IS, IT'S A DRUG THAT IS
4 USED IN ADDITION TO AN ANALGESIC IN ORDER ENHANCE THE
5 ACTIVITY OF THE ANALGESIC. THIS PARTICULAR DRUG IS
6 EFFECTIVE ESPECIALLY IN TERMINAL CARE IN THAT IT DOES NOT
7 DEPRESS THE RESPIRATORY SYSTEM WHILE IT IS A C.N.S.
8 DEPRESSANT.
9 Q. GIVEN WHAT YOU STUDIED AND YOUR VALUATION WITH RESPECT
10 TO MR. ALLDREDGE, DO YOU HAVE AN OPINION THAT AT THE TIME OF
11 HIS CAUSE OF DEATH, IT WAS INDUCED AS A RESULT OF MORPHINE
12 RESPIRATION DEPRESSANT?
13 A. I DO HAVE AN OPINION.
14 Q. AND WHAT IS YOUR OPINION?
15 A. THAT THEY'RE NOT RELATED.
16 Q. AND WHY DO YOU SAY THAT?
17 A. I LOOKED AT THE PEAKS AND THE TROUGHS AND THE LACK OF AN
18 ADDITIVE EFFECT SECONDARY TO THE CO-ANALGESIC GIVEN. I ALSO
19 LOOKED AT THE ABSOLUTE DOSE THAT WAS GIVEN IN EACH CASE.
20 AND LOOKED AT THE DOSE OF THE ATIVAN, WHICH WAS EXTREMELY
21 LOW, AND I CONCLUDED THAT THE DRUGS DID NOT CONTRIBUTE TO
22 THE RESPIRATORY DEPRESSION.
23 Q. I NOW WANNA DIRECT YOUR ATTENTION TO PATIENT JUDITH
24 LARSEN. AND DO YOU REMEMBER DOING A SIMILAR ANALYSIS WITH
25 RESPECT TO HER?
3545
1 A. YES, I DO.
2 Q. AND WAS HER SITUATION MATERIALLY DIFFERENT THAN THE
3 OTHER TWO YOU'VE TESTIFIED ABOUT?
4 A. NO, NO DIFFERENCE.
5 Q. AND DID YOU ATTEMPT TO CALCULATE AN ADDITIVE FACTOR WITH
6 RESPECT TO HER?
7 A. YES, I DID.
8 Q. WOULD YOU PLEASE EXPLAIN YOUR CALCULATIONS WITH RESPECT
9 TO THAT PATIENT?
10 A. WELL, THERE WERE OTHER DRUGS THAT WERE PRESCRIBED, BUT
11 NO OTHER DRUGS WERE GIVEN FOR THE ENTIRE DAY PRIOR TO HER
12 EXPIRATION. AND AS A MATTER OF FACT, I BELIEVE THAT THERE
13 WERE NO OTHER DRUGS THAT WERE GIVEN OR NO OTHER DRUGS THAT
14 ARE ACCEPTED OUTSIDE OF THE MORPHINE SULFATE FOR
15 APPROXIMATELY 48 HOURS PRIOR TO DEATH.
16 Q. DO YOU HAVE AN OPINION BASED UPON THE STUDY THAT YOU
17 CONDUCTED WHETHER OR NOT HER DEATH WAS A RESULT OF
18 MORPHINE-RELATED RESPIRATORY DEPRESSION?
19 A. IN MY OPINION, IT IS NOT.
20 Q. AND TELL US PLEASE WHY YOU SAY THAT.
21 A. THERE IS NO ADDITIVE EFFECT SECONDARY TO THE PATIENT NOT
22 ACCEPTING ANY MEDICATIONS PRIOR TO THE DAY OF HER DEATH.
23 AND THAT THE DOSES OF THE MORPHINE THAT WERE GIVEN DID NOT
24 ACCUMULATE. SO I DID NOT SEE ANY RELATIONSHIP.
25 Q. WAS THERE A RELATIONSHIP TO ANY PEAKS IN TERMS OF THE
3546
1 TIMING OF HER DEATH?
2 A. WELL, SHE DIED APPROXIMATELY AN HOUR AND 40 MINUTES
3 AFTER THE LAST DOSE. SO NO, IT WOULD HAVE BEEN CLOSER TO A
4 TROUGH THAN A PEAK.
5 Q. YOU ALSO DID A SIMILAR STUDY WITH RESPECT TO LYDIA,
6 PATIENT LYDIA SMITH. DO YOU RECALL THE CIRCUMSTANCES OF
7 THAT STUDY?
8 A. YES, I DO.
9 Q. AND WOULD YOU PLEASE TELL US WHAT YOU FOUND WITH RESPECT
10 TO HER?
11 A. WELL, HERS WAS A SPECIAL CASE IN THAT THE DOSE OF THE
12 MORPHINE WAS SO LOW AS TO BE NOT COMPARABLE TO THE OTHERS.
13 MOST OF HER DOSING WAS AT THE 5 MILLIGRAM. ONLY THE LAST
14 TWO DOSES WERE GIVEN AT THE 10-MILLIGRAM LEVEL.
15 Q. DO WE HAVE A COMPLICATING FACTOR IN THAT YOU HAD TO
16 CONSIDER ANY OTHER ADDITIVE COMPONENTS OF HER MEDICATIONS?
17 A. NOT SIGNIFICANT.
18 Q. AND WHEN YOU SAY NOT SIGNIFICANT, WOULD YOU TELL US WHAT
19 YOU MEAN?
20 A. IN THE CASE OF LYDIA, SHE WAS GIVEN RISPERDAL I BELIEVE
21 AT 8 O'CLOCK IN THE MORNING. SHE WAS GIVEN DEPAKENE AT 8
22 O'CLOCK IN THE MORNING. SHE EXPIRED LATE THAT NIGHT. WHILE
23 THOSE DO HAVE LONGER HALF LIVES THAN MORPHINE, THEY WERE
24 CERTAINLY PLUNGING TOWARD TROUGH BY THE TIME OF DEATH.
25 THERE WERE OTHER SCHEDULED MEDICATIONS THAT WERE
3547
1 SUPPOSED TO BE GIVEN THAT DAY. AS A MATTER OF FACT, THEY
2 WERE SUPPOSED TO BE RE-DOSED, THE RISPERDAL AND THE
3 DEPAKENE, ABOUT MIDDAY, BUT THOSE WERE NOT GIVEN.
4 Q. DO YOU HAVE AN OPINION AFTER YOU'VE REVIEWED YOUR
5 FINDINGS AND CONDUCTED YOUR STUDY AS TO WHETHER OR NOT SHE
6 WOULD HAVE DIED AS A RESULT OF MORPHINE-INDUCED RESPIRATORY
7 DEPRESSION?
8 A. MY OPINION IS THAT SHE WOULD NOT.
9 Q. AND WOULD YOU TELL US PLEASE WHY?
10 A. FOR THE SAME REASONS AS BEFORE. THE DOSES WERE
11 EXTREMELY LOW. THE ADDITIVE EFFECT WAS NOT THERE. AND THE
12 ANALGESICS THAT WERE GIVEN -- THE NON ANALGESICS THAT WERE
13 GIVEN, WERE LARGELY OUT OF THE SYSTEM BY THE TIME OF DEATH.
14 Q. NOW FINALLY, DID YOU CONDUCT A SIMILAR EVALUATION OF THE
15 CIRCUMSTANCES OF PATIENT MARY CRANE?
16 A. YES, I DID.
17 Q. AND CAN YOU GENERALLY DESCRIBE THE CIRCUMSTANCES YOU
18 FOUND WITH RESPECT TO HER MEDICATIONS AT THE TIME OF HER
19 DEATH?
20 A. MARY CRANE WAS UNIQUE IN THAT BOTH DOSES OF MORPHINE
21 SULFATE GIVEN ON THE DAY OF DEATH WERE GIVEN AT THE
22 5-MILLIGRAM LEVEL, EXTREMELY LOW DOSES. AND MY CONCLUSION
