Handling patients on recreational drugs

Zoya* sat across the desk poring over the medical consent form. She had struggled with dysfunctional uterine bleeding all her life. While other girls in high school enjoyed an easy adolescence with three to five days of periods, she would be spending three days in the school sanatorium nursing periods that lasted seven days and were extremely painful. She survived on injectable painkillers.

This alone was enough to make Zoya an oddball among her peers. At home, Zoya grew up with boys only and was somewhat a tomboy. She dressed different, spotted stylish hair-cuts and by 19, she rode a fancy motorbike that she had coveted for years. Her brothers saved for two years and bought it for her as a birthday gift.

Zoya gave her mother a series of mini-heart attacks over the years by riding alone to crazy destinations but no amount of pleading from her dad would take her. She was just Zoya. The only thing she could not seem to get on top of were her incredibly stubborn menses. At 35, her mind was made up, she was sure she had no desire to sire babies and had no use for a uterus that had only served to torture her for over two decades.

The decision to let go of her uterus was an easy one. The difficult part was comprehending the complexity of the surgery and the risks thereof. I sat across Zoya, answering her questions as we went through each segment of the consent form. Thereafter it was my turn to fire back with questions. She gave a negative response to my inquiry on alcohol and tobacco use but confirmed long-standing marijuana use.

It may have been a routine question for me but a positive response demanded further information sharing on how this may impact her response to anaesthesia during surgery and pain control thereafter. Further, the information helped me caution her on the possibility of withdrawal symptoms while in the hospital.

Despite Zoya acknowledging the fact that it was going to be a difficult post-operative period, she did not comprehend just how tumultuous it would get! The surgery was uneventful, with good recovery from anaesthesia. The first post-operative day was also very peaceful as she slept through most of it.

Her second day heralded the full picture of marijuana withdrawal. She was unable to sleep, with short fitful naps.  She wouldn’t eat anything, despite this being the time for resuming a full diet. She was extremely irritable and uncooperative, necessitating heavy sedation to facilitate sleep and to allow the nurses to care for her effectively.

The psychiatrist’s main role was to keep her calm enough to allow for normal post-operative recovery but since Zoya was not interested in giving up her marijuana use, this was not the time to deal with her addiction. The priority was to control her pain, ensure good wound healing, managing the side effects of her medication and getting her back on her feet.

She did go home on the fourth day, with a bag of medication to keep her comfortable for the next few days as her body settled down. Her caregiver was under strict instructions to ensure that Zoya ate at least three meals a day and drank two litres of water. We left the rest to Zoya to decide the way forward regarding her recreational habits.

As the debate about legalising marijuana goes on around the world and even right here at home, what is not in question is that it remains an addictive, mind-altering substance. It is therefore a no-brainer that abstaining from the same will result in withdrawal symptoms. Further, it will pose a risk to care if the patient fails to inform their doctor about the use.

Well, Zoya was back in a week for her review. She was back to her habit but I was glad that her surgical recovery was otherwise on track. I was just glad that she was upfront about it and we were able to plan appropriately for her care. Our doors remain open, should she choose to kick the habit!

Dr Bosire is an obstetrician/gynaecologist