State's Three-Drug Execution Cocktail Is Native To Hospital Supply Shelves

Apr 3, 2017

To the eight men scheduled to be executed over 10 days this month by the state of Arkansas, the question is when. When will they die? On the day and time of the state's choosing — April 17, 20, 24 and 27 — or some later date, dependent on a court-ordered stay of their execution? For others without more than a passing interest in the news, the question might be why, followed by how.

How does the state end the life of an inmate, without pain but without error?

In Arkansas's case, the answer, for better or worse, is lethal injection. 

Specifically, a three-part drug cocktail introduced intravenously and comprised of solutions commonly used for other purposes, according to Dr. Scott Pace, CEO of the Arkansas Pharmacists Association.

“I think the question that you hit on is, Are these drugs used in other parts of medicine? And the answer is absolutely they are.  But they are used in therapeutically appropriate doses.  For the purposes of an execution, they are used in much larger doses,” he said.

The drug cocktail consists of midazolam (or Versed), vecuronium bromide and potassium chloride. In order, these drugs sedate the inmate, stop his breathing and finally stop his heart.  The law does not require that the execution be painless; only that it not be “cruel and unusual.”  

Dr. Scott Pace, CEO of the Arkansas Pharmacists Association
Credit Arkansas Pharmacists Association

Pace said midazolam belongs to a class of drugs that includes the well-known anti-anxiety drugs Valium and Xanax.

“Midazolam is used intravenously to help sedate a patient and relax them before a surgical procedure or before a procedure like a colonoscopy.  So it’s used routinely,” he said.  In addition to the sedation, he said the drug tends to create some short-term memory loss, so that a patient undergoing a colonoscopy would emerge with no real memories of the procedure.

Pace said the second drug in the cocktail, vecuronium bromide, is a neuromuscular blocker.

“It is used in surgical procedures to render a patient where they don’t move or kind of jerk around during surgeries, so it creates a temporary paralysis,” he said.  He said at the dose necessary for an execution, the muscles being paralyzed would include the diaphragm, which will stop the inmate’s breathing.

Potassium chloride, the third drug, is used "every day in every medical facility," he said, as a potassium replacement. At low levels it helps a person recover from a dramatic loss of hydrating fluids, after vomiting or diarrhea, for instance. It is also found in many processed foods. 

“At higher doses, potassium chloride can cause heart arrhythmias and can subsequently cause the heart to stop.”

In 2013, the state weighed a one-drug execution protocol, and though current state law allows for such a protocol, a barbiturate, it hasn't adopted it for this planned round of executions. Thirty other states that allow the death penalty have lethal injection cocktails in various drug combinations, but even one-drug lethal injections include a preliminary sedative.

Pace said the drugs that make up Arkansas’s three-drug cocktail don’t interact with each other. They work independently and sequentially.

“There’s really no interaction between the three.  They’re just given in that order for those specific purposes.  You wouldn’t want to, for instance, give the vecuronium before you caused the patient to relax and be sedated.  That would be a bad sensation, to be paralyzed without any sedative,” he said. 

In fact, according to reports, that's exactly what happened in the 2015 botched execution of Clayton Lockett. Lockett had been given an appropriate dose of midazolam and thought unconscious when he raised his head and began to speak. He writhed and appeared physically pained for many minutes until finally suffering a heart attack. 

(Documents obtained later by the Tulsa World suggest that the cause of the botched execution was a collapsed vein and not ineffective or insufficient drugs.)

But the first drug is not technically a pain reliever, Pace says, although it does cause sedation and an unawareness of surroundings.

“It is my understanding that the doses that they’re using of the medications far exceed what would be used for a colonoscopy, for example.  So you may be talking about a 30, 40 or 50 times greater dose than what you would be given for a procedure like that,” he said.

The state has said the executions must take place before those drugs expire, due to the difficulty in obtaining more, but has offered few other details about the drugs in question, such as where they came from or how much they cost.

“The law prohibits the disclosure of information about drug suppliers or manufacturers,” said Solomon Graves, a spokesperson for the Arkansas Department of Corrections, referring to an Arkansas law currently being challenged in state court.

He did confirm the drugs are midazolam, vecuronium bromide and potassium chloride.

When asked about the state's conspicuously condensed scheduling of executions, Gov. Asa Hutchinson has said the expiration date on the state's supply of midazolam (or Versed) is May 1.

But why isn't it easy to replenish supplies of drugs? Hospitals don't halt surgeries until new drug solutions can be acquired.

“Drug suppliers do not want their names associated with the drugs that are used to kill people,” said Amherst College Professor Austin Sarat, who has studied and written about the death penalty extensively.  

Many European suppliers of drugs don't want to be found to have played any role in capital punishment.

Amherst College Professor Austin Sarat is the author of "Gruesome Spectacles," a chronicle of botched executions
Credit Amhest College

Barring a last-minute appeal, the executions are set to take place two inmates at a time over a ten-day period beginning  April 17.  The consolidated schedule has already attracted international attention.  

Sarat said the planned executions in Arkansas are the reverse of a trend taking place nationally.

“The United States is today in a period of national reconsideration of the death penalty.  The number of death sentences across the country has dramatically declined.  The number of executions have similarly dramatically declined,” said Sarat, who attributed the decrease to waning public support, conflicts with constitutional commitments and concerns about the arbitrary nature of who among the guilty gets the death penalty.

“It is against that background that these executions will be carried out,” he added.

This story is produced by Arkansas Public Media. What's that? APM is a nonprofit journalism project for all of Arkansas and a collaboration among public media in the state. We're funded in part through a grant from the Corporation for Public Broadcasting, with the support of partner stations KUAR, KUAF, KASU and KTXK. And, we hope, from you! You can learn more and support Arkansas Public Media’s reporting at arkansaspublicmedia.org. Arkansas Public Media is Natural State news with context.