Substance Use Following Bariatric Weight Loss Surgery

A new study published in the Archives of Surgery (“Substance Use Following Bariatric Weight Loss Surgery” ) documents an increase in not only alcohol, but drugs, and cigarettes in those that have gastric bypass surgery.     The study began with 155 participants of which about 2/3 had Roux-en-Y and 1/3 had adjustable gastric band.     The study showed a significant increase in alcohol use at 24-months in the RNY patients but not the banded group.    This is in line with Dr. Ostlund’s findings and Dr. King’s findings.

The study also looked at cigarettes and drug use, not just alcohol use.   I’ve written to Dr. Alexis Conason, the clinical psychologist who was the principal author of this study, to ask for additional information and a copy of the study and if she has any additional comments.   Her website indicates she provides counseling on obesity and bariatric issues as well as mindful eating.

Some things that concerned me about the results of this study was the large decrease in responses by year 2.   At year 1, the numbers of respondents was less than half, and by year 2, only 24% had responded.      This problem could be grossly under-reported.    Also, as many of us are aware and as Dr. King found in her study, these problems typically don’t present until year 2.    I don’t know if it is normal to see such losses in your study group, but when people aren’t doing as well as they hoped they may be less inclined to respond.    But when you are doing well, you may be more eager to respond.

I am pleased that this doctor chose to examine these problems in an aggregate (as a group of substances used to self-medicate) versus isolating each problem substance (like alcohol).     Many of the studies so far only looked at alcohol.  The increases in alcohol problems for RNY patients was typically attributed to increased absorption and to psychological transfer.    The root problem, ‘what keeps the person going back?’ isn’t addressed by absorption.    A normal response, after realizing alcohol is more potent, would be to avoid or dilute the substance.    But what drives the person to seem out the feeling the substance of issue provides?   To me, that is the root question.     And why only after RNY surgery and not lap-band surgery?

I think that the whole spectrum of problems (substance use including prescription drugs, alcohol, and illegal drugs, depression and other mood disorders, shopping, gambling, etc) should be looked at and cross-referenced with the specific type of weight loss surgery.    The duodenal switch variations should be able to be isolated from the RNY’s.   Same with lap-band and the gastrectomies.

My thought is the restrictive procedures will likely continue to indicate to increased risk of acquiring these new self-medicating behaviors.    However, as there are differences in the day-to-day life between RNY and DS patients and there are also some different malabsorption issues, it would be fascinating if the increased risks are similar.

Since, it is getting close to Christmas, I’ll continue my wish list.   I would love to see a study where they did tissue nutrient sampling pre-surgery, and at various intervals post-surgery (3, 6, 12, 24+ months out, even 10 yrs).   And for a whole host of nutrients, not just the typical compounds they test for in serum blood samples, which do not necessarily reflect nutrient deficiencies.    The dream would be to get good data on the long-term malabsorption of calcium, magnesium, iron, B-12, as well as other micro-nutrients.   Then to correlate that data against who and who does not develop what problem 2 years later.

Hopefully Dr. Conason will respond.   If so, I will keep you apprised.   Let me know your thoughts.

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Congressman Jesse Jackson Jr. diagnosed bi-polar after DS gastric-bypass surgery.

My heart goes out to Jesse Jackson Jr., and his family.    This is very devastating and is terribly difficult to understand, if, like many gastric bypass patients, there is no history of any problems like this before surgery – as is very typical.

To try and look on the bright side, this is THE FIRST TIME (other than here) that I have seen any mention that these problems are directly attributed to the gastric bypass surgery and the resulting problems associated with nutrient deficiency are the cause.      I have little doubt that during the next days, if not weeks, there will be hosts of psychologists on TV explaining that this is likely the result of a previous food addict no longer able to self-soothe with food (ie., that he was controlling his bi-polar by over eating).