23 IS BASED UPON THOSE LOW DOSES, I DIDN'T SEE ANY RELATIONSHIP
24 TO RESPIRATORY DEPRESSION SECONDARY TO THOSE DOSES.
25 Q. WOULD YOU LIKE TO DO SOME MORE ARTWORK FOR US?
3548
1 A. WHAT WOULD YOU LIKE?
2 Q. PROBABLY NOT. COULD YOU GRAPH THE CIRCUMSTANCE
3 CONCERNING MARY CRANE?
4 A. IF YOU HELP ME WITH THE TIMES.
5 MR. STIRBA: OKAY. YOUR HONOR, MAY HE APPROACH THE
6 PAD AGAIN?
7 THE COURT: YES.
8 Q. (BY MR. STIRBA) FIRST OF ALL, DOCTOR --
9 THE COURT: IF YOU NEED TO GO --
10 Q. (BY MR. STIRBA) -- BEFORE --
11 THE COURT: IF YOU WANT TO GO --
12 Q. (BY MR. STIRBA) -- WOULD YOU WRITE YOUR NAME ON THIS
13 SHEET OF PAPER AND JUST DATE IT FOR US PLEASE?
14 A. WHAT IS THE DATE?
15 Q. AFRAID YOU'D ASK THAT.
16 MR. MAY: 30TH.
17 MR. STIRBA: THANKS, JOHN.
18 Q. NOW, IF YOU COULD DEMONSTRATE GRAPHICALLY WHAT YOUR
19 FINDINGS ARE CONCERNING MARY CRANE PLEASE.
20 A. MARY CRANE. IN MY MIND, THE PATIENTS ARE BEGINNING TO
21 RUN TOGETHER, BUT AM I CORRECT THAT SHE HAD RECEIVED
22 RISPERDAL AND DEPAKENE AT 8 A.M.? LET'S JUST CHECK THAT.
23 Q. RISPERDAL, 8 O'CLOCK.
24 A. OKAY. I THINK I KNOW THE REST.
25 Q. OKAY.
3549
1 A. OKAY. IF THIS IS THE TIME FROM 8 O'CLOCK IN THE MORNING
2 TO MIDNIGHT, MY RECOLLECTION IS THAT SHE RECEIVED A DOSE OF
3 RISPERDAL AND A DOSE OF DEPAKENE AT THAT TIME. BOTH OF
4 THOSE DRUGS WOULD HAVE BEEN ELEVATED TO PEAK WITHIN AN HOUR,
5 CERTAINLY WITHIN AN HOUR AND A HALF. RISPERDAL IS A DRUG
6 THAT HAS A HALF LIFE OF APPROXIMATELY 24 HOURS. SO WE'RE
7 LOOKING AT APPROXIMATELY WHAT, 16 HOURS THERE. SO IT WOULD
8 HAVE BEEN BEYOND, HALF OF THE DRUG WOULD HAVE GONE.
9 DEPAKENE HAS A HALF LIFE OF APPROXIMATELY TEN HOURS, SO
10 AT 2, 4, 6, 8, 10, HALF THE DRUG WOULD HAVE BEEN GONE HERE,
11 SO VERY LITTLE OF IT WOULD HAVE BEEN LEFT BY THE TIME SHE
12 EXPIRED AT -- WAS IT 11:30?
13 Q. 11:35 ON THE EVENING OF JANUARY 7TH.
14 A. OKAY. I BELIEVE THAT SHE GOT A DOSE OF ABOUT 5
15 MILLIGRAMS OF MORPHINE AT TWENTY HUNDRED.
16 Q. 2000 HOURS, THAT'S CORRECT.
17 A. AND AGAIN, WE'RE LOOKING AT APPROXIMATELY ONE HOUR TO
18 PEAK AND TWO HOURS OF HALF LIFE. AND THEN SHE GOT ANOTHER
19 ONE AT 2300?
20 Q. YES.
21 A. 2300 WOULD HAVE BEEN HERE. SO IT WOULD HAVE BEEN
22 SOMETHING LIKE THAT. AND SHE DIED AT 2335?
23 Q. 35.
24 A. OKAY. THAT WOULD HAVE BEEN RIGHT ABOUT HERE AT THE TIME
25 OF DEATH.
3550
1 Q. NOW, IS THERE ANY SIGNIFICANCE TO THE FACT THAT SHE WAS
2 RECEIVING A DURAGESIC FORMULATION AT THE TIME OF HER DEATH?
3 A. CERTAINLY IT WOULD BE SIGNIFICANT, BUT IT WOULD NOT BE
4 SIGNIFICANT WITH RESPECT TO PEAKS AND TROUGHS, AND THE
5 REASON IS, THIS HAS NOTHING TO DO WITH THE DRUG ITSELF
6 BECAUSE THE DRUG ITSELF HAS A VERY SHORT HALF LIFE. BUT
7 IT'S PUT INTO A UNIQUE DOSAGE FORM THAT SLOWLY LEACHES OUT
8 THE MEDICATION OVER A THREE-DAY PERIOD AT A PREDICTABLE
9 RATE, SO THAT WOULD HAVE BEEN -- I BELIEVE THAT WAS PLACED
10 ON AT 8 O'CLOCK IN THE MORNING, SO WE WOULD HAVE SEEN A VERY
11 STEADY THING, NO PEAKS, NO TROUGHS, IDEALLY WITH THAT
12 PARTICULAR MEDICATION FOR A THREE-DAY PERIOD.
13 Q. IS THAT -- WOULD THAT HAVE AN ADDITIVE EFFECT WITH
14 RESPECT TO THE OTHER MEDICATIONS WHICH YOU HAVE IDENTIFIED
15 WERE IN HER SYSTEM AT THE TIME OF HER DEATH?
16 A. IT CERTAINLY COULD HAVE HAD AN ADDITIVE EFFECT WITH THE
17 MORPHINE, BUT AT THE SAME TIME, THE MORPHINE IS GIVEN AFTER
18 THE TWO OTHER C.N.S. DEPRESSANTS HAVE LARGELY DISSIPATED, SO
19 THERE'S SORT OF A LEVELING EFFECT OF THE TWO. THIS DRUG IS
20 LARGELY GIVEN SO THAT WE HAVE CONTINUOUS RELIEF -- RELEASE
21 OF THE MEDICATION SO THAT THE PATIENT WILL BE COMFORTABLE
22 FOR A LONG PERIOD OF TIME. BUT UNFORTUNATELY, PAIN DOESN'T
23 UNDERSTAND THAT, AND WILL HAVE SPIKES AND TROUGHS OF PAIN
24 ITSELF, AND THAT'S WHY MORPHINE IS GIVEN FOR WHAT WE CALL
25 BREAKTHROUGH PAIN.
3551
1 Q. WHAT SIGNIFICANCE IF ANY WOULD THE DURAGESIC FORMULATION
2 HAVE IN TERMS OF RESPIRATORY DEPRESSION GIVEN THE FACT IT
3 HAS NO PEAKS OR TROUGHS?
4 A. WELL, IT WOULD HAVE THE EXACT SAME RESPIRATORY
5 DEPRESSANT EFFECT AT ANY TIME; THAT IS, THERE ARE NO PEAKS
6 OR TROUGHS WITH RESPECT TO THE DURAGESIC.
7 Q. SO BASED UPON YOUR ANALYSIS OF PATIENT MARY CRANE'S
8 SITUATION, DO YOU HAVE AN OPINION AS TO WHETHER OR NOT SHE
9 WOULD HAVE EXPIRED AS A RESULT OF A MORPHINE-INDUCED
10 RESPIRATORY DEPRESSION?
11 A. YES, I HAVE AN OPINION, AND I THINK THAT THEY'RE NOT
12 RELATED.
13 Q. AND WHY DO YOU SAY THAT?
14 A. LARGELY BECAUSE, NUMBER ONE, THE DOSE IS EXTREMELY SMALL
15 IN BOTH CASES, WITH THE MORPHINE SULFATE WE'RE TALKING ABOUT
16 5 MILLIGRAMS GIVEN JUST TWICE.
