Substance misuse following Roux-en-Y gastric bypass surgery

Alcohol Misuse post Metabolic and Bariatric Surgery: A Systematic Review of Longer-term Studies with Focus on new Onset Alcohol use Disorder and Differences Between Surgery Types

BACKGROUND

Evidence suggests an increased risk of alcohol problems post-surgery where no problematic alcohol use was present prior to surgery which may be different across types of surgery.

OBJECTIVE

To characterise the risk of new onset alcohol misuse post bariatric surgery, differences between surgeries and the impact over time.

METHODS

All published studies on new and relapsing alcohol use were reviewed. Data were classed as 'subjective' (clinical interview, self-report questionnaires) and 'objective' (hospital admissions, substance misuse programmes) and further categorised by follow up time - 'shorter-term' (one year), 'medium-term' (one year to two years) and 'long-term' (> two years).

RESULTS

Twenty-three of the forty-two studies included in the review reported new onset data. Nine studies reported on differences between surgery types. In those reporting objective measures, all of which were long term, RYGB carried a higher risk than SG, followed by LAGB. All but one study using subjective measures reported a small but significant number of new onset concerning alcohol use, and comparisons between surgery types had more varied results than the objective measures. Studies of substance abuse programmes found high rates of new onset cases (17-60%).

CONCLUSION

This systematic review provides support for the consensus guidance suggesting patients should be informed of a small but significant risk of new onset alcohol use following bariatric surgery, with the strongest evidence in the medium- to long-term and in those who have had RYGB followed by SG.

Predictors of Alcohol Use, Alcohol-Related Problems, and Substance Use Following Adolescent Metabolic and Bariatric Surgery

Objective

To identify factors associated with incident alcohol consumption, hazardous drinking, alcohol-related problems, and substance use up to 8 years following metabolic and bariatric surgery (MBS) during adolescence.

Background

In this cohort, nearly half of those who underwent MBS as adolescents screened positive for alcohol use disorder, symptoms of alcohol-related harm, or alcohol-related problems within 8 years post-surgery. Moreover, persistent or heavy marijuana use following MBS during adolescence is higher than national data.

Methods

This study includes 217 adolescents (aged 13-19 years) enrolled in a 5-center prospective cohort study who underwent Roux-en-Y gastric bypass or vertical sleeve gastrectomy between 2007 and 2011 and were followed for up to 8 years. Participants self-reported alcohol use via the Alcohol Use Disorders Identification Test and substance use for up to 8 years.

Results

Female sex, pre-surgery lower body mass index, and pre-surgery substance use were independently associated with increased risk of incident post-surgery hazardous drinking. Pre-surgery psychiatric counseling was significantly associated with increased risk for new-onset substance use post-surgery. Starting substance use post-surgery or continuing pre- to post-surgery was independently associated with a higher risk of post-surgery hazardous drinking. Greater percent weight loss, starting post-surgery or continuing pre- to post-surgery psychiatric counseling, using alcohol, and hazardous drinking were independently associated with a higher risk of post-surgery substance use.

Conclusions

Future research with a nonsurgical control group should be examined to further elucidate the relationships between MBS and alcohol and substance use following surgery during adolescence.

Use of Postoperative Opioid Therapy Following Endoscopic Sleeve Gastroplasty

INTRODUCTION

There are no established guidelines on periprocedural and postprocedural pain management after endoscopic sleeve gastroplasty (ESG). This study aimed to determine the need for perioperative and postoperative opioid therapy in patients undergoing ESG.

METHODS

This retrospective study comprised consecutive patients undergoing ESG. The primary outcome was the percentage of patients requiring postoperative outpatient opioid therapy. Secondary outcomes included frequency and dosage of perioperative pain medications and postoperative pain scores.

RESULTS

Of the 67 patients included, 39 (58.2%) required opioids in the perioperative setting. The mean ± SD opioid dose was 12.3 ± 8.4 morphine milligram equivalents. Postoperatively, 17.9% of patients required home opioid prescriptions. More than a third of patients reported no pain.

DISCUSSION

In patients undergoing ESG, postoperative opioid therapy should be individualized to attenuate opioid overprescription and the risk of opioid overuse.

Weight Regain and Ingestive Behavior in Women after Metabolic Surgery

This study investigated associations between maladaptive ingestive behaviors and weight regain in women who underwent metabolic surgery 2-10 years ago. Using a web-based survey, we assessed emotional, external, and restrained eating (Dutch Eating Behavior Questionnaire-DEBQ), food cravings (Food-Craving Inventory-FCI), and other behaviors (e.g., Eating Disorder Examination Questionnaire-EDE-Q; Alcohol Use Disorder Identification Test-Concise-AUDIT-C) in 36 women (42.9 ± 9.5 years old) post-surgery. We found that weight regain was specifically associated with increased frequency of cravings for sweets (r = 0.43), higher global scores in the EDE-Q (r = 0.38), and time elapsed since surgery (r = 0.35; all p's < 0.04). Multiple regression analysis revealed that the association between weight regain and sweet cravings interacted with time after surgery (p = 0.04), with the strongest association observed in women assessed closer to the surgery (i.e., 2.0-2.8 years). The combination of time after surgery and its interaction with sweet cravings accounted for 31% of the individual variations in weight regain (p = 0.005). Notably, among participants who reported alcohol consumption (31 of 36), 55% had an AUDIT-C score indicating hazardous drinking. These findings highlight the relevance of attending to patients' reports of frequent sweet cravings and screening for alcohol use to enhance strategies tailored to prevent weight regain and alcohol-related health problems post-surgery.

Substance abuse screening prior to bariatric surgery: an MBSAQIP cohort study evaluating frequency and factors associated with screening

INTRODUCTION

Patients undergoing bariatric surgery experience substantial risk of pre- and postoperative substance use. Identifying patients at risk for substance use using validated screening tools remains crucial to risk mitigation and operative planning. We aimed to evaluate proportion of bariatric surgery patients undergoing specific substance abuse screening, factors associated with screening and the relationship between screening and postoperative complications.

METHODS

The 2021 MBSAQIP database was analyzed. Bivariate analysis was performed to compare factors between groups who were screened for substance abuse versus non-screened, and to compare frequency of outcomes. Multivariate logistic regression analysis was performed to assess the independent effect of substance screening on serious complications and mortality, and to assess factors associated with substance abuse screening.

