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The Best of Pill Pushing - Total eclipse of the heart - A history of lethal injection in America - (1/16/2020)

By Dr. Ron Gasbarro

Society at the time
The year was 1982. In that year, The Weather Channel aired on cable television for the first time. Cal Ripken, Jr. of the Baltimore Orioles played the first of what eventually becomes his record-breaking streak of 2,632 consecutive Major League Baseball games. The first compact discs (CDs) were produced in Germany. The first emoticons were posted by computer scientist Scott Fahlman. The Chicago Tylenol murders occurred when 7 people in the Chicago area died after ingesting capsules laced with potassium cyanide. In 1982, Britain’s Prince William, Duke of Cambridge, as well as his wife, Catherine, Duchess of Cambridge, were born. John Belushi, drug addict, and Saturday Night Live comic and Jack Webb, actor of Dragnet fame died. 

At the 24th Grammy Awards, the Best Song of the Year was Bette Davis Eyes. Album of the Year went to John Lennon and Yoko One for Double Fantasy. At the 55th Academy Awards, Gandhi won the Best Picture Oscar, with Ben Kingsley winning Best Actor for that picture. Best Actress Award went to Meryl Streep for her role in Sophie’s Choice. During 1982, the Falklands War was a 10-week deadly conflict between Argentina and the United Kingdom over two British overseas territories in the South Atlantic: the Falkland Islands, and South Georgia and the South Sandwich Islands. The Brits won. 

And on December 7, 1982, Texas became the first state to use lethal injection to carry out capital punishment for the execution of Charles Brooks, Jr., a convicted murderer who was on death row for over 4 years. 

The drug(s) in question – Agents used in executing prisoners
In today's executions, 3 drugs are typically given in stages. First, an anesthetic is administered to render the person unconscious. The second drug is a paralytic to keep the inmate from moving. The third and final drug is used to stop the heart. Death ensues quickly. Yet, as will be discussed, the drugs do not always work with the humane swiftness that they should. 

In most states, the intravenous (IV) injection is a series of drugs given in a set sequence, designed to first induce unconsciousness followed by death through paralysis of respiratory muscles and/or by cardiac arrest through depolarization of cardiac muscle cells. Traditionally, the execution of the condemned in most states involves 3 separate injections (in sequential order):
1. Sodium thiopental or pentobarbital: quick-acting barbiturates and anesthetic agents used at high doses that render the person unconscious in less than 30 seconds. Depression of respiratory activity is one of the characteristic actions of this drug. Consequently, the lethal-injection doses will – even in the absence of the following two drugs – cause death due to lack of breathing in a fashion similar to opioid overdoses.
2. Pancuronium bromide: a muscle relaxant (neuromuscular-blocking agent), which causes complete, fast, and sustained paralysis of the skeletal striated muscles, including the diaphragm and the rest of the respiratory muscles; this would eventually cause death by asphyxiation. Vecuronium bromide, cisatracurium besilate, and rocuronium bromide are 3 other pharmacologically-related paralytics also used in lethal injection cocktails. 
3. Potassium chloride: a potassium salt that increases the blood and cardiac concentration of potassium to stop the heart via an abnormal heart beat and thus cause death by cardiac arrest.

The drugs are not mixed externally as that can cause them to precipitate and render them ineffective. Also, a sequential injection is necessary to achieve the desired effects in the appropriate order: administration of the barbiturate essentially renders the person unconscious; the infusion of the neuromuscular-blocking drug induces complete paralysis, including that of the lungs and diaphragm rendering the person unable to breathe. If the person being executed was not already completely unconscious, the injection of a highly concentrated solution of potassium chloride could cause severe pain at the site of the IV line, as well as along the punctured vein, but it interrupts the electrical activity of the heart muscle and causes it to stop beating, bringing about the death of the person being executed. However, many states do not adhere to the 3-drug protocol, as shown below. 

Lethal injection "firsts"
[DPIC, 2014]
First state to use lethal injection: Texas, December 7, 1982
First state to use 1-drug method: Ohio, December 8, 2009 (single drug was sodium thiopental)
First state to use pentobarbital in 3-drug protocol: Oklahoma, December 16, 2010
First state to use pentobarbital in 1-drug protocol: Ohio, March 10, 2011
First state to use midazolam in 3-drug protocol: Florida, October 15, 2013
First state to use midazolam in 2-drug protocol: Ohio, January 16, 2014 (the other drug was pentobarbital).