I doubt many of them have read or will be familiar with the results of Dr. Wendy King’s study and Dr. Ostlund’s study that shows the risk of developing alcoholism, substance abuse, depression and suicide attempt are quadrupled when a patient has their intestines bypassed (ie., in the Roux-en-Y or Duodenal Switch).     In comparison the restrictive procedures (ie., lap-band or sleeve gastrectomy) showed no increase as compared to the general population.

Another important finding of Dr. King is that she was able to show what many of us already know, and that is that these issues typically do not present until around the 2-yr mark.       This is another indication that this is not addiction transfer.   One would expect that if this is a response to no longer being able to soothe with food, the issues would show up sooner rather than later.

In addition, after surgeons started becoming aware of what a huge problem this was, they started implementing procedures such as the pre-surgical psychological screening, alcohol use questionnaires and certifications, and required post-surgical counselling.   But since these issues are rarely present prior to surgery, the screening is of little value in prevention.   It’s similar with the post-surgical counselling.   Since the issues typically show up later, it is likely past any required counselling requirements.    You can read my previous post on my thoughts on the ‘alcohol use questionnaire’.

The National Enquirer spoke to a Dr. Carson Liu who did admit that these problems can be caused by nutrient deficiency, which is a step in the right direction.   He is one of the first doctors I’ve read that have come out to say this.  One concern of mine is that in the very next sentence after attributing the cause to nutrient deficiency, he explains that he typically first uses lithium to treat.    Well, if a problem is caused by nutrient deficiency, wouldn’t it make sense to treat it with nutrients?   Perhaps the doctor meant that they stabilize the patient with lithium before they begin on nutrient therapy…I hope so.    Unfortunately, unless you go to a holistic doctor it may be unlikely a doctor will look for or prescribe nutrients.   Since lab results often don’t give a very indicative picture of your nutrient and so many doctors use the labs as a guidepost, it may not happen.     You may need to talk to your doctor about the difference between serum blood test results and tissue results.   Most lab results only tell you what is circulating in your blood.

For those interested in treatment, I list here the nutrient regime I take as well as an explanation on the Intravenous MicroNutrient Therapy I do a couple of times a month.

I wrote to”The Doctors” website to please do a story on this.     Maybe they’ll listen.  I’d love to hear what you all think about this, so please send me your comments.

Reuters:

http://www.reuters.com/article/2012/07/28/usa-jackson-health-idUSL2E8IS0M220120728

Huffington Post

http://www.huffingtonpost.com/2012/07/28/jesse-jackson-jr-mayo-clinic_n_1712416.html

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Alcohol Use Patient Agreement? Is this the prevention or merely protection from liability?

I was recently forwarded this from Dr. Wendy King, the principal on the new study, ” Prevalence of Alcohol Use Disorders Before and After Bariatric Surgery” .      I was astonished to see that this type of release is now recommended before bariatric surgery.     It is alarming in that it appears to be a liability waiver.    I had RNY in 2000 and my ex-husband in 2001.    I would have been quite alarmed had I been presented with this and required to sign something of this nature before surgery.      What is even more strange is that this form is asking the patient to certify that they have been truthful in revealing their pre-surgical alcohol consumption when the most startling thing about the phenomena of “addiction transfer” is that the person rarely has a history of alcohol of drug problems before surgery.     One has to ask, what is the purpose of requiring patients to sign an agreement so very specific.    When I first started writing, bariatric surgeons insisted this surgery did not cause alcoholism or addiction.   If that were the case, why require a form such as this?    I am all for education and counselling the bariatric patient on all the various and sundry changes that will affect them post-operatively.   But is this the way to do it?   And I don’t see anything about say, taking your vitamins every day, getting sufficient protein every day, or any of the other things the patient should do after surgery…. just the alcohol.        I would love to hear what you all think about this .      Did you have to sign anything like this before you had surgery?    If you had been asked to sign something like this, what would you have thought?   Would it have changed anything?   Made you re-think anything?   I’d love to hear your thoughts on this, so please comment?