RESULTS

A total of 210, 804 patients were included, with 133,313 (63.2%) undergoing screening and 77,491 (36.8%) who did not. Those who underwent screening were more likely to be white, non-smoker, and have more comorbidities. The frequency of complications was not significant (e.g., reintervention, reoperation, leak) or similar (readmission rates 3.3% vs. 3.5%) between screened and not screened groups. On multivariate analysis, lower substance abuse screening was not associated with 30-day death or 30-day serious complication. Factors that significantly affected likelihood of being screened for substance abuse included being black (aOR 0.87, p < 0.001) or other race (aOR 0.82, p < 0.001) compared to white, being a smoker (aOR 0.93, p < 0.001), having a conversion or revision procedure (aOR 0.78, p < 0.001; aOR 0.64, p < 0.001, respectively), having more comorbidities and undergoing Roux-en-y gastric bypass (aOR 1.13, p < 0.001).

CONCLUSION

There remains significant inequities in substance abuse screening in bariatric surgery patients regarding demographic, clinical, and operative factors. These factors include race, smoking status, presence of preoperative comorbidities, and procedure type. Further awareness and initiatives highlighting the importance of identifying at risk patients is critical for ongoing outcome improvement.

Incidence of Substance Use Disorder Following Bariatric Surgery: A Retrospective Cohort Study

BACKGROUND

New-onset substance use disorder (SUD) following bariatric surgery is a significant concern that is likely multi-factorial, although the etiologies are unclear. Previous studies have identified variable rates of SUD along with utilizing different methods and measures. The objective of this study is to evaluate new-onset SUD diagnoses among adults following bariatric surgery and compare these rates to those in the general population as well as those diagnosed with overweight or obesity.

METHODS

Data was extracted from TriNetX Research Platform and used to build three cohorts of adults: those who had bariatric surgery (bariatric surgery cohort), those diagnosed with obesity or overweight, and a general population cohort. Rates of incident SUD were compared among these three groups. Initial encounters for all individuals were from January 1, 2018, to June 30, 2019.

RESULTS

The incidence rate of SUD in patients with a history of bariatric surgery was 6.55% (n = 2523). When compared to the general population, persons who had any type of bariatric procedure had a decreased risk of new-onset SUD with an overall odds ratio (OR) [95% confidence limits (CL)] of 0.89 [0.86, 0.93]. When compared to persons with overweight or obesity, bariatric patients were less likely to develop any form of SUD (OR: 0.65 [0.62, 0.67]).

CONCLUSION

While overall rates of new-onset SUD are lower among those who had bariatric surgery, they also vary by surgery and substance type. Efforts should still be made to address new-onset SUD in order to optimize the post-surgical care of patients.

Opioid Use After Gastric Bypass, Sleeve Gastrectomy or Intensive Lifestyle Intervention

OBJECTIVE

To compare opioid use in patients with obesity treated with bariatric surgery versus adults with obesity who underwent intensive lifestyle modification.

SUMMARY OF BACKGROUND DATA

Previous studies of opioid use after bariatric surgery have been limited by small sample sizes, short follow-up, and lack of control groups.

METHODS

Nationwide matched cohort study including individuals from the Scandinavian Obesity Surgery Registry and the Itrim health database with individuals undergoing structured intensive lifestyle modification, between August 1, 2007 and September 30, 2015. Participants were matched on Body Mass Index, age, sex, education, previous opioid use, diabetes, cardiovascular disease, and psychiatric status (n = 30,359:21,356). Dispensed opioids were retrieved from the Swedish Prescribed Drug Register from 2 years before to up to 8 years after intervention.

RESULTS

During the 2-year period before treatment, prevalence of individuals receiving ≥1 opioid prescription was identical in the surgery and lifestyle group. At 3 years, the prevalence of opioid prescriptions was 14.7% versus 8.9% in the surgery and lifestyle groups (mean difference 5.9%, 95% confidence interval 5.3-6.4) and at 8 years 16.9% versus 9.0% (7.9%, 6.8-9.0). The difference in mean daily dose also increased over time and was 3.55 mg in the surgery group versus 1.17 mg in the lifestyle group at 8 years (mean difference [adjusted for baseline dose] 2.30 mg, 95% confidence interval 1.61-2.98).

CONCLUSIONS

Bariatric surgery was associated with a higher proportion of opioid users and larger total opioid dose, compared to actively treated obese individuals. These trends were especially evident in patients who received additional surgery during follow-up.

Prevalence of food addiction among patients undergoing metabolic/bariatric surgery: A systematic review and meta-analysis

Candidates for metabolic/bariatric surgery show a high prevalence of food addiction (FA). However, few studies have investigated FA prevalence after bariatric surgery, especially using longitudinal studies. This systematic review with a meta-analysis aimed to determine pre- and postoperative prevalence of FA among patients undergoing metabolic/bariatric surgery. It included both cross-sectional and longitudinal studies that used the Yale Food Addiction Scale (YFAS). The following databases were searched: MEDLINE, ScienceDirect, LILACS, PsycArticles, CENTRAL, greylit.org, and opengrey.eu. Studies that used the YFAS to evaluate FA in pre- or postoperative patients were included. A random-effects meta-analysis was performed with cross-sectional studies to calculate the weighted prevalence of FA at the pre- and postoperative moments. For longitudinal studies, which measured FA at both time points for the same individuals, absolute prevalence reduction (APR) was calculated. Of the 6626 records, 40 studies were included in the meta-analysis. The preoperative weighted prevalence of FA was 32% (95% CI: 27-37%; 33 groups), whereas the postoperative prevalence was 15% (95% CI: 12-18%; 14 groups). Seven longitudinal studies showed a weighted APR of 26 p.p. (95% CI: 10-41 p.p.). Observational data suggest a reduction in the prevalence of FA among patients that undergo bariatric surgery. Interventional studies are needed to confirm these findings.

Roux-en-Y Gastric Bypass Is Associated With Increased Hazard for De Novo Alcohol-related Complications and Liver Disease

GOAL

The goal of this study was to determine if bariatric surgeries are associated with de novo alcohol-related complications.

BACKGROUND

Bariatric surgery is associated with an increased risk of alcohol use disorders. The effect of bariatric surgeries on other alcohol-related outcomes, including liver disease, is understudied.

