Publication
Article
Evidence-Based Diabetes Management
The Link Between a Common Type of Bariatric Surgery and Increased Alcohol Use
Author(s):
Bariatric surgery is an expensive approach to weight loss, but it does seem to work. Major studies have verified up to 25% weight loss 2 years after surgery and the maintenance of at least 15% of weight loss 20 years after surgery.1 In certain individuals, gastric bypass has been life changing, while resulting in vast alterations in body type and self-esteem.
Gastric bypass surgery, in its various forms, can be a valuable tool to combat obesity, having positive effects on mortality and comorbidities (including glycemic levels, insulin resistance, heart disease, and musculoskeletal stress).1 For the most part, managed care organizations have recognized its value, and when making reimbursement decisions rely on guidelines of the major societies, like the American Society for Metabolic and Bariatric Surgery (ASMBS), to determine eligibility criteria for surgery (eg, body mass index >40 m/kg2 or 35—40 m/kg2 with other risk factors).
As effective as it is, bariatric surgery does carry risks. These include not only perioperative mortality and infection, but other, less-obvious effects. An anecdotal finding that has received additional support recently may begin to concern managed care executives, for it highlights what we know and don’t know about a 20-year-old procedure.
Popularity and Cost
The most recent figures on the popularity of gastric bypass in the United States are from the ASMBS: The group reported that the number of weight-loss surgeries of any type was about 220,000 per year in 2008, but fell to perhaps 160,000 per year 2010.2 Still, the 15-year rise in utilization had been stunning: Only 16,000 surgeries were performed annually in the early 1990s.2
In a 2009 study by the Longitudinal Assessment of Bariatric Surgery (LABS) Consortium, of 4,779 patients followed, 71.4% had undergone Roux-en-Y gastric bypass (Figure 1), which is generally considered the most common procedure. In comparison, 25.1% underwent laparoscopic gastric banding, and 3.5% other procedures, including duodenal switch and gastric sleeve.3
Cremieux and colleagues4 published a study in 2008 outlining the economic impact of bariatric surgery. They found that the average cost for all bariatric surgery types was $24,500 ($26,000 for open surgery and $17,000 for laparoscopic surgery), which included costs incurred 1 month before and 2 months postsurgery. Laparoscopic band placement was at the low end of the range, and bypass surgery was at the high end. However, with the many benefits of significant weight loss resulting from the surgery, the investigators used modeling to calculate that health plans would still recoup their coverage investment within 2 to 4 years.4
A Link Between Surgery and Alcohol Abuse?
When determining the economic payback of bariatric surgery, Cremieux and associates4 considered the principal known risks of surgery in 2008, including mortality and perioperative infection. The possibility of another significant complication that is associated with the most popular form of weight-loss surgery may well alter this estimate.
Until 2012, the link between bariatric surgery and alcohol abuse was only the subject of anecdotal reports.5 In 2006, Oprah Winfrey hosted an episode of her show which publicized the association (http://www.oprah.com/oprahshow/Gastric-Bypass-Surgery-and-Alcoholism-Video). Then the Journal of the American Medical Association published a study in 2012 that firmly demonstrated a connection between excessive alcohol use and bariatric surgery. Interestingly, the emergence of excess alcohol use in those undergoing weight-loss surgery is not immediate—it seems to occur only in the second year postsurgery.6 As of now, only the association has been documented. This does not point to the possible cause of such a relationship, but a working hypothesis has the ring of truth to it.
A 2010 study of patients entering a substance abuse program at one hospital yielded an important clue, that the number of patients who had undergone bariatric surgery was overrepresented—perhaps up to 6% of individuals entering the program had had gastric modification procedures.7 A 2013 study of a separate, subsequent patient population at the same hospital confirmed the observation.8
Experts believe that patients undergoing the procedure, especially Rouxen- Y gastric bypass, have altered alcohol processing in the body. However, there is no consensus on the actual mechanism of this fault. Some suspect that alcohol reaches the small intestine more rapidly in patients who have undergone the procedure, where it is quickly absorbed, reaching the bloodstream more quickly than if it had to pass through the stomach. Researchers tested this hypothesis by studying alcohol absorption in patients before and after Roux-en-Y bypass.9 After undergoing bariatric surgery, breath testing revealed that after 1 glass of wine, several patients exceeded the 0.08% legal limit for driving. This may not be the whole story though. Others have found through animal studies that the mechanism may be far more complicated.10
The Evidence Begins to Mount
Most of the early, well-designed outcomes information on gastric bypass procedures comes from the LABS; their 2012 investigation put gastric bypass providers and the medical community on notice. Although the absolute incidence of excess alcohol use was still relatively low, the risk for heavier alcohol use (≥4 drinks per week) after the Roux-en-Y procedure was definitely higher than in patients undergoing gastric banding.
The researchers, from the LABS Data Coordinating Center at the University of Pittsburgh, prospectively studied all patients who underwent bariatric surgery at 10 American hospitals over a 5-year span, ending in 2011.6 Nearly 2000 participants (median age, 47 years; median body mass index, 45.8 kg/m2) completed assessments preoperatively, at 1 year, and 2 years postoperatively and were included in the study evaluation. The researchers observed that although alcohol use disorders were not different between the baseline and 1-year postoperative period, a significant difference was revealed by year 2. At that time, 9.6% of patients had excessive alcohol use compared after bariatric surgery compared with 7.6% of patients at baseline (P =.01). A previous history of regular alcohol consumption was associated with 6.3-fold increased odds of excessive alcohol use in year 2 (P <.001), but also a person receiving a Roux-en-Y procedure was estimated to have more than twice the risk of excessive alcohol intake compared with patients undergoing laparoscopic banding procedures (P <.001) (Table).6 Significantly, half of these patients with alcohol problems did not have them before.11
And the addictive risks of bariatric surgery are not limited to alcohol use disorders, said Sameer Murali, MD, MHSH, a bariatrician from the Southern California Permanente Group, in Fontana, California. “After gastric bypass surgery, I’ve had patients who have been bankrupted from gambling, and another who racked up thousands of dollars in shopping bills.” There appears to be something far more wide-ranging that is occurring in the addictive centers in the brain, according to Murali.
In 2013, researchers published the results of an investigation of 11,000 patients in Sweden.12 They found that Roux-en-Y gastric bypass was associated with greater inpatient admission rates for alcohol dependence compared with banding surgery, which was not associated with an admission increase.12 Over the mean follow-up for these patients of 8.6 years, the investigators observed a hazard ratio of 2.3 compared with baseline and twice the risk compared with gastric banding.
A 2013 study from the New York Obesity Nutrition Research Center at St. Luke’s—Roosevelt Hospital in New York revealed that the dependence may not be limited to alcohol intake but to other forms of substance use, like drugs and smoking.13 They obtained preoperative assessments and evaluated the outcomes of 155 people who received either Roux-en-Y or gastric band surgery. Postoperative questionnaires were obtained at specific intervals until 24 months postsurgery (one-fourth of patients responded to the survey at year 2). They hypothesized that “patients who underwent weight-loss surgery would exhibit an increase in substance use (drug use, alcohol use, and cigarette smoking) following surgery to compensate for a marked decrease in food intake.” Their findings confirmed a significant rise in alcohol use through 24 months after surgery in those receiving Roux-en-Y gastric bypass (P =.011) and overall greater substance use, starting at 1 month postsurgery (P ≤.002).13
Interestingly, participants who had undergone Roux-en-Y bypass surgery experienced an initial decrease in the frequency of alcohol use immediately after the procedure, followed by the significant rise. Alexis Conason, PsyD, principal study author, told Evidence-Based Diabetes Management, “The overall effect was primarily driven by the use of alcohol in participants who underwent Roux-en-Y gastric bypass. We initially hypothesized a ‘symptom substitution’ theory, but the research has not yet clarified whether that is an underlying mechanism.”
A further investigation into the reason behind the excess patients with substance use disorders (SUDs) after bariatric surgery was conducted by psychologists from Eastern Michigan University.14 They assessed 141 patients who had gastric bypass at least 2 years previously through online surveys. Fourteen percent of the study participants reported misuse of substances in the postsurgical period. Karen Saules, PhD, and her colleagues found a connection between individuals’ excess substance use behavior and presurgical food addiction and subjective hunger issues. However, Saules told Evidence-Based Diabetes Management, “About two-thirds of those who develop substance use disorders (SUDs) after bariatric surgery did not report having any substance use problems before surgery (ie, “newonset” SUD). It might not be surprising that we found a 14% post-bariatric SUD rate in our study, but it is quite surprising that most of those cases were middle-aged women who developed SUDs out of thin air,” she said.
Another common finding of the clinical research, Saules commented, is that “individuals who develop SUDs after bariatric surgery seem to be very likely to have a family history of SUD…but not one themselves.”
Murali said, “The reward center in the brain is powered primarily by eating in those of us who struggle with our weight. Bariatric surgery breaks up this relationship with food, with a suddenness that you cannot be prepared for. Breaking up in any circumstance is pretty emotional,” but this relationship must end. “When we end any relationship,” Murali continued, “then something has to happen to that displaced emotion. It might be depression, it may be that you move on to a new relationship that is just as abusive as the one you left. Or you can go on to a new relationship that is beneficial to you, such as developing relationships with people instead,” such as those in support groups, who have common challenges and have the patient’s respect.
“As it turns out, this is a really complex issue that likely involves both psychological and physiological factors,” Saules said. Animal models have shown that rats demonstrated increased alcohol uptake when it was administered orally after bariatric surgery.10 These researchers followed up their earlier work by administering alcohol intravenously after bariatric surgery, finding that the uptake of alcohol administered in this way was increased after surgery as well. “If intake increases even with intravenous administration, this suggests the mechanism does not simply involve how alcohol is processed in the gut,” said Saules.
The Unanswered Questions
Cremieux and colleagues’4 research established that the return on investment in bariatric surgery for a health plan was relatively quick. The surgery’s possible benefits include lower glycemic levels, lower stress on joints, and improved health status, all leading to lower costs over time. Thus, the risk—benefit for patients and plans seems to be positive for most individuals. The finding of an association (though not welldefined) between Roux-en-Y surgery and excessive alcohol use may begin to influence this equation for patients and health plans.
It is possible that stronger evidence to define this recently discovered relationship could shift future utilization of Roux-en-Y surgery to procedures like gastric banding, which do not appear to carry these risks. Health plans and insurers may consider adding assessments of possible SUD into their precertification criteria for Roux-en-Y bariatric surgery in an effort to better select patients who may not be subject to the increased risk.
However, additional research is needed to clearly define the interplay between physiologic factors, psychological components, and family and personal history of SUD before these actions can be supported. In the meantime, informed consent may be the only useful tool plan that providers have today to address this risk. And it is being discussed in the physician’s office, when bariatric surgery is an option. Murali emphasized, “Even though it is a poorly defined risk factor, it is not necessarily rare, and I bring it up with patients considering bariatric surgery. It does come up as part of informed consent.
EBDM
References
1. Sjöström L. Review of the key results from the Swedish Obese Subjects (SOS) trial - a prospective controlled intervention study of bariatric surgery. J Intern Med. 2013;273:219-234.
2. Longitudinal Assessment of Bariatric Surgery (LABS). Weight Control Information Network, National Institute of Diabetes and Digestive and Kidney Diseases. http://win.niddk.nih.gov/publications/labs.htm#howmany. Published January 2010 Accessed January 25, 2014.
3. The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009; 361:445-454.
4. Cremieux PY, Buchwald H, Shikora SA, Ghosh A, Yang HE, Buessing M. A study on the economic impact of bariatric surgery. Am J Manag Care. 2008;14:589-596.
5. Ertelt TW, Mitchell JE, Lancaster K, Crosby RD, Steffen KJ, Marino JM. Alcohol abuse and dependence before and after bariatric surgery: A review of the literature and report of a new data set. Surg Obes Relat Dis. 2008;4:647-650.
6. King WC, Chen J-Y, Mitchell JE, et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA. 2012;307:2516-2525.
7. Saules KK, Wiedemann A, Ivezaj V, et al. Bariatric surgery history among substance abuse treatment patients: prevalence and associated features. Surg Obes Related Dis. 2010;6:615-621.
8. Wiedemann AA, Saules KK, Ivezaj V. Emergence of new onset substance use disorders among post-weight loss surgery patients. Clinical Obesity. 2013;3(6):194—201.
9. Woodard GA, Downey J, Hernandez-Boussard T, Morton JM. Impaired alcohol metabolism after gastric bypass surgery: a case-crossover trial. J Am Coll Surg. 2010;212:209—214.
10. 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.
11. Doheny K. After bariatric surgery, alcohol abuse more likely: Second year after weight loss surgery may be riskiest. WebMD Health News, June 18, 2012. http://www.webmd.com/diet/
weight-loss-surgery/news/20120618/afterbariatric-surgery-alcohol-abuse-more-likely. Accessed January 31, 2014.
12. Östlund 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.
13. Conason A, Teixeira J, Hsu CH, Puma L, Knafo D, Geliebter A. Substance use following bariatric weight loss surgery. JAMA Surg. 2013;148(2):145-150.
14. Reslan S, Saules KK, Greenwald MK, Schuh LM. Substance misuse following Roux-en-Y gastric bypass surgery. {published online October 8, 2013]. Subst Use Misuse.
Although many health plans, like Kaiser Permanente, require health assessments and ask about addictive behaviors, it is still difficult to predict who may experience this problem. Even though a history of alcohol use or substance abuse disorder may be an identifier, “you can’t really prohibit bariatric surgery because of this link,” said Murali. “I do try to move these folks away from Roux en-Y, but the addiction transfer problem still exists with other forms of bariatric surgery. If we identify patients who are high risk, we [at Kaiser] send them to our addiction specialists. In those patients, we actually ask for 1 year of sobriety before going into surgery. Even with those cases, because the effect size is so large, you cannot predict who is going to experience addiction transfer. Social support (of peers who are struggling with the same issues) may be a better predictor of success, of being able to weather these challenges.”