17 POINT NUMBER TWO, WE'RE SEEING THE TWO OTHER
18 C.N.S. DEPRESSANTS THAT COULD HAVE PLAYED A ROLE LARGELY
19 DISSIPATED BY THE TIME OF DEATH.
20 POINT NUMBER THREE, IF WE WERE GOING TO SEE RESPIRATORY
21 DEPRESSION SECONDARY TO EVEN THIS SMALL DOSE, MOST LIKELY IT
22 WOULD HAVE OCCURRED AT THE PEAK, AND IT DID NOT.
23 Q. AND YOU'RE REFERRING TO THE PEAK AT THE 2000 HOUR.
24 A. THE PEAK AT THE 2000 WOULD HAVE HAD A GREATER IMPACT
25 WHEN ADDED TO THE OTHER TWO C.N.S. DEPRESSANTS THAN THE PEAK
3552
1 AT THE 2300 DOSE.
2 Q. FINE. ONCE AGAIN, I WANT YOU TO GET CREDIT. COULD YOU
3 JUST PUT YOUR NAME ON THERE AND DATE IT?
4 A. (WITNESS COMPLIES.)
5 MR. STIRBA: THANK YOU. THAT'S ALL I HAVE FOR THIS
6 WITNESS, YOUR HONOR.
7 THE COURT: MS. BARLOW.
8 CROSS-EXAMINATION
9 BY MS. BARLOW:
10 Q. GOOD AFTERNOON, DR. SUPERNAW.
11 A. GOOD AFTERNOON.
12 Q. YOU TEACH AT TEXAS TECH, IS THAT CORRECT?
13 A. YES, IT IS.
14 Q. AND DO YOU -- DID YOU KNOW DR. WEITZEL BEFORE YOU WERE
15 CONTACTED TO TESTIFY IN THIS CASE?
16 A. I DID NOT.
17 Q. YOU'RE A DOCTOR OF PHARMACOLOGY.
18 A. PHARMACY.
19 Q. PHARMACY. WHEN YOU TRAIN AS A PHARMACIST, YOU TRAIN TO
20 BE A PHARMACIST, IS THAT CORRECT?
21 A. THAT'S CORRECT.
22 Q. AND THAT'S WHAT THIS DEGREE THAT YOU GOT GOES TOWARDS
23 BECOMING, A PHARMACIST, IS THAT CORRECT?
24 A. THAT'S CORRECT.
25 Q. AND YOU ACTUALLY SERVED AS A PHARMACIST FOR TWO YEARS,
3553
1 AND THEN SINCE THEN YOU HAVE BEEN TEACHING.
2 A. THAT'S CORRECT.
3 Q. YOUR CLINICAL EXPERIENCE YOU INDICATE WAS WHEN YOU WERE
4 AT THE UNIVERSITY OF PACIFIC?
5 A. THAT'S CORRECT.
6 Q. WHEN YOU SAY YOUR CLINICAL EXPERIENCE AS A PHARMACIST,
7 WHAT CLINICAL EXPERIENCE DO YOU HAVE?
8 A. WELL, I WAS SPEAKING SPECIFIC TO PAIN MANAGEMENT RELATED
9 CLINICAL EXPERIENCE. AND MY EXPERIENCE WAS IN A PRIVATE
10 CLINIC FOR PAIN CARE AND THEN LATER I DIRECTED THE
11 UNIVERSITY OF PACIFIC'S CHRONIC PAIN TREATMENT PROGRAM.
12 Q. BUT YOU'RE NOT AN M.D.
13 A. NO, I'M NOT.
14 Q. SO YOU COULDN'T REALLY DIAGNOSE AND ORDER PAIN
15 MEDICATION.
16 A. THAT IS CORRECT.
17 Q. SO HOW DID YOU INTERACT WITH THE M.D.'S? DID YOU ADVISE
18 THEM AS TO WHAT WERE CORRECT DOSAGES, CORRECT MEDICATIONS TO
19 GIVE FOR PAIN?
20 A. WE ADVISED THEM ON HOW THE DRUGS WORKED, HOW THEY WERE
21 ABSORBED, HOW THEY METABOLIZED, HOW THEY WERE DIFFERENT FROM
22 ONE ANOTHER, AND HOW TO BEST USE THEM.
23 Q. DID YOU HAVE A PATIENT CASELOAD YOURSELF TO DO THAT?
24 A. WELL, THE TEAM DID. THE TEAM -- THIS WAS AN
25 INTERDISCIPLINARY TEAM THAT TOOK CARE OF ALL OF THE
3554
1 PATIENTS.
2 Q. SO TO MAKE SURE I UNDERSTAND, AN M.D. WOULD GO IN, YOU
3 KNOW, WOULD COME TO YOU AS PART OF THE TEAM AND SAY WE HAVE
4 THIS PERSON WHO IS MANIFESTING THIS PAIN. AND THEN YOU
5 WOULD ADVISE THEM AS TO WHAT DRUGS WOULD BE BEST FOR THAT?
6 A. WE WOULD ASK THEM WHAT THEY WOULD WANT TO ACCOMPLISH
7 WITH A PARTICULAR PATIENT. WHEN I SAY A TEAM, THERE WAS A
8 PHYSICIAN, USUALLY A PHYSIATRIST OR A NEUROLOGIST. THERE
9 WAS ALSO A SOCIAL WORKER, NURSE, PHYSICAL THERAPIST,
10 PHARMACIST, COUPLE OF OTHERS DEPENDING ON THE NATURE OF THE
11 PARTICULAR CASE.
12 Q. AND YOUR ROLE IN THAT TEAM WOULD BE TO SAY THIS IS WHAT
13 THIS DRUG DOES.
14 A. YES, ESSENTIALLY, UH-HUH.
15 Q. AND WHERE DID YOU GET THAT INFORMATION?
16 A. MY TRAINING, I -- I WENT THE ROUTE OF GETTING MY
17 DOCTORATE RATHER THAN THE FIVE-YEAR BACCALAUREATE DEGREE AS
18 A PHARMACIST BECAUSE I WANTED TO DO SOME EXTRA THINGS, SO MY
19 EDUCATION WAS LARGELY IN -- IN COLLEGE.
20 Q. WHEN YOU'VE TALKED ABOUT HALF LIFE TODAY, WHERE DO YOU
21 GET THAT INFORMATION? ISN'T IT FROM THE P.D.R.?
22 A. WELL, WE HAVE TO UNDERSTAND, THE P.D.R. IS WRITTEN BY
23 THE DRUG MANUFACTURERS THEMSELVES, SO SOMETIMES THE
