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