Alcohol and other addictions after bariatric surgery. #obsmuk 's 22nd May chat blog by Dr Denise Ratcliffe

Alcohol and other addictions after bariatric surgery

Bariatric surgery is the most effective treatment for obesity in regards to weight loss and treatment of obesity related conditions. Perhaps more importantly, it is safe with a low risk of complications and death.

However, the evidence on longer-term outcomes following bariatric surgery has evolved and there is a growing awareness of the psychological difficulties that can arise following surgery, including addictive behaviours that are the topic of the forthcoming #obsmuk chat.

The types of addictive behaviours that have been discussed following surgery include alcohol, shopping, gambling, sexual behaviour, exercise etc.  The concept of “addiction transfer” following surgery is a widely held lay belief. It is based on the premise that the individual’s presumed pre-operative addiction to food is transformed into an addiction to other substances or behaviours after surgery (Mitchell et al., 2015).  This is underpinned by the concept of “symptom substitution theory” whereby elimination of a particular symptom without treating the underlying cause will result in the appearance of a substitute symptom (Kazdin et al., 1982). 

There are multiple issues and controversies about the concept of “addiction transfer” including a significant debate about whether food addiction is a useful or valid concept. Apart from some data about alcohol, there has been little data published which supports the onset of a post-surgical addictions although there is an acknowledgement that further research needs to be conducted (Mitchell et al., 2015). The research on increased rates of alcohol dependency post certain types of bariatric operations is a consistent and concerning finding.  The remainder of this blog will focus on reviewing the literature about alcohol before identifying some discussion questions.

What is the evidence regarding alcohol and bariatric surgery?

Alcohol use disorder  (AUD) is a pattern of alcohol use that involves problems controlling alcohol intake,  being preoccupied with alcohol, continuing to use alcohol even when it causes problems, having to drink more to get the same effect, or having withdrawal symptoms upon rapidly decreasing or stop drinking.  AUD can be mild, moderate or severe. Alcohol use disorders must be distinguished from excessive alcohol intake that can be defined as any alcohol intake that is more the weekly recommended alcohol intake. Excessive alcohol intake is common and is different from alcohol use disorders.

The Alcohol Use Disorders Identification Test (AUDIT) is a widely used 10-item screening tool which focuses on alcohol use and consequences in the previous 12 months.  An AUDIT score of >8 indicates harmful/hazardous alcohol use and possible dependence.  This screening tool and threshold are widely used in most of the research that has focused on alcohol problems following bariatric surgery. 

King et al. (2017) analysed data from the LABS-2 study which is a prospective, observational  longitudinal study of >2000 individuals having a primary bariatric procedure between 2006-2009 (note that the sleeve gastrectomy was not included). The researchers collected baseline data about a range of psychological variables, including alcohol and illicit drug use, and followed up on an annual basis. The study found that the prevalence of AUD increased substantially over time after RYGB from approximately 7% presurgery to 16% at year 7, while remaining stable for those who had a gastric band (from 6% to 8%). There was a slight increase in illicit drug use (primarily marijuana) following the bypass compared to the band, but there is a need for further research due to measurement/screening issues and lack of inclusion of a range of drugs (including opiates).

Azam et al. (2018) conducted a systematic review of alcohol use pre and post-bariatric surgery and found that there the prevalence of AUD post-bypass increases over time. In particular, they found that AUD tends to increase from two years post-surgery. 

Those individuals having a gastric bypass are at increased risk for AUD.  This is because bariatric surgery procedures lead to different alcohol pharmokinetics. Studies show that individuals who have had a bypass reach higher peak alcohol concentration more quickly after surgery and take more time to return to a sober state. In addition, there are changes in alcohol reward sensitivity following RYGB. There is currently uncertainty  regarding alcohol problems following sleeve gastrectomy.

A number of pre-operative factors have been found to independently increase the risk of post-operative AUD symptoms. These include male gender, younger age, smokers, low social support, those who have pre op hx of substance use, and those who have had recent psychiatric treatment were at increased risk (King et al., 2012; King et al., 2017). It is important to note that AUD can be a new problem. King et al. (2012) reported that many (60.5%) of those who developed AUD did not have a history of AUD prior to surgery and Mitchell et al. (2015) reported 43.8% did not have a history. Contrary to the “addiction transfer” hypothesis, binge eating and loss of control eating are not associated with the development of problematic alcohol or substance use outcomes (King et al., 2017).

What do current guidelines recommend?

The ASMBS guidelines for psychological assessment (Sogg et al., 2016) recommend routine assessment of alcohol and substance use issues prior to surgery. There is consensus that current alcohol or drug dependency is a contraindication for surgery and most services require at least one-year abstinence prior to surgery.  However, a history of dependency is not a contraindication. All studies which have been conducted in this area highlight the importance of educating those having bariatric surgery about the risks of alcohol post-operatively. Furthermore, they recommend proactively screening for post-op alcohol problems. 

It is needless to say that the potential increased risk of alcohol dependence after some bariatric operations must be weighed against the potential benefits of bariatric surgery.

Questions

1. What information is provided to patients pre-operatively about possible problems with addiction (in particular alcohol) following bariatric surgery?

2. What variations in alcohol use disorders (AUD) have you noticed between different bariatric procedures?

3.       How can we distinguish between Alcohol Use Disorder and non-problematic alcohol intake?

4. How long are individuals advised to avoid alcohol following their bariatric surgery?

How are post-op problems with alcohol use identified?

5.      What other addictions have been anecdotally reported by people following bariatric surgery?

Dr Denise Ratcliffe

Consultant Clinical Psychologist

  

References

Azam  H., Shahrestani, S. & Phan, K (2018).  Alcohol use disorders before and after bariatric surgery: a systematic review and meta-analysis. Annals of Translational Medicine, 6(8), 148-156.

Kazdin AE. Symptom substitution, generalization, and response covariation: implications

for psychotherapy outcome. Psychol Bull. 1982;91(2):349-365.

King, W. et al.  (2012). Prevalence of Alcohol Use Disorders Before and After Bariatric Surgery. JAMA, 307, 23, 2516-2526.

King, W. et al. (2017). Alcohol and other substance use after bariatric surgery: prospective

evidence from a U.S. multicenter cohort study. SOARD, 13, 1392-1404.

Mitchell, J. et al., (2015). Addictive Disorders after Roux-en-Y Gastric Bypass. SOARD, 11, 4, 897-905.

Sogg, S., Lauretti, J. & West-Smith, L. (2016). Recommendations for the presurgical psychosocial evaluation of bariatric surgery patients. SOARD, 12, 731-749.