MATERIALS AND METHODS

Using the IMS PharMetrics database, we performed a cohort study of adults undergoing bariatric surgery or cholecystectomy, excluding patients with an alcohol-related diagnosis within 1 year before surgery. The primary outcome was any alcohol-related diagnosis after surgery. We fit a multivariable Cox proportional hazards model to determine independent associations between bariatric surgeries [Roux-en-Y gastric bypass (RYGB); adjustable gastric band; sleeve gastrectomy] versus cholecystectomy and the development of de novo alcohol-related outcomes. We further fit complication-specific models for each alcohol-related diagnosis.

RESULTS

RYGB was significantly associated with an increased hazard of any de novo alcohol-related diagnosis [adjusted hazard ratio (AHR)=1.51, 95% confidence interval (CI): 1.40-1.62], while adjustable gastric band (AHR=0.55, 95% CI: 0.48-0.63) and sleeve gastrectomy (AHR=0.77, 95% CI: 0.64-0.91) had decreased hazards. RYGB was associated with a 2- to 3-fold higher hazard for alcoholic hepatitis (AHR=1.98, 95% CI: 1.17-3.33), abuse (AHR=2.05, 95% CI: 1.88-2.24), and poisoning (3.14, 95% CI: 1.80-5.49).

CONCLUSIONS

RYGB was associated with higher hazards of developing de novo alcohol-related hepatitis, abuse, and poisoning compared with a control group. Patients without a history of alcohol use disorder should still be counseled on the increased risk of alcohol use and alcohol-related complications, including alcohol-related liver disease, following RYGB, and should be monitored long term for the development of alcohol-related complications.

High-Risk Alcohol Use and Disordered Eating Behavior Before and 1 Year After Sleeve Gastrectomy

Background

Evidence suggests a rise in alcohol misuse after some bariatric procedures. Whether undergoing sleeve gastrectomy raises the risk of high-risk alcohol use is unclear.

Objective

To characterize the risk of high-risk alcohol use 1 year after sleeve gastrectomy and collect preliminary data on potential associations between disordered eating and high-risk drinking post-surgery.

Methods

We interviewed 97 patients before and 1 year after sleeve gastrectomy and assessed for high-risk alcohol use via a modified version of the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Eating behavior was assessed using the Three Factor Eating Questionnaire Revised-18 (TFEQ-R18).

Results

The prevalence of high-risk drinking increased from 13.4% prior to surgery to 22.7% 1 year after sleeve gastrectomy; 16.5% of our sample reported new high-risk drinking equivalent to an incidence of 19.0%. New high-risk drinkers appeared more likely to report lower cognitive restraint scores and higher scores for emotional and uncontrolled eating at baseline and had larger improvements in disordered eating scores post-surgery although these differences approached, but did not reach, statistical significance.

Conclusion

One in five non-high-risk drinkers developed new high-risk alcohol intake 1 year after sleeve gastrectomy. New high-risk drinkers appear to have greater disordered eating at baseline and reported greater improvement in eating behavior than those who did not develop new high-risk drinking. These results are consistent with the addiction transfer hypothesis postulating that some patients may replace disordered eating with alcohol misuse after sleeve gastrectomy.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05847-3.

The Association Between Bariatric Surgery and Psychiatric Disorders: a National Cohort Study

PURPOSE

Previous studies have shown that bariatric surgery reduces the risk of cardiovascular outcomes. Less is known about the effects of bariatric surgery on psychiatric disorders. This cohort study compared the differential risk of psychiatric disorders between those who did and did not undergo bariatric surgery, from before until after the surgery.

MATERIALS AND METHODS

We used PearlDiver-Mariner, a national all-payor claims database. Patients were followed for 1 year before and after the index date and a difference-in-differences (DiD) study design was executed.

RESULTS

We included 56,661 bariatric surgery patients matched to 56,661 individuals with obesity. Among bariatric surgery patients, the risk of psychiatric was 18% 1 year before and increased to 70% 1 year after surgery. Among individuals with obesity, the risk of psychiatric disorders also increased from 1 year before to 1 year after, but by less (21% versus 46%). DiD analysis suggested that bariatric surgery was associated with a 27 percentage point differential increase in the risk of psychiatric disorders across all patients, representing a 135% relative increase. Results using 3 years as the pre- and post-periods lead to similar inferences.

CONCLUSION

Preexisting psychiatric disorders are similarly prevalent among bariatric surgery patients and individuals with obesity. The prevalence of psychiatric disorders increased over time for both groups, but to a larger extent among bariatric surgery patients. Adequate treatment for psychiatric disorders and appropriate implementation of behavioral health interventions may be needed to reduce the burden of psychiatric disorders following bariatric surgery.

Opioid consumption in patients undergoing Roux-en-Y bariatric surgery compared with population controls with and without obesity

BACKGROUND

Patients with obesity are prescribed more opioids than the general population.

OBJECTIVES

To compare opioid consumption in patients with obesity who underwent Roux-en-Y bariatric surgery (RYGB) with population controls with and without obesity, not undergoing bariatric surgery, and to identify characteristics associated with opioid use.

SETTING

This study included all patients with a principal diagnosis of obesity, aged 18-72 years, with a RYGB surgical code in the Swedish Patient Register between 2007 and 2013.

METHODS

RYGB patients (n = 23,898) were age- and sex-matched with 1 control patient with obesity (n = 23,898) and 2 population controls without obesity (n = 46,064). Participants were classified as nonconsumers and consumers based on their opioid dispensations during the 12 months before baseline. Opioid consumption was assessed for 24 months.

RESULTS

Nonconsumers. Within 24 months, a significantly higher proportion of RYGB patients (16.6%) started using opioids compared with the controls with obesity (14.3%, P < .0001) and population controls (5.4%, P < .0001). RYGB patients and controls with obesity had higher median daily intake of opioid morphine equivalent (MEQ) (2.8 mg/d) than population controls (2.5 mg/d, P < .0001). Consumers. Within 24 months, the proportion of RYGB patients and controls with obesity that was using opioids were similar (53.1% and 53.4%), but higher compared to population controls (38.0%, P < .0001). The median daily opioid MEQ was higher among RYGB patients than in population controls (10.5 versus 7.8 mg/d, P < .0001). RYGB patients, overall, had higher incidence of bowel surgery and cholecystectomy compared with controls with obesity and population controls, leading to prolonged opioid use in this group. Opioid consumption in general was associated with chronic pain and psychiatric disorder, which were more common in patients with obesity than in the population controls.