Table 1 - Executions by lethal injections [DPIC, 2014]



The good, the bad, and the ugly
While death by lethal injection is controversial, particularly among those who do not believe capital punishment should be allowed, it is a far cry better than some of the other methods used for execution. 

Until the 1890s, hanging was the primary method of execution used in the United States [DPIC, 2017a]. Hanging is still used in Delaware and Washington, although both have lethal injection as an alternative method of execution. For execution by this method, the inmate may be weighed the day before the execution, and a rehearsal is done using a sandbag of the same weight as the prisoner. This is to determine the length of 'drop' necessary to ensure a quick death. If the rope is too long, the inmate could be decapitated, and if it is too short, the strangulation could take as long as 45 minutes. The rope, which should be 3/4-inch to 1 1/4-inch in diameter, must be boiled and stretched to eliminate spring or coiling. The knot should be lubricated with wax or soap "to ensure a smooth sliding action," according to the 1969 U.S. Army manual [The Corrections Professional, 1996].

Immediately before the execution, the prisoner's hands and legs are secured, he or she is blindfolded, and the noose is placed around the neck, with the knot behind the left ear. The execution takes place when a trap-door is opened and the prisoner falls through. The prisoner's weight should cause a rapid fracture-dislocation of the neck. However, instantaneous death rarely occurs [Weisberg, 1991]. If the inmate has strong neck muscles, is very light, if the 'drop' is too short, or the noose has been wrongly positioned, the fracture-dislocation is not rapid and death results from slow asphyxiation. If this occurs the face becomes engorged, the tongue protrudes, the eyes pop, the body defecates, and violent movements of the limbs occur [The Corrections Professional, 1996; Weisberg, 1991].

Firing squad

On March 23, 2015, the firing squad was reauthorized in Utah as a viable method of execution if, and only if, the state was unable to obtain the drugs necessary to carry out a lethal injection execution [DPIC, 2017a]. For execution by this method, the inmate is typically bound to a chair with leather straps across his waist and head, in front of an oval-shaped canvas wall. The chair is surrounded by sandbags to absorb the inmate's blood. A black hood is pulled over the inmate's head. A doctor locates the inmate's heart with a stethoscope and pins a circular white cloth target over it. Standing in an enclosure 20 feet away, 5 shooters are armed with 30 mm caliber rifles loaded with single rounds. One of the shooters is given blank rounds. Each of the shooters aims his rifle through a slot in the canvas and fires at the inmate. [Weisberg, 1991] The prisoner dies as a result of blood loss caused by rupture of the heart or a large blood vessel, or tearing of the lungs [Weisberg, 1991].

Gas chamber
In 1924, the use of cyanide gas was introduced as Nevada sought a more humane way of executing its inmates [DPIC, 2017a]. Today, 5 states authorize lethal gas as a method of execution, but all have lethal injection as an alternative method. A federal court in California found this method to be cruel and unusual punishment. For execution by this method, the condemned person is strapped to a chair in an airtight chamber. Below the chair rests a bucket of sulfuric acid. A long stethoscope is typically affixed to the inmate so that a doctor outside the chamber can pronounce death. Once everyone has left the chamber, the room is sealed. The warden then gives a signal to the executioner who flicks a lever that releases crystals of sodium cyanide into the pail. This causes a chemical reaction that releases hydrogen cyanide gas. (Weisberg, 1991) The prisoner is instructed to breathe deeply to speed up the process. Most prisoners, however, try to hold their breath and some struggle. The inmate does not lose consciousness immediately but is conscious of the horrible pain as if he is having a heart attack. The inmate dies from hypoxia, the lack of oxygen to the brain [Weisberg, 1991]. As of April 17, 2015, Oklahoma introduced death by nitrogen gas as an alternative to lethal injection if the necessary drugs cannot be found or if the cyanide method is found unconstitutional. Nitrogen is a naturally occurring gas in the atmosphere, and death would be caused by forcing the inmate to breathe only nitrogen, thereby depriving him or her of oxygen. 

