Evidence-Based Reviews

Alcohol-use disorders after bariatric surgery: The case for targeted group therapy

Current Psychiatry. 2017 January;16(1):39-44,48-49

Treatment can target the unique causes and stresses that may raise the risk of alcohol-related substance abuse after surgery

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References

1. Conason A, Teixeira J, Hsu CH, et al. Substance use following bariatric weight loss surgery. JAMA Surg. 2013;148(2):145-150.

2. Lent MR, Hayes SM, Wood GC, et al. Smoking and alcohol use in gastric bypass patients. Eat Behav. 2013;14(4):460-463.
3. Mitchell JE, Steffen K, Engel S, et al. Addictive disorders after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2015;11(4):897-905.
4. Wee CC, Mukamal KJ, Huskey KW, et al. High-risk alcohol use after weight loss surgery. Surg Obes Relat Dis. 2014;10(3):508-513.
5. Diagnostic and statistical manual of mental disorders, 4th, text rev. Washington, DC: American Psychiatric Association; 2000.
6. King WC, Chen JY, Mitchell JE, et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA. 2012;307(23):2516-2525.
7. Heinberg LJ, Ashton K. History of substance abuse relates to improved postbariatric body mass index outcomes. Surg Obes Relat Dis. 2010;6(4):417-421.
8. Cuellar-Barboza AB, Frye MA, Grothe K, et al. Change in consumption patterns for treatment-seeking patients with alcohol use disorder post-bariatric surgery. J Psychosom Res. 2015;78(3):199-204.
9. Ivezaj V, Saules KK, Schuh LM. New-onset substance use disorder after gastric bypass surgery: rates and associated characteristics. Obes Surg. 2014;24(11):1975-1980.
10. Svensson PA, Anveden Å, Romeo S, et al. Alcohol consumption and alcohol problems after bariatric surgery in the Swedish obese subjects study. Obesity. 2013;21(12):2444-2451.
11. Ostlund MP, Backman O, Marsk R, et al. Increased admission for alcohol dependence after gastric bypass surgery compared with restrictive bariatric surgery. JAMA Surg. 2013;148(4):374-377.
12. Reslan S, Saules KK, Greenwald MK, et al. Substance misuse following Roux-en-Y gastric bypass surgery. Subst Use Misuse. 2014;49(4):405-417.
13. Gearhardt AN, Corbin WR. Body mass index and alcohol consumption: family history of alcoholism as a moderator. Psychol Addict Behav. 2009;23(2):216-225.
14. Grucza RA, Krueger RF, Racette SB, et al. The emerging link between alcoholism risk and obesity in the United States. Arch Gen Psychiatry. 2010;67(12):1301-1308.
15. Davis JF, Tracy AL, Schurdak JD, et al. Roux en y gastric bypass increases ethanol intake in the rat. Obes Surg. 2013;23(7):920-930.
16. Davis JF, Schurdak JD, Magrisso IJ, et al. Gastric bypass surgery attenuates ethanol consumption in ethanol-preferring rats. Biol Psychiatry. 2012;72(5):354-360.
17. Ziauddeen H, Fletcher PC. Is food addiction a valid and useful concept? Obes Rev. 2013;14(1):19-28.
18. Pepino MY, Okunade AL, Eagon JC, et al. Effect of Roux-en-Y gastric bypass surgery: converting 2 alcoholic drinks to 4. JAMA Surg. 2015;150(11):1096-1098.
19. Changchien EM, Woodard GA, Hernandez-Boussard T, et al. Normal alcohol metabolism after gastric banding and sleeve gastrectomy: a case-cross-over trial. J Am Coll Surg. 2012;215(4):475-479.
20. Steffen KJ, Engel SG, Pollert GA, et al. Blood alcohol concentrations rise rapidly and dramatically after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2013;9(3):470-473.
21. Biegler JM, Freet CS, Horvath N, et al. Increased intravenous morphine self-administration following Roux-en-Y gastric bypass in dietary obese rats. Brain Res Bull. 2015;123:47-52.
22. Polston JE, Pritchett CE, Tomasko JM, et al. Roux-en-Y gastric bypass increases intravenous ethanol self-administration in dietary obese rats. PLoS ONE. 2013;8(12):e83741. doi: 10.1371/journal.pone.0083741.
23. Ochner CN, Laferrère B, Afifi L, et al. Neural responsivity to food cues in fasted and fed states pre and post gastric bypass surgery. Neurosci Res. 2012;74(2):138-143.
24. Saules KK, Wiedemann A, Ivezaj V, et al. Bariatric surgery history among substance abuse treatment patients: prevalence and associated features. Surg Obes Relat Dis. 2010;6(6):615-621.
25. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry. 2005;62(6):593-602.
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28. Wang SS, Brownell KD, Wadden TA. The influence of the stigma of obesity on overweight individuals. Int J Obes Relat Metab Disord. 2004;28(10):1333-1337.
29. Durso LE, Latner JD, Hayashi K. Perceived discrimination is associated with binge eating in a community sample of non-overweight, overweight, and obese adults. Obes Facts. 2012;5(6):869-880.
30. Durso LE, Latner JD, White MA, et al. Internalized weight bias in obese patients with binge eating disorder: associations with eating disturbances and psychological functioning. Int J Eat Disord. 2012;45(3):423-427.
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33. Vartanian LR, Novak SA. Internalized societal attitudes moderate the impact of weight stigma on avoidance of exercise. Obesity (Silver Spring). 2011;19(4):757-762.
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Maladaptive alcohol use has emerged as a risk for a subset of individuals who have undergone weight loss surgery (WLS); studies report they are vulnerable to consuming alcohol in greater quantities or more frequently.^1,2 Estimates of the prevalence of “high-risk” or “hazardous” alcohol use after WLS range from 4% to 28%,^3,4 while the prevalence of alcohol use meeting DSM-IV-TR⁵ criteria for alcohol use disorders (AUDs) hovers around 10%.⁶

