Study Supports Link Between Bariatric Surgery And Alcohol Use Disorder
by Kate O'Rourke
Boston—About 17% of patients who undergo Roux-en-Y
gastric bypass (RYGB) have an alcohol use disorder three years after
their surgery, new research shows.
This rate is approximately 10% higher than what is seen in the
general population, as found in data from the National Institutes of
Health (NIH).
The study suggests that all patients undergoing RYGB need to be
cautioned regarding alcohol use, and routinely asked about such problems
during follow-up visits, said James Mitchell, MD, chairman of the
Department of Psychiatry and Behavioral Science at the University of
North Dakota School of Medicine and Health Sciences, in Grand Forks, who
presented the findings at Obesity Week 2014 (abstract 201).
The study included 201 RYGB patients in the Longitudinal Assessment
of Bariatric Surgery (LABS), an NIH-funded consortium of six clinical
centers and a data-coordinating center that works with NIH staff to
conduct research involving bariatric surgery.
Patients were interviewed three years after surgery, using the
Structured Clinical Interview for DSM Disorders (SCID-DSM)-IV, and
accessory impulse control disorders criteria. SCID criteria for alcohol
use disorder require a positive response to ingestion of five or more
drinks on one occasion as a screening question, which based on
pharmacokinetic research in RYGB patients, is excessive. The researchers
also evaluated patients with the Alcohol Use Disorders Identification
Test (AUDIT), which assigns a score based on answers to a series of
questions, such as how often during the past year the respondent failed
to do what was normally expected because of drinking. Alcohol use
disorder symptoms were defined as an AUDIT score greater than 8, or a
positive response to symptoms of alcohol dependence or alcohol-related
harm. The median age of patients in the study was 48 years, and 81% were
women.
The investigators found that 16.9% of patients had an alcohol use
disorder three years after RYGB, with 41.2% of them being a de novo
problem (Table 1). Patients with a history of alcohol abuse were at
highest risk, but some reported that cases were new. Conversely, 26.9%
had a history of alcohol use disorder before surgery by SCID and/or
AUDIT definition, but did not report symptoms of an alcohol use problem
within the three years after surgery. The investigators also identified
fluctuations in other addictive disorders, such as impulsive-compulsive
buying and Internet use (Table 2)
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between weight loss surgery and alcohol abuse. “There is definitely
enough convincing evidence that some patients are at risk for problems
with alcohol after [weight loss] surgery,” said Stephanie Sogg, PhD,
staff psychologist at Massachusetts General Hospital, and assistant
professor at Harvard Medical School, in Boston.
Dr. Sogg, who gave an overview of the evidence at Obesity Week,
pointed out that numerous studies have been published about alcohol use
after bariatric surgery, but many have small sample sizes and/or low
response rates, and almost all are retrospective. The studies also use a
wide range of assessment methods (i.e., questionnaires and interviews)
and different definitions of alcohol use, misuse and abuse, which makes
comparison across studies difficult
“Some studies merely look at alcohol use. Others look at high-risk,
hazardous or problem drinking, and some studies look at whether patients
have symptoms of or meet the criteria for alcohol abuse or dependence,”
Dr. Sogg said
Many studies also don’t make a distinction between three different
subgroups: individuals who have alcohol problems at the time of surgery
and continue to have problems afterward, recovered substance abusers who
relapse after surgery and individuals who develop new-onset alcohol
problems after surgery. “These are three very clinically distinct
subgroups and many studies lump them all together,” she said.
Dr. Sogg pointed out that overall, studies have shown that after
weight loss surgery, there is an increase in alcohol use, with a higher
percentage of patients reporting any alcohol use as well as increased
quantities and/or frequencies of alcohol consumption among those who use
it.
A previous study using data from LABS showed that the risk for
developing an alcohol use disorder was greater in the second year after
surgery than the first (JAMA 2012;307:2516-2525). The Swedish
Obese Subjects Study found that the rate of self-reported alcohol
problems continued to increase for 10 years (Obesity 2013;21:2444-2451)
“Across all of the studies, the prevalence of alcohol problems after
surgery ranges from 4% to 28%, with about 10% meeting criteria for
abuse/dependence; this includes patients who previously had these
problems,” Dr. Sogg said. “What is strikingly consistent is that across
all studies, if you look at all of the people who develop problems with
alcohol after surgery, about 60% of those cases are new-onset cases.
In contrast, some individuals reduce alcohol intake after weight loss
surgery. “Anywhere between 17% and 59% of patients who had problem
drinking before surgery reported being free of such problems when they
were assessed at some point after surgery,” Dr. Sogg noted. Weight loss
surgery may have opposite effects on drinking patterns, depending on an
individual’s genotype or phenotype. Studies in rats have revealed that
RYGB increases alcohol consumption in wild-type rats (who ordinarily do
not like alcohol) and decreases consumption in genetically
“alcohol-preferring” rats (Obes Surg 2013;23:920-930; Biol Psychiatry 2012;72:354-360).
RYGB in particular can change the sensitivity to or the
pharmacodynamics of alcohol after weight loss surgery. After RYGB,
patients who drink alcohol reach a higher peak blood alcohol level more
quickly, and a longer time is required for alcohol to clear out of their
system (Surg Obes Relat Dis 2007;3:543-548; Obes Surg 2010;20:744-748)
“These changes become more pronounced as time goes on after surgery,
not less pronounced,” Dr. Sogg said. These pharmacodynamic changes may
be linked to the onset of alcohol problems after RYGB
“People who have alcohol problems after surgery are much more likely
to have undergone a bypass, and that makes us suspect that there is some
anatomic and metabolic basis for this.”
Research findings on whether similar pharmacodynamic changes occur in
patients who had a sleeve gastrectomy are mixed; such changes were
found in one study but not in others, and no studies have yet examined
the prevalence of alcohol problems among patients who have had a sleeve
gastrectomy, a procedure that only recently has been performed in large
numbers.
Factors common to both the gastric bypass and sleeve gastrectomy that
could lead to higher and more rapid blood alcohol concentrations
include less alcohol dehydrogenase in the stomach, faster gastric
emptying, shorter transit time in the intestines to break down the
alcohol, lower body weight and less food in the stomach when alcohol is
consumed. “We tell our bariatric surgery patients not to eat and drink
at the same time. If you drink on an empty stomach, you are definitely
going to feel more intoxicated,” Dr. Sogg said.
She said it is important for clinicians to ensure that all patients
undergoing weight loss surgery be screened for alcohol use problems
before surgery and be educated about the risk for postoperative
problems. Dr. Sogg counsels patients to be watchful for early warning
signs of increased alcohol consumption, and not to drink at all after
surgery if they are going to drive.
“It is also important for surgery practices to identify the
appropriate referral resources to use when they do encounter patients
who have this kind of problem,” Dr. Sogg said. However, she also noted,
“It is not yet clear whether a patient who has alcohol problems after
surgery will respond to traditional addiction treatment approaches or if
they need specifically tailored care.”
Dr. Mitchell also believes that all patients should be cautioned and
monitored, and that a history of a substance use disorder should not
rule out a patient for bariatric surgery. “The monitoring can be done by
carefully and nonjudgmentally asking about such problems during
follow-up visits,” Dr. Mitchell said. “If there is a suspicion of such
problems, but the patient denies it, I would ask for permission to talk
with another family member.”
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