Re: {Insert Patient Name}
Medical Record #: ______________________________
Surgeon:  ____________________________________
Proposed surgery: ______________________________

Alcohol Use Patient Agreement
I, {patient’s name}, have reported the following alcohol and/or substance use to Dr. {Dr.’s name}:
__________________________________________
__________________________________________
My signature below indicates the following

1. I have been completely thorough and honest in my disclosure of my alcohol and substance use.
2. I understand that I will be permanently more susceptible to the effects of alcohol after surgery.
3. I understand that I should avoid alcohol for the first 3–6 months after surgery and that I should drink in extreme moderation afterward.
4. I understand that I am at higher risk for developing problematic use after surgery and that abstinence from alcohol is the best way to reduce this risk and other medical and psychological complications.
5. I agree that if my surgeon or another member of the surgery team (nurse, nutritionist, psychologist, etc.), have concerns about my alcohol and/or substance use, I will seek consultation and/or treatment as recommended.
6. I have had the opportunity to ask questions regarding alcohol and substance use.
Other:
Signature:
__________________ Date:_______________

 

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There is no empirical evidence to backup the idea of “addiction transfer”

Hello All,

Dr. Wendy King just published a new study on the prevalence of Alcohol Use Disorders Before and After Bariatric Surgery.   She is presenting this at the American Society of Metabolic and Bariatric Surgery in San Diego this week.   I emailed her to discuss this and to get her comments so we will see if she responds….stay posted everyone.

This is phenomenal news.   Ground-breaking for us in that she is one of the first in the bariatric community to speak out against the myth of “addiction transfer” and state plainly that there is no evidence to support it.   Rather the evidence supports the opposite.

Here is an excerpt from what she told Reuters:

“This idea of addiction transfer has been popular in the general media, but there is no empirical evidence to back it up,”

Here is the entire article and a link to her paper where you can download the pdf http://jama.jamanetwork.com/article.aspx?articleID=1185618:

NEW YORK (Reuters Health) – For some obese people, drinking problems may become a new burden following weight loss surgery, according to a new study out Monday.

Although the rate of alcohol abuse climbed only two percent after the procedures, researchers say this translates into more than 2,000 new cases of abuse every year in the U.S.

Two years following their surgery, patients described more symptoms of dependence — such as needing a drink in the morning or failing to meet normal expectations — and more alcohol-related harms, such as black-outs, feelings of guilt or injuring someone.

The jump in drinking problems was seen mainly among people who had gastric bypass surgery, which reduces the stomach to the size of a golf ball.

“This is something that we need to really pay attention to,” said Dr. Robin Blackstone, president of the American Society for Metabolic & Bariatric Surgery.

But, she added to Reuters Health, the findings aren’t surprising as alcohol sensitivity is known to go up after gastric bypass. That’s because the acid in the stomach usually makes some of the alcohol molecules less potent before they are absorbed.

“When you have a gastric bypass you disconnect most of the acid,” said Blackstone, who wasn’t involved in the new work. “We really don’t believe they should be using alcohol at all after the procedure.”

More than 220,000 Americans had some type of weight loss surgery in 2009, at a price of about $20,000 per patient, according to the American Society for Metabolic and Bariatric Surgery.

Surgery is considered the gold-standard treatment for morbid obesity, which plagues about 15 million Americans and is linked to a host of health problems, including diabetes and heart disease.

One previous study found seven percent of patients experienced complications from weight-loss surgery, but most were minor wound problems. Serious complications — such as massive bleeding or kidney failure — occurred in less than three percent of patients.

The new study, published in the Journal of the American Medical Association, highlights another potential risk of gastric bypass, said researcher Wendy King of the University of Pittsburgh. She presented her findings Monday at the annual meeting of the American Society for Metabolic & Bariatric Surgery in San Diego.

The results are based on nearly 2,000 patients at various U.S. centers.

Each underwent a weight loss procedure, including gastric bypass and gastric banding, in which a silicone band is placed around the top portion of the stomach to restrict food intake. They answered questions about their drinking habits before their surgery and again one and/or two years later. The researchers then rated the alcohol use on a scale developed by the World Health Organization to measure alcohol use disorders.

