"take a pill!"

dronabinol

This is an update on my pot problem. I went to go see my family practitioner for a routine Diabetes management visit and she asked me about my complaints. I went into the whole drama about the nausea and activity intolerance. She asked me if I understood why my surgeon was unwilling to prescribe Dronabinol (Trade name: Marinol, the active ingredient in cannabis) for my nausea, particularly since there was a lot of reason to believe it would work. I do not, and I told her that.

She sat back in her chair and said "enough is enough." She wrote me the prescription herself and handed it to me. We had been discussing this issue for some time before my visit and she knew how frustrated I was to be caught between this rock and that hard place. Receiving the prescription was a profound relief. She asked me if I was going to tell my surgeon that she did this for me.

"Damn right I am" I said. For one thing, he deserves to know what medications I am taking while I am under his active post-surgical management, but also I'm not going to be intimidated by a simple disagreement with him. That helps no one. We're both adults, we can handle this. In fact, to his credit, when I did tell him, he just congratulated me on being proactive and seeking a solution for my problems until I found one.

To complete the picture here, my family practitioner has known me as a patient for more than ten years. My surgeon has known me about five months at this writing, four months when he refused my request for a Dronabinol prescription. My family practitioner has all that time and experience with me to draw upon, she's seen me at my best and at my worst, she's seen me face a number of difficult medical decisions. She knows me.

I first believed that my surgeon was the best and only person really to prescribe Dronabinol for me because of the neuroendocrine complications of a gastrectomy. Now I am reconsidering that stance. If there is a judgment call to be made, my family practitioner is in a much better position to do it. My surgeon is just getting to know me. He is not in the same position as my family practitioner.

Further, my family practitioner is a generalist. She's responsible for caring for me as a whole person, and she has considerable skills in that area. Worrying about the nausea was only one part of this problem, it also had a social inhibitory effect, and it left me in the crappy position of being forced to choose between my physical well-being and my legal well-being.

That is, I can obtain cannabis, but it is illegal for me to buy, use and possess it currently in New York State, even for medical purposes. Further, as I am currently looking for a job, I would be setting myself up for a big hassle, and possibly losing a job opportunity, should I choose to treat my nausea by smoking cannabis and then having it show up on a pre-employment urine drug screen. My decision was simply not to use cannabis and live through the periods of nausea, even though cannabis is a safe and very effective treatment. That wasn't fair to me.

My family practitioner recognized that and did something about it. It required doing something counter-intuitive--prescribing an appetite stimulant for a bariatric surgery patient. I can't overestimate how important it is to have at least one medical doctor who knows you well and with whom you enjoy a long-standing and trusting rapport if you are considering bariatric surgery, or any other similarly complicated medical procedure. You need someone with a prescription pad who knows you well.

My surgeon is a specialist, he knows a lot about a few things, but he's understandably not as proficient at stepping back to look at the whole patient, and he's only known me for a short time. However, that kind of gestalt overview of my situation is actually not what I need most from him, I have someone to do that--my family doctor. I need for my surgeon to be the expert on the surgery and the follow-up for recovery from it.

I think he should change his mind about this issue, don't get me wrong, but this is not a deal-breaker for me as his patient. He's just wrong. He's not an ass, he's not letting this disagreement stand in the way of our relationship going forward. Nor am I. I'm complicated, I need several eyes on my problems, and if all my doctors agree on everything, well, probably not all of them are thinking very much about my problems.

In my surgeon's defense, now that I have taken the Dronabinol I have begun to understand some reasons why he might shy from prescribing it readily. It is an appetite stimulant. It gave me "the munchies." In the hands of a patient without the eating management skills that I developed in years of psychotherapy for my eating disorder I can certainly see how this agent could confound weight loss. Further, in the hands of a post-surgical bariatric patient with an active and un-managed eating disorder (unfortunately, there are far too many of these roaming around) it could conceivably nudge a prone patient into dangerous behavior, i.e., causing the patient to eat until self-injury.

In my case, I recognized what was going on when I got "the munchies" and simply became more vigilant about what I was eating. It was a bother, I kept reaching for food and then stopping myself. That was a minor hassle I could do without, but the hassle of maintaining that vigilance was an easy trade-off for being able to enjoy a dinner with my friends without looking like I was about to hurl the entire time. "The munchies" effect wears off in a few hours. The anti-nausea effect lasts much longer.

Also, let's be honest (so few are), Dronabinol gets you high. It reminds me of the experience of eating a pot brownie from my youth. That's not so bad for me and it's not something I found to be disabling. For someone prone to addictive behavior, this could cause more problems than it solves. Powerful drugs deserve respect, Dronabinol too.

Further, another down-side for Dronabinol is that the oral dosing takes about an hour to reach full effect. Smoking or inhaling cannabis works in a couple of minutes. Further, Dronabinol has to be refrigerated (cannabis does not), so I can't just carry it around all the time. That's a nuisance. It was also difficult to find a pharmacy who kept it in stock. It took me a couple of days to get it filled in Manhattan! I can only imagine what it might be like in other places.

Now that I do have it I'll probably just use it on days when I have some social eating event planned and I feel the nausea syndrome coming on. That coincidence of events is pretty rare, it has only happened twice so far in my own recovery, so I might not even use it again before this whole neuroendrocrine homeostatic chaos syndrome completely resolves (I anticipate that at about the six month mark). I could have done without the Dronabinol, that's true, but I shouldn't have to.

There are so many unpleasant things that happen as a result of bariatric surgery that no one can help me with. I think it is very important to get help with those things that can be helped. This post-operative centrally-mediated nausea is one of those things, but it has to be done carefully, and by providers who have the time, interest and resources to ponder considered judgment calls like prescribing an appetite stimulant to a post-op bariatric surgery patient.

There's no more of a cookie-cutter formula for this than there is with anything else in dealing with morbid obesity. It's a confounding problem, with many highly complex and conflicting factors to consider. One of the things I've learned about hunger while researching all this is that there are redundant systems for it in the body. If you shut down hunger one way, there's other ways for it to arise, not surprising given it's role in survival and reproduction.

I fear that bariatric surgery, with it's profound and powerful implications in treating obesity and Diabetes, is bound to become fast-tracked into a situation analogous to the use of Viagra for erectile dysfunction. No one treats sexual dysfunction in a multi-disciplinary context any more despite the fact that it is well-known that some significant portion of those patients are suffering from a psychosocial problem that can't be addressed effectively with a little blue pill. Consumers simply want to be prescribed the pill and the pharmacology industry has made millions this way.

When something works, everyone wants it, and it becomes a profit center in a profit-driven health-care financing model. The subtleties of the Art of medicine get lost in all that. I fear that bariatric surgery is destined to go the way of cosmetic surgery, or the treatment of erectile dysfunction and become a consumer-driven phenomenon. That's going to hurt people. But, that's another discussion....

next - I feel good!