24 INFORMATION IS RATHER BIASED OR RATHER SLANTED, SO THAT IS
25 NOT MY PRIMARY REFERENCE. BUT I CERTAINLY REFER TO IT.
3555
1 Q. AS DO MOST PHYSICIANS.
2 A. UNFORTUNATELY.
3 Q. YOU'D RATHER THEY REFER TO SOMETHING ELSE, IT SOUNDS
4 LIKE.
5 A. WELL, AS LONG AS THE PHYSICIAN UNDERSTANDS THAT WHAT
6 GOES INTO THE PHYSICIANS' DESK REFERENCE IS INFORMATION THAT
7 IS SUPPLIED TO THE PUBLISHER BY THE DRUG COMPANY ITSELF, SO
8 IT -- IT TENDS TO BE ONE-SIDED, NOT TERRIBLY BALANCED. AND
9 IT'S ON A DRUG-BY-DRUG BASIS RATHER THAN A DISEASE
10 STATE-BY-DISEASE STATE BASIS. ONE PAYS TO GET ONE'S DRUG
11 LISTED IN THE P.D.R.
12 Q. BUT MOST PHYSICIANS USE THE P.D.R.
13 A. YOU'RE ABSOLUTELY CORRECT.
14 Q. YOU NEED A SPECIAL -- MAYBE A DOCTOR IN PHARMACY TO
15 RECOGNIZE THAT P.D.R. MAY NOT BE CORRECT?
16 A. I WOULDN'T CHALLENGE THAT IT'S NOT CORRECT. IT'S JUST
17 THE BALANCE AND IT'S THE SPIN.
18 Q. THEY WANNA SELL THEIR DRUGS.
19 A. SURE THEY DO.
20 Q. WHEN YOU'RE TALKING ABOUT HALF LIFE, YOU'RE TALKING
21 ABOUT THE AMOUNT OF TIME BASICALLY THAT A CERTAIN DRUG OR
22 ITS METABOLITE IS IN THE BLOOD, IS THAT CORRECT?
23 A. WELL, CAN WE SAY CHEMICAL HALF LIFE VERSUS PHYSIOLOGIC
24 HALF LIFE? IF WE'RE TALKING CHEMICAL HALF LIFE, WE'RE
25 TALKING ABOUT THE DRUG ITSELF, HOW LONG IT TAKES TO GET OUT
3556
1 OF THE SYSTEM, HALF OF THE DRUG TO GET OUT OF THE SYSTEM.
2 IF WE'RE TALKING ABOUT --
3 Q. WELL, LET'S STOP WITH THAT THEN --
4 A. OKAY.
5 Q. -- ISN'T THAT WHAT YOU'VE BEEN TALKING ABOUT IS THE
6 CHEMICAL HALF LIFE?
7 A. ACTUALLY, I WAS TALKING ABOUT THE PHYSIOLOGIC HALF LIFE.
8 Q. PHYSIOLOGIC HALF LIFE IS HOW LONG THE EFFECT --
9 A. HOW LONG --
10 Q. -- IS IN THE BODY.
11 A. -- THE PRIMARY DRUG PLUS THE ACTIVE METABOLITE.
12 Q. AND THE EFFECT ON, SAY, THE BRAIN OR THE LIVER OR
13 WHATEVER ORGAN.
14 A. THAT'S CORRECT.
15 Q. SO WHEN YOU'RE TALKING HALF LIFE, YOU'RE NOT TALKING
16 ABOUT HOW LONG IT'S IN THE BLOODSTREAM?
17 A. YES, WE ARE.
18 Q. WELL, ON DIRECT, WHEN YOU'RE TALKING ABOUT HALF LIFE OF
19 TWO TO FOUR HOURS, WAS THAT HOW LONG IT'S IN THE
20 BLOODSTREAM?
21 A. THAT'S HOW LONG -- IT'S NOT THE DRUG ITSELF. IT'S HOW
22 LONG THE DRUG WILL MAINTAIN ITS LEVEL DOWN TO ONE-HALF OF
23 WHAT IS ORIGINALLY PUT INTO THE SYSTEM.
24 Q. IN THE BLOODSTREAM?
25 A. THAT IS ONE INDICATOR. IT'S -- IT'S LARGELY IN THE
3557
1 SYSTEM, THOUGH.
2 Q. HAVE YOU BEEN TRAINED IN GERIATRICS AT ALL?
3 A. NO. I HAVE CONSULTED FOR MANY SKILLED NURSING
4 FACILITIES, BUT I HAVE NO FORMAL TRAINING IN GERIATRICS.
5 Q. ARE YOU FAMILIAR WITH THE GERIATRIC DOSING HANDBOOK?
6 A. YES.
7 Q. DO YOU USE IT?
8 A. NO.
9 Q. SO YOU DIDN'T USE IT IN DETERMINING THE HALF LIFE OF ANY
10 OF THESE DRUGS.
11 A. NO. I DID NOT USE ANY HANDBOOK PER SE.
12 Q. IS IT NOT TRUE THAT PHARMACOLOGY IS DIFFERENT IN THE
13 ELDERLY?
14 A. NOT IN AND OF ITSELF. A DRUG HAS A MECHANISM OF ACTION,
15 AND THAT MECHANISM OF ACTION IS THE SAME IRRESPECTIVE OF
16 WHETHER THE PERSON IS OF VARIOUS ETHNIC GROUPS OR THE AGE OF
17 THE INDIVIDUAL.
18 Q. BUT THE DURATION OF THE EFFECT IS AFFECTED BY A PERSON
19 BEING ELDERLY, ISN'T THAT CORRECT?
20 A. NOT JUST SECONDLY TO AGE, NO, THAT'S NOT TRUE.
21 Q. SO IT'S MORE THE FACT THAT MAYBE A LIVER DOESN'T
22 FUNCTION AS WELL?
23 A. THAT'S CORRECT.
24 Q. THAT KIDNEYS DON'T FUNCTION AS WELL?
25 A. THAT'S CORRECT.
3558
1 Q. AND YOU OFTEN SEE THAT IN THE ELDERLY?
2 A. YES.
3 Q. SO YOU DO SEE A LONGER DURATION OF EFFECT USUALLY IN THE
4 ELDERLY?
5 A. WELL, BUT THAT'S TOO MUCH OF A GENERALIZATION. I THINK
6 THAT YOU SEE A LONGER DURATION OF EFFECT IF THE PERSON DOES
7 NOT HAVE AN INTACT LIVER AND/OR IF THE PERSON DOES NOT HAVE
8 COMPLETE KIDNEY FUNCTION.
