Saturday, September 11, 2010

Alcohol Use Following Bariatric Surgery -- What Your Doctor May Not Tell You

When we first contemplated Tom's rouen y gastric bypass surgery, one of His serious concerns and questions was related to drinking.  He'd been a heavy drinker for nearly all of His adult life, and alcohol use was one of His very much treasured pleasures.  Each time we brought up the subject, we were told that He'd have to stop drinking altogether for at least the first six or seven months.  What might happen with regard to His drinking after that was much less clear.  Looking back at it from this perspective, it feels to me that those professionals that dealt with us hedged their answers; carefully avoiding giving it to us straight.  On the one hand, the fact that we did not know then what we know now probably increased the potential for Him to go ahead with the surgery.  However, our lack of clear information left us battling against an addictive process that we had no warning about at all.

Tom has been amazingly successful following His weight loss surgery.  He lost half His body weight, and saw the elimination of  a host of serious health issues including diabetes, hypertension, hyper-lipidemia, and sleep apnea.  He was entirely compliant with the dietary guidelines imposed by the surgery, and followed the medical advice regarding abstinence from alcohol for seven months.  Last October, when he first began drinking again, He was at first tentative about it, but it very quickly began to ratchet up to unhealthy levels.  Too, we began to see reactions to alcohol that semed very dramatic and extreme -- far out of proportion to the amounts that He was consuming.  As a result, our family has recently begun to tackle issues related to alcohol addiction that have become hugely problematic in the wake of Tom's bariatric surgery.  It has been a difficult and painful time for us.  All of the gory details of our process are described on our other blog, but we want to publish the more straightforward account of our struggle with this issue here so that those who may be encountering the same issues can learn from what we've experienced. 

Your doctor may not tell you the truth about the ways that bariatric surgery can change your relationship to alcohol.  There is great uncertainty in the bariatric surgery medical community about what all the data and anecdotal evidence really means.  So perhaps that explains the reluctance to speak clearly to patients and potential patients about the likely risks and realities concerning alcohol use, especially after rouen y gastric bypass surgery.  It is our hope that, by telling our story, we'll spare someone else from having to stumble along the same path we've followed.


Our family reached a crisis point with Tom's use of alcohol in mid-June.  He became unemployed and so entered involuntarily into a de facto retirement for which He was not emotionally prepared.  Struggling with the blow to His ego and self-concept, He began to drink daily at very heavy levels.  On August 30, He wrote the following on our other blog:

I have been teetering back and forth about the wisdom of exposing much about this aspect of my/our life.
I have a behavior goal I am finding challenging, and that I need to control more effectively -- my alcohol consumption. I am hesitant to reveal this for fear of a cascade or vitriolic comments.
Ten years ago,  … I was obese, heavily tobacco addicted, and used alcohol to excess on a regular basis. I have over the last decade managed to entirely end my tobacco consumption (tobacco free since January 2000), and my obesity ended once and for all with my loss of 160 pounds in 2009 after my gastric bypass surgery. The benefits for my health have been amazing for me.
I am determined now to get my drinking under control. Especially after my job loss, I began to drink to excess regularly and daily. I have found my sudden career ending very difficult. I have experienced a range of emotions from fear for our future, to remorse, to ANGER, to depression, to feeling a sense of loss of control (loss of control I always a huge problem for me), and I have self-medicated with my good friend Jack Daniel. However, this is not new behavior for me.
My drinking history since my gastric bypass has been "interesting." After my surgery I abstained entirely from any alcohol for seven months, which was a recommended time period by my medical team. Then I returned to drinking. A challenging aspect of all this is that after Rouen Y Gastric Bypass procedures alcohol you consume gets "dumped" into your blood stream in a "raw" form without the digestive processing a normal gastrointestinal system accomplishes when someone drinks alcohol. This intensifies the intoxicating effects of alcohol, and is particularly acute if one drinks rapidly.
This is my last great health issue and I am determined to control it. Furthermore I am determined not to completely eliminate the behavior altogether as I did with smoking, but to moderate my consumption.

With that as the stated goal, we began to work together to figure out how to do it.  He and I talked and negotiated and discussed.  We formulated a plan that was intended to help Him reduce His alcohol consumption while retaining  for Him the option of using alcohol at some "moderate" level. 

We went through a very tumultuous period of a couple of weeks, establishing limits and making plans -- which He pushed against, thwarted, manipulated.  Addiction is a terrible beast.

Tom is, however, a Man of great personal strength and character.  When He becomes convinced, at a rational/scientific level, of the need to make a change or behave in a particular fashion, there is no stopping Him.  At my insistence, He began to investigate the health effects of extreme alcohol use, and in doing that, He came upon interesting and informative material about the effects of alcohol use after bariatric surgery.  Armed with knowledge, He has begun the process of changing His life -- and ours.

Here is what He discovered (information that every bariatric surgery patient who also uses alcohol ought to have):

It turns out there is an overwhelming body of research on Rouen Y gastric bypass patients indicating that the effects of alcohol on them are greatly enhanced, and not only that but it takes way longer for them to return to sobriety after drinking than for people who are gastrointestinally normal. My god -- there is a reason for me to be struggling as I am/have! There really is an issue here. I am not just a crazy weakling! There are significant anecdotal reports of patients who, years after their surgeries, drank very small amounts alcohol, such as having two glasses of champagne in toasts of a child's wedding, and then being arrested for DUI, when a normal person would not have been seriously impaired.


Then, on September 10, He wrote:
I've been up most of the last three nights. I am reading that insomnia is the most common alcohol withdrawal symptom. I am not an exception to that rule (darn it). I've had about 6 hours of sleep in the last three nights. I hope I become so exhausted tonight that I finally sleep. Last night (well early this morning) I decided to see if I might use my involuntary wakefulness productively, so I went into further researching the relationship between RY gastric bypass weight loss surgery and alcohol abuse/addiction. The information is far more damning than I had understood even with what I read a few days ago. It turns out the same "mechanical" changes they made to my gastrointestinal system, simultaneously set me up to become alcohol dependent. We really never saw the kinds of behaviors I was having when drinking until I resumed drinking after my surgery. What I am finding in research explains this dynamic. It also leads me to a decision that makes me terribly sad but determined. I must end my drinking. Just as when I encountered my diabetes I decided sugar was poison for me and I would never eat it again, now I have to realize that alcohol is poison for me now and I must end all consumption of it. I am way unhappy and grieving, but better to grieve the loss of my alcohol than my liver or my/our future.
The most direct definitive article I read last night was:
"The New Science of Addiction
Alcoholism in People Who Had Weight-Loss Surgery Offers Clues to Roots of Dependency
By JANE SPENCER Wall Street Journal July 18, 2006; Page D1
On the heels of a five-year boom in weight-loss surgeries, researchers are observing an unusual phenomenon: Some patients stop overeating --but wind up acquiring new compulsive disorders such as alcoholism, gambling addiction or compulsive shopping.
Awareness of the issue is just beginning to surface. Some bariatric-surgery centers say they are starting to counsel patients about the issue. Substance-abuse centers, including the Betty Ford Center in Rancho Mirage, Calif., say they are seeing more bariatric-surgery patients checking in for help with new addictions. And alcohol use has become a topic of discussion on bariatric-surgery-support sites, such as Weight Loss Surgery Center, wls center.com.
Some psychologists describe it as a type of "addiction transfer," an outcome of substance-abuse treatment whereby patients swap one compulsive behavior for another. At the Betty Ford Center, about 25% of alcoholics who relapse switch to a new drug, such as opiates.
The behavior has long been explained as a psychological phenomenon as patients seek new strategies for filling an inner void. But as substance-abuse experts learn to decode the brain's addiction pathways, some researchers are coming to believe that swapping behaviors may have a neurological basis. A new wave of research suggests that the biochemical causes of compulsive eating are extremely similar to those underlying other self-destructive addictions, such as alcohol or cocaine addiction. Alcohol use in particular is a concern for bariatric patients because some versions of the surgery can change the way patients metabolize alcohol, making it far more powerful.
Exploring the overlaps between compulsive eating and other addictions is a growing focus at the National Institute on Drug Abuse, which spent$1.4 million on obesity research last year. Researchers at NIDA hope to piggyback on the drug industry's extensive research on obesity in an effort to find new compounds that might treat multiple types of impulse-control disorders at once.
"The potential is extraordinary," says Nora Volkow, NIDA director. "A drug that could condition craving behavior -- whether it's for chocolate or cocaine -- would be a gigantic market."
Dozens of clinical trials on addiction treatments are under way at the National Institutes of Health. Topiramate, an epilepsy drug marketed by Ortho-McNeil Neurologics under the name Topamax, is currently being studied for binge eating, alcohol dependence, cocaine addiction and compulsive gambling.
Bupropian, marketed by GlaxoSmithKline as the antidepressant Wellbutrin and the smoking-cessation drug Zyban, is currently being studied as a treatment for gambling, obesity, nicotine dependence and alcoholism. And Rimonabant, made by Sanofi-Aventis is being reviewed by the Food and Drug Administration as a treatment for obesity and associated health problems, but it is also being studied as a treatment for alcoholism.
Estimates on the prevalence of new addictions after weight-loss surgery vary widely. Philip Schauer, director of bariatric surgery at the Cleveland Clinic and current president of the American Society for Bariatric Surgery, estimates that only about 5% of bariatric-surgery patients develop a new compulsive behavior after surgery, such as alcoholism, compulsive shopping or smoking. He adds there is no evidence that the new addictions have any direct link to the surgery.
At U.S. Bariatric, a weight-loss surgery center with offices in Orlando and Fort Lauderdale, Fla., therapists estimate that roughly 20% of patients acquire new addictive behaviors. Melodie Moorehead, a psychologist who spoke at a session during the American Society for Bariatric Surgery Association annual meeting last month, cited preliminary data suggesting that roughly 30% of bariatric-surgery patients struggle with new addictions after surgery. But she says the issue requires further study.
One possible reason for the disparity in estimates is that alcohol problems can surface several years after the surgery, when surgeons are no longer tracking patients as closely. And some patients may not see a link between their drinking and the surgery, or report their problem to a surgeon. Roughly 140,000 bariatric surgeries are performed in this country each year.
Some bariatric doctors dismiss the issue as pure coincidence. "People don't become alcoholics as a side effect of the surgery," says Neil Hutcher, past president of the American Society for Bariatric Surgery. "They become alcoholics for the same reasons anyone becomes an alcoholic. The surgery is not a cure-all for everything transpiring inthe patient's life."
For a variety of reasons -- including the fact that alcohol is high in calories -- bariatric-surgery patients are often advised not to drink alcohol for the first six months to a year after surgery. In addition, most bariatric centers screen patients for heavy alcohol use, and exclude patients who exhibit signs of alcohol dependence.
"The surgery creates profound changes in people, both physical and mental," says Dr. Schauer. "Even though they're good changes, they could ignite problems in people with active substance-abuse problems."
Gastric bypass surgery, which accounts for 75% of all bariatric surgeries in the U.S., involves sectioning off a small portion of the stomach into a pouch that bypasses the first part of the small intestine. As a result, alcohol passes rapidly into the intestine where it is quickly absorbed into the bloodstream. "You shorten the time to the brain so much that if you liked alcohol before, you'll love it now," says Mark Gold, professor of psychiatry and neuroscience at the University of Florida College of Medicine. (Lap-band procedures, which account for 20% of U.S. weight-loss surgeries, don't have the same impact. The procedure involves restricting part of the stomach with a silicon band, but doesn't change the absorption process.)
The issue is a sensitive one for the bariatric-surgery community following a series of major studies raising questions about the long-term health benefits of the procedure. A large study of 60,000 gastric-bypass patients published in the Journal of the American Medical Association last October, found that 40.4% of patients who had the surgery were readmitted to a hospital at least once during the three years after surgery, double the 20.2% rate of hospitalizations in the three years prior to surgery. (See related article on this page about bariatric-surgery procedures.) Some in the field hope the concerns about substance abuse will add to the growing interest in psychological counseling of patients.
Some research suggests that obesity might offer some protection against other types of addictions, including alcohol. A study of 9,125 adults published earlier this month in the Archives of General Psychiatry found that obese people had a 25% decrease in likeliness for substance abuse. And in 2004, researchers at the University of Florida, Gainesville, published an study of 298 women showing that obese women have lower rates of alcohol use than the general population. The researchers theorize that food and alcohol trigger the same reward sites in the brain. Some people may feed their addictive cravings with food; others with alcohol.
Neuroimaging studies suggest that obese people and substance abusers have abnormal levels of dopamine in the brain, contributing to cravings. "They always feel something is lacking, and in order for them to feel OK, they need to use something that boosts the dopamine in brain," says Gene-Jack Wang, chairman of the Medical Department Brookhaven National Laboratory.
Bankole Johnson, chairman of the department of psychiatric medicine at the University of Virginia, says gastric-bypass surgery provides a mechanical solution that leaves the underlying neurobiological problem untreated. "It's like a thirst," says Dr. Johnson. If you're thirsty -- and there's no water -- you'll drink lemonade."

We are into a new phase of our post bariatric surgery lives.  Getting here has been very difficult.  Being here however, seems "good."  To some degree, we wish we'd known all of this much earlier.  On the other hand, there were so many changes and adjustments to make in the wake of the surgery.  Perhaps, if we'd tried to tackle this too, we'd have just found ourselves overwhelmed with the enormity of the changes.

For now, it is enough if we can share something valuable about all of this with others in the same boat.

swan

9 comments:

Anonymous said...

I love love love your commitment to each other.

Algor Langeaux said...

I am very glad that you posted this.

I am very much in pre-gastric bypass surgery mode - basically at this point having jumped through all the hoops, and looking at them setting a date for surgery firmly.

I have given away most of my pantry at this point, but had kept the alcohol on the counter, even though I am a very irregular drinker. Quite frankly though, there really isn't much reason to keep it around at this point... I see no reason not to go ahead and give this to responsible friends just like the food I won't be able to eat again.

You have met your goal of giving someone important information they didn't have.

Thank you supremely.

Raheretic said...

Algor, we were thrilled to awaken to your comment this morning. How wonderful to hear from you again our old friend. There can be no greater reward for the time swan spent editing our posts about my/our alcohol struggles, and sanitizing them of the more graphic details included in our chronicaling of them on The Heron Clan Blog, than to find out that this information here has reached a good friend in a fashion timely enough to be useful.

As you go forward with your gastric bypass surgery process (and I know that has already begun)please feel free to contact any of us at any time for support here,or via email, and we'd be very pleased to call you on the phone, skype, whatever.

If you haven't yet done so, you might find looking back over this entire Blog may provide you some additional resources and information.

I would just say too, I can so recall where I was personally at the point in the process where you are now. I was fearful, and mourning the aspects of my life I so feared losing. Algor, I don't miss them. There are so many things I enjoy and you cannot imagine how good it feels to have my health. I didn't realize the extent to which I was unhealthy until I became healthy.

Before my surgery I read the bariatric surgery commmunity adage, "nothing tastes as good as being thin feels." (It is the bariatric community's version of what is for the poly community. "communicate commounicate, communicate"). I thought, "yeah right, what horse shit!" I can tell you today, that for me, that adage has, in fact, become reality. I don't want to paint a rosy picture. This involes risk, pian, struggle and huge change.
My surgery went badly involving complications that almost never happen, but that as per usual with me, if something can occur exceptionally, did in my case.

It is easy in anticipating this to see only the struggle, pain, and difficulty ahead....only what will be lost. What will be gained will be mind blowing, and will make over your life. I feel like i have gained an extra 20 years.

Thank you my/our friend. You have given all three of us much by commenting here, as you have, and btw., I still believe Algor invented the Internet:)

All the best,

Tom

Go confidently in the direction of your dreams. Live the life you've imagined.

Raheretic said...
This comment has been removed by the author.
Raheretic said...
This comment has been removed by the author.
Raheretic said...

Editors note: Just a few minutes ago I posted the above comment in response to Algor Langeaux. Blogger, in its infinite munificence, thought my exposition was so significant, that it posted my comment three times.

You will also see above here two comments which were deleted. Those two deletions were the two redundant iterations of my comment back to Algor.

I suspected that despite the brilliance of what I communicated, reading it once was more than enough, even for me:)

All the best everyone,

Tom

Go confidently in the direction of your dreams. Live the life you've iomagined.

Algor Langeaux said...

I actually have gone back and taken a second look from the beginning recently, thanks for the offer. I have also suggested to others that they do the same.

I am doing the Roux-en-Y, and am having a concurrent panniculectomy. At this point I have done all the preliminary hoop jumping and am waiting on final approval of the insurance company prior to surgery.

I have pre-emptively started my pre-surgical liquid diet, so that pretty much as soon as it gets approved they can set the earliest date possible.

I did my research and found the best place to have the surgery done in my region. It is 80 miles away, but luckily it is only about a mile from the duplex I bought my parents a decade ago, and the other half of the duplex is currently unoccupied... so I will be able to stay close to the doctors for as long as I need to during recovery.

Stay strong... nothing good comes easy (which says more than I might like about my sex life, actually)

...and despite protestations, I didn't invent the internet, I just perfected it.

Anonymous said...

good points and the details are more precise than somewhere else, thanks.

- Norman

mintradz said...

This wouldn't be posted any better! That's is the thing with gastric bypass surgery, you are given a chance to lose some weight with a great prize. Be strong!