A new medical investigation changes our understanding of Elvis Presley’s untimely death, and offers some useful pearls for psychiatric practice.
CHRIS AIKEN: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.
KELLIE NEWSOME: Elvis Presley was born on January 8, 1935, and if he was still alive he would have celebrated his 88th birthday this month. But the chances that he would have made it to old age were very slim, even without the prescription drug abuse and fried banana sandwiches.
Rock stardom is not the joyride it’s made out to be. Grueling schedules, lack of privacy, never knowing who your real friends are, and all the fame magnifying your self-conscious thoughts. Who needs that? In 2007, researchers from the Center for Public Health in Liverpool examined the lifespans of the top 1,000 rock stars of the 20th Century. The oldest was Elvis and the youngest Eminem – these were 20th century stars, and they drew their cohort from a list of the top 1,000 rock albums. They found an alarming rate of death among these rock legends – with mortality rates almost double that of the average mortal.
In the past year, two new books have come out on Elvis’s death, and both arrived at the same fatalistic conclusion: His fate was in his genes. The books are Destined to Die Young by investigative journalist Sally Hoedel and The Strange Medical Saga of Elvis Presley by retired physician Forrest Tennant. Dr. Tennant is a pain and addictions specialist who ran UCLA’s methadone clinic. He was also an expert witness in a wrongful death case involving Elvis Presley, which gave him unique access to Elvis’s doctors and medical records. For this podcast, we read those books, as well as papers in peer reviewed journals to fact check all the theories and arrive at our own best guess of what happened to Elvis.
CHRIS AIKEN: On the morning of August 16, 1977, Elvis Presley sat down at his piano in Graceland for what would be his final performance, “Some day when we meet up yonder, We'll stroll hand in hand again, In a land that knows no partin', Blue eyes crying in the rain.” It was 8:00 am in the morning, but for Elvis – a night owl – it was the end of a long day. He had just finished two hours of racquetball and was readying for bed. He took his usual dose of sleeping meds and went to the bathroom. Before he sat down on the toilet, his heart stopped beating and he fell to the floor.
There’s a myth that Elvis died straining on the toilet, and yes – that can trigger a heart attack – but the forensic report conclude he died in a few seconds before sitting down. A few hours later, his fiancé Ginger Alden found him lying unresponsive. He was rushed to Baptist Memorial Hospital in Memphis and pronounced dead at 3:30 pm. The cause of death, according to the pathology report, was cardiac. His enlarged heart stopped beating after slipping into a sudden arrhythmia.
When he died, Elvis had disease in nearly every major organ system in the body.
- Megacolon, gastric ulcer
- Fatty liver
- Traumatic brain injury
- Arthrtitis and herniated discs
- Hypertension and cardiomyopathy
- Glaucoma and labyrinthitis
- Prediabetes and high cholesterol
- Antitripsin deficiency
- Tooth decay
How does that happen in a 42 year old man? In this two-part podcast, we’re going to look into 5 potential causes of his death. If you’re not among the 50 million Elvis fans, we promise you’ll learn some useful psychopharmacology along the way. Here are the 5 potential causes, keeping in mind that none of them are mutually exclusive
1. Heart attack
2. Drug overdose
3. Ehlers Danlos Syndrome
4. Head injury
5. A common pharmacokinetic effect that will help you understand a lot of adverse medication effects in your own practice.
KELLIE NEWSOME: There is a 6th theory, which is that Elvis never died. Sightings of Elvis are as common as UFOs, and the first one happened within a few hours of his death. At the Memphis airport, a man who resembled the King was seen boarding a one way plane to Argentina. The passenger registered under the name John Burrows, a pseudonym that Elvis often used when checking into hotels. At least, that was the rumor. In reality Memphis did not offer international flights at the time of his death. But that doesn’t change the meaning of the story. Elvis sightings belong to the genre of faith, not fact.
CHRIS AIKEN: Back to the medical record. Let’s walk through each of the 5 causes of death. The first cause – a heart attack – was put forth by the pathologist who examined his body. Elvis had an enlarged heart, and this greatly increases the risk of arrhythmia. The second cause – drug overdose - is the more popular explanation, because it fits with the myth of an indulgent Elvis. It also fits with our current opioid epidemic. Elvis did have opioids and sedatives in his system at the time of his death. Two opioids: codeine and meperidine (Demerol), and 6 sedatives which he took for anxiety and insomnia: three barbiturates, the barbiturate-like Quaalude, the benzodiazepine Valium, and two older gaba-ergic hypnotics that were discontinued in the 1990’s because of their high addictive potential: ethinamate (Valamin) and ethchlorvynol (Placidyl).