9 Q. SO IN AN ELDERLY PERSON WHERE YOU HAVE A LIVER THAT'S
10 NOT FUNCTIONING AS WELL, KIDNEYS NOT FUNCTIONING AS WELL,
11 THE HALF LIFE OF THESE DRUGS, HOW LONG THEY'RE IN THE
12 SYSTEM, WOULD BE LONGER, IS THAT NOT CORRECT?
13 A. THAT'S CORRECT.
14 Q. DID YOU LOOK AT ANY OF THESE PATIENTS TO LOOK AT THEIR
15 LIVER OR KIDNEY --
16 A. YES, I DID.
17 Q. -- FUNCTIONS? AND YOU FACTORED THAT INTO WHAT YOU WERE
18 DOING.
19 A. THERE WAS NOTHING NOTED.
20 Q. AND YOU BEING -- YOU NOT BEING A DOCTOR CLEARLY DIDN'T
21 DIAGNOSIS THESE PEOPLE FOR --
22 A. NO, I WAS LOOKING --
23 Q. -- CLINIC ASSESSMENT.
24 A. I WAS LOOKING FOR THE LAB VALUES.
25 Q. IT'S BEEN A LONG LUNCH, I HAVE TO GO BACK OVER MY NOTES
3559
1 HERE. AND I BELIEVE YOU TESTIFIED AS TO ADDITIVE CENTRAL
2 NERVOUS SYSTEM EFFECT OF THE OTHER PSYCHOTROPIC DRUGS,
3 LEAVING ASIDE THE MORPHINE, IS THAT CORRECT?
4 A. YES.
5 Q. AND CAN YOU SAY CATEGORICALLY THAT THEY HAD NO ADDITIVE
6 EFFECT IN THESE CASES?
7 A. NO. CENTRAL NERVOUS SYSTEM DRUGS THAT DO DEPRESS THE
8 CENTRAL NERVOUS SYSTEM WOULD HAVE ADDITIVE EFFECTS. IT'S
9 THE LEVEL OF SIGNIFICANCE THAT I QUESTIONED.
10 Q. NOT BEING A MEDICAL DOCTOR OR A PHYSICIAN, YOU CANNOT
11 GIVE AN OPINION AS TO WHAT -- WHAT EFFECT THESE PSYCHOTROPIC
12 DRUGS OR MORPHINE HAD ON ANY PREVIOUS MEDICAL CONDITION OF
13 ANY OF THESE INDIVIDUALS, IS THAT CORRECT?
14 A. THAT'S CORRECT.
15 Q. YOU'RE JUST TALKING JUST, YOU KNOW, ON AVERAGE, THIS IS
16 WHAT HAPPENS WITH THE AVERAGE PERSON.
17 A. YES.
18 Q. YOU MADE THE STATEMENT THAT THE DRUG ATIVAN IS A CENTRAL
19 NERVOUS SYSTEM -- HAS A CENTRAL NERVOUS SYSTEM EFFECT, BUT
20 NOT RESPIRATORY DEPRESSION, IS THAT CORRECT?
21 A. YES, THAT'S CORRECT.
22 Q. AND WHAT IS THAT EFFECT?
23 A. I'M SORRY?
24 Q. WHAT CENTRAL NERVOUS SYSTEM EFFECT DOES IT HAVE IF IT'S
25 NOT DEPRESSION?
3560
1 A. WELL, CENTRAL NERVOUS SYSTEM DEPRESSION IS SORT OF A
2 GLOBAL TERM, MEANING THAT IT DEPRESS THE ELECTRICAL
3 EXCITABILITY OF THE CENTRAL NERVOUS SYSTEM. BUT I USE THIS
4 PROBABLY POOR ANALOGY OF THE SMOKE ALARM, WHAT -- IT DOES
5 NOT INCREASE THE -- OR DECREASE THE SENSITIVITY OF THAT
6 CARBON DIOXIDE ALARM AS OTHER CENTRAL NERVOUS SYSTEM
7 DEPRESSANTS MIGHT.
8 Q. SO HAVING ATIVAN ON BOARD PROBABLY WOULDN'T AFFECT A
9 RESPIRATION RATE, IS THAT -- AM I UNDERSTANDING THAT
10 CORRECTLY?
11 A. THAT'S CORRECT. IT DOES NOT AFFECT THE SENSITIVITY OF
12 THE ALARM THAT TELL US TO BREATHE AGAIN AS DOES MORPHINE OR
13 AS DOES OTHER -- AS DO OTHER C.N.S. DEPRESSANTS.
14 Q. SUCH AS HALDOL, RISPERDAL?
15 A. CORRECT.
16 Q. YOU'VE USED SOME CHARTS HERE THAT I THINK IS THE EASIEST
17 TO LOOK UP DRUGS FOR THE SYSTEM OF THESE PATIENTS. THIS ONE
18 IS STATE'S EXHIBIT -- OR MARKED STATE'S EXHIBIT 38. IT'S
19 FOR JUDITH LARSEN. IT APPEARS THAT THERE HAD BEEN SEVERAL
20 DRUGS UP TO THE 22ND OF DECEMBER. DOES THAT COMPORT WITH
21 YOUR RECOLLECTION OF THE RECORDS?
22 A. YES. I -- I MUST BE RIGHT UP FRONT WITH YOU. I DID NOT
23 GO BACK SEVERAL WEEKS. I WENT BACK JUST SEVERAL DAYS PRIOR
24 TO DEATH.
25 Q. OH, OKAY. SO WE'RE LOOKING AT -- SHE DIED ON THE 3RD.
3561
1 DID YOU GO BACK TO JUST WHEN THE MORPHINE WAS STARTED?
2 A. NO. I WENT BACK AT LEAST 48 HOURS IN EACH CASE.
3 Q. WELL, THAT WOULD BE -- 48 HOURS WOULD BE BACK TO THE 1ST
4 OF JANUARY. AND I'LL INDICATE TO YOU THAT THE FACT THAT
5 THESE ARE JUST CIRCLED MEANS THAT IT WAS ORDERED, BUT NOT
6 GIVEN.
7 A. OKAY.
8 Q. SO, YOU KNOW, WE -- WE AGREE WITH YOU THAT IN THE LAST
9 ONE, TWO, THREE, FOUR, FIVE DAYS OF HER LIFE, MORPHINE WAS
10 ALL SHE WAS GIVEN. BUT YOU DIDN'T GO BACK AND LOOK HERE AND
11 SEE WHAT EFFECT IF ANY THESE DRUGS THAT WERE GIVEN FROM THE
12 6TH OF DECEMBER ON HAD ON HER PHYSICAL CONDITION, DID YOU?
