Along with the Covid-19 pandemic in recent years, America has experienced, but not dealt with, a self-inflicted epidemic of anesthetic agent deaths. The illicitly-sold anesthetic agent causing many of the deaths in 2023 was fentanyl. This drug was the leading cause of death amongst adults 18 to 45 years old in the United States in 2022. Many of the victims did not realize that the drugs they had illegally purchased contained lethal doses of fentanyl. The drugs they believed they were buying were tainted with fentanyl to give the buyer a more dramatic effect than might be expected from the cocaine, oxycodone, morphine, or other opiates they thought they were buying. Fentanyl killed by dropping the blood pressure or the drive to breathe below levels necessary for survival. More shocking than the consequences of misplaced trust in drug dealers was the occasionally lethal impact of unintentional fentanyl exposure to infants and children.
Tinkering with anesthetic agents has a long and colorful history. Agents, such as ‘ether’ and laughing gas [nitrous oxide] were being used for amusement and altered consciousness early in the eighteenth century. Horace Wells, a dentist in Hartford, Connecticut, was one of the first healthcare providers to notice the usefulness of nitrous oxide as a pain-blocking agent.
In 1799, Humphry Davy, an internationally famous British scientist, suggested that nitrous oxide would be useful during surgery because of its ability to block pain, as well as alter consciousness. No serious medical practitioners pursued this idea until Dr. Wells witnessed the effects of this “Laughing Gas” on volunteers who inhaled nitrous oxide. At a very unscientific demonstration, Dr. Wells noticed that a young man who inhaled the gas became confused and combative and accidentally cut his leg on a chair. The wound was deep, but the injured man did not complain of any pain associated with the laceration even as he became more coherent.
Dr. Wells suspected that giving ‘laughing gas’ to his patients could eliminate the pain associated with dental procedures. He confirmed this by having one of his own teeth pulled after inhaling the anesthetic. Wells requested and acquired permission from the Massachusetts General Hospital in Boston to demonstrate his anesthetic agent in 1845. The demonstration failed because the patient regained consciousness in the middle of the procedure and screamed in pain. Because of this very public embarrassment, the general medical community labelled Wells a quack.
Dr. Wells had bad luck in his nonprofessional life, as well as in his dental career. Subsequent to the mishap at the Mass General, he was incarcerated for beating up a prostitute. His jailers let him retain his medical equipment, thereby allowing the profoundly depressed dentist to perform the first anesthetic-assisted suicide by severing his femoral artery after breathing just enough nitrous oxide to blunt the pain.
As anesthetic agents were more generally employed, accidental anesthetic deaths occurred. The chemistry and pharmacology of ether, nitrous oxide, and less benign anesthetic and ‘hypnotic’ [e.g., barbiturates] agents were not sufficiently understood to enable physicians and dentists to calculate appropriate doses and delivery rates to avoid lethal outcomes. The obvious reason we are experiencing a resurgence of fatalities with agents like fentanyl is that the illicitly manufactured and distributed agents have no information on the nature and dose of constituent materials. Taking drugs that blunt the drive to breathe, including fentanyl, ketamine [think Matthew Perry] and propofol [think Michael Jackson], is pharmacologic Russian roulette.
The ideal anesthetic would eliminate pain without depressing breathing, affecting blood pressure, causing paralysis, or altering consciousness. That this can be achieved has been demonstrated by Mother Nature. There have been a few people born without the ability to register pain. They invariably die at an early age because they do not realize they have suffered injuries that, left untreated, kill them.
The probable cause for this defect in pain perception is a congenital lack of a transmission site on nerve endings needed for relaying information associated with tissue damage to the brain. An agent that only temporarily blocks the transmission site or sites that enable us to feel pain without causing any life-threatening side effects has not been identified. Perhaps 2024 will be the year we get lucky and discover the ideal anesthetic. That achievement would rank alongside the landing on the moon, the discovery of antibiotics, the first successful heart transplant, and the invention of beer.
Dr. Lechtenberg is an Easton resident who graduated from Tufts University and Tufts Medical School in Massachusetts and subsequently trained at The Mount Sinai Hospital and Columbia-Presbyterian Medical Center in Manhattan. He worked as a neurologist at several New York Hospitals, including Kings County and The Long Island College Hospital, while maintaining a private practice, teaching at SUNY Downstate Medical School, and publishing 15 books on a variety of medical topics. He worked in drug development in the U.S., as well as in England, Germany, and France.