Heavy alcohol users or patients who have active AUD at the time of WLS are at greater risk for continuation of these problems after surgery.^2,6 For patients with a long-remitted history of AUD, the evidence regarding risk for post-WLS relapse is lacking, and some evidence suggests they may have better weight loss outcomes after WLS.⁷

However, approximately two-third of cases of post-WLS alcohol problems occur in patients who have had no history of such problems before surgery.^5,8,9 Reported prevalence rates of new-onset alcohol problems range from 3% to 18%,^6,9 with the modal finding being approximately 7% to 8%. New-onset alcohol problems appear to occur at a considerable latency after surgery. One study found little risk at 1 year post-surgery, but a significant increase in AUD symptoms at 2 years.⁶ Another study identified 3 years post-surgery as a high-risk time point,⁸ and yet another reported a linear increase in the risk for developing alcohol problems for at least 10 years after WLS.¹⁰

This article describes a group treatment protocol developed specifically for patients with post-WLS substance use disorder (SUD), and explores:

risk factors and causal mechanisms of post-WLS AUDs
weight stigma and emotional stressors
the role of specialized treatment
group treatment based on the Health at Every Size® (HAES)-oriented, trauma-informed and fat acceptance framework.

Post-WLS patients with alcohol problems may be a distinct phenotype among people with substance abuse issues. For this reason, they may have a need to address their experiences and issues specific to WLS as part of their alcohol treatment.

Etiology

Risk factors. Empirical findings have identified few predictors or risk factors for post-WLS SUD. These patients are more likely to be male and of a younger age.⁶ Notably, the vast majority of individuals reporting post-WLS alcohol problems have undergone Roux-en-Y gastric bypass (RYGB), rather than other WLS procedures, such as the laparoscopic adjustable gastric band,^6,11 suggesting some physiological mechanism specific to RYGB.

Other potential predictors of postoperative alcohol problems include a pre-operative history of depression, generalized anxiety disorder, smoking, and/or recreational drug use.^3,6 Likewise, patients with depression or anxiety disorder symptoms after surgery also may be at higher risk for postoperative alcohol problems.⁴ The evidence of an association between postoperative weight outcomes and post-WLS alcohol problems is mixed.^3,12 Interestingly, patients who had no personal history of substance abuse but who have a family history may have a higher risk of new-onset alcohol problems after surgery.^9,12

Causal mechanisms. The etiology of post-WLS alcohol problems is not well understood. If anything, epidemiological data suggest that larger-bodied individuals tend to consume lower levels of alcohol and have lower rates of AUD than individuals in the general population with thinner bodies.¹³ However, an association has been found between a family history of SUD, but not a personal history, and being large.¹⁴ This suggests a shared etiological pathway between addiction and being “overweight,” of which the onset of AUD after RYGB may be a manifestation.

Human and animal studies have shown that WLS may affect alcohol use differently in specific subgroups. Studies have shown that wild-type rats greatly increase their consumption of, or operant responding for, alcohol after RYGB,¹⁵ while genetically “alcohol-preferring” rats decrease consumption of, or responding for, alcohol after RYGB.¹⁶ A human study likewise found some patients decreased alcohol use or experienced improvement of or remission of AUD symptoms after WLS.⁴ Combined with the finding that a family history of substance abuse is related to risk for post-operative AUD, these data suggest a potential genetic vulnerability or protection in some individuals.

Turning to potential psychosocial explanations, the lay media has popularized the concepts of “addiction transfer,” or “transfer addiction,”¹² with the implication that some patients, who had a preoperative history of “food addiction,” transfer that “addiction” after surgery to substances of abuse.

However, the “addiction transfer” model has a number of flaws:

it is stigmatizing, because it assumes the patient possesses an innate, chronic, and inalterable pathology
it relies upon the validity of the controversial construct of “food addiction,” a construct of mixed scientific evidence.¹⁷

References

1. Conason A, Teixeira J, Hsu CH, et al. Substance use following bariatric weight loss surgery. JAMA Surg. 2013;148(2):145-150.

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Alcohol-use disorders after bariatric surgery: The case for targeted group therapy

References

Etiology

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