Further, our knowledge of post-WLS SUD argues against “addiction transfer.” As noted, postoperative alcohol problems are more likely to develop years after surgery, rather than in the first few months afterward when eating is most significantly curtailed. Additionally, post-WLS alcohol problems are significantly more likely to occur after RYGB than other procedures, whereas the “addiction transfer” model would hypothesize that all WLS patients would be at equal risk for postoperative “addiction transfer,” because their eating is similarly affected after surgery.
Links to RYGB. Some clues to physiological mechanisms underlying alcohol problems after RYGB have been identified. After surgery, many RYGB patients report a quicker effect from a smaller amount of alcohol than was the case pre-surgery.18 Studies have demonstrated a number of changes in the pharmacodynamics of alcohol after RYGB not seen in other WLS procedures19:
- a much faster time to peak blood (or breath) alcohol content (BAC)
- significantly higher peak BAC
- a precipitous initial decline in perceived intoxication.18,20
Anatomical features of RYGB may explain such changes.8 However, an increased response to both IV alcohol and IV morphine after RYGB21,22 in rodents suggests that gastrointestinal tract changes are not solely responsible for changes in alcohol use. Emerging research reports that WLS has been found to cause alterations in brain reward pathways,23 which may be an additional contributor to changes in alcohol misuse after surgery.
However, even combined, pharmacokinetic and neurobiological factors cannot entirely explain new-onset alcohol problems after WLS; if they could, one would expect to see a much higher prevalence of this complication. Some psychosocial factors are likely involved as well.
Emotional stressors. One possibility involves a mismatch between post-WLS stressors and coping skills. After WLS, these patients face a multitude of challenges inherent in adjusting to changes in lifestyle, weight, body image, and social functioning, which most individuals would find daunting. These challenges become even more acute in the absence of appropriate psychoeducation, preparation, and intervention from qualified professionals. Individuals who lack effective and adaptive coping skills and supports may have a particularly heightened vulnerability to increased alcohol use in the setting of post-surgery changes in brain reward circuits and pharmacodynamics in alcohol metabolism. For example, one patient reported that her spouse’s pressure to “do something about her weight” was a significant factor in her decision to undergo surgery, but that her spouse was blaming and unsupportive when post-WLS complications developed. The patient believed that these experiences helped fuel development of her post-RYGB alcohol abuse.
Specialized treatment
The number of patients experiencing post-WLS alcohol problems likely will continue to grow, given that the risk of onset of has been shown increase over years. Already, post-WLS patients are proportionally overrepresented among substance abuse treatment populations.24 Empirically, however, we do not know yet if these patients need a different type of addiction treatment than patients who have not had WLS.
Some evidence suggests that post-WLS patients with alcohol problems may be a distinct phenotype within the general population with alcohol problems, as their presentations differ in several ways, including their demographics, alcohol use patterns, and premorbid functioning. A number of studies have found that, despite their increased pharmacodynamic sensitivity to alcohol, people with post-WLS AUDs actually consume a larger amount of alcohol on both typical and maximum drinking days than other individuals with AUDs.24 Additionally, although the median age of onset for AUD is around age 20,25 patients presenting with new-onset, post-WLS alcohol problems are usually in their late 30s, or even 40s or 50s. Further, many of these patients were quite high functioning before their alcohol problems, and are unlikely to identify with the cultural stereotype of a person with AUD (eg, homeless, unemployed), which may hamper or delay their own willingness to accept that they have a problem. These phenotypic differences suggest that post-WLS patients may require substance abuse treatment approaches tailored to their unique presentation. There are additional factors specific to the experiences of being larger-bodied and WLS that also may need to be addressed in specialized treatment for post-WLS addiction patients.
Weight stigma. By definition, patients who have undergone WLS have spent a significant portion of their lives inhabiting larger bodies, an experience that, in our culture, can produce adverse psychosocial effects. Compared with the general population, patients seeking WLS exhibit psychological distress equivalent to psychiatric patients.26 Weight stigma or weight bias—negative judgments directed toward people in larger bodies—is pervasive and continues to increase.27 Further, evidence suggests that, unlike almost all other stigmatized groups, people in larger bodies tend to internalize this stigma, holding an unfavorable attitude toward their own social group.28 Weight stigma impacts the well-being of people all along the weight spectrum, affecting many domains including educational achievements and classroom experiences, job opportunities, salaries, and medical care.27 Weight stigma increases the likelihood of bullying, teasing, and harassment for both adults and children.27 Weight bias has been associated with any number of adverse psychosocial effects, including symptoms of depression, anxiety, and eating pathology; poor body image; and a decrease in healthy self-care behaviors.29-33