13 A. ON HER PHYSICAL CONDITION? NO. I WAS LOOKING AT
14 RESPIRATORY DEPRESSION, AND CLEARLY, THOSE WOULD HAVE BEEN
15 COMPLETELY CLEARED BY THE TIME OF DEATH.
16 Q. AS FAR AS --
17 A. BY CLEAR --
18 Q. -- RESPIRATORY --
19 A. -- BY CLEAR, I MEAN THEY WOULD HAVE BEEN OUT OF HER
20 SYSTEM BY THE TIME, YOU KNOW --
21 Q. RIGHT. SO ANY RESPIRATORY DEPRESSION AFFECTING THE PATH
22 WOULD HAVE BEEN BACK HERE, AND YOU DIDN'T LOOK BACK --
23 A. NO.
24 Q. -- TO THOSE DATES.
25 A. I DID NOT.
3562
1 Q. NOW, ON THE LAST DAY OF HER LIFE, SHE RECEIVED LOOKS
2 LIKE 140 MILLIGRAMS OF MORPHINE. AND THIS DOESN'T HAVE THE
3 DOSAGE OF TIMES, BUT LET'S PULL OUT HER BINDER AND LOOK AT
4 THAT. IN FACT, I CAN PROBABLY LOOK AT THE PHYSICIANS'
5 ORDERS HERE. APPEARS THAT ON THE 31ST OF DECEMBER, THERE
6 WAS AN ORDER OF 5 MILLIGRAMS OF MORPHINE EVERY FOUR HOURS
7 AROUND-THE-CLOCK. AND IT WAS CHANGED ON THE 1ST OF JANUARY
8 TO 5 MILLIGRAMS EVERY THREE HOURS AROUND-THE-CLOCK. THE
9 FACT THAT IT WAS ORDERED EVERY THREE HOURS AROUND-THE-CLOCK,
10 WOULD THAT -- WELL, GIVEN THE HALF LIFE IS TWO TO FOUR HOURS
11 FOR MORPHINE, IS THAT CORRECT?
12 A. TWO HOURS IS WHAT I USE.
13 Q. TWO HOURS --
14 A. WE'RE TALKING ABOUT INTRAMUSCULAR MORPHINE. WE'RE NOT
15 TALKING ABOUT ORAL MORPHINE, YES.
16 Q. RIGHT, RIGHT.
17 A. TWO HOURS.
18 Q. AND JUDITH LARSEN WAS 93 YEARS OLD, IS THAT CORRECT?
19 YOU'LL TAKE MY WORD FOR IT?
20 A. I WILL. YES, I WILL.
21 Q. AND DURING THE LAST FEW DAYS OF HER LIFE, I BELIEVE THAT
22 URINE OUTPUT WAS MINIMAL. WOULD THAT TELL YOU ANYTHING
23 ABOUT HER CONDITION OF HER KIDNEYS?
24 A. NOT NECESSARILY.
25 Q. BUT YOU DON'T, AS YOU SIT HERE, HAVE ANY KNOWLEDGE AS TO
3563
1 WHETHER HER LIVER AND/OR KIDNEYS WERE FUNCTIONING TO WASH
2 OUT THE MORPHINE, IS THAT CORRECT?
3 A. NO. I FOUND NO DATA IN THE RECORDS THAT WOULD TELL ME
4 THAT INFORMATION.
5 Q. OKAY. SO IF SHE'S GETTING, SAY, 5 MILLIGRAMS EVERY
6 THREE HOURS, ASSUMING THAT YOU'RE CORRECT THAT SHE'S -- THAT
7 HALF LIFE'S ONLY TWO HOURS FOR HER, HALF OF IT'S GONE, MORE
8 THAN HALF OF IT'S GONE BY THE TIME SHE GETS THE NEXT SHOT,
9 IS THAT RIGHT?
10 A. THAT'S CORRECT.
11 Q. THERE STILL IS PLENTY IN THE SYSTEM.
12 A. YES, THERE IS. YES, THERE IS. THERE'S AN OVERLAP IN
13 THE DOSING, YES.
14 Q. AND IN FACT, AS WE LOOK AT THE LAST COUPLE OF DAYS OF
15 HER LIFE, I BELIEVE SHE PASSED AWAY ON THE 3RD, WE FIND --
16 LET'S SEE, IS THERE -- WHICH BUTTON DO I PUSH?
17 MR. STIRBA: HERE. I'M GETTING BETTER AT THIS
18 MYSELF.
19 MS. BARLOW: OH, THERE IT IS. THANK YOU.
20 Q. THIS GETS NOISY AND ANNOYING, SO WE TURN IT OFF, SO WE
21 HAVE TO WAIT FOR IT TO WARM UP AGAIN. IF YOU WOULD TAKE
22 DOWN JUDITH LARSEN'S BINDER, IT'S ONE OF THOSE GRAY ONES
23 RIGHT THERE NEXT TO YOU. I SAW JOHN DO THAT. HOPEFULLY
24 THAT WORKS.
25 AND IF YOU'D TURN TO MED-507, IT'S UNDER THE TAB CALLED
3564
1 MEDS AND GRAPHS. DO YOU USE THESE SAME KINDS OF DOCUMENTS
2 IN YOUR WORK.
3 A. THESE?
4 Q. YES.
5 A. YES, VERY SIMILAR.
6 Q. SO I FORTUNATELY DON'T HAVE TO EXPLAIN IT ALL TO YOU.
7 A. NO, YOU DON'T.
8 Q. WE HAVE ON THE 1ST OF JANUARY AN ORDER FOR 5 MILLIGRAMS
9 EVERY THREE HOURS AROUND-THE-CLOCK. AND EVIDENTLY, THAT WAS
10 ENTERED AT 1830 ON THE 1ST OF JANUARY. WE HAVE DOSES ON THE
11 2ND OF JANUARY, WE HAVE DOES ON THE 3RD OF JANUARY.
12 WHEN IT'S GIVEN EVERY THREE HOURS LIKE THAT
13 AROUND-THE-CLOCK, DOES IT EVER CLEAR OUT OF THE SYSTEM?
14 A. YOU HOPE NOT. YOU WANT IT --
15 Q. YOU'RE EXPECTING IT NOT TO, RIGHT?
16 A. THAT'S CORRECT, THAT'S CORRECT. YOU WANT --
17 Q. OKAY. YOU --
18 A. -- TO REACH WHAT WE CALL A STEADY STATE.
19 Q. RIGHT. SO MAYBE YOU HAVE WHAT YOU HAD WITH THE
20 DURAGESIC. YOU DON'T REALLY HAVE PEAKS AND TROUGHS, YOU GOT
21 A STEADY STATE.
22 A. INSTEAD OF LOOKING LIKE THE HIMALAYAS, IT LOOKS MORE
23 LIKE THE GREEN MOUNTAINS OF VIRGINIA.
24 Q. WHICH ARE NOT NEARLY AS HIGH AS WHAT WE HAVE OUT HERE.
25 A. BUT VERY ROLLING.
3565
1 Q. SO YOU DON'T HAVE THIS SHARP SPIKY PEAK EFFECT --
2 A. THAT'S CORRECT.
3 Q. -- IF YOU'RE GIVING IT EVERY THREE HOURS.
4 A. AFTER FIVE DOSES, YOU WOULD NO LONGER HAVE THAT, THOSE
5 PEAKS AND --
6 Q. AND IF, YOU KNOW, THIS IS A PERSON WHOSE KIDNEYS AND
7 LIVER WERE NOT FUNCTIONING AS WELL AS, YOU KNOW, A NORMAL
8 HEALTHY YOUNG ADULT, AND PERHAPS THE HALF LIFE INSTEAD OF
9 TWO HOURS WAS THREE HOURS, WHICH IS WITHIN THE REALM OF
10 POSSIBILITY, ISN'T IT?
11 A. YES.
12 Q. OKAY. AND IN FACT, MIGHT BE ON A CONSTANT PEAK, MIGHT
13 THEY NOT, IF THEY'RE GETTING IT EVERY THREE HOURS?
14 A. WELL, ONCE IT'S CONSTANT, IT'S NO LONGER A PEAK. YOU
15 WOULD SAY IT'S AT A STABLE LEVEL.
16 Q. SO INSTEAD OF THE ROLLING HILLS, YOU MIGHT HAVE MORE OF
17 A STRAIGHT LINE IF THE PEAK --
18 A. WELL, THAT -- IDEALLY, YOU WOULD LIKE THE STRAIGHT LINE,
19 BUT YOU STILL HAVE A BIT OF A ROLL.
20 Q. OKAY. BUT THAT DEPRESSANT EFFECT WOULD BE THERE MORE
21 CONSTANTLY GIVEN THE SCENARIO I JUST GAVE YOU, ISN'T THAT
22 CORRECT?
23 A. RIGHT. THERE WOULD BE NO POINTS IN TIME WHERE IF -- IF
24 IT'S GIVEN AROUND-THE-CLOCK EVERY THREE HOURS, AND YOU SAID
25 IF THERE WAS LIVER DAMAGE OR THE KIDNEYS WEREN'T WORKING --
3566
1 Q. OR IF IT JUST TOOK THREE HOURS BECAUSE TWO TO FOUR IS
2 WHAT YOU SAID WAS -- WELL, LET'S --
3 A. YEAH --
4 Q. -- JUST GO --
5 A. -- YEAH --
6 Q. -- WITH THAT. IF THERE WERE LIVER, IF --
7 A. OKAY.
8 Q. -- THERE WERE KIDNEY DAMAGE --
9 A. THEN THERE WOULD NOT BE A POINT IN TIME WHERE IT WAS
10 MORE LIKELY TO CAUSE RESPIRATORY DEPRESSION THAN OTHER
11 TIMES.
12 Q. THE SAME CONSTANT RESPIRATORY DEPRESSION EFFECT WOULD BE
13 THERE AT ALL TIMES.
14 A. YES.
15 Q. THEN IT APPEARS THAT 15 -- WELL, EXCUSE ME, 1700 WAS THE
16 LAST OF 5 MILLIGRAMS, AND THEN WE WENT TO 10 MILLIGRAMS AT
17 1830, WHICH IS WHAT, JUST -- IF THAT WAS AT 1700, AND THEN
18 THE 10 MILLIGRAMS WAS GIVEN AT 1830, THAT'S ONLY AN HOUR AND
19 A HALF LATER, IS THAT NOT CORRECT?
20 A. UH-HUH.
21 Q. NOW, WE'VE HAD THIS AT 1830, WHICH IS THE 10 MILLIGRAMS
22 SCHEDULED AROUND-THE-CLOCK. WE HAVE WHAT'S CALLED A NOW
23 ORDER HERE ON THE -- ON PAGE 509, WHICH WAS APPARENTLY ALSO
24 GIVEN AT 1830 FOR 15 MILLIGRAMS, IS THAT CORRECT?
25 A. IT APPEARS TO BE.
3567
1 Q. SO WE HAVE A TOTAL OF 25 MILLIGRAMS THAT WERE GIVEN AT
2 1830?
