"Legalize it, don't criticize it..."

my pot problem

Regular readers will remember that I was unwilling to have gastric bypass surgery because of the dearth of knowledge concerning the long-term effects of rearranging the intestinal tract. My doubts were not so much about the mechanical rationale for shortening the tract, it was for tossing a wrench into the neuroendocrine black-box of the gut.

Bariatric surgeons had discovered, quite by accident, that certain bariatric surgical procedures had a powerful effect on poorly-understood neuroendocrine mechanisms in the gut, with the happy effect of essentially curing type 2 Diabetes with a knife. Now they were rapidly moving towards such revolutionary actions as changing the name of the field to "metabolic surgery" and vigorously arguing to payers that it's cheaper to pay a surgeon to do some surgery than to pay an endocrinologist to manage a diabetic for life. They're right on all counts, but that's just with what we know now.

Such bandwagon-jumping can be dangerous. While the bariatric surgery community later on would be free to say "sorry, wow, we didn't know that" when some undesirable sequellae emerge down the road, I'd be the one living with them, permanently and irretrievably. It just didn't make sense to me, so I steadfastly refused gastric bypass every time it was urged on me, which was every time I talked to any bariatric medical provider. I don't blame them for this single-mindedness, it's really an epistemological problem, i.e., it is what their data tell them to do, they just forget that's not the only way to know something.

What made the difference for me in choosing the sleeve gastrectomy was that general surgeons have been doing subtotal gastrectomies for decades, if there was something super weird that ended up emerging in the long term for these patients, it would be known by now. Yes, I realize bowel resections have been followed over the long-term as well, but I was also disinterested in tip-toeing around dumping syndrome, chronic diarrhea, malnutrition, and other realities that people who have gastric bypass surgery regularly face.

I wanted gastric banding, though I was uncomfortable with placing a foreign body inside my abdomen permanently. We do have some longer-term experience with this, particularly in Europe, and it hasn't been great. I'd have to almost beat the odds to have a trouble-free long-term course. Of course, this decision has to be balanced against the long-term risks of not doing surgery, which for me were significant and increasing.

As I've discussed elsewhere, my surgeon talked me into the sleeve gastrectomy, partially because I could retain my anatomy, most notably my pylorus, and I wouldn't be mucking around with the neuroendocrinology of the small bowel. This, combined with the experience that sleeve gastrectomy was a more powerful intervention in terms of expected weight loss than the gastric band, along with the lack of placement of a foreign body, was what convinced me to choose this option.

Well, best laid plans being what they are, I now find myself on the horns of a neuroendocrine dilemma I did not anticipate. The part of the stomach that I had removed secretes a number of powerful peptide hormones. These hormones, and the part of the stomach that secretes them, has just recently been understood at all, as in the last decade, and drug companies are of course conducting a lot of research into finding a way to manipulate these hormonal pathways pharmacologically.

They should. I can tell you from personal experience that the effects are dramatic. I now regularly am passing through periods when food disgusts me, and eating is very unpleasant. If I could have taken a pill that did this, I could have lost any amount of weight easily and comfortably. On my worst days, merely walking past a restaurant can bring on nausea. When it's not quite that bad, the first bite of food will nauseate me, and I completely, totally, lose interest in the second bite. Eating becomes a chore, something I do as little of as I can get away with, as infrequently as I can get away with it.

I do not experience hunger, and I have not since the day of surgery over three months ago, no matter how long I go without food, no matter how negative my caloric balance. On better days, I can enjoy eating from a sensual standpoint, enjoying the taste, fragrance, and texture of food, but I am still not hungry, and I don't eat to satisfy a drive.

I discovered something, quite by happy accident, that completely reverses this problem. After using this remedy, on my worst days I could reliably and immediately return to the experience of my better days, enjoying food from a sensual standpoint, without swinging on some neuroendocrine pendulum over to hunger. The nausea disappears completely within a couple of minutes and it is not replaced by anything like "the munchies." It simply disappears. The effect is dramatic, shockingly so. The remedy is cannabis.

cannabis

I have a new appreciation for the fondness that cancer patients have for cannabis. It works. It has a few minor side effects, most of which are euphoric. If I had cancer, and cannabis made it possible to eat, woe be unto those standing in my way. Illegality wouldn't concern me, social stigmas wouldn't concern me, I'd figure out how to get it and I would use it without shame or social restraint. Fortunately, in some enlightened states, cancer patients, and presumably people like myself, don't have to deal with the criminal underground to get their medicine, nor do they have to make a habit of avoiding law enforcement. That's a good thing, movement in the right direction, long overdue

As a bariatric surgery patient I should have the same access to medicine that will improve my post-operative course, but I don't. I am not dying, and I have to think about my career, and my health over the long-term. I am right now looking for a job, and in health-care such a job is likely to involve pre-employment urine drug screening, so I can't just go off on my own and start smoking pot, even on the rare occasions that I would do so to reverse this nausea, because it remains detectable in urine for weeks after even occasional use. Smoking is a bad idea altogether, people with marijuana prescriptions also get a vaporizer, a machine that delivers the drug via an inhaled route without the tar and other undesirable by-products of combusting the marijuana plant.

