The sleep-inducing drug that would be the first of three used to kill eight Arkansas inmates next month has been the subject of lawsuits and national ethics debates after some botched executions in several states.
The contention, by the inmates' attorneys as well as death penalty opponents, is that midazolam is inadequate at blocking the pain caused by the subsequent drugs used to kill -- vecuronium bromide, a paralytic that inhibits breathing, and potassium chloride, to stop the heart.
In bungled executions using midazolam in recent years in Oklahoma, Ohio, Arizona and Alabama, the condemned prisoners eventually died, but the prolonged procedures lasted from 30 minutes to nearly two hours.
Arkansas Attorney General Leslie Rutledge has successfully defended the state's three-drug protocol, established by Act 1096 of 2015, in the state's highest court.
In late February, the U.S. Supreme Court declined to hear an appeal by the state's prisoners, prompting Gov. Asa Hutchinson to schedule the executions for mid-April.
Lawmakers and Arkansas officials pushing for the executions to proceed have noted that it has been more than a decade since the state carried out its highest form of punishment, leaving the victims' families in limbo.
In court documents, attorneys for Rutledge's office pointed to a U.S. Supreme Court precedent that prisoners must provide a "known and available" alternative to the midazolam protocol when protesting its use.
A spokesman for Rutledge declined to make her available for comment for this article, citing the possibility of further legal challenges by the inmates.
"The concerns you read about are always, 'It may, or it maybe or it could," said Rep. Doug House, R-North Little Rock, who sponsored the legislation that became Act 1096. "No expert has ever come out and said it doesn't work."
Midazolam belongs to the class of drugs called benzodiazepines, a group of psychoactives. The best-known of these is Valium, used to treat anxiety.
Beyond its link to executions, midazolam is widely known in the medical field for its general use as a sedative, and occasionally for inducing anesthesia, according to Dr. Joseph Sanford, an assistant professor of anesthesiology at the University of Arkansas for Medical Sciences.
Working on receptors in the brain, Sanford said, midazolam causes "hypnosis and amnesia," meaning it will make the patient sleepy and prevent him from forming memories, with doses of as much as 2 milligrams. For the average patient, 14 milligrams would be enough to put him out for 80 minutes, he said.
Because it is not an anesthetic, Sanford said, when midazolam is used to put patients under for surgery, it is usually combined with a pain reliever -- often an opiate -- to prevent the physical reactions associated with pain.
"Midazolam does not block pain," Sanford said.
Before the introduction of midazolam in death penalty procedures in 2013, many states -- Arkansas one of them -- used barbiturates as either the first in a three-drug cocktail or as the sole drug in lethal injections, according to Megan McCracken, an attorney with the Death Penalty Clinic at the University of California, Berkeley, School of Law.
As U.S. manufacturers of those drugs shut down and European providers refused to sell them to prisons, many states switched to midazolam, McCracken said. While barbiturates are still legal as a single-drug method of execution in Arkansas, court filings indicate that the state has had little success in procuring them.
In 2014, Oklahoma's execution of Clayton Lockett, using midazolam as the first of three drugs, took 43 minutes. It was later discovered that paramedics and a doctor struggled to properly place an IV line in Lockett, according to the Tulsa World.
Several months later, Arizona executed Joseph Wood using a mixture of midazolam and an opiate, hydromorphone, as the first injection. That execution also went awry, according to news reports and Wood's attorney, Dale Baich, who was a witness to the death.
"After 10 minutes or so, his mouth opened wide, and he gasped," Baich told the Arkansas Democrat-Gazette. "He was gulping and gasping and struggling to breathe, and that went on for the next hour and 47 minutes."
Last year, Arizona agreed to stop using midazolam in its lethal injections. Oklahoma executed another inmate using midazolam in 2015 but has not carried out the death penalty since.
The lack of a different drug may affect Arkansas' ability to carry out the eight executions next month.
The Department of Correction's batch of potassium chloride -- the final dose of the three-drug protocol -- expired in January, and officials have yet to announce a new supply. However, Hutchinson told reporters last week that he was confident the drug could be obtained before April 17, when the first two executions are scheduled.
Under Hutchinson's schedule, the executions will be carried out in pairs over a period of 10 days. McCracken said she is concerned that the pace of the executions will put pressure on prison officials, increasing the likelihood of a botched execution.
Hutchinson told reporters that he was left with no choice other than to schedule the executions in quick order.
Arkansas has not executed anyone since 2005, in part because of legal challenges and the difficulty in obtaining execution drugs. Hutchinson said that has created a "backlog" on death row. There is also a small window of time to carry out the executions before the prison's supply of midazolam expires at the end of April.
"I'd love to have those extended over a period of multiple months and years, but that's not the circumstances that I find myself in," Hutchinson said. "The families of the victims that have endured this for so many years deserve this conclusion."
Citing the deaths of Lockett and Wood, as well as prolonged executions in Alabama and Ohio, the Arkansas inmates filed an amended appeal in Pulaski County Circuit Court last week seeking to have the midazolam protocol declared "cruel and unusual punishment."
Their pleas -- citing testimony from an Oklahoma State University pharmacology professor -- claims midazolam fails to negate the experiences of "pain, panic and suffocation" from the subsequent paralytic, followed by the "burning pain" of potassium chloride.
The state's execution protocol specifies that the condemned be given two doses of midazolam totaling 500 milligrams. Sanford, the UAMS anesthesiologist, said that at that level, the normal effects of the sedative would be "profound," but it would be impossible to say what the experience would be like when combined with the subsequent lethal drugs.
"Whether the patient still experiences pain under anesthesia is still an area of active research, surprisingly," Sanford said.
Information for this article was contributed by Michael R. Wickline of the Arkansas Democrat-Gazette.
Metro on 03/05/2017