opiads and gastric bypass................got to get this to my MD

I originally posted on the general forum regarding my struggles with my opiad use and absorption problems due to neck surgery and chronic pain....being treated like an addict is one thing ...if i was one....but im not.  My most recent visit to my PcP was regarding getting off my meds due to I didnt want to be treated like an addict and would rather be in pain than have the narcotics nurse put words in my mouth etc...my PCP made the statement that there is no documentation regarding opiod malabsorption...even though its documented in my files my vits and minerals etc and potassium pills didnt absorb....so while i wait for ellners office to forward some docs to me I found this article....hoping it helps others like me....

Director, Clinical Pharmacy Services, MSC-Medical Services Company, Jacksonville, Florida
 

 

The number of bariatric surgical procedures performed in the United States has risen dramatically, from an estimated 16,000 procedures in the early 1990s to about 103,000 in 2003.^[1] The surgery may involve a restrictive procedure (ie, vertical-banded gastroplasty or adjustable gastric banding), or a combination of restrictive and malabsorptive procedures (ie, biliopancreatic diversion or Roux-en-Y gastric bypass). Roux-en-Y gastric bypass is the most frequently performed variety in the United States, and it involves forming a small stomach pouch to restrict food intake and then reconnecting the small intestine to the pouch.

Bypassing a large portion of the stomach and small intestine puts these patients at risk for malabsorption, and it also changes the absorption of some medications. Patients are prone to deficiencies in the fat-soluble vitamins (A, D, E, and K) and in calcium.^[2,3] Thus, appropriate supplementation with iron, vitamin B₁₂, calcium, and folate is an important consideration.^[2,3] In some cases, parenteral iron infusion may be necessary to avoid anemia, particularly in menstruating women.^[3]

Due to changes in the acidic environment and the reduced surface area for drug absorption, changes in drug delivery route or dose may be necessary to assure adequate drug concentrations. Avoiding extended-release formulations is recommended, due to their long absorptive phase in the intestine.^[2,4] Immediate-release formulations with a more frequent dosing schedule may be required. It may be useful to use a liquid formulation to eliminate the drug absorption phase where possible.^[2] Other routes, such as intramuscular, transdermal, subcutaneous, and inhalation, may be considered. However, it is also important to keep in mind the impact obesity may have on these routes of administration.^[2]

The salt form of medications may also require consideration.^[2,4] For example, calcium citrate does not require stomach acid for absorption and would be a more reasonable choice than calcium carbonate, which requires a higher acid concentration.^[2,4]

Nonsteroidal anti-inflammatory drugs (NSAIDs) and oral bisphosphonates should be avoided in this population, since these patients are at increased risk for ulceration due to the reduced stomach size.^[2] Consider using alternatives for pain relief, such as acetaminophen, tramadol, and/or opiates. Likewise, alternatives for osteoporosis prevention can be used.^[2]

For gastric bypass patients, it is thus appropriate to regard these factors: route of drug administration, salt formation, monitoring of medication blood levels to assure therapeutic concentrations, and appropriate nutrient and vitamin supplementation. As indicated, the impact of obesity and changes in lean body mass may also be important considerations when choosing drug form and dose.^[2,5]

 

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Medscape Pharmacists. 2006;7(2) © 2006  Medscape
 

Cite this article: Brigette Nelson. How Does Bariatric Surgery Affect the Absorption of Medications? Medscape. Dec 18, 2006.

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i am confused? i take large amount of opiates for chronic pain faile dback surgires and aritis and i have  a apin contrat also so it shows i am not abusing them.. and need them so are you sayong thta after surgery the opiates wont work?? they do not have asprin in them

I am having difficulty reading your post.....as to the aspirin....it depends on what type of gastric surgery and what your physician determines what will work for you...You might re-read your contract.

I too am confused.  Are you claiming that opiates are malabsorbed in people who have had RNY?  If so, the article you posted does not support that, unless the opiates you use are time-release.  So, what is your ultimate goal?  To get off the opiates?  If so, how are you going to deal with the pain?  Is your goal to get different ones/more?

Immediate-release formulations with a more frequent dosing schedule may be required......noted in the documentation

it supports the time-release, with reference to the above....ultimate goal...educate the MD and clinic...that the above statement

supports the dosing I am on...regardless as to the "normal patient requirements".   I would love to get off the opiates...unfortunately due to the chronic nature of my injury...it may never be possible...the laws regarding distribution of schedule c drugs has changed in the last couple of years...making it harder for those that truly need pain control to not only get them prescribed..and administered.   My rights as a patient, my rights to quality of life  are at risk...Thier policy is for thier protection...and I understand that...my goal is to educate the powers that be....to show documentation that a gastric bypass does have malabsorption issues  with not just vitamins, minerals and protien etc.

I choose not to be treated as an addict....would rather be in pain than have them "determine what my pain levels are supposed to be based on a normal persons absorption rate"....my goal is not to get different drugs or more...my goal is to maintain a quality of life as close to the one I had before my injury....that is my right...

this is not the first battle over my patient rights to medical care...and probably not the last....the first took 3 yrs and damaged nerves beyond repair...because I was "logged as a "typical workers comp claim...just wanting free medical care and a quick payout"....after 3 yrs of battling....seeing 16 surgeons md imaging centers ect...only to be told it was in my head....when a lay person with no medical experience can see a problem with a bone that wasnt there before...and finalyy having to go out of state to have surgery to correct a much delayed and needed surgery....you might be able to understand why i fight for my rights....because of how I fought and won for them ....it changed policy in my state...but sadly left me damaged....