All of these drugs were present at or below the therapeutic range, with one exception – codeine – but codeine is an inactive prodrug. It has no analgesic, opioid-like effects until it is converted in the liver to morphine. But even with therapeutic levels, the combination still could have killed him. Sedatives and opioids both cause death through respiratory depression, and Elvis had 4 risk factors that put him at greater risk of opioid overdose
1. Respiratory illness – COPD
2. Systemic illness
3. He had a history of drug overdose
4. Sedative use. The benzo alone would have increased the risk of an opioid overdose death 4-fold
Even if Elvis was not taking an opioid, it is possible that the sedatives could have added up to a fatal dose even if each was in the therapeutic range on its own.
That is a good argument against prescribing multiple controlled substances within the same class. I often see patients who present like that, saying they need temazepam for sleep at night and clonazepam for anxiety during the day. In the past I was more agreeable to this. I figured that if I converted the doses to clonazepam equivalents, and the total daily dose was in the therapeutic range, it was alright.
But today we live in a different age. The opioid epidemic, and the increase in inappropriate prescriptions of controlled substances during COVID, mean higher scrutiny of these meds. The benzo conversion I was relying on is not an exact science. There are many conversion tables and they all give different figures because the human body is not exact – those conversions are just approximations along a bell curve. In today’s world, I prefer to more exact in the quantities and dosages of controlled substances I’m prescribing.
KELLIE NEWSOME: One drug we were surprised to see missing from Elvis’ system is amphetamine. Elvis has a long history of amphetamine use. His classmates report that he used amphetamines in high school. He may have been treating symptoms of ADHD, as his friends from that era also report that he was unable to sit still and fidgeting all the time. Later he took amphetamines to boost his energy and confidence before a show, and lose the weight that kept building through his cheeseburger, bacon, and butter coated diet.
If the coroner’s report is correct – that Elvis died of a cardiac arrhythmia, then the amphetamine would have raised that risk even further. Stimulants are associated with rare cases of sudden cardiac death, which earned them a black box warning and a temporary ban in Canada in the early 2000’s. These deaths usually have a genetic basis. They tend to happen in young adults when they are exercising, and there is no reliable way to screen for them although a family history of sudden cardiac death before age 35 or a personal history of fainting while exercising can tip you off to the risk.
We don’t know if Elvis had ADHD, but if he did it would have probably been treated with methylphenidate/Ritalin. Back then, ADHD was only treated in children, and methylphenidate was preferred; amphetamines were second line. That’s still the case today, as the largest metaanalysis to date found methylphenidate had the best risk/benefit profile in childhood ADHD.
CHRIS AIKEN: Amphetamines were mainly given to adults in the 1950’s, 60’s, and they were given in droves, but not for ADHD. These drugs were marketed for obesity and depression in adults, and doctors thought they worked. Doctors – not the FDA – ran the show when Elvis started taking them, through the American Medical Association (AMA). Between 1905 and 1955, the AMA was the main arbiter of whether a drug worked. To advertise in their journals, they required the drug manufacturer to prove its efficacy, and they published a PDR-like guide to those approvals in their annual book New and Nonofficial Remedies.
If you noticed a problem with that arrangement, you are not alone. The AMA had a financial incentive to approve drugs – more approvals meant more advertising. In the 1950’s the AMA was under financial duress and increasingly dependent on advertising revenue. Democratic Senator Estes Kefauver investigated this dubious relationship and proposed a bill that would wrench control of drug approvals from the AMA and land it in the hands of the FDA. Physicians were strongly against it, but Kefauver’s interest was in protecting patients, whom he saw as playing a passive role in the medical-pharmaceutical alliance, or in Kefauver’s words, “He who orders does not buy; and he who buys does not order,”.
KELLIE NEWSOME: Like Elvis Presley, Senator Kefauver was from Tennessee, and in 1956 Kefauver was the better known of the two. Kefauver was running for vice president alongside Adlai Stevenson, while Elvis had not yet been crowned King. A derisive review from the Harvard Crimson sums up the sentiment: “Elvis Presley is a new star from Tennessee, who looks like a cross between Estes Kefauver and Rudolph Valentino.” Elvis spoke out in support of the Kefauver’s campaign, but he lost to Eisenhower-Nixon. Kefauver rejoined the Senate and went on to introduce his drug regulation bill in 1959.