Seeking a more humane method of execution than hanging, New York built the first electric chair in 1888 [DPIC, 2017a]. Soon, other states adopted this execution method. Today, electrocution is not used as the sole method of execution in any state. Electrocution was the sole method in Nebraska until the State Supreme Court ruled the method unconstitutional in February 2008. For execution by the electric chair, the person is usually shaved and strapped to a chair with belts that cross his chest, groin, legs, and arms. A metal skullcap-shaped electrode is attached to the scalp and forehead over a sponge moistened with saline. The prisoner is then blindfolded [Weisberg, 1991]. After the execution team has withdrawn to the observation room, the warden signals the executioner, who pulls a handle to connect the power supply. A jolt of between 500 and 2000 volts, which lasts for about 30 seconds, is given. This process continues until the prisoner is dead. The prisoner's hands often grip the chair and there may be violent movements of the limbs which can result in dislocation or fractures. The tissues swell. Defecation occurs. Steam or smoke rises and there is a smell of burning [Weisberg, 1991]. US Supreme Court Justice William Brennan (1906-1997) once offered the following description of an execution by electric chair: 
“...the prisoner's eyeballs sometimes pop out and rest on [his] cheeks. The prisoner often defecates, urinates, and vomits blood and drool. The body turns bright red as its temperature rises, and the prisoner's flesh swells and his skin stretches to the point of breaking. Sometimes the prisoner catches fire....Witnesses hear a loud and sustained sound like bacon frying, and the sickly sweet smell of burning flesh permeates the chamber” [Ecenbarger, 1994]. 

The death penalty 
In 2016, 30 people were handed the death penalty in the US, far lower than during the 1980s and 1990s, when such sentences were at their peak (See Figure 1) [DPIC, 2017b]. The number is a sharp drop from the 49 death sentences in 2015 and only 15% of the peak of 315 in 1996, according to a report from the Death Penalty Information Center (DPIC), a nonprofit organization that opposes capital punishment and monitors death sentences and executions. A growing unwillingness of juries to sentence defendants to death is one of many reasons contributing to the overall drop in executions. Twenty people were executed in 2016 (all male; 16 - white, 2 – black, 2 – Latino; age range – 33-72), the fewest since 1991, when 14 people were put to death (all male; 7 – black, 6- white, 1 – Latino; age range – 30-59). The highest number of executions was in 1999 with 98 such punishments. Another factor leading to a decline in executions includes shortages of the drugs needed to carry out lethal injections.

A majority of Americans favor the death penalty for those convicted of murder, but current support for the death penalty is as low as it has been in the past 40 years. A 2015 Pew Research Center survey found that 56% favor the death penalty for people convicted of murder, while 38% are opposed (See Figure 2). Public support for capital punishment peaked in 1995 when almost 80% of Americans favored it [Pew, 2015]. The reasons for the decline is public support is illustrated in Figure 3


Figure 1 - Death Penalty Information Center; 2016


Figure 2 – Pew Research Center; 2015


Figure 3 – Pew Research Center; 2015 


Death row
Death row refers both to the physical space where those awaiting execution are held and the general population who have been sentenced to death. Capital punishment is as old as written law. It was the ascribed punishment for 25 different crimes under Hammurabi's Code (c. 1700 BC). Since condemned individuals are typically confined between the moments of judgment and execution, some form of “death row” must be equally ancient. Through the centuries, however, death row has evolved from a rudimentary cell located near the place of public execution to a highly specialized, segregated unit within a modern penal facility. 

As of April 1, 2017, there were 2,843 death row inmates in the US. The number of death row inmates changes daily with new convictions, appellate decisions overturning conviction or sentence alone, commutations, or deaths (See Table 2).  

Table 2 – Total number of death row inmates known to the NAACP Legal Defense as of April 1, 2017 [NAACP, 2017]

Race of defendant


1,205 (42%)


1,184 (42%)


375 (13%)

Native American

25 (<1%)



2,790 (98%)


53 (2%)


Drug shortages and side effects

Sodium thiopental

Texas has 317 inmates on death row, but only enough of a key lethal injection drug to execute two of them [Horne, 2017]. Ohio has just one dose of the drug left.  

A nationwide shortage of sodium thiopental, an anesthetic that is part of the 3-drug cocktail used in lethal injections, has thrown capital punishment in the US into disarray, delaying executions and forcing the change of execution protocols in several states.

In June 2017, Hospira (Lake Forest, IL), the sole US company approved to manufacture the drug, announced it will no longer produce sodium thiopental. This move followed a global campaign by death penalty opponents and pressure by Italian government officials after the company sought to shift production of the drug to an Italian plant. 