CONCLUSION

RYGB surgery increased the risk of prolonged opioid use in patients with obesity who were nonconsumers before surgery but had no effect on overall opioid use among prior consumers. RYGB-associated complications requiring surgery influenced opioid use for both nonconsumers and consumers. Regular reassessments of pain mechanisms and specific treatment owing to type of pain could prevent unnecessary opioid use in this patient group.

Long-term incidence of hypoglycaemia-related events after bariatric surgery or usual care in the Swedish Obese Subjects study: A register-based analysis

AIMS

To examine the incidence of hypoglycaemia-related events over a period of up to 31 years in patients treated with bariatric surgery in the prospective, controlled Swedish Obese Subjects (SOS) study.

MATERIALS AND METHODS

The SOS study (n = 4047) is a prospective controlled intervention study. The present analysis included 1989 patients treated with bariatric surgery and 2027 control patients with obesity who received usual care. Diagnosed hypoglycaemia and events commonly attributed to hypoglycaemia (confusion, syncope, epilepsy and seizures), requiring hospital or specialist outpatient treatment, were identified by searching the National Patient Register. Analyses were stratified by baseline glycaemic status. Hazard ratios were adjusted for inclusion year, age, sex, smoking, glycated haemoglobin (HbA1c) level and body mass index at baseline. At the time of analysis (December 31, 2018), the median follow-up was 22 years.

RESULTS

Compared with usual care, bariatric surgery was associated with increased incidence of hypoglycaemia-related events in patients without baseline diabetes (168 and 219 events, respectively; log-rank P = .011), with a more pronounced risk during the first years of follow-up (test of time-treatment interaction P = .010). Multivariate analyses in patients without baseline diabetes indicated that male sex (P < .001), older age (P = .001) and higher HbA1c levels (P = .006) were associated with hypoglycaemia-related events. No association was found between risk of hypoglycaemia-related events and bariatric surgery in patients with baseline diabetes.

CONCLUSIONS

Bariatric surgery is associated with an increased incidence of hypoglycaemia-related events in patients without baseline diabetes, especially during the first years after treatment.

Food addiction among morbidly obese patients: prevalence and links with obesity complications

BACKGROUND

In the context of obesity, little is known about the prevalence of food addiction nor about the phenotype of obese patients with food addiction. Objectives: To assess: (i) the prevalence of food addiction among obese patients eligible for obesity surgery; (ii) the relationship between clinical features and the complications of obesity. Methods: Consecutive patients consulting for the first time were included. The Yale Food Addiction Scale (YFAS) 2.0 questionnaire was used to diagnose food addiction and its severity. Demographics, clinical features, and obesity complications were systematically collected. Statistics: Student's test was used for numerical variables and Chi-square test or Fisher's exact test for categorical variables. Results: A total of 292 patients were included: 79% female, age (mean ± SD) 42.6 ± 13.0 yrs., body mass index (BMI) 43.2 ± 6.8 kg/m². One hundred and eight patients (37%) had food addiction: 58% severe, 33% moderate, 9% mild. Food addiction prevalence was 39% (n = 61/156) among patients eligible for obesity surgery. Food addiction was more frequent among the unemployed, compared to professionally active patients (41.0% vs. 33.5%, p = 0.046). Clinical and metabolic phenotypes and obesity complications were similar between patients with and without food addiction. Conclusion: Food addiction was present in 37% of obese patients, but was not associated with clinical features or obesity complications. Therefore, it should be systemically assessed for appropriate management.

A review of the psychosocial aspects of clinically severe obesity and bariatric surgery

For the past 2 decades, clinically severe obesity (operationalized as a body mass index ≥40 kg/m2) has increased at a more pronounced rate that less severe obesity. As a result, the surgical treatment of obesity (bariatric surgery) has become a more widely accepted, yet still underutilized, treatment for persons with severe obesity and significant weight-related health problems. Psychologists play a central role on the multidisciplinary team involved in the preoperative assessment and postoperative management of patients. They also have played a central role in clinical research which has enhanced understanding of the psychosocial and behavioral factors that contribute to the development of severe obesity as well as how those factors and others contribute to postoperative outcomes. This article, written specifically for psychologists and other mental health professionals who currently work with these patients or are considering the opportunity to do so in the future, reviews these contributions over the past 20 years. The article highlights how this work has become a fundamental part of international clinical care guidelines, which primarily focus on preoperative psychosocial screening. The article also outlines avenues for future research in the field, with a specific focus on the need for additional behavioral and psychosocial interventions to promote lifelong success after bariatric surgery. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Marijuana and Bariatric Surgery

PURPOSE OF REVIEW

Marijuana use presents a unique challenge to bariatric surgery programs. We review the recent evidence examining marijuana use on outcomes following bariatric surgery.

RECENT FINDINGS

Recent studies have not demonstrated an increased risk of short-term surgical complications or differences in up to 2-year weight loss following surgery among marijuana users. However, studies have demonstrated increased risks in two areas: pain management and problematic eating behaviors. Additionally, preoperative marijuana use has been linked to increased postoperative marijuana use which may undermine weight loss and increase risk for weight regain. There are still many unanswered questions regarding marijuana use and bariatric surgery, and the limited literature base has produced mixed results when considering marijuana as a contraindication for bariatric surgery. Programs must take into consideration the laws of their state, individual patterns of use, and route of administration when considering whether marijuana is a contraindication for surgery.

Vagotomy increases alcohol intake in female rats in diet dependent manner: Implications for increased alcohol use disorder after roux-en-y gastric bypass surgery

