Dear Dr. Roach: Recently in your column, you discussed the need for dosages to be exact in some situations. What about the medical marijuana issue? In our small town, there are four dispensaries. If someone truly felt he or she needed it for medical issues, would that person get the same dosage at each location? If the doctor prescribes aspirin, he doesn't have me go to the willow tree, or to the willow dispensary down the street.
A: You are exactly right that the content of the active components of marijuana varies from strain to strain and even from plant to plant. This makes getting exact dosages impossible. This is a general problem with natural products, which is why Western medicine has preferred to identify, extract and purify the active ingredients.
There is a potential downside to this philosophy, which is that the purification may remove other substances, which may themselves have an effect or may modify the effect of a substance found in the original natural product. This appears to be the case with marijuana, as there are at least two compounds with important potential medical benefits, tetrahydrocannabinol (THC, which has several subtypes, especially delta-9 and delta-4) and cannabidiol (CBD). The effect of dronabinol (Marinol), a synthetic form of delta-9 THC, is reported as being very different from natural marijuana by most people who have used both, though this may be an effect of dose, of speed of onset, or of expectations. Hence the interest in medical marijuana, with its multiple compounds and ability for growers to emphasize the THC or CBD content.
Recreational users of marijuana have experience in achieving the correct dosage; however, for medical use (such as seizures), that ability isn't relevant. I suspect the future will include a greater degree of chemical analysis of the THC and CBD content in a given batch.
Roux-en-Y bariatric surgery
Dear Dr. Roach: I was told that a gastric bypass only makes the stomach smaller and does not affect metabolism. Is this true?
A: There are several different types of bariatric surgery (surgical procedures designed to help people lose weight). About 50 percent of bariatric procedures done now are of a type called Roux-en-Y gastric bypass. This procedure does indeed make the stomach smaller: The primary means for weight loss is a sensation of the stomach feeling full after ingesting less food. However, the small intestine also is bypassed, causing some food not to be properly absorbed.
Also, removing a portion of the stomach changes some of the hormones involved in weight loss (especially one called ghrelin, which promotes hunger and is made in the portion of the stomach that is removed). So it does affect metabolism. Lower levels of ghrelin lead to less hunger. After two years, the expected loss of excess weight (the difference between what the person weighed and what he or she should weigh) is about 70 percent with a Roux-en-Y. Part of the reason this type of bariatric surgery may be more effective than other types, such as the gastric sleeve procedure or gastric banding, could be due to the hormonal changes associated with removing the ghrelin-producing cells.
Bariatric surgery remains the most effective long-term weight solution for people with serious weight problems, but it is not for everybody.
Readers: The booklet on edema and lymphedema provides information on the causes of foot and ankle swelling. Readers can order a copy by writing: Dr. Roach, Book No. 106, 628 Virginia Dr., Orlando, FL 32803. Enclose a check or money order (no cash) for $4.75 with the recipient's printed name and address. Please allow four weeks for delivery.