The solution for me is a prescription for the active ingredient in cannabis, which is known by the trade name Marinol, and is as available as any narcotic at the corner drug store. I could present such a prescription at the time I submit to a pre-employment urine drug screening and be exempted from the social/employment consequences of the discovery of cannabinoid metabolites in my urine. I also wouldn't have to smoke anything.

I asked my surgeon for this and he refused, citing concerns about "cross-addiction" emerging in bariatric patients post-surgically. This is a valid concern, but I think it should be measured against the other concerns, not simply thrown-up as a knee-jerk road-block. I have been in treatment for nine years for an eating disorder which is related to addiction disorders, I am still under active psychological care for such. I have managed this problem successfully for a number of years pre-surgically, does that not count for something? Does that not significantly lower my risk for cross-addiction? Of course it does.

No, I don't think an over-riding concern for bringing on an addictive disorder is at work here. I think there are a number of social factors at work here, and I now newly appreciate the obstacles that advocates for medical marijuana face within a puritanical and backward American society, still trapped in the "Reefer Madness" propaganda and the association of recreational/social marijuana use with African-American culture and organized crime.

Beyond that, another thing I think is at work is the over-all biases about the emotional make-up of the obese. We are seen as out-of-control gluttons who prefer the short-term rewards of over-eating (or getting high) to the long-term rewards of good health and psychosocial stability. Again, that stereotype, like all stereotypes, didn't just appear out of nowhere. I've known obese people who fit it to a T, and I've certainly known first-hand the various psychological pulls that would encourage one to err in that direction.

But, individual practitioners have a responsibility to know their patients as individuals, and even more importantly, know their own biases well enough to see things as they really are. I know that's a tall order, but to whom much is given, much is expected.

All I wanted is what is known as a non-refillable prn prescription. That is, a small number of pills just to have on hand so I can do something about my inability to even be within sight and smell of food on some days, and protection against the social consequences of the metabolites of cannabis showing up in a pre-employment drug screening. This effect I am experiencing resolves on it's own in a few months, this wouldn't be a long-term intervention, just a one-time short-term addition to my pharmacologic tool box.

Right now, if I were given to smoking marijuana to relieve this nausea, I could lose a job opportunity, and create a permanent record of being suspect of illicit drug use, simply because I'd like to walk past a restaurant without becoming physically nauseated on my worst days. That's not fair, and it is a lot to put me through, simply to minimize one post-operative risk.

That's wrong. Plain and simple, and I am angry about it. Fortunately, the anger makes me feel better on my worst days, but I shouldn't have to chose between feeling well and getting a job. Further, with a Marinol prescription I could take a pill instead of being tempted to smoke marijuana to treat this. Taking the pill is much safer, both from a health standpoint and from a social standpoint. Putting me in a position where I am actually encouraged to do something illegal in order to feel well is unfair.

I am denied this option for no medical justification I can identify, and some of my doctors, notably my cardiologist, completely agree with me. My cardiologist did mention that he felt it was counter-intuitive to prescribe an appetite stimulant to a bariatric surgery patient and he's right, it is. But, doctors perform such counter-intuitive measures when faced with medical evidence on a regular basis.

Other medical doctors I know socially also agree with my position, but I'm not willing to ask them (or even my cardiologist) for help with this because (aside from the fact that doing such would resemble the doctor-shopping that drug addicts engage in on a regular basis) the problem, uncomfortable as it is, is not life-threatening. I can tough this out. My bariatric surgeon is the right person to write the prescription, and ironically, if anyone should not need convincing, it is him. It is the right drug for the right reason.

To be fair to my surgeon, the DEA is hard on doctors who prescribe schedule-3 controlled substances. I can understand him wanting to avoid the withering glare of the regulators, they can be just as backward and uninformed as the general Puritanical public. But, you know what? I'm hurting here. This is not a great place to be, and there's no medical reason for me to suffer. As a hospice nurse, a treater of symptoms primarily, this really bothers me.

So, legalize it, don't criticize it. I'm going to join NORML now.

next - crossing a threshold