A variety of weight loss surgeries have been developed to fight the obesity epidemic, with Roux-en-Y gastric bypass (RYGB) being one of the most effective and popular procedures. However, the underlying mechanisms behind its efficacy are still not well understood. Furthermore, growing clinical evidence suggests that RYGB may result in increased risk for development of alcohol use disorder (AUD). The vagus nerve is a potentially critical contributor to increased risk of AUD following RYGB due to the potential for significant damage to the vagus during surgery, which has been confirmed in rodent studies. Studies aiming at the mechanisms underlying development of alcohol or substance use disorders following the surgery have exclusively used male rats, despite the majority of RYGB patients being female. Thus, the current study had two objectives: 1) to investigate the effect of RYGB on ethanol (EtOH) intake in female rats using a protocol previously established in male rats, and 2) to test the effect of vagal damage and high fat diet (HFD) on EtOH intake in female rats. In the first study, 22 female rats were maintained on HFD for four weeks and then split into two surgical groups, RYGB (n = 10) and Sham (n = 12). All rats then underwent a two-bottle choice test of increasing EtOH concentrations: 2%, 4%, 6%, 8%. Rats were then forced to abstain from EtOH for two weeks, after which access to 8% EtOH was reinstated. The RYGB female rats significantly increased their intake for low concentrations of EtOH (2% and 4%) and during the reinstatement period for 8%. These results mirror those seen in male rats, and thus, confirms RYGB in female rats as an equally viable model to males. In the second study, 40 female rats were separated into four groups: HFD/Sham, HFD/Vagotomy, normal diet (ND)/Sham, and ND/Vagotomy. All rats then were subjected to the same two-bottle choice test protocol as in the previous study. Rats in the vagotomy condition had significantly greater preference for 2% and 4% EtOH compared with Sham-operated controls. EtOH intake, either in ml or adjusted for body weight, was greater in rats maintained on ND compared with rats maintained on HFD. These data suggest that vagal damage may, at least in part, contribute to increased preference for EtOH. Furthermore, this increase in EtOH preference is counter to the blunting effect of HFD. In conclusion, the data presented here suggest a role for vagal damage in risk of AUD after weight loss surgery.

Meeting of Minds around Food Addiction: Insights from Addiction Medicine, Nutrition, Psychology, and Neurosciences

This review, focused on food addiction (FA), considers opinions from specialists with different expertise in addiction medicine, nutrition, health psychology, and behavioral neurosciences. The concept of FA is a recurring issue in the clinical description of abnormal eating. Even though some tools have been developed to diagnose FA, such as the Yale Food Addiction Scale (YFAS) questionnaire, the FA concept is not recognized as an eating disorder (ED) so far and is even not mentioned in the Diagnostic and Statistical Manuel of Mental Disorders version 5 (DSM-5) or the International Classification of Disease (ICD-11). Its triggering mechanisms and relationships with other substance use disorders (SUD) need to be further explored. Food addiction (FA) is frequent in the overweight or obese population, but it remains unclear whether it could articulate with obesity-related comorbidities. As there is currently no validated therapy against FA in obese patients, FA is often underdiagnosed and untreated, so that FA may partly explain failure of obesity treatment, addiction transfer, and weight regain after obesity surgery. Future studies should assess whether a dedicated management of FA is associated with better outcomes, especially after obesity surgery. For prevention and treatment purposes, it is necessary to promote a comprehensive psychological approach to FA. Understanding the developmental process of FA and identifying precociously some high-risk profiles can be achieved via the exploration of the environmental, emotional, and cognitive components of eating, as well as their relationships with emotion management, some personality traits, and internalized weight stigma. Under the light of behavioral neurosciences and neuroimaging, FA reveals a specific brain phenotype that is characterized by anomalies in the reward and inhibitory control processes. These anomalies are likely to disrupt the emotional, cognitive, and attentional spheres, but further research is needed to disentangle their complex relationship and overlap with obesity and other forms of SUD. Prevention, diagnosis, and treatment must rely on a multidisciplinary coherence to adapt existing strategies to FA management and to provide social and emotional support to these patients suffering from highly stigmatized medical conditions, namely overweight and addiction. Multi-level interventions could combine motivational interviews, cognitive behavioral therapies, and self-help groups, while benefiting from modern exploratory and interventional tools to target specific neurocognitive processes.

Characterizing non-heroin opioid overdoses using electronic health records

INTRODUCTION

The opioid epidemic is a modern public health emergency. Common interventions to alleviate the opioid epidemic aim to discourage excessive prescription of opioids. However, these methods often take place over large municipal areas (state-level) and may fail to address the diversity that exists within each opioid case (individual-level). An intervention to combat the opioid epidemic that takes place at the individual-level would be preferable.

METHODS

This research leverages computational tools and methods to characterize the opioid epidemic at the individual-level using the electronic health record data from a large, academic medical center. To better understand the characteristics of patients with opioid use disorder (OUD) we leveraged a self-controlled analysis to compare the healthcare encounters before and after an individual's first overdose event recorded within the data. We further contrast these patients with matched, non-OUD controls to demonstrate the unique qualities of the OUD cohort.

RESULTS

Our research confirms that the rate of opioid overdoses in our hospital significantly increased between 2006 and 2015 (P < 0.001), at an average rate of 9% per year. We further found that the period just prior to the first overdose is marked by conditions of pain or malignancy, which may suggest that overdose stems from pharmaceutical opioids prescribed for these conditions.

CONCLUSIONS

Informatics-based methodologies, like those presented here, may play a role in better understanding those individuals who suffer from opioid dependency and overdose, and may lead to future research and interventions that could successfully prevent morbidity and mortality associated with this epidemic.

Validation of the Yale Food Addiction Scale 2.0 and estimation of the population prevalence of food addiction

BACKGROUND & AIMS

Food addiction (FA) is likely to contribute to the global obesity epidemic. Most studies of FA have been conducted within clinical and/or highly selected populations, suggesting that prevalence estimates of FA may be biased. This is problematic as valid estimates of the population prevalence of FA is a requirement for informing and designing public health initiatives focusing on this phenotype. Therefore, we aimed to estimate the weighted prevalence of food addiction in the adult general population of Denmark.

METHODS

A random sample of 5000 individuals aged 18 to 62 from the Danish population was invited to participate in a survey, which included the Yale Food Addiction Scale (YFAS 2.0) and several rating scales measuring eating pathology and other psychopathology. Health, demographic and socioeconomic data from the Danish registers were linked to all invitees to allow for attrition analysis. The analysis had three steps: I) Psychometric validation of the Danish version of YFAS 2.0 II) Attrition analysis to examine selection bias, and III) Estimation of the weighted prevalence of FA taking attrition into account.

RESULTS

The confirmatory factor analysis of the YFAS 2.0 supported a one-factor model, and the scale had good internal consistency. The YFAS 2.0 score correlated with eating pathology including binge eating frequency, impulsivity and body mass index (BMI). The survey response rate was 34.0% (n = 1699) with a slight overrepresentation of respondents with higher socioeconomic status. The crude prevalence of FA was 9.0%. When taking attrition into account, the weighted prevalence of FA was 9.4% CI 95% [7.9-10.9].

CONCLUSIONS

The psychometric properties of the Danish version of the YFAS 2.0 were good. The weighted prevalence of FA was very similar to the crude prevalence estimate. This suggests that attrition may not be a large problem when estimating the prevalence of FA with the YFAS 2.0.

