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Comment on: Alcohol and other substance use after bariatric surgery: prospective evidence from a us multicenter cohort study
Author’s Accepted Manuscript Comment on: Alcohol and Other Substance Use after Bariatric Surgery: Prospective Evidence from a US Multicenter Cohort Study Stephanie Sogg www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1550-7289(17)30183-1S1550-7289(17)30152-1 http://dx.doi.org/10.1016/j.soard.2017.04.014 SOARD3003
To appear in: Surgery for Obesity and Related Diseases Cite this article as: Stephanie Sogg, Comment on: Alcohol and Other Substance Use after Bariatric Surgery: Prospective Evidence from a US Multicenter Cohort S t u d y , Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2017.04.014 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Comment on: Alcohol and Other Substance Use after Bariatric Surgery: Prospective Evidence from a US Multicenter Cohort Study.
Stephanie Sogg, Ph.Da. a
The Massachusetts General Hospital Weight Center, Harvard University Medical School, Boston, MA
Corresponding Author: Stephanie Sogg, Ph.D., MGH Weight Center, 50 Staniford Street, 4th Floor, Boston, MA 02114. [email protected]
Conflict of interest disclosure: The author has no conflicts of interest to report at this time.
Comment on: Alcohol and Other Substance Use after Bariatric Surgery: Prospective Evidence from a US Multicenter Cohort Study
Concerns about addictive behaviors arising after weight loss surgery (WLS) first began to emerge about 15 years ago [1], and mention of this phenomenon began to appear in the lay media several years later [2]. However, empirical research on this topic seemed to lag a bit behind; over the next several years, when this topic was investigated at all, sample sizes were small, methodology/measurement varied considerably, and study design was typically cross-sectional, limiting interpretations. In 2012, King et al. [3] published the results of their longitudinal research on alcohol use and alcohol use disorder (AUD) symptoms after WLS, using the large, multi-site Longitudinal Assessment of Bariatric Surgery (LABS) sample, employing rigorous methodology, well-defined alcohol use variables, and a follow-up period of two years. That study has, arguably, become a ‘gold standard’ among studies on alcohol use and misuse after bariatric surgery. In this issue of SOARD, the LABS group has published an extension of the watershed 2012 findings. Their earlier work has been extended in two ways. First, the current study includes a follow-up period of up to seven years, making it among the longest-term investigations on this topic to date. Second, the investigation has been extended to examine the use of non-alcohol substances of abuse and participants’ utilization of substance use disorder (SUD) treatment. These are topics that were seldom included in earlier studies. Overall, this study has yielded a great deal of additional useful information about substance use issues after WLS. Because this investigation examined illicit drug use, rather than drug use disorders, and the most concrete findings seem to be related to alcohol use and misuse, this commentary will focus on the latter.
One general finding of the previous LABS study [3], and others in the literature [4, 5], that was again found here is that Roux-en-Y gastric bypass (RYGB) seems to be a specific predictor of substance-related outcomes after WLS (relative to laparoscopic gastric banding (LAGB)). Briefly, the study findings strongly suggest that RYGB, significantly more than LAGB, increases the risk for onset of AUD, illicit drug use, and undergoing SUD treatment. The authors observed an increase in the overall prevalence of alcohol use, AUD and illicit drug use over time markedly so in the RYGB patients. Concerningly, they found that among the RYGB patients with no AUD at
baseline, approximately one in five endorsed AUD at some time in the 5 years following surgery (that figure was about half as large for LAGB patients).
The findings of the current study underscore the importance of post-operative screening for substance-related problems – and doing so over the long-term, rather than only in the first few months or year after surgery. This study also suggests some areas in which much more information is needed, in order to improve our ability to predict/prevent, monitor, and treat substance-related issues after surgery.