The bill went nowhere at first, but in 1962 a worldwide scandal over a sleep medicine pushed it into law. The sleep medicine was thalidomide, and the scandal did not involve its efficacy but its safety. Babies exposed to the drug were born with serious malformations, including short limbs. The drug never made it to approval in the US, but the wordwide scandal was enough to shock the US government into passing Senator Kefauver’s bill.
CHRIS AIKEN: At first, the FDA grandfathered in the amphetamines for depression and weight loss, but that took a sharp turn in 1970 when the DEA classified them as schedule II controlled substances. Many years later, Shire tried to reclaim those lucrative approvals for its amphetamine product Vyvanse. They succeeded with binge eating disorder, but the drug failed in both large trials of major depression.
Elvis might have qualified for a diagnosis of binge eating disorder. His personal physician described a typical meal Elvis meal as three double cheeseburgers, half a pound of fries, and a whole pound of bacon on the side…. About 5,000 calories in one sitting, twice the recommended calories for an adult male in an entire day. And Elvis often took amphetamines to lose weight before a tour. Amphetamines do lead to weight loss, and they do so by reducing caloric intake, but this benefit is short lived. Elvis weighed 350 pounds at the time of his death, which would place his BMI at 48, above the 40 cut-off for the highest risk Class 3 obesity.
In Elvis’s day, the preferred amphetamine for weight loss was a 3-to-1 mixture of amphetamine salts branded as Obetrol (the original formulation also contained methamphetamine). Obetrol fell out of use in the 1980’s, and in 1994 the manufacturer changed its name to Adderall – as in ADD for All – and started marketing the drug for ADHD.
KELLIE NEWSOME: In Elvis’ time, ADHD was a rare condition diagnosed only in children. The main symptom was hyperactivity and impulsivity – not inattention – and the disorder went by names that discouraged overdiagnosis. Who wants to be diagnosed with minimal brain dysfunction or hyperkinetic disorder of childhood? The name was changed to ADHD in 1980, and in 1987 a revised edition of the DSM opened the door for diagnosis in adults, stating that 30% of children with ADHD continue to have some symptoms into adulthood.
CHRIS AIKEN: Prescribing for adult ADHD was still off label until 2004 when Shire gained the first FDA approval with Adderall XR. More approvals followed, and in 2014 Arbor Pharmaceuticals re-releasing the original racemic amphetamine, cleverly renaming it Evekeo and burying any reference to its original incarnation as the widely abused Benzedrine, the form of amphetamine preferred by Elvis Presley.
KELLIE NEWSOME: But if Elvis came to us today, with a documented history of ADHD observed in multiple settings and dating back to early childhood, would we continue his amphetamine?
CHRIS AIKEN: Probably not. There are a few contraindications to stimulants and amphetamines, and Elvis had one of them: hypertrophic cardiomyopathy. This disorder, which thickens the heart walls in about in 1 in 500 people, is the leading cause of sudden cardiac death. Psychostimulants and atomoxetine are contraindicated in hypertrophic cardiomyopathy because their noradrenergic effects can set off ventricular tachycardias and cardiac arrest. Clonidine, however, is often used to treat hypertension in hypertrophic cardiomyopathy, so this would have been a better choice for Elvis if he indeed had ADHD.
This is different from the sudden death we worry about with prolonged QTc – you know the risk you see on lots of psych meds like citalopram and antipsychotics. Prolonged QTc also causes fatal arrhythmia, but through torsades de pointe; the risk for torsades goes up as the heart rate goes down. Death by ventricular tachycardia becomes more likely as the heart rate goes up, which is why young athletes sometimes die while playing sports after using cocaine or stimulants.
KELLIE NEWSOME: And while stimulants cause ventricular tachycardia, opioids cause the opposite problem. They prolong the QTc – a particularly problem with methadone – and can trigger fatal torsades de pointe. Elvis had opioids and sedatives, not amphetamines, in his system when he died. Did the combination of opioids and sedatives cause his breathing to stop? Or did the opioids send his already weakened heart into torsades de pointe? Find out in our next episode.
Earn your CME for this episode through the link in the show notes, or subscribe to the print journal online and get $30 off with the promo code PODCAST. Keep up with the latest research with Dr. Aiken’s DailyPsych feed on LinkedIn and Twitter (handle @chrisaikenmd) where he posts a new research study every day.