The Neuroendocrine and Metabolic Outcomes of Bariatric Surgery Depend on Presurgical Control over Eating

BACKGROUND

The outcomes of bariatric surgery are very irregular and mostly unpredictable. The search for variables of predictive value is encouraged to help preventing therapeutic failures.

OBJECTIVE

We aimed to confirm the hypothesis that preexisting eating behaviors could predict neuroendocrine and metabolic outcomes of gastric bypass surgery in morbidly obese subjects.

METHODS

Twenty-one morbidly obese patients from the Bariatric Surgery Program of our hospital were selected according to the specific inclusion and exclusion criteria for this study. The subjects filled out a validated questionnaire to quantify the "loss-of-control" (LC) dimension of food craving and provided serum samples at the onset of the study and 1 year after gastric bypass surgery. Hematological, metabolic, and hormonal variables were studied by conventional clinical tests and enzyme immunoassays and checked for correlations with LC both before and after surgery.

RESULTS

Those patients that had exhibited worse eating control at the beginning of the study experienced a better metabolic response 1 year after surgery in terms of reduction of serum insulin, HOMA1-IR, HOMA2-IR, and vitamin D1; all these variables were inversely correlated with presurgical LC. Serum brain-derived neurotrophic factor (BDNF) levels showed the same tendency; in fact, BDNF significantly decreased only in those patients with worse eating control.

CONCLUSIONS

Problematic eating behaviors may predict a better response of insulin resistance and a specific reduction of serum BDNF in morbidly obese patients after gastric bypass surgery.

The effects of bariatric surgery on psychological aspects of eating behaviour and food intake in humans

Bariatric surgery has emerged as an increasingly popular weight loss intervention, with larger and more endurable weight loss compared to pharmacological and behavioural interventions. The degree of weight loss patients experience varies, between individuals, surgeries and over time. An explanation as to why differing weight loss trajectories exist post-surgery could be due to the complex interplay of individual differences in relation to eating behaviours and appetite. Thus the aim of this narrative review is to explore literature between 2008 and 2018, to assess the impact of impact of bariatric surgery on food selection and nutrient status, on eating behaviour traits and on disturbed and disordered eating behaviour, to determine their impact of weight loss success and weight loss trajectories. Immediately post-surgery, up until 1-2 years post-surgery, there is a reliance upon the surgery's alteration of the gastrointestinal tract to control food intake and subsequently lose weight. Energy intake is reduced, dietary adherence is higher, supplement intake is higher, appetite ratings are lower, there is a reduction in psychopathology, and an increase in wellbeing. After this point, patients become more susceptible to weight regain, as this is the point where passive observation of the weight reducing action of surgery, moves into more cognitive effort, on the part of the individual, to control energy intake. There are various factors which influence an individual's ability to successfully regulate their energy intake post-surgery, such as their level of Disinhibition, Restraint, Hunger, Emotional Eating, Uncontrolled Eating, psychopathology and wellbeing. The need for continued psychological and nutritional support post-surgery is necessary to reduce weight regain susceptibility.

Use of Opioid Analgesics Before and After Gastric Bypass Surgery in Sweden: a Population-Based Study

BACKGROUND

Little is known regarding the use of opioid analgesics among patients who have undergone bariatric surgery. The Roux-en-Y gastric bypass (RYGB) procedure has been shown to significantly increase the rate of absorption of and exposure to morphine, raising concerns regarding the potentially increased risk of side-effects and the development of substance-use disorder.

OBJECTIVES

The aim of this study was to describe the pattern of opioid use over time following RYGB and to see if the pattern differs between patients with a high opioid consumption (HOC) prior to surgery and those with a low consumption (LOC).

SETTING

University Hospital of Örebro, Sweden.

METHODS

The study was a descriptive retrospective population-based cohort study where two registers with complete coverage were cross-matched.

RESULTS

The study population comprised 35,612 persons (1628 HOC, and 33,984 LOC). After surgery, the number of HOC patients increased to 2218. Mean daily opioid consumption in the total population and the LOC group increased after surgery (p < .0005). In the HOC group, there was no difference between mean daily consumption before and after surgery.

CONCLUSION

In this nationwide study, we have showed that there is an increase in consumption of opioid analgesics after gastric bypass surgery in Sweden. The increase in the number of individuals with high opioid consumption in the total population was mainly due to an increase in the group of patients with a low consumption prior to surgery.

Exploring pre-surgery and post-surgery substance use disorder and alcohol use disorder in bariatric surgery: a qualitative scoping review

INTRODUCTION

Bariatric surgery (BS) produces superior weight loss compared to non-surgical interventions. However, studies suggest bariatric patients who have undergone gastric-bypass surgery have an increased risk of developing new onset substance use disorder (SUD) or suffer negative outcomes after surgery. As such, many bariatric programs consider alcohol/ illicit drug misuse a contraindication to BS. The purpose of this systematic review was to investigate weight loss outcomes, post-surgery substance use patterns and other morbidity/mortality in BS patients with a history of substance use/SUD.

METHODS

Studies were identified by searching Ovid Medline(R), Embase, and PsychInfo. We included all study types investigating humans of any age/sex who had undergone any BS procedure with data regarding substance use before and/or after surgery. Outcome measures included metabolic outcomes and psychiatric outcomes after bariatric surgery in patients reporting substance use prior to bariatric surgery and substance use patterns after bariatric surgery.

RESULTS

Fifty-eight studies were included in the review. Studies reporting weight loss after BS did not demonstrate an association between substance use and negative weight loss outcomes. Several studies reported a significant portion of participants having new onset or increased substance use after BS. Factors associated with new onset or increased substance use/SUD after BS included the type of surgery, a history of SUD, a family history of SUD, coping skills/life stressors, age, male sex and alcohol sensitization after surgery.

CONCLUSION

Substance use history does not appear to influence weight loss after BS, however it may contribute to increased substance use after BS. Clinicians should ensure valid screening tools when assessing BS candidates for substance use history and ensure long term follow-up care post-operatively.

Changes in Alcohol Use after Metabolic and Bariatric Surgery: Predictors and Mechanisms

PURPOSE OF REVIEW

This review synthesized the literature on predictors and mechanisms of post-bariatric alcohol problems, in order to guide future research on prevention and treatment targets.