The shortage of sodium thiopental has forced the 35 states using lethal injection to scramble for any remaining stock and to explore alternatives. Some states, including California, Arizona, and Nebraska, were able to obtain the drug from suppliers in England and India. The British government has since banned such shipments. A class-action lawsuit against the Food and Drug Administration’s decision to allow the importation of the drug into the country without adequate inspection or quality checks is pending. Death penalty opponents have raised questions about the quality of the drugs, arguing that if the drugs were expired or otherwise failed to work effectively, inmates could suffer significant pain, violating the ban on cruel and unusual punishment.  

Whether executions will have to be delayed depends largely on the ability of states to make changes to their lethal injection protocols without legislative or regulatory changes. 

In some states, switching to a new drug protocol is easily done. For an execution in December 2016, Oklahoma replaced sodium thiopental with pentobarbital, a drug commonly used to euthanize animals. It is believed to be the first time the drug was used in a lethal injection. Ohio plans to completely do away with the 3-drug cocktail. Beginning in March 2018, the state will use a single dose of pentobarbital, becoming the first state to use the drug alone. This protocol is untested and many states are watching Ohio before changing their own protocols. 

States continue to seek additional sources of sodium thiopental. In January 2017, 13 states asked the US Department of Justice for help in identifying sources for the scarce drug or by making federal supplies available to states. The drug has been introduced for use in executions by lethal injection in certain jurisdictions in the US in combination with other drugs. It was introduced to replace pentobarbital after the manufacturer disallowed that drug's use for executions. 


Midazolam has been used as part of a 3-drug cocktail, with vecuronium bromide and potassium chloride in Florida and Oklahoma prisons [DPIC, 2014]. Midazolam has also been used along with hydromorphone in a 2-drug protocol in Ohio and Arizona [DPIC, 2014]. Ohio used midazolam in the execution of Dennis McGuire in January 2014; it took McGuire 24 minutes to die after the procedure started, and he gasped and appeared to be choking during that time, leading to questions about the dosing and timing of the drug administration, as well as the choice of drugs. Ohio resumed executions in January 2017, using a cocktail of midazolam, vecuronium bromide, and potassium chloride but this was blocked by a federal judge. On 25 July 2017, Ronald Phillips was executed with a 3-drug cocktail that included midazolam after the US Supreme Court refused to grant a stay. 

Florida used midazolam to execute William Happ in October 2013. The usage of midazolam in executions has become controversial after condemned inmate Clayton Lockett apparently regained consciousness and started speaking midway through his execution when Oklahoma attempted to execute him with an untested 3-drug lethal injection cocktail using midazolam 100 mg. Prison officials reportedly discussed taking him to a hospital before he was pronounced dead of a heart attack 40 minutes after the execution began. An observing doctor stated that Lockett's vein had ruptured. It is not clear which drug or drugs caused his death or what quantities of vecuronium bromide and potassium chloride were released before the execution was canceled. 

In Glossip v. Gross, attorneys for 3 Oklahoma inmates argued that midazolam could not achieve the level of unconsciousness required for surgery, meaning severe pain and suffering was likely. They argued that midazolam was cruel and unusual punishment and thus contrary to the Eighth Amendment to the US Constitution (prohibits the federal government from imposing excessive bail, excessive fines, or cruel and unusual punishments, including torture). In June 2015, the US Supreme Court ruled they failed to prove that midazolam was cruel and unusual when compared to known alternatives.

The execution of Ronald Bert Smith in Alabama on December 8, 2016 "went awry soon after (midazolam) was administered" again putting the effectiveness of the drug in question. On April 24, 2017, Arkansas carried out a double-execution of Jack Jones, 52, and Marcel Williams, 46. The state of Arkansas attempted to execute 8 people before their supply of midazolam expired on April 30, 2017. Two of the 8 were granted a stay of execution, and another death row inmate, Ledell T. Lee, 51 was executed on April 20, 2017. 

Where the drugs are today
The “ideal” death cocktail would be quick and painless. And the search for the right combination continues. On August 24, 2017, the state of Florida put a man to death with an anesthetic never used before in a US lethal injection, carrying out its first execution in more than 18 months on an inmate convicted of two racially motivated murders. Authorities said 53-year-old Mark Asay, the first white man executed in Florida for the killing of a black man, was pronounced dead at 6:22 PM. Thursday at the state prison in Starke. Asay received a 3-drug injection that began with the anesthetic, etomidate (Amidate®). 