Before surgery, 7.6 percent of the patients had drinking problems. One year later, the number hadn’t changed much, but at two years, it had gone up to 9.6 percent.

More than half of the 167 patients who had drinking problems following their surgery had not been abusing alcohol prior to their surgery. Alcohol issues were particularly common in those who had gastric bypass, known as Roux-en-Y, and in younger men.

King said it’s unclear why people would develop drinking problems after weight-loss surgery, but it could be due to the increased alcohol sensitivity when people resume their normal drinking habits a couple years after surgery.

According to King, there is no reason to believe the procedures would replace one addiction for another.

“This idea of addiction transfer has been popular in the general media, but there is no empirical evidence to back it up,” she told Reuters Health, adding that binge eating before surgery was not linked to later drinking problems in her study.

Blackstone said the findings shouldn’t deter very obese people from having gastric bypass, which is typically preferred when people need to shed a lot of poundage. Younger, healthier people might consider other options such as a gastric band or sleeve, which haven’t been linked to alcohol problems.

“People who get weight-loss surgery are getting it because they are really unhealthy,” Blackstone said. “I think (this study) needs to be taken into account in terms of procedure choice, but the big picture of metabolic surgery is really about obesity.”

SOURCE: http://bit.ly/L92706 Journal of the American Medical Association, online June 18, 2012.

(c) Copyright Thomson Reuters 2012. Check for restrictions at: http://about.reuters.com/fulllegal.asp

 

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Nutritional deficiencies after Roux-en-Y gastric bypass for morbid obesity often cannot be prevented by standard multivitamin supplementation

Note:   I just want to apologize to all for not posting sooner.  I’ve been studying for a test.  I will try and do better in the future – I have not forgotten you all, and I thank you for your patience.   I am also on FaceBook and Twitter now (@gerl_369)

http://www.ajcn.org/content/87/5/1128.full.pdf+html

Here is another interesting article out of Denmark that shows how nutrient deficiency progresses during the first two years after Roux-en-Y gastric bypass surgery.   Two years after surgery, 98% of patients require additional supplementation over and above the standard vitamin regime initially prescribed.

Some of the conclusions from the study show the lack of effectiveness of multi-vitamin therapy and it documents the rapidity of the onset of the deficiencies, with most deficiencies presenting at the 6th peri-operative month.   One of the more common recommendations of doctors to the gastric bypass patients is to double their multi-vitamins, but according to this study the effectiveness of that approach has not even been determined.   If one of something isn’t working, it doesn’t necessarily make sense that doubling it will.    The author’s recommendation is to develop a daily single-dose supplement and determine the most effective route of administration to encourage compliance and improve overall health outcome.

After two years, 80% of patients required additional B-12, 60% required additional calcium and iron and 45% required additional folic acid – on top of the multi-vitamin they’d been taking.   Smaller percentages were prescribed additional nutrients such as zinc, magnesium and B-vitamins.

This article is concerning in light of the finding that only about 35% of bariatric patients are compliant with their supplementation at all.    After two years, most patients are no longer under their bariatric surgeon’s care and are now being followed by their primary care practitioner who may, or may not, have significant experience with nutrient deficiency.

Bariatric patients should educate themselves on which laboratory tests are available to test for nutrient deficiencies, how indicative they are of actual tissue deficiency, what those optimum levels for their well-being should be, and associate those levels with a supplement regimen that adequately helps them maintain those levels.

One piece of information from this study that really caught my attention was the identification of the rapid onset of deficiency around the six month mark.   Most of the people that contact me regarding addiction transfer indicate that their problems did not start right after surgery, but rather during this 6-24 months post-operative period when this rapid onset of nutrient deficiency occurs.    There is still much to be studied and learned, but I for one would love it if they followed the recommendations of this paper and developed a one-shot effective supplement that was proven to be absorbable and effective.

If you have any questions, please email me at (lisanelson_2@yahoo.com, follow me on Twitter (@gerl_369) and FaceBook (It’s Not Addiction Transfer after Gastric Bypass Surgery)

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Gastric Bypass Surgery Decreases the Desire to Drink – Say What?