RECENT FINDINGS

Consistent evidence suggests an elevated risk of developing problems with alcohol following bariatric surgery. While there is a paucity of empirical data on predictors of problematic alcohol use after bariatric surgery, being male, a younger age, smoking, regular alcohol consumption, pre-surgical alcohol use disorder, and a lower sense of belonging have predicted alcohol misuse post-operatively. This review synthesizes potential mechanisms including specific bariatric surgical procedures, peptides and reinforcement/reward pathways, pharmacokinetics, and genetic influences. Finally, potential misperceptions regarding mechanisms are explored. Certain bariatric procedures elevate the risk of alcohol misuse post-operatively. Future research should serve to elucidate the complexities of reward signaling, genetically mediated mechanisms, and pharmacokinetics in relation to alcohol use across gender and developmental period by surgery type.

Psychopathology, disordered eating, and impulsivity as predictors of outcomes of bariatric surgery

Outcomes of bariatric surgery, while frequently impressive, are not universal and vary between patients and across surgical procedures. Between 20% and 30% of patients experience suboptimal weight loss or significant weight regain within the first few postoperative years. The reasons for this are not fully understood, but likely involve both physiologic processes, behavioral factors, and psychological characteristics. Evidence suggests that preoperative psychosocial status and functioning can contribute to suboptimal weight losses and/or postoperative psychosocial distress. Much of this work has focused on the presence of recognized psychiatric diagnoses and with particular emphasis on mood disorders as well as binge eating disorder. Several studies have suggested that the presence of preoperative psychopathology is associated with suboptimal weight losses, postoperative complications, and less positive psychosocial outcomes. Contemporary psychological theory suggests that it may be shared features across diagnoses, rather than a discrete diagnosis, that better characterizes psychopathology. Mood and substance use disorders as well as binge eating disorder, share common features of impulsivity, although clinicians and researchers often use complementary, yet different terms, such as emotional dysregulation or disinhibition (i.e., loss of control over eating, as applied to food intake), to describe the phenomenon. Impulse control is a central factor in eating behavior and extreme obesity. It also may contribute to the experience of suboptimal outcomes after bariatric surgery, including smaller than expected weight loss and psychosocial distress. This paper reviews the literature in these areas of research and articulates a direction for future studies of these complex relationships among persons with extreme obesity.

Systematic Review of Food Addiction as Measured with the Yale Food Addiction Scale: Implications for the Food Addiction Construct

BACKGROUND

The concept of food addiction attracts much interest in the scientific community. Research is mainly based on the Yale Food Addiction Scale (YFAS), a tool developed to assess food addiction. Substance use disorder criteria have been used to develop this scale.

OBJECTIVE

The aim of this paper was to review the clinical significance of food addiction diagnoses made with the YFAS and to discuss the results in light of the current debate on behavioral addictions.

METHODS

We performed a systematic review of the studies that assessed food addiction with the YFAS published between January 2014 and July 2017 by searching the electronic databases PsycINFO, MEDLINE, and PsycARTICLES.

RESULTS

Sixty publications were included in the analysis. Thirty-three studies examined nonclinical samples and 27 examined clinical samples. All studies used YFAS scoring results to define food addiction. The prevalence of food addiction according to the YFAS varied largely by the studied samples. In general, a higher body mass index and the presence of eating disorders (EDs), especially binge eating disorder (BED), were associated with higher YFAS scores.

CONCLUSION

The concept of food addiction has not been established to this day although it can be grouped with other EDs such as BED. More research is needed to understand this behavior and the differences between food addiction and other EDs. The criteria for food addiction should be revisited in light of the concepts currently used to examine behavioral addictions.

How Do Individuals Develop Alcohol Use Disorder After Bariatric Surgery? A Grounded Theory Exploration

BACKGROUND

Bariatric surgery is the most effective treatment for severe obesity. However, following Roux-en-Y gastric bypass (RYGB) surgery, a small minority of patients develop new-onset alcohol use disorder (AUD), the aetiology of which is poorly understood.

AIM

The aim is to construct a theory to explain the development of AUD among a sample of individuals who reported problematic drinking following RYGB.

METHOD

Semi-structured interviews were conducted with eight RYGB patients diagnosed with AUD attending a multi-disciplinary outpatient weight management service at a public hospital in the Republic of Ireland. A constructivist grounded theory methodology was used to analyse interview transcripts.

RESULTS

Participants' main concern was identified as 'unresolved psychological issues' which were managed by 'external coping mechanisms', namely, 'eating to cope'. After RYGB, comfort eating was no longer possible to the same extent. Following a 'honeymoon period', participants' need for an external coping mechanism resurfaced. 'Filling the void' provides a framework to explain how participants managed the symptoms of their unresolved psychological issues through 'behavioural substitution', that is, drinking alcohol instead of eating.

CONCLUSION

The theoretical framework of 'filling the void' adds to contemporary research that conceptualises AUD behavioural substitution as 'addiction transfer' by describing the process by which the phenomenon occurs as well as the characteristics of participants. The clinical implication of this research is to advocate for a reshaping of treatment of RYGB patients, with increased psychological input following surgery.

Effect of new persistent opioid use on physiologic and psychologic outcomes following bariatric surgery

INTRODUCTION

New persistent opioid use following surgery is a common iatrogenic complication, developing in roughly 6% of patients after elective surgery. Despite increased awareness of misuse and associated morbidity, opioids remain the cornerstone of pain management in bariatric surgery. The potential impact of new persistent opioid use on long-term postoperative outcomes is unknown. We sought to determine the relationship between new persistent opioid use and 1-year postoperative outcomes for patients undergoing bariatric surgery.

METHODS

Using data from the MBSC registry, we identified patients undergoing primary bariatric surgery between 2006 and 2016. Using previously validated patient-reported survey methodology, we evaluated patient opioid use preoperatively and at 1 year following surgery. New persistent use was defined as a previously opioid-naïve patient who self-reported opioid use 1 year after surgery. We used multivariable logistic regression models to evaluate the association between new persistent opioid use, risk-adjusted weight loss, and psychologic outcomes (psychological wellbeing, body image, and depression).

RESULTS

27,799 patients underwent primary bariatric surgery between 2006 and 2016. Among opioid-naïve patients, the rate of new persistent opioid use was 6.3%. At 1-year after surgery, patients with new persistent opioid user lost significantly less excess body weight compared to those without new persistent use (57.6% vs. 60.3%; p < 0.0001). Patients with new persistent opioid use had significantly worse psychological wellbeing (35.0 vs. 33.1; p < 0.0001), body image (19.9 vs. 18.0; p < 0.0001), and depression scores (2.4 vs. 5.0; p < 0.0001). New persistent opioid users also reported less overall satisfaction with their bariatric surgery (75.1% vs. 85.7%; p < 0.0001).

