Compounding pharmacies now supply execution drugs with limited oversight
The failed execution of Christa Pike this week has drawn fresh scrutiny of what The Wall Street Journal described as the “shaky and secretive” supply chain for lethal injection drugs. Pike, sentenced to death in 1996 for the murder of Colleen Slemmer, received two doses of pentobarbital, a sedative that at least 17 states use for capital punishment. Tennessee officials halted the procedure and sent her to a hospital after she remained alive; her attorneys said as of Thursday evening she was unconscious and on a ventilator.
The Tennessee Department of Correction said it followed established protocol and that the drug has consistently been effective. The department declined to answer questions about where the drug was sourced.
The episode is Tennessee’s second failed execution attempt this year. In May, during the attempted lethal injection of a different inmate, a medical professional failed to establish the IV correctly. The provider said in a deposition last year that he had not done a procedure like that in over a decade and did not have hospital privileges. Experts said that because major medical groups condemn lethal injections, the people administering the drugs often have limited medical qualifications.
Lethal injections date to the late 1970s, when the goal was to offer convicted criminals a quicker and more painless death than the electric chair or hanging. Oklahoma introduced the practice in 1977, and other states quickly followed. Capital punishment is currently legal in 27 states, and injections are the most common form of execution.
The drug supply has shifted as anti-capital-punishment activists successfully pressured pharmaceutical companies over the years to place restrictions on their drugs for execution use. Despite the restrictions, companies have still found their drugs used in some executions and have sued states. Alvogen sued Nevada in 2018 for using its sedative midazolam to carry out executions, prompting Nevada to return its unused supply. Fresenius Kabi sued Nebraska the same year for obtaining its medicines, including potassium chloride, for a planned execution; a judge ultimately allowed the execution to go forward.
Some states have since turned to compounding pharmacies, which make customized, non-FDA-approved versions of prescription medicines. Compounded drugs are not subject to the same review for safety, effectiveness and quality as approved pharmaceuticals. States often buy a powdered form of pentobarbital in bulk directly from domestic or overseas suppliers, which compounding pharmacies turn into injectable solutions, according to a 2025 review of execution protocols from the Justice Department. One court filing says Tennessee spent more than $1 million on pentobarbital for executions over two years, though it did not name the suppliers.
States often pay cash for drugs to use in executions, making it harder to trace the supply chain, said Deborah Denno, a Fordham University law professor who has studied lethal injection for 33 years. Corrections departments may buy the drugs from compounders, or even from each other, she said.
For years, states used the anesthetic sodium thiopental for lethal injections. Hospira, a manufacturer later bought by Pfizer, halted production of that drug because of raw material issues in 2010, and activists capitalized on the moment to target other drug companies whose products were used in executions. States initially used a three-drug protocol: one drug to cause unconsciousness, another to stop a person’s breathing, and a third to stop the heart. Now, because of supply issues with those drugs, some states use only pentobarbital.
Nine inmates in Tennessee have sued the state, saying its lethal injection protocol causes “a high risk of torturous death.” A Justice Department review highlighted concerns about the drug being linked to a condition that causes fluid to rapidly fill the lungs, leading recipients to feel like they are suffocating or drowning. Experts disagreed as to whether people who received the drug could feel pain or suffering. In legal filings before her execution date, Pike’s attorneys argued that because of a blood disorder, using pentobarbital exacerbated her risk of developing the condition. Her lawyers wrote: “The sensation of pulmonary edema will be like ‘drowning in one’s own blood.’”
The federal government adopted pentobarbital for executions during President Trump’s first term. The Biden administration issued a federal moratorium on capital punishment in 2021. The second Trump administration reinstated the practice and, in April, said it would allow pentobarbital and executions by firing squad.
Tennessee has not given a reason for why Pike’s injections were ineffective, but the governor paused executions for the rest of the year and ordered an independent review. Some states are revisiting alternative methods of execution. Idaho, Mississippi, Oklahoma, South Carolina and Utah permit executions by firing squad in certain circumstances, and Alabama, Arkansas, Mississippi, Oklahoma and Louisiana allow executions by nitrogen gas.