I fight now to not only help myself ....but could possibly make a difference for someone else down the road....

more explanations in the other posted replys should you care to read....thanks for your opinion

 

I am also confused what you trying to achieve or prove.

I noticed that after RNY I absorb more of the opiates than I did before surgery. I need less for the same pain control. The delivery is much faster.  That may be due to my smaller size, but now even 1 small lortab 5 mg makes me woozy 5-10min  after taking it.  I only can take them when I know I can lay down.

I have been on opiates for years.  Never once have I have been accused of being an addict by any physician. Can you explain why they are accusing you of this? I have yet to hear about these drugs not being able to be absorbed by patients that have had gastric bypass surgery.  Only time released medication.  I'm sorry, but I feel like we are not getting the whole story here.  Have you changed alot of doctors in a certain period of time?  Drug testing for patients on prescription drugs that are prescribed legally????

same doctor, same drugs...have tried accupuncture, etc...and yes class c drugs regulated by the government, recent rules in dea have been cracking down on MD writing rx for opiads for those that don't really need it....hence many institutions writing schedule c drugs have been re-evaluating thier patient status/needs and contracting the patients to only get opiads from that particular MD...any other req for drugs from any other MD...even if you go to er and they go to prescribe a schedule c  opiate "if you dont advise them that you are already contracted with your primary care physician for opiads...regardless if they are giving you something different than what you are on..." thier report gets turned in to your PCP who sees that opiads were ordered...they red flag you for seeking or searching " the policy is then that they discontinue your opiads immediately....which by the way on some cschedule c drugs can be deadly...and red flag your medical records and contact the pharmacy...then it goes nationwide....literally...............this is what I was told by the narcotics nurse, the pharmacy and my MD....his fear is that they can take away his privilege of writing RX for opiads....over one bad case thats all it takes...

so you might check with your clinic policy or MD policy....I have been on opiads since 2004 due to this neck injury....sure there was never any problem getting them ...they were called to the pharmacy and I went and picked them up ...simple....

this has happened since the last year.....so the whole story is ....same doctor, no doctor changes....no searching...

what has changed is I now have to once a month go down physically pick up my Secure RX after visiting a Narc nurse, pull a ball out of a basket ..if the color of the day comes up...urine test...if urine test comes up neg....I get warned and put on notice that if it comes neg again at any random time...in other words they can call me in at any day any time and say we need a drug test...this last section has never happened to me ...so far I must be picking the correct color balls....I can no longer pick up the rx a week in advance to make sure the pharmacy carries enough stock....if they dont have it after they recieve the secure rx I have to go back to the MD get another secure RX have the pharmacy call and make sure the dr is aware they dont have the drugs for me and I have to look if the other stores carry it or the hospital has it....this has happened 2 x  to me....

and yes drug testing for prescribed legally drugs is happening due to recent changes in the law.  Its under the ruse of preventing illegal sales of prescription drugs ....

sorry so long...hope that answered your question

 

trying to educate.....evidently a lot of people.....not trying to prove anything...and yes your delivery is faster...its absorbed quickly...but if you are going to sleep on it...how long does it last in your system to control the pain.....and as this is for your RNY surgery...I am guessing you were given a relatively small amount to be used as needed...perhaps less than a thirty day supply?

 

Chronic pain is different than "after surgery pain"....I too have had surgeries after the gastric bypass...and needed them for less than the required amount....I healed and that pain was done and over with....this is chronic...never going away with me 24/7 with levels in pain ranging from 3...controlled and I am functional enough to carry on household chores to 7 which has me hunched over and a left arm nearly non functional with no sensation/touch/feel and neck pain so severe the best relief is to get the 10lb head I have and lay down to relieve some of the pressure....

I too get "woozy-relief" when I take a morphine....however it doesnt put me to sleep...it relieves pain....but only for about 1-2 hrs vs the 1 every 4hr dose....it wears off quickly....I would think, correct me if im wrong that if you are laying down...fall asleep?...then you probably arent aware of how long the drug stays in you...I am trying to do normal things in life...not be asleep through it.

That's why I asked question.  You try to convince the doc that due to RNY you malabsorb the meds when in fact - you most likely have no problem with absorption of them.  You don't malabsorb the meds - your body processes them faster.  Or at least that' how it feels to you.  I get that with alcohol - I get drunk on one glass of wine and I feel "sober" 1 hr later. (though I know that I am not sober) 

I deal with some chronic pain due to herniated disks but I manage that using mostly natural methods and only when really needed use opiates. Since I absorb rapidly - there is a very fast delivery - I get the smallest possible dosage (sometimes 1/2 pill)  and take them more frequently, to provide more stable blood level. Beside that I exercise as much as I can (yoga) and use natural herbal remedies to control pain (non addictive) as well as acupuncture.  I also make sure that I don't "overdue".

as you know - since you are dealing with the pain meds for  awhile now - they do changed how they manage the opiates. Also - lately there is a lot of press about transfer addiction after RNY.  I know at least 2 people who develop drug problems and needed in-house treatment, and another one who is alcoholic, Sad.

But coming back to your situation - you may need talk to the doc to change how the drugs are delivered.

Also - since you use the drugs for a while now - you know that body develop tolerance to them.  And eventually you need  more and more to provide the same pain relief. 

I hope you find a solution to your issue. One way may be to ask the doc to check your level as you take them and test it every 1 hr or so. So the doc and you would know how fast your body absorb it and how fast it process it.

 

here is what I found... not sure if that would help you;

http://www.drugs.com/answers/i-need-opinions-on-strong-effec tive-non-extended-428810.html