Etomidate is a short-acting intravenous anesthetic agent used for the induction of general anesthesia and sedation for short procedures such as reduction of dislocated joints, tracheal intubation, and cardioversion [Vinson & Bradbury, 2002]. It was developed at Janssen Pharmaceutica in 1964 and was introduced as an intravenous agent in 1972 in Europe and in 1983 in the United States. Though approved by the Florida Supreme Court, etomidate has been criticized by some as being unproven in an execution. Etomidate replaces midazolam, which has become harder to acquire after many pharmaceutical companies began refusing to provide it for executions.

The execution protocol for Mr. Asay began at 6:10 PM. About a minute after the first drug was administered, Asay's feet jerked slightly and his mouth opened. A minute or two later, after receiving the paralytic, rocuronium bromide, and the heart-stopping potassium acetate, he was motionless and subsequently was pronounced dead by a doctor. A spokeswoman for the corrections department said there was no complication in the procedure and that Asay did not speak during it. Also, it was Florida's first time using potassium acetate, which was erroneously used in a 2015 Oklahoma execution in Oklahoma instead of the usual potassium chloride, but has not been used elsewhere, a death penalty expert said. Asay was the 24th inmate executed since Gov. Rick Scott (R) has taken office, the most under any governor in Florida history.

Deciding on a protocol
Eleven states have switched, or have stated their intention to switch, to a one-drug lethal injection protocol. A one-drug method is using the single drug sodium thiopental to execute someone. The first state to switch to this method was Ohio, on December 8, 2009.

In 2011, after pressure by activist organizations, the manufacturers of sodium thiopental and pentobarbital halted the supply of the drugs to US prisons performing lethal injections and required all resellers to do the same.

On July 27, 2012, Virginia replaced pancuronium bromide, one of the three drugs used in execution by lethal injection, with rocuronium bromide. 

On October 3, 2016, Ohio announced that it would resume executions on January 12, 2017, using a combination of midazolam, rocuronium bromide, and potassium chloride. Prior to this, the last execution in Ohio was in January 2014. 

On August 17, 2017, Nevada announced that it would use three new drugs (diazepam [Valium], fentanyl, and cisatracurium) in the upcoming scheduled execution of Scott Dozier.  

A 2017 study found that 4 US states that allow capital punishment – Arkansas, Arizona, Mississippi and Virginia – are stockpiling lethal injection drugs that are in short supply and that would otherwise be needed for life-saving medical procedures [Pilkington, 2017].

Ron Gasbarro, PharmD, is a registered pharmacist, medical writer, and principal at Rx-Press.com. Read more at www.rx-press.com


Death Penalty Information Center. Description of execution methods; 2017a.  Available at: https://deathpenaltyinfo.org/descriptions-execution-methods   

Death Penalty Information Center. Execution list 2016; 2017b. Available at: https://deathpenaltyinfo.org/execution-list-2016 

Death Penalty Information Center. State by state lethal injection; 2014. Available at: https://deathpenaltyinfo.org/state-lethal-injection 

Death Penalty Information Center. The Death Penalty in 2016: Year end report; Washington DC: DPIC; 2016.  Available at: https://deathpenaltyinfo.org/documents/2016YrEnd.pdf  

Ecenbarger W. Perfecting Death: When the state kills it must do so humanely. Is that possible? The Philadelphia Inquirer Magazine; January 23, 1994.

Horne J. Lethal injection drug shortage. The Council of States Governments. July-August 2017 [newsletter].

NAACP Legal Defense and Educational Fund, Inc.; Death Row USA. Spring 2017.

Oleson JC. Death Row. Encyclopedia of Prisons & Correctional Facilities. Thousand Oaks, CA: SAGE Reference Online; 2004:215-21. 

Pew Research Center. Less support for death penalty, especially among Democrats [press release]; April 16, 2015. 

Pilkington E. States are stockpiling lethal injection drugs that could be used to save lives. The Guardian; April 20, 2017. 

The Corrections Professional. Executions - Preparing staff for the hard task ahead; Vol. 1, February 16, 1996.

Vinson DR, Bradbury DR. Etomidate for procedural sedation in emergency medicine.  Ann Emerg Med. 2002;39:592-8.

Weisberg J. This is Your Death. The New Republic; July 1, 1991.



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