One very clear gap in the current empirical literature is an absence of any studies investigating the emergence or recurrence of AUD/SUD after the sleeve gastrectomy (SG) procedure. This is to be expected, given the relatively recent increase in the prevalence of LSG procedures. However, given that SG is now becoming increasingly common, with current prevalence matching or exceeding that of RYGB [6], there is an urgent need to determine whether LSG patients are at similar risk for substance misuse after surgery, to promote thorough and accurate preoperative education for LSG patients. In addition, identifying similarities or differences between SG and RYGB in the prevalence of post-operative substance use issues may yield important information regarding potential physiological mechanisms underlying these problems.
Another domain in which more work is needed is to examine the distinction between new-onset post-surgical substance use problems, and cases in which these issues are actually a recurrence of problems that had existed, but remitted, at some point before surgery. Because lifetime history of AUD/SUD was not assessed in the current study, the subset of the sample with “incident” AUD was likely a mix of both types of cases, and the two subgroups may differ significantly in risk factors, precipitants, course, and possibly even response to treatment.
Notably, several studies have found a post-operative decrease of alcohol use/misuse in a subset of patients with heavy or problematic use before surgery [7]. The cumulative view of incident AUD in this study does not yield information about participants whose previous AUD may have improved during the 7-year post-operative follow-up period for this study, which would also be useful information.
The authors of this study have identified a number of baseline and post-operative predictors of post-operative substance-related outcomes; our current practice should incorporate this knowledge, and patients should be screened for these risk factors at pre-operative evaluation and during post-operative follow-up to ensure that appropriate education and monitoring are deployed. However, there is still more to be learned about both pre- and post-operative risk factors for developing AUD after surgery. Knowledge of pre-operative predictors is crucial for adequate preoperative education and preventive efforts at risk reduction, as well as identifying specific individuals who may require closer monitoring for AUD after surgery. Identifying post-operative risk factors is important as well, as clinicians could use these as ‘red flags’ for increased risk of AUD when working with post-operative patients. Future research identifying additional predictors will further enhance our ability to prevent these problems, or at minimum, facilitate earlier identification and treatment.
It is worth noting that some of the null findings regarding predictors in this study were quite informative. A common, and “common-sense” explanation for the risk of new-onset substance misuse after WLS is the “addiction transfer” model, which posits that those individuals misusing substances after surgery were “addicted to food” before surgery and “transferred” that addiction to alcohol and other drugs afterward. Although this explanation feels intuitive, this study provides evidence to the contrary; namely, that neither pre-surgical binge eating nor pre-surgical loss of control eating predicted post-operative substance-related outcomes. The “addiction transfer” theory is somewhat tautological, yielding little new or useful information, and given that it does not seem to stand up to empirical scrutiny, it may be time to retire this model.
Finally, more granular investigation is needed to identify the period of highest risk for the onset of substance-related problems after WLS. Within this study’s data set, the authors were not able to examine the chronology of alcohol or drug use/misuse over time for individual participants. Identifying a ‘critical period’ for substance misuse after surgery would facilitate the development of follow-up protocols to provide monitoring and support at the time when they are most needed, and to educate patients about when, and how, to best be vigilant for the onset of such problems. Though the findings of the authors’ 2012 study suggest that the risk period for developing AUD does not seem to begin before about two years post-op [3], the findings of the current study suggest that the risk continues, or
even increases, over the subsequent several years; this corroborates the findings over a 10-year follow-up period from the Swedish Obesity Study (SOS) group [8].
This is especially concerning when considered in conjunction with another important finding of this study, which is that the rates of AUD and illicit drug use in this sample significantly outpaced the rates of participants’ undergoing SUD treatment. This suggests, as the authors note, that individuals developing issues with substances after WLS are under-identified and under-treated. These findings of increasing risk for substance misuse over the very-long-term after WLS, combined with evidence of underutilization of addictions treatment, hold a crucial message. They argue persuasively for longer-term post-operative monitoring for substance-related symptoms and problems. Importantly, given this long-range time frame of risk, it seems clear that education about post-operative substance use issues must expand well beyond the walls of bariatric practices. Several years after surgery, most bariatric patients are in infrequent (or no) contact with their bariatric centers. Thus, bariatric clinicians are not the only providers who need to be aware of the risks of substance use and misuse after WLS. Efforts should be made by the bariatric community to educate non-bariatric colleagues who are likely to be working with bariatric patients (e.g., internists, endocrinologists, mental health providers) of these risks and the long-term need to screen WLS patients for substance use and misuse.
[1] Mitchell JE, Lancaster KL, Burgard MA, Howell LM, Krahn DD, Crosby RD, et al. Long-term follow-up of patients' status after gastric bypass. Obes Surg. 2001;11:464-8. [2] Spencer J. The New Science of Addiction --- Alcoholism in People Who Had WeightLoss Surgery Offers Clues to Roots of Dependency. The Wall Street Journal. New York, NY2006. p. D1. [3] King W, Chen J, Mitchell J, Kalarchian M, Steffen KJ, Engel S, et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA. 2012;307:2516-25.
[4] Ivezaj V, Saules KK, Schuh LM. New-onset substance use disorder after gastric bypass surgery: rates and associated characteristics. Obes Surg. 2014;24:1975-80. [5] Ostlund MP, Backman O, Marsk R, Stockeld D, Lagergren J, Rasmussen F, et al. Increased admission for alcohol dependence after gastric bypass surgery compared with restrictive bariatric surgery. JAMA Surg. 2013;148:374-7. [6] Esteban Varela J, Nguyen NT. Laparoscopic sleeve gastrectomy leads the U.S. utilization of bariatric surgery at academic medical centers. Surg Obes Relat Dis. 2015;11:987-90. [7] Wee CC, Mukamal KJ, Huskey KW, Davis RB, Colten ME, Bolcic-Jankovic D, et al. High-risk alcohol use after weight loss surgery. Surg Obes Relat Dis. 2014;10:508-13. [8] Svensson P-A, Anveden Å, Romeo S, Peltonen M, Ahlin S, Burza MA, et al. Alcohol consumption and alcohol problems after bariatric surgery in the swedish obese subjects study. Obesity. 2013;21:2444-51.
PII: DOI: Reference:
S1550-7289(17)30183-1S1550-7289(17)30152-1 http://dx.doi.org/10.1016/j.soard.2017.04.014 SOARD3003
To appear in: Surgery for Obesity and Related Diseases Cite this article as: Stephanie Sogg, Comment on: Alcohol and Other Substance Use after Bariatric Surgery: Prospective Evidence from a US Multicenter Cohort S t u d y , Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2017.04.014 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Comment on: Alcohol and Other Substance Use after Bariatric Surgery: Prospective Evidence from a US Multicenter Cohort Study.
Stephanie Sogg, Ph.Da. a
The Massachusetts General Hospital Weight Center, Harvard University Medical School, Boston, MA
Corresponding Author: Stephanie Sogg, Ph.D., MGH Weight Center, 50 Staniford Street, 4th Floor, Boston, MA 02114. [email protected]
Conflict of interest disclosure: The author has no conflicts of interest to report at this time.
Comment on: Alcohol and Other Substance Use after Bariatric Surgery: Prospective Evidence from a US Multicenter Cohort Study
Concerns about addictive behaviors arising after weight loss surgery (WLS) first began to emerge about 15 years ago [1], and mention of this phenomenon began to appear in the lay media several years later [2]. However, empirical research on this topic seemed to lag a bit behind; over the next several years, when this topic was investigated at all, sample sizes were small, methodology/measurement varied considerably, and study design was typically cross-sectional, limiting interpretations. In 2012, King et al. [3] published the results of their longitudinal research on alcohol use and alcohol use disorder (AUD) symptoms after WLS, using the large, multi-site Longitudinal Assessment of Bariatric Surgery (LABS) sample, employing rigorous methodology, well-defined alcohol use variables, and a follow-up period of two years. That study has, arguably, become a ‘gold standard’ among studies on alcohol use and misuse after bariatric surgery. In this issue of SOARD, the LABS group has published an extension of the watershed 2012 findings. Their earlier work has been extended in two ways. First, the current study includes a follow-up period of up to seven years, making it among the longest-term investigations on this topic to date. Second, the investigation has been extended to examine the use of non-alcohol substances of abuse and participants’ utilization of substance use disorder (SUD) treatment. These are topics that were seldom included in earlier studies. Overall, this study has yielded a great deal of additional useful information about substance use issues after WLS. Because this investigation examined illicit drug use, rather than drug use disorders, and the most concrete findings seem to be related to alcohol use and misuse, this commentary will focus on the latter.
One general finding of the previous LABS study [3], and others in the literature [4, 5], that was again found here is that Roux-en-Y gastric bypass (RYGB) seems to be a specific predictor of substance-related outcomes after WLS (relative to laparoscopic gastric banding (LAGB)). Briefly, the study findings strongly suggest that RYGB, significantly more than LAGB, increases the risk for onset of AUD, illicit drug use, and undergoing SUD treatment. The authors observed an increase in the overall prevalence of alcohol use, AUD and illicit drug use over time markedly so in the RYGB patients. Concerningly, they found that among the RYGB patients with no AUD at
baseline, approximately one in five endorsed AUD at some time in the 5 years following surgery (that figure was about half as large for LAGB patients).
The findings of the current study underscore the importance of post-operative screening for substance-related problems – and doing so over the long-term, rather than only in the first few months or year after surgery. This study also suggests some areas in which much more information is needed, in order to improve our ability to predict/prevent, monitor, and treat substance-related issues after surgery.
One very clear gap in the current empirical literature is an absence of any studies investigating the emergence or recurrence of AUD/SUD after the sleeve gastrectomy (SG) procedure. This is to be expected, given the relatively recent increase in the prevalence of LSG procedures. However, given that SG is now becoming increasingly common, with current prevalence matching or exceeding that of RYGB [6], there is an urgent need to determine whether LSG patients are at similar risk for substance misuse after surgery, to promote thorough and accurate preoperative education for LSG patients. In addition, identifying similarities or differences between SG and RYGB in the prevalence of post-operative substance use issues may yield important information regarding potential physiological mechanisms underlying these problems.
Another domain in which more work is needed is to examine the distinction between new-onset post-surgical substance use problems, and cases in which these issues are actually a recurrence of problems that had existed, but remitted, at some point before surgery. Because lifetime history of AUD/SUD was not assessed in the current study, the subset of the sample with “incident” AUD was likely a mix of both types of cases, and the two subgroups may differ significantly in risk factors, precipitants, course, and possibly even response to treatment.
Notably, several studies have found a post-operative decrease of alcohol use/misuse in a subset of patients with heavy or problematic use before surgery [7]. The cumulative view of incident AUD in this study does not yield information about participants whose previous AUD may have improved during the 7-year post-operative follow-up period for this study, which would also be useful information.
The authors of this study have identified a number of baseline and post-operative predictors of post-operative substance-related outcomes; our current practice should incorporate this knowledge, and patients should be screened for these risk factors at pre-operative evaluation and during post-operative follow-up to ensure that appropriate education and monitoring are deployed. However, there is still more to be learned about both pre- and post-operative risk factors for developing AUD after surgery. Knowledge of pre-operative predictors is crucial for adequate preoperative education and preventive efforts at risk reduction, as well as identifying specific individuals who may require closer monitoring for AUD after surgery. Identifying post-operative risk factors is important as well, as clinicians could use these as ‘red flags’ for increased risk of AUD when working with post-operative patients. Future research identifying additional predictors will further enhance our ability to prevent these problems, or at minimum, facilitate earlier identification and treatment.