3 A. YES. AND THAT AGREES WITH MY RECORDS.
4 Q. AND WHAT KIND OF EFFECT WOULD THAT HAVE ON MRS. LARSEN?
5 A. WHAT I DID -- WITH YOUR PERMISSION, CAN I TALK ABOUT THE
6 CUMULATIVE PEAKS RATHER THAN THE INDIVIDUAL DOSE.
7 Q. OKAY.
8 A. OKAY. WHEN YOU -- WHEN YOU START SQUEEZING THE SPACE
9 BETWEEN THE DOSES TOGETHER, WE GET WHAT WE CALL ACCUMULATED
10 PEAKS RATHER THAN THE INDIVIDUAL DOSING PEAKS.
11 Q. OKAY.
12 A. AND SO IN PROJECTING THOSE, I FOUND THAT THE LARGEST
13 PEAK OCCURRED AT 1100. THE SECOND LARGEST PEAK OCCURRED AT
14 1500. AND THE THIRD LARGEST ACCUMULATIVE PEAK OCCURRED AT
15 1855. I PROJECTED HER DEATH AT 2010, SO YOU'RE PROBABLY
16 WONDERING HOW I CAME UP WITH THE CONCLUSION THAT I GAVE
17 MR. STIRBA. AND THE ANSWER IS, THERE WERE THREE LARGER
18 PEAKS THAT WOULD HAVE CAUSED SIGNIFICANTLY MORE RESPIRATORY
19 DEPRESSION PREVIOUS TO HER DEATH THAN THERE WERE AT -- THAN
20 THERE WAS AT THE TIME OF HER DEATH.
21 Q. AND THESE ARE CUMULATIVE?
22 A. CORRECT.
23 Q. AND YOU BASED THAT ON THE FACT THAT, SAY, ON THE 3RD OF
24 JANUARY ON THIS, ON PAGE 510, WE HAVE TWO MORE NOW ORDERS,
25 ONE OF 25 MILLIGRAMS AT -- LOOKS LIKES TEN HUNDRED HOURS.
3568
1 A. YES.
2 Q. WHEN YOU SAY THE CUMULATIVE EFFECT, YOU FOUND AT TEN
3 HUNDRED HOURS OR 11?
4 A. 1100, BECAUSE ANOTHER DOSE WAS GIVEN AT 1100 OF 30
5 MILLIGRAMS.
6 Q. SO WE'VE GOT 25 AT TEN. 30 AT 11.
7 A. UH-HUH. FIVE AT 1230.
8 Q. BUT YOU SAY THE PEAK DOSE WAS AT 11 WHEN --
9 A. WELL, THE PEAK ACCUMULATIVE DOSE WHAT WAS AT 11. 1100
10 WAS THE GREATEST LEVEL OF THE DRUG IN HER SYSTEM. THE
11 SECOND GREATEST WAS AT 1500 AND THE THIRD GREATEST WAS A
12 1855.
13 Q. AND YOU CAN'T SAY WHAT EFFECT -- BECAUSE YOU'RE NOT A
14 PHYSICIAN -- WHAT EFFECT THAT MIGHT HAVE HAD ON ANY PHYSICAL
15 CONDITION THAT SHE HAD.
16 A. I CANNOT.
17 Q. INDEED, SHE DIED AN HOUR AND 40 MINUTES AFTER THE LAST
18 DOSE, IS THAT CORRECT?
19 A. THAT'S CORRECT.
20 Q. AND THAT'S PRIOR TO WHAT YOU WOULD THINK WOULD BE THE
21 PEAK TIME?
22 A. NO, IT'S SIGNIFICANTLY AFTER.
23 Q. SORRY THEN. I THOUGHT THE PEAK CAME TWO HOURS AFTER.
24 A. OKAY. ARE WE TALKING ABOUT THE PEAK OF THAT PARTICULAR
25 DOSE?
3569
1 Q. RIGHT.
2 A. OKAY. YOU'RE CORRECT FOR THAT DOSE.
3 Q. FOR THAT DOSE.
4 A. UH-HUH.
5 Q. BUT THAT WAS NOT THE HIGHEST CONCENTRATION SHE HAD
6 BECAUSE SHE'D HAD ALL THESE OTHERS EARLIER THAT YOU'RE
7 SAYING WERE ON THE DOWNTURN.
8 A. THAT'S CORRECT.
9 Q. BUT IT IS ONE MORE THAT HAPPENED WITHIN TWO HOURS OF
10 HER --
11 A. IT ACTUALLY NEVER HAPPENED; THAT IS, SHE DIED BEFORE IT
12 REACHED PEAK.
13 I'M SORRY, I'M SORRY. I'M GETTING CONFUSED NOW. NO,
14 SHE HAD HER LAST DOSE AT 1830, IS THAT WHAT YOU HAVE ON YOUR
15 RECORDS?
16 Q. BELIEVE SO, BUT I'LL CHECK FOR SURE.
17 A. AND HER --
18 Q. ACTUALLY, THERE WERE TWO DOSES AT 1830.
19 A. THAT ADDED UP TO 25 MILLIGRAMS, UH-HUH.
20 Q. RIGHT.
21 A. AND SHE DIED AN HOUR AND 40 MINUTES LATER. SO YES, I'M
22 SORRY, IT IS BEYOND THE PEAK OF THAT LAST DOSE. THE PEAK
23 WOULD HAVE OCCURRED AT -- AT APPROXIMATELY 1930, AND SHE
24 EXPIRED AT 2010.
25 Q. SO THE PEAK'S AN HOUR AFTER, NOT TWO HOURS AFTER.
3570
1 A. RIGHT. NOW, YOU'RE CONFUSING PEAK AND HALF LIFE.
2 Q. PEAK IS AN HOUR AFTER, AND YOU'RE SAYING THE HALF LIFE
3 IS TWO HOURS AFTER.
4 A. THAT'S CORRECT.
5 Q. THANK YOU. I'M ON THE SAME PAGE NOW.
6 TALKING ABOUT MARY CRANE, WE HAVE, AS YOU SAY, A UNIQUE
7 OR DIFFERENT CIRCUMSTANCE WITH HER BECAUSE WE HAD THE
8 DURAGESIC PATCH THAT WAS PLACED ON ADMISSION. SO SHE HAS 50
9 MICROGRAMS PER HOUR, WHICH IS PROBABLY A HIGH NORMAL DOSE,
10 ISN'T IT, FOR AN ELDERLY PERSON?
11 A. NOT NECESSARILY. I'VE -- IT COMES IN 25 MICROGRAMS, 50
12 MICROGRAMS, 75 MICROGRAMS, AND 100. AND SOME PATIENTS HAVE
13 MORE THAN ONE PATCH ON.
14 Q. AND IN FACT, SHE HAD TWO AT HER DEATH TOTALLING 75
15 MICROGRAMS, IS THAT NOT CORRECT?
16 A. I DIDN'T KNOW THAT THERE WERE TWO, BUT YES, 75
17 MICROGRAMS IS CORRECT.
18 Q. DO YOU ONLY GO BACK 24 HOURS THEN --
19 A. NO, I HAD TO GO A LITTLE FURTHER BECAUSE THIS PARTICULAR
20 DRUG IS UNIQUE IN THAT IT WILL LEACH OUT THE FENTANYL, WHICH
21 IS THE NARCOTIC THAT IS CONTAINED IN THE DURAGESIC PATCH FOR
22 A THREE-DAY PERIOD.
23 Q. SO YOU WENT BACK WHAT, ONE, TWO, THREE DAYS?
24 A. WELL, I WENT BACK TO FIND OUT WHEN THE LAST TIME IT WAS
25 THAT SHE WAS GIVEN THAT, AND IT WAS THREE DAYS PRIOR TO THAT
3571
1 MORNING. AND THEN SHE WAS GIVEN THE FINAL 75 MILLIGRAMS
2 THAT MORNING AT 8 A.M.
3 Q. RIGHT. SO THREE DAYS BEFORE, YOU WENT BACK TO JANUARY
4 4TH, WHICH IS WHEN IT WAS INCREASED TO 75 MICROGRAMS.