CONCLUSIONS

New persistent opioid use is common following bariatric surgery and associated with significantly worse physiologic and psychologic outcomes. More effective screening and postoperative surveillance tools are needed to identify these patients, who likely require more aggressive counseling and treatment to maximize the benefits of bariatric surgery.

Food addiction, in obese patients seeking bariatric surgery, is associated with higher prevalence of current mood and anxiety disorders and past mood disorders

The current cross-sectional study investigates the prevalence of the food addiction (FA) phenotype and its association with psychiatric disorders in bariatric surgery candidates. It also investigates the eating behavior characteristics associated with FA and the association between FA and loss of control over specific foods high in sugar, salt and/or fat. We included 128 bariatric surgery candidates and we assessed FA (YFAS 2.0), mood and anxiety disorders, suicidality, eating disorders (current bulimia nervosa and current anorexia nervosa), alcohol and tobacco use disorders (MINI 5.0.0, beck depression inventory, AUDIT, Fagerström Test for Nicotine Dependence) and eating behavior (DEBQ). Prevalence of FA in our sample was 25%. FA was significantly associated with higher prevalence of current mood and anxiety disorders and past mood disorders, higher current suicidality but not with eating disorders and alcohol use disorder. FA was significantly associated with higher emotional eating, and with loss of control over consumption of foods high in fat, sugar and/or salt, but not of fruits, vegetables or grain products. Our results provide arguments for considering psychiatric disorders and suicidality in FA and for considering FA as an addictive disorder in obese patients, with many risk factors in common with other addictions.

From bingeing to cutting: the substitution of a mal-adaptive coping strategy after bariatric surgery

BACKGROUND

An increase in self-harm emergencies after bariatric surgery have been documented, but understanding of the phenomenon is missing.

CASE PRESENTATION

The following case report describes a 26-year-old woman with obesity, who initiated self-harm behaviour after bariatric surgery. The patient reported that the self-harm was a substitute for binge eating, which was anatomically impeded after bariatric surgery.Pre-surgical psychosocial assessment revealed Anorexia Nervosa in youth, which had later migrated to Binge Eating Disorder. At the time of surgery, the patient was not fulfilling the diagnostic criteria for Binge Eating Disorder because of a low frequency of binges. The remaining binges occurred when experiencing negative affect.

CONCLUSIONS

Previous eating disorder pathology is an important consideration in pre-surgical assessments. For patients with affect-driven pre-surgical Binge Eating Disorder, therapeutic intervention before and after bariatric surgery could be indicated in order to secure the development of adaptive coping strategies. Furthermore, body weight as the only outcome measure for the success of surgery seems insufficient.

Food addiction and bariatric surgery: a systematic review of the literature

Emerging research suggests that rates of food addiction are high among individuals seeking bariatric surgery, but little is known about associated features and the prognostic significance of pre-operative food addiction. Thus, this article provides a systematic review and synthesis of the literature on food addiction and bariatric surgery. Articles were identified through PubMed and SCOPUS databases, resulting in a total of 19 studies which assessed food addiction among pre-bariatric and/or post-bariatric surgery patients using the Yale Food Addiction Scale. Most studies were cross-sectional, and only two studies prospectively measured food addiction both pre-operatively and post-operatively. The presence of pre-surgical food addiction was not associated with pre-surgical weight or post-surgical weight outcomes, yet pre-surgical food addiction was related to broad levels of psychopathology. The relationship between food addiction and substance misuse among individuals undergoing bariatric surgery is mixed. In addition, very few studies have attempted to validate the construct of food addiction among bariatric surgery patients. Results should be interpreted with caution due to the methodological limitations and small sample sizes reported in most studies. Future rigorous research with larger and more diverse samples should prospectively examine the clinical utility and validity of the food addiction construct following bariatric surgery.

Food for Thought: Reward Mechanisms and Hedonic Overeating in Obesity

PURPOSE OF REVIEW

This review examines the food addiction model and the role of food hedonic pathways in the pathogenesis and treatment of obesity.

RECENT FINDINGS

The hedonic pathway interacts with the obesogenic environment to override homeostatic mechanisms to cause increase in body weight. Weight gain sustained over time leads to "upward setting" of defended level of body-fat mass. There are neurobiological and phenotypic similarities and differences between hedonic pathways triggered by food compared with other addictive substances, and the entity of food addiction remains controversial. Treatment for obesity including pharmacotherapy and bariatric surgery impacts on neural pathways governing appetite and hedonic control of food intake. The food addiction model may also have significant impact on public health policy, regulation of certain foods, and weight stigma and bias. Recent rapid progress in delineation of food hedonic pathways advances our understanding of obesity and facilitates development of effective treatment measures against the disease.

The importance of nutrition in aiding recovery from substance use disorders: A review

BACKGROUND

Nutrition is a prerequisite for health; yet, there is no special nutritional assessment or guidance for drug and alcohol dependent individuals, despite the fact that their food consumption is often very limited, risking malnutrition. Further, the premise is examined that malnutrition may promote drug seeking and impede recovery from substance use disorders (SUD).

METHOD

A narrative review addressed the relationship between substance use disorders and nutrition, including evidence for malnutrition, as well as their impact on metabolism and appetite regulation. The implications of the biopsychology of addiction and appetite for understanding the role of nutrition in SUD were also considered.

RESULTS

The literature overwhelmingly finds that subjects with alcohol use disorder (AUD) and drug use disorder (DUD) typically suffer from nutrient deficiencies. These nutrient deficiencies may be complicit in the alcoholic myopathy, osteopenia and osteoporosis, and mood disorders including anxiety and depression, observed in AUD and DUD. These same individuals have also been found to have altered body composition and altered hormonal metabolic regulators. Additionally, brain processes fundamental for survival are stimulated both by food, particularly sweet foods, and by substances of abuse, with evidence supporting confusion (addiction transfer) when recovering from SUD between cravings for a substance and craving for food.

CONCLUSION

Poor nutritional status in AUD and DUD severely impacts their physical and psychological health, which may impede their ability to resist substances of abuse and recover their health. This review contributes to a better understanding of interventions that could best support individuals with substance use disorