FOOD (INFORMATION) for THOUGHT: Alcoholism/WLS

Alcoholism after gastric bypass: Is it in your mind or gut?

Scientists have competing ideas for why gastric bypass patients show higher rates of alcohol abuse post-surgery

As researchers scramble to find explanations for alcoholism after gastric bypass surgery, many doctors still don’t know to warn patients about the risk. By Steph Yin | Posted January 9, 2015

In 2009, Jackie Kim received a gastric bypass that shrunk her stomach and rerouted part of her small intestine. Within a year, she had lost 180 pounds and felt great.

Then her troubles with alcohol set in. It started with ordering wine in place of dessert at dinner. “At first I thought, ‘This is great, I don’t have to sit at the table twiddling my fork while everyone else is eating their crème brûlée,’” recalled Kim, a 44-year-old medical consultant living in St. Louis, Missouri.

But soon the occasional glass of wine turned into much more.

Kim spent the next two years fighting addiction. “Lots of scary stuff happened during those years,” she said. She regularly drank alone at home, two bottles of wine at a time. Before long, she was hiding bottles from her husband, driving while drunk, blacking out and discovering injuries she didn’t remember getting.

Her story is not uncommon. In 2012, a large study published in the Journal of the American Medical Association reported that the percentage of patients abusing alcohol increased from 7.6 percent before surgery to 9.6 percent two years after surgery — that’s potentially an additional 2,000 alcoholics each year in the United States. Since then, a growing body of evidence has corroborated these findings. The longest-running study suggests the effect persists even a decade after surgery.

Still, many patients today are unaware of the risk of alcoholism when they get a gastric bypass, and scientists themselves are not completely sure why the risk exists. One early theory was addiction transfer, which suggested that people might adopt new addictions after weight-loss surgery because they can no longer fulfill their food addictions. But more recent evidence suggests there may be an anatomical explanation: specific metabolic and hormonal changes triggered by gastric bypass that leave patients especially vulnerable to alcoholism but not other addictions. It’s also possible that both explanations are right — or neither.

“Whether it’s addiction transfer or something else going on, we really don’t know at this point,” said James Mitchell, a doctor and professor of neuroscience at the University of North Dakota. What’s certain, he said, is that the high rates of alcoholism in patients who have had a gastric bypass operation cannot be attributed to chance.

Doctors have long touted gastric bypass surgery as the gold standard for weight-loss operations. Of the 200,000 bariatric procedures performed in the United States each year, roughly 80 percent are gastric bypass surgeries. Research shows the surgery not only causes weight loss — 90 percent of gastric bypass patients keep off 50 percent of their extra weight even a decade after surgery — but also resolves related illnesses such as type 2 diabetes, heart disease and cancer, leading to a 40 percent overall reduction in mortality for gastric bypass patients.

But alcoholism could be a dark consequence of the surgery for some patients — even if no one is sure why.

The explanation of addiction transfer assumes that people who overeat are often predisposed to addiction. Researchers have reported addiction transfer in many forms — a recovering alcoholic might start chain-smoking, for instance. But the general idea is often contested, partly because it can be difficult to pinpoint the roots of addiction: some argue it is physiological, while others insist it is driven by psychology.

One physiological explanation for addiction, first described by a neuroscientist at the University of Florida named Kenneth Blum, is a blunted response to dopamine, a chemical that gets released in our brains when we perform high-reward activities such as eating, having sex, doing drugs and listening to music. Dopamine not only helps us register pleasure from these activities, it also motivates us to repeat them over and over again in search of more pleasure.

In 1990, Blum found a correlation between alcoholism and a genetic deficiency in dopamine-binding receptors in the brain, called D2 receptors. People with compromised D2 receptors seek higher thrills to satisfy their reward cravings than people with normal D2 receptors, Blum believes. He predicts that gastric bypass patients with a D2 deficiency turn to other high-reward activities, such as drinking alcohol, because they can’t binge eat with a constricted stomach.

Still, most scientists attribute addiction to a combination of genetic and environmental factors. Blaming addiction on a single gene is too simplistic, said Lance Dodes, a psychiatrist based in Boston who has written three books on the topic, including one called Breaking Addiction. Dodes believes addiction has a psychological basis. He argues that consuming a substance or behaving compulsively provides an outlet for people who feel otherwise unable to take direct action in their lives. Many of his alcoholic patients, he said, start feeling better the moment they decide to take a drink — not when the alcohol actually enters their bodies.

Addictions can be interchangeable because they are a psychological response to feeling trapped, said Dodes. “We call them separate addictions, but they’re really just one mechanism.”

But one major problem with Blum’s and Dodes’s ideas is that there’s little evidence of higher alcoholism rates after a different common bariatric surgery: gastric banding. Also known as lap banding, this surgery installs an inflatable belt around the stomach to constrict it. Unlike gastric bypass, banding does not permanently alter the stomach’s architecture.

The difference between the two surgeries suggests that alcohol abuse is related to structural changes from gastric bypass, said Alexis Conason, a New York City psychologist and researcher.

In 2012, Conason published a study in JAMA Surgery that found a significant increase in alcohol use for patients after gastric bypass, but not gastric banding. The study also found no significant increase in patients’ use of other drugs, including cigarettes, or compulsive behaviors such as gambling. “If it were addiction transfer, we’d be seeing it across the board,” Conason said.

Researchers have proposed a few physiological explanations for increased alcoholism specifically after gastric bypass. Some believe it’s due to changes in alcohol metabolism, since alcohol enters the bloodstream more quickly in a smaller stomach. A 2011 study from surgeons at Stanford University found that six months after surgery, gastric bypass patients reached higher blood alcohol levels more quickly than they did before surgery. This type of fast and high peak often characterizes addictive drugs, said North Dakota’s Mitchell. Cocaine and heroin, for example, both produce brief, intense rushes that leave users wanting more.

But it’s also possible that increased alcohol dependence has nothing to do with alcohol absorption in the stomach. Recently, a team of researchers led by neuroscientists at the Pennsylvania State University College of Medicine found that rats that had been given gastric bypasses developed a higher dependence on alcohol. Here’s the twist: the effect held even when the rats were given alcohol intravenously instead of orally. The authors concluded that alcohol abuse after gastric bypass could very well occur independently of how quickly alcohol passes from the gut to the bloodstream.

Instead, anatomical changes to the stomach might impact patients’ dopamine response, the Penn State researchers suggested. Some scientists have found that gastric bypass surgery can alter the signaling of D2 receptors. The mechanism for this is unclear, although preliminary research has identified altered patterns of gene expression in areas of the brain that process dopamine. Other researchers suggest that appetite-mediating gut hormones play a role, particularly those that affect dopamine signaling, such as insulin, leptin and grehlin. Scientists have shown that leptin and grehlin levels change after gastric bypass surgery, and both hormones are known to modulate alcohol consumption.

It’s also possible the explanation is not so clear-cut. Conason admits that researchers can’t completely write off addiction transfer, and there might be other reasons why alcoholism is more prevalent than other addictions. For instance, gastric bypass patients may simply be more likely to drink alcohol than take other drugs, which are less socially acceptable.

The risk of alcohol abuse is serious, Mitchell said, but it is one of many considerations for gastric bypass candidates. Particularly for people facing life-threatening conditions such as diabetes or heart disease, the possibility of alcohol abuse might not be strong enough for patients to actually forgo the surgery.

Even so, Mitchell and most of his colleagues agree that doctors need to strongly communicate the risk of alcohol abuse to patients before surgery. In many cases, including Jackie Kim’s, doctors don’t highlight the risk at all.

After years of counseling and seeing her addiction wreak havoc on her relationships and physical health, Kim reached a breaking point. She hasn’t touched a drink in more than two years. “But it wasn’t easy,” Kim said of her hard-fought recovery. She knows that others also might not have been coached on the risks, so she mentors patients who have had the surgery and posts in bariatric support groups online.

Kim believes that being aware of the problem would have made all the difference for her. “I experienced a lot of anger with my surgeons afterwards for not doing a better job educating me,” she said. “If they had told me not to drink, I wouldn’t have started in the first place — and it wouldn’t have spiraled into what it became.”

Very interesting. Thanks.

You have to have an addictive personality to start with, I am far too lazy for addictions, they take actual effort to chase around drugs or go buy alcohol.  I am seriously not that ambitious and I can't tolerate anything that makes me feel out of control.  The closest thing I think I am addicted too is lemons, I love them, but when they got expensive I cut back and I only buy one bag every 5 days for less then 4.00 dollars so I guess I could find a lot worse addictions.

 

I just don't relate.

 

This was an interesting article, but I also think that the tone of the article may have been overblown, considering that the increase in alcoholism after RNY is 2% (from 7.6% to 9.6%).  While it is an increase, it certainly does not signal a catastrophic side effect of the surgery.  Given all of the potentially deadly effects of morbid obesity, the increase is an interesting data point, but not one that would - or did - factor into my decision to have surgery.

This article has been very informative for me. I am two years post op and recognize that alcohol may now be a problem 😕

I didn't drink prior to surgery but have recently (last six months) began drinking wine every day, one glass to as many as two bottles at a time.

Not only has my weight loss stalled but I have started gaining again.

My pre-op information sessions covered this possibility but I dismissed it thinking it wouldn't effect me.

D2 receptor deficiency makes sense to me as I don't believe it is an addiction transfer for me.

Thanks for posting this 😊

 

I was searching for a forum that was oriented to discussing alcoholism and RNY.  So, I do appreciate your comments on your struggle and only wish there were more comments following that contained more info, or were more meaty.

I've pretty much traveled along the same path as you.  I'm just now coming to grips with taking action to address my alcoholism and the future is certainly unknown.  Like you, wine was my tipping point from being a social drinker to an out of control drunk.  I could go on and talk about how "great" it was after RNY (almost ten years ago) to have a couple of glasses on wine, get high almost immediately and sober up very quickly when I stopped drinking and never having a hangover.  Those who haven't shared that experience will not understand (as evidenced by some of the comments following your post)

And, for those that argue the 2% increase in alcoholism is hardly statistically significant, I would comment that  I have doubts about whether or not that figure is to be believed, as I have serious reservations about how truthful respondents to such surveys  are.  Or, perhaps how far along they are in recognizing they are in trouble with the alcohol use.

 

So, back to my situation.  I'm retired, and  my wife of 46 years is retired.  We have no children and really no close family (I have none, while my wife as a few nieces and nephews).  My Wife has shared in my addiction and is  frankly less prepared to face it.  She suffers from clinical depression and has a history of hospitalization and ECT treatment.  Unlike me, she has no close or even casual friends and finds her self medicating with wine to provide relief that her antidepressants don't provide.  It certainly falls on me to provide the ground breaking and path finding to turning our lives back to a more healthy lifestyle.  

My general plan to regain control of our lives is to implement behavior change along the following:

1. Stop drinking (DUH);
2. Begin a physical exercise routine;
3. Enroll in groups or classes that provide stimulus and a change of people and settings from our current 'rut'.
4. It's easy enough to craft a plan, but I realize the key is to follow on with it, and towards that end, I believe I will have to be more regimented and scheduled in my routine than I have ever been before in my Life.  It is most certainly the truth that in order to change a behavior one has to change one's routine and incorporate that change into a lifestyle.  This change can be done, but it has to be imprinted and of strong enough reward to replace alcohol.  So, just one more post from someone struggling and in closing I am extending my best wishes and luck to all that face this issue.

Our beautiful daughter had gastric bypass in 1996. She was 27 years old and just graduated from college. She liked to drink alcohol, but it never seemed problematic. She married in 1998, had a son in 2000 and was sober her entire pregnancy. Around 2003, drinking became an issue. She would drink, get sick and go to bed. She taught school for a year and a half, then entered into a business venture on borrowed money. The business failed, she left her husband and son in 2008 for a much older man (drinking buddy), but still lived alone in her own townhouse that her husband helped her obtain, close to his and their son's residence. She fixed up a room for her son and hoped he would spend time there; but when she passed out several times, he no longer wanted to be there, afraid that she would die in his presence. She worked a temp job at a large corporation HQ and did so well that they hired her permanently. She was hospitalized many times over the next few years and did complete sobriety programs, but couldn't find an AA group where she felt comfortable. At each ER visit, she was told that she would die if she didn't stop drinking. How she was able to maintain her job and home through all this is truly amazing. She was so intelligent, a world traveler, and had a winning personality. She was a very hard worker, diligent and dedicated. The hospitalization and ER calls became more frequent, as well as disability leave. She kept her job and earned two master's degrees in the last five years of her life. Her liver just couldn't take any more and she died on February 4, 2017. There is a huge hole in my heart. Alcohol is insidious. If you have this procedure; don't drink...ever.

I'm sorry for the loss of your daughter. I've seen too many people lose their battle with alcohol after RNY. It's a real problem for sure.

Thank you for sharing your daughter's story. I hope it resonates with people who think we're scaremongering when we warn about the dangers of cross addiction and alcoholism.

Sorry to hear of the loss of your daughter and Thank you for sharing her story.