5 A. THAT'S CORRECT.
6 Q. AND YOU'RE SAYING THAT THERE WAS NO SYNERGISTIC EFFECT
7 BETWEEN THE DURAGESIC AND THE MORPHINE?
8 A. OH, THERE CERTAINLY IS.
9 Q. AND WHAT IS THAT SYNERGISTIC EFFECT?
10 A. WELL, THEY'RE BOTH NARCOTIC ANALGESICS, AND SO THEY
11 WOULD HAVE ADDITIVE EFFECT. BUT MY POINT WAS THAT NO MORE
12 SO AT ONE POINT IN TIME THAN ANOTHER BECAUSE THAT PARTICULAR
13 DRUG DOES NOT HAVE PEAKS AND TROUGHS.
14 Q. SO YOU HAVE THE CONSTANT CENTRAL NERVOUS SYSTEM --
15 A. CONSTANT BLOOD LEVEL OF THE DRUG.
16 Q. RIGHT. AND THE CONSTANT CENTRAL NERVOUS SYSTEM
17 DEPRESSANT EFFECT.
18 A. YES.
19 Q. AND TO THAT YOU ADD TRAZODONE, DEPAKENE, RISPERDAL,
20 SERZONE. ARE THEY CENTRAL NERVOUS SYSTEM DEPRESSANT DRUGS?
21 A. THEY ARE. WHAT I LOOKED AT, WELL, FOR EXAMPLE, SERZONE.
22 SERZONE WOULD NOT HAVE BEEN IN THE SYSTEM AT THE TIME OF
23 DEATH. IT HAS A HALF LIFE OF APPROXIMATELY FOUR HOURS, AND
24 IT WAS GIVEN MUCH IN ADVANCE OF HER DEATH.
25 Q. BUT FOR THESE LAST FIVE DAYS -- EXCUSE ME, FOUR DAYS
3572
1 THAT YOU LOOKED AT, SHE DID HAVE THESE CENTRAL NERVOUS
2 SYSTEM DEPRESSANT DRUGS ON BOARD UP UNTIL MAYBE THE VERY
3 LAST DAY.
4 A. YEAH, I'M STARTING TO GET THE PATIENTS CONFUSED NOW, BUT
5 I BELIEVE THAT SHE HAD HER RISPERDAL AND THE DEPAKENE AT 8
6 O'CLOCK IN THE MORNING.
7 Q. ON THE DAY THAT SHE DIED?
8 A. CORRECT. SHE DIED AT 11:30 AT NIGHT, I BELIEVE --
9 Q. BUT I'M -- I'M LOOKING AT THE PREVIOUS THREE DAYS AND
10 ASKING YOU, IS ISN'T TRUE --
11 A. I'M SAYING --
12 Q. -- THAT THERE WILL BE CENTRAL NERVOUS SYSTEM DEPRESSANTS
13 ON THOSE PREVIOUS THREE DAYS?
14 A. ON THE PREVIOUS THREE DAYS? YES. NOT AT THE TIME OF
15 DEATH, BUT YES --
16 Q. I UNDERSTAND --
17 A. -- YOU'RE CORRECT.
18 Q. -- YOU'RE TALKING ABOUT THE PREVIOUS THREE DAYS.
19 A. YES.
20 Q. AND NOT BEING A PHYSICIAN, YOU DON'T KNOW WHAT EFFECT
21 THOSE WOULD HAVE HAD ON HER -- ON ANY PREEXISTING PHYSICAL
22 CONDITION.
23 A. I'M SORRY, I WOULDN'T.
24 MS. BARLOW: MAY I HAVE JUST A MOMENT, YOUR HONOR?
25 THE COURT: YES.
3573
1 Q. (BY MS. BARLOW) AND YOU SAID WITH MARY CRANE, YOU WENT
2 BACK TO THE LAST CHANGE OF THE DURAGESIC PATCH.
3 A. YES.
4 Q. WITH THE OTHERS, DID YOU GO BACK BEYOND 24 OR 48 HOURS
5 TO LOOK AT THE DRUGS --
6 A. NO.
7 Q. -- THAT THEY WERE GETTING?
8 A. ONLY IF THERE WERE DRUGS THAT HAD EXTREMELY LONG HALF
9 LIFES, AND I DIDN'T FIND ANY BEYOND 24 HOURS, THAT WOULD BE
10 THE RISPERDAL HAS A 24-HOUR HALF LIFE.
11 Q. SO YOU'RE NOT GIVING ANY OPINION THEN ABOUT ANY EFFECT
12 PRIOR TO 24 HOURS BEFORE, EXCEPT FOR MARY CRANE, OF THESE
13 DRUGS ON THESE PEOPLE ON THEIR PHYSICAL CONDITION?
14 A. THAT'S -- WELL, PRIOR TO 48 HOURS, THAT'S CORRECT.
15 Q. NOW, YOU HAVE BEEN RETAINED TO BE A WITNESS IN THIS
16 CASE, IS THAT CORRECT?
17 A. THAT'S CORRECT.
18 Q. AND RETAINED BY THE DEFENDANT.
19 A. BY THE ATTORNEY.
20 Q. BY COUNSEL.
21 A. YES, UH-HUH.
22 Q. AND HOW MUCH ARE YOU BEING PAID?
23 A. $200 PER HOUR.
24 Q. DO YOU HAVE ANY IDEA HOW MANY HOURS YOU'VE SPENT ON
25 THIS?
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1 A. NO, I DON'T. I CAN TELL YOU WAITING OUTSIDE, MANY,
2 MANY.
3 Q. HAVE YOU EVER TESTIFIED BEFORE?
4 A. NO, NOT IN A CRIMINAL CASE.
5 Q. YOU MAY NEVER WANT TO DO IT AGAIN, RIGHT? THE WAITING
6 OUTSIDE THAT'S FUN.
7 MS. BARLOW: I THINK THAT'S ALL I HAVE, YOUR HONOR.
8 THE COURT: ANY REDIRECT?
9 MR. STIRBA: YES, YOUR HONOR.
10 REDIRECT EXAMINATION
11 BY MR. STIRBA:
12 Q. DOCTOR, IN TERMS OF PAIN MANAGEMENT IS IT -- IS IT
13 SIGNIFICANT THAT YOU HAVE AN OVERLAPPING OF DOSES?
14 A. IT'S DESIRABLE.
15 Q. AND WOULD YOU EXPLAIN THAT FOR US PLEASE?
16 A. IF WE DON'T HAVE AN OVERLAPPING OF -- OF WHAT I CALL
17 ADDITIVE EFFECT, THERE WILL BE MOMENTS WHEN THE PATIENT IS
18 IN PAIN AND MOMENTS WHEN THEY'RE PAIN FREE. WHAT WE ATTEMPT
19 TO DO IN CONTEMPORARY PAIN MANAGEMENT IS TO GIVE THE DRUG
20 FREQUENTLY ENOUGH TO MINIMIZE THE NUMBER OF TROUGHS THAT
21 ALLOW THE PAIN TO RECUR, AND TO MINIMIZE THE NUMBER OF PEAKS
22 SO THAT WE DON'T HAVE EXCESSIVE DOSING. SO WE SEQUENCE THE
23 DOSING OF THE DRUG TO KEEP THE PATIENT PAIN TREE.
24 MR. STIRBA: THANK YOU. THAT'S ALL I HAVE, JUDGE.
25 RECROSS-EXAMINATION
3575
1 BY MS. BARLOW:
2 Q. JUST BASED ON THAT, YOU'RE ASSUMING THAT ALL OF THESE
3 PEOPLE HAD PAIN THAT WARRANTED THE ADMINISTRATION.
4 A. YES, THAT'S AN ASSUMPTION I MADE, YES.
5 MS. BARLOW: THANK YOU. NO FURTHER QUESTIONS.
6 THE COURT: OKAY. MAY THIS WITNESS BE EXCUSED?
7 MR. STIRBA: YES, YOUR HONOR.
8 MS. BARLOW: YES.