As many of you who routinely read my blog can imagine, the title of this study was bound to catch my attention.    Really?    Was someone actually trying to prove such a thing when  it seems obvious the opposite is true.

I was so intrigued, I contacted one of the authors of the study, Stephan Benoit, who was kind enough to send me a copy of the study and to spend some time talking with me about the details as well as another one they plan on publishing soon.  Here is the current study:

Gastric Bypass Surgery Attenuates Ethanol Consumption in Ethanol-Preferring Rats

One of the important things he pointed out was that the rats in this study were actually alcoholic rats to begin with.    He explained, what is important is where you start out at (as far as alcohol consumption goes), which almost seems counter-intuitive.   In mice that were already alcoholic, gastric bypass surgery appeared to actually decrease the desire to drink.   However, in the study yet to be published, they used non-alcoholic mice and found the converse to be true.

It was a real pleasure discussing this with him, and he seemed to agree that there is much more to this than the one-dimensional addiction transfer model that has been previously used to explain this phenomena.

We discussed some of the difficulties he’s run into with his research, which include getting gastric bypass patients to be honest and open about very difficult and painful issues, so that he gets accurate data.

One of my concerns was the study period.   I explained the term “honeymoon period”, and how for many of us, things went very well the first year, and that by following patients who are still in that 1-yr time frame, it may be unlikely that his data with capture the true scope of the problem.

I don’t know if it is more psychological, that we stay more strictly “on program” that first year or if it there is something bio-chemical going on and then it sort of fades after a while.  Something does seem to change after that first year though.

If any of you all have any thoughts on this, ideas on your own experience, please send me a line or a comment.   We may be able to get some assistance collecting some confidential data – so I would really appreciate your input!

L.

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Daily Nutrient Regimen

Often I am asked what my daily vitamin regimen is.   This is what I strive to do daily.   To be honest I’m not always able to do this but I usually get close, but I also do the IV treatment which hopefully makes up for any shortfall.  I just do the best I can which is still better than I was.

Typical Vitamin Regimen
Protein Shakes (40-60 grams) in morning either whey or dried egg whites which ever suits you (egg whites upset my stomach)
Magnesium Taurate (125 mg 3x per day) or liquid Magnesium Chloride Solution (important not to get the magnesium oxide which is what is usually at the drug stores)
Vitamin D3 drops (1,000 IU/drop) at least 3 under tongue per day
Vitamin A drops (micellized (5,000 IU/drop) 1 drop under tongue per day
MultiVitamin (Good Quality) Three Servings Divided morning lunch and dinner (liquid Centrum or your favorite, recommend one without the calcium in it – take calcium separate)
Calcium Citrate (150 mg) 2 capsules 3 x per day morning lunch and dinner (this may not be enough)
Omega 3’s (look at labels) – either get liquid if you can stand it or go with capsules. You must read the labels though. A therapeutic dose for cholesterol it is EPA 1800-2160 mg and DHA 1200-1440 mg, for Depression it can be higher
Iron (Take with 1,500 mg Vitamin C – Never with Calcium)
B-12 Injection 1cc weekly (methylcobalamin not cyanocobalamin)

I also do Intravenous Micronutrient Therapy (aka Myer’s cocktail) every other week now. I started weekly but now go every 2-3 weeks.

Tyrosine (500-1500 mg) works kind of like coffee without the jitters. For me it provides clarity and focus. It’s good to take in the morning and afternoon when you need to work or study. Not if you are trying to relax. (as needed)

DL-Phenylalanine (500-1500 mg) provides a happy good feeling. It upsets my stomach, so try it and see if it works for you. I really like it but unfortunately it makes me sick.

Taurine (500-1500 mg) relaxing, calming amino acid (a lot of these hangover “cures” and such at the convenience stores put this in their product)

Product called “GabaTone” for relaxation that has valerian root, lithium, taurine …. in it

Milk Thistle is good for your liver

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