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Case Report
Methamphetamine Use Following Bariatric Surgery in an Adolescent Sanjeev Dutta, MD, MA1; John Morton, MD, MPH1; Elizabeth Shepard, MD2; Rebecka Peebles, MD2; Susan Farrales-Nguyen, RN, MSN, FNP1; Lawrence D. Hammer, MD2; Craig T. Albanese, MD1 Departments of 1Surgery and 2Pediatrics, Lucile Packard Children’s Hospital, Stanford University Medical Center, Stanford, CA, USA Bariatric surgery is increasingly popular as a therapeutic strategy for morbidly obese adolescents. Adolescence represents a sensitive period of psychosocial development, and children with considerable weight loss may experience greater peer acceptance, accompanied by both positive and negative influences. Substance abuse exists as one of these negative influences. We present the case of an adolescent bariatric surgical patient who abused methamphetamines in the postoperative period, with consequent nutritional instability. A concerted effort must be made in the preoperative assessment of adolescent bariatric patients to delineate a history of illicit drug use, including abuse of diet pills and stimulants. Excessive postoperative weight loss or micronutrient supplementation non-compliance should raise a suspicion of stimulant use and appropriate screening tests should be performed. The consequent appetite suppression may manifest with signs of malnutrition such as bradycardia, hypotension, and weakness. Inpatient nutritional rehabilitation and psychiatric assessment should be considered. Key words: Adolescent, methamphetamine, obesity, morbid obesity, bariatric surgery
diet medication in the 1950s and 1960s, accounting for 31 million prescriptions in 1967,1 but has since been banned due to its extremely addictive properties and severe side-effect profile. Methamphetamine continues to be a commonly abused street drug, and its use by patients who present for consideration of bariatric surgical procedures has been reported.2 While assessment recommendations for bariatric surgery have emphasized the importance of preoperative psychiatric and substance abuse history,3 there are no reports of new-onset stimulant abuse in the postoperative period. We present a novel case in which an adolescent bariatric surgical patient used recreational methamphetamines in the postoperative period with consequent nutrtional instability. As pediatric surgeons embark on surgical treatment of morbid obesity in the adolescent population,4 we must be aware of the potential for methamphetamine (and other illicit drug) abuse in the pre- and postoperative periods in this particularly vulnerable population.
Case Report Introduction Methamphetamine use is popular among individuals suffering from morbid obesity due to its appetite suppressant effect. It was a commonly prescribed Reprint requests to: Sanjeev Dutta, MD, Division of Pediatric Surgery, Lucile Packard Children’s Hospital, 780 Welch Road, Suite 206, Stanford, CA 94305 - 5733, USA. Fax: 650 725 5577; e-mail:
[email protected]
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A 17-year-old female presented to the Lucile Packard Children’s Hospital Pediatric Weight Clinic with extreme obesity. Her calculated body mass index at that visit was 46.3 kg/m2, with weight 130 kg (286 lb) and height of 167 cm (66 inches). Her presenting symptoms included headaches, back pain, knee pain, dysfunctional uterine bleeding, a history of breathing problems attributed to asthma, and heavy snoring. © FD-Communications Inc.
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Adolescent Bariatrics and Amphetamine Use
A full medical work-up was performed. Ophthalmologic evaluation revealed bilateral papilledema but MRI of the brain was negative for intracerebral tumors. A diagnosis was made of pseudotumor cerebri in the setting of morbid obesity. An orthopedic evaluation revealed bony degeneration in her lumbar spine at L4 and L5. Menorrhagia was ongoing despite a negative endocrine and coagulation work-up. Pulmonary function testing did not show obstructive pulmonary disease, but instead a restrictive thoracic component consistent with her severely obese status. Psychological assessment included evaluation by a psychiatrist. The patient reported periods of low mood as a result of her weight problem, for which she had been routinely teased and excluded by peer groups. Her family situation was noted to be stable. She had no clinical psychiatric diagnoses, and there was no history of alcohol or drug usage. The patient also denied binge eating, laxative or diuretic use, diet pills, or fasting. She was believed to be an appropriate bariatric surgical candidate based on her work-up and the guidelines set forth by the Adolescent Bariatric Study Group.5 The patient underwent a laparoscopic Roux-en-Y gastric bypass operation in November 2004, with uneventful postoperative recovery. She was hospitalized 2 months postoperatively for partial bowel obstruction which was successfully treated with laparoscopic lysis of a single adhesive band. At her 4-month follow-up, the patient admitted to not taking her supplements (B12, Actigall®, and omeprazole) on a regular basis, and that she was distracted from her daily nutritional regimen by increased activity with friends. She was counseled on this matter, and measures such as pill boxes and a daily log were instituted. At her 7-month clinic visit, the patient was found to be compliant with her nutritional and medical regimen. Her weight was 82.9 kg (BMI 30.7), indicating an appropriate postoperative weight loss of 44.3 kg (97.5 lb). Her mother raised concerns that the patient was spending an inordinate amount of time with a neighbor whom she believed to be a negative influence, including possible use of marijuana and alcohol. One week following this visit, the patient was assessed by the surgical team for excruciating abdominal pain. The pain had been intermittent over the preceding week. Bloodwork including liver function tests, complete blood count, amylase, and a chemistry panel were all within nor-
mal limits. An ultrasound of the abdomen showed cholelithiasis but no evidence of cholecystitis or choledocholithiasis. A renal protocol CT scan did not reveal nephrolithiasis. Her pain resolved spontaneously, and she was discharged home. At her 8-month follow-up visit, the patient reported weakness and light-headedness. Further assessment revealed a blood pressure of 110/50 and a heart rate of 48. She denied any other symptomatology and insisted that she was compliant with her nutritional regimen. Electrolyte panel and liver enzymes were within normal limits. Her total serum protein was 5.6 g/dL (normal 6.0-8.0 g/dL) and her serum albumin was 3.2 g/dL (normal 3.5-5.0 g/dL). Remaining bloodwork was normal. A urine toxicology screen was positive for methamphetamines. When approached with this information, the patient became tearful and admitted to smoking methamphetamine twice daily for the previous 2-3 weeks, and to not being compliant with her diet and medications. It also emerged that there was a strong family history of prior methamphetamine use including her father and two brothers, and a history of amphetamine use by her neighbor-friend. The patient reported significantly reduced appetite and sleep during the period of drug use, although she was not actively trying to restrict food intake, and claimed to take the drug for its euphoric effects. She denied binging or purging behaviors. The patient was fearful of the consequences of her drug use and was not planning to use methamphetamine again. The multidisciplinary team (including adolescent medicine, psychiatry and surgery) delineated two problems, stimulant substance abuse and malnutrition. It was believed that the patient’s malnutritive state was secondary to her reduced appetite from methamphetamine use rather than any conscious restrictive or purging behaviors. Her bradycardia was attributed to her malnutrition. She was admitted to the hospital in July 2005 for treatment of her nutritional instability, and placed on strict medical bedrest with multiple small meals. She was not experiencing amphetamine withdrawal symptoms. ECG was read as sinus bradycardia, but otherwise normal. After a 22-day hospital stay, she was discharged with stable vital signs and on six small meals per day, with weight 80 kg. In March 2006, she weighs 80.3 kg (BMI 28.3), and continues to do well. Obesity Surgery, 16, 2006
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Discussion Methamphetamine (a.k.a. crank, meth, crystal, speed, ice, bennies, glass, pep pills, and uppers), is a central nervous system stimulant that may be administered by intravenous injection, smoking, snorting, or by oral consumption. It is more potent than amphetamine as a CNS stimulant although it is weaker in other properties.6,7 Methamphetamine releases high levels of dopamine which stimulates brain cells, enhancing mood and body movement.6 In addition to its euphoric effects, methamphetamine has an appetite suppressant effect: hence its use and abuse among individuals suffering from morbid obesity.8 Methamphetamine produces euphoria, increased alertness, paranoia, decreased appetite and increased physical activity. Negative health effects include stroke, cardiac arrhythmia, hyperthermia, stomach cramps, shaking, anxiety, irritability, insomnia, and Parkonsonian-type symptoms.9 Prolonged use can result in symptoms resembling schizophrenia including auditory and visual hallucinations, panic, and paranoia.10 Up to 36% of methamphetamine users are introduced to the drug prior to 16 years of age.9 White females in their twenties are the most common methamphetamine users, with weight loss cited as one of the most common reasons for use.9 With epidemic increases in the rate of adolescent obesity, particularly among females, we can expect corresponding increases in methamphetamine abuse in this population. In addition, as morbidly obese adolescents lose weight through bariatric surgery, they may gain further peer acceptance that can unfortunately lead to adverse consequences mediated through peer pressure such as illicit drug use. A careful search for indicators of substance abuse or predisposition to it should be instituted in the preoperative assessment of adolescent patients who are considering bariatric surgery. Our patient had a significant family history of methamphetamine use that was not revealed in the preoperative period. Postoperative indicators in this patient included rapid weight loss, personality change, disregard for the postoperative nutritional regimen, and negative peer influences. Her bradycardia and hypotension were secondary to a combination of nutritional noncompliance and dehydration. 782
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Although our patient was not thought to exhibit an eating disorder and had appropriate weight loss, one should be suspicious of anorexic or binging-purging behaviors in bariatric surgical patients who have supranormal rates of postoperative weight loss. Segal and colleagues11 have documented 5 cases of a post bariatric surgical eating disorder and have proposed addition of a new eating disorder that they term Post Surgical Eating Avoidance Disorder (PSEAD). Patients with PSEAD do not fulfill the DSM-IV criteria for anorexia nervosa, bulimia nervosa, or binge-eating disorder. A hallmark of this condition is a reaction of extreme anxiety or active negative attitude in the face of nutritional correction by healthcare professionals. This arises from an intense fear of weight regain. Our patient was quite agreeable and compliant to nutritional correction.
References 1. Anglin MD, Burke C, Perrochet B et al. History of the methamphetamine problem. J Psychoactive Drugs 2000; 32: 137-41. 2. Segal A, Libanori HT, Azevedo A. Bariatric surgery in a patient with possible psychiatric contraindications. Obes Surg 2002; 12: 598-601. 3. Inge TH, Garcia V, Daniels S et al. A multidisciplinary approach to the adolescent bariatric surgical patient. J Pediatr Surg 2004; 39: 442-7; discussion 446-7. 4. Garcia VF, DeMaria EJ. Adolescent bariatric surgery: treatment delayed, treatment denied, a crisis invited. Obes Surg 2006; 16: 1-4. 5. Inge TH, Krebs NF, Garcia VF et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics 2004; 114: 217-23. 6. Cho AK, Melega WP. Patterns of methamphetamine abuse and their consequences. J Addict Dis 2002; 21: 21-34. 7. Carneiro JRI, Nader AC, Oliveira JEP et al. Past use of amphetamiines in candidates for gastric bypass surgery in a university hospital. Obes Surg 2006; 16: 31-4. 8. Bray GA. Use and abuse of appetite-suppressant drugs in the treatment of obesity. Ann Intern Med 1993; 119: 707-13. 9. Cretzmeyer M, Sarrazin MV, Huber DL et al. Treatment of methamphetamine abuse: research findings and clinical directions. J Subst Abuse Treat 2003; 24: 267-77. 10. Yui K, Ikemoto S, Ishiguro T et al. Studies of amphetamine or methamphetamine psychosis in Japan: relation of methamphetamine psychosis to schizophrenia. Ann NY Acad Sci 2000; 914: 1-12. 11. Segal A, Kinoshita Kussunoki D, Larino MA. Post-surgical refusal to eat: anorexia nervosa, bulimia nervosa or a new eating disorder? A case series. Obes Surg 2004; 14: 353-60.
(Received February 19, 2006; accepted March 29, 2006)