It is worth noting that some of the null findings regarding predictors in this study were quite informative. A common, and “common-sense” explanation for the risk of new-onset substance misuse after WLS is the “addiction transfer” model, which posits that those individuals misusing substances after surgery were “addicted to food” before surgery and “transferred” that addiction to alcohol and other drugs afterward. Although this explanation feels intuitive, this study provides evidence to the contrary; namely, that neither pre-surgical binge eating nor pre-surgical loss of control eating predicted post-operative substance-related outcomes. The “addiction transfer” theory is somewhat tautological, yielding little new or useful information, and given that it does not seem to stand up to empirical scrutiny, it may be time to retire this model.
Finally, more granular investigation is needed to identify the period of highest risk for the onset of substance-related problems after WLS. Within this study’s data set, the authors were not able to examine the chronology of alcohol or drug use/misuse over time for individual participants. Identifying a ‘critical period’ for substance misuse after surgery would facilitate the development of follow-up protocols to provide monitoring and support at the time when they are most needed, and to educate patients about when, and how, to best be vigilant for the onset of such problems. Though the findings of the authors’ 2012 study suggest that the risk period for developing AUD does not seem to begin before about two years post-op [3], the findings of the current study suggest that the risk continues, or
even increases, over the subsequent several years; this corroborates the findings over a 10-year follow-up period from the Swedish Obesity Study (SOS) group [8].
This is especially concerning when considered in conjunction with another important finding of this study, which is that the rates of AUD and illicit drug use in this sample significantly outpaced the rates of participants’ undergoing SUD treatment. This suggests, as the authors note, that individuals developing issues with substances after WLS are under-identified and under-treated. These findings of increasing risk for substance misuse over the very-long-term after WLS, combined with evidence of underutilization of addictions treatment, hold a crucial message. They argue persuasively for longer-term post-operative monitoring for substance-related symptoms and problems. Importantly, given this long-range time frame of risk, it seems clear that education about post-operative substance use issues must expand well beyond the walls of bariatric practices. Several years after surgery, most bariatric patients are in infrequent (or no) contact with their bariatric centers. Thus, bariatric clinicians are not the only providers who need to be aware of the risks of substance use and misuse after WLS. Efforts should be made by the bariatric community to educate non-bariatric colleagues who are likely to be working with bariatric patients (e.g., internists, endocrinologists, mental health providers) of these risks and the long-term need to screen WLS patients for substance use and misuse.
[1] Mitchell JE, Lancaster KL, Burgard MA, Howell LM, Krahn DD, Crosby RD, et al. Long-term follow-up of patients' status after gastric bypass. Obes Surg. 2001;11:464-8. [2] Spencer J. The New Science of Addiction --- Alcoholism in People Who Had WeightLoss Surgery Offers Clues to Roots of Dependency. The Wall Street Journal. New York, NY2006. p. D1. [3] King W, Chen J, Mitchell J, Kalarchian M, Steffen KJ, Engel S, et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA. 2012;307:2516-25.
[4] Ivezaj V, Saules KK, Schuh LM. New-onset substance use disorder after gastric bypass surgery: rates and associated characteristics. Obes Surg. 2014;24:1975-80. [5] Ostlund MP, Backman O, Marsk R, Stockeld D, Lagergren J, Rasmussen F, et al. Increased admission for alcohol dependence after gastric bypass surgery compared with restrictive bariatric surgery. JAMA Surg. 2013;148:374-7. [6] Esteban Varela J, Nguyen NT. Laparoscopic sleeve gastrectomy leads the U.S. utilization of bariatric surgery at academic medical centers. Surg Obes Relat Dis. 2015;11:987-90. [7] Wee CC, Mukamal KJ, Huskey KW, Davis RB, Colten ME, Bolcic-Jankovic D, et al. High-risk alcohol use after weight loss surgery. Surg Obes Relat Dis. 2014;10:508-13. [8] Svensson P-A, Anveden Å, Romeo S, Peltonen M, Ahlin S, Burza MA, et al. Alcohol consumption and alcohol problems after bariatric surgery in the swedish obese subjects study. Obesity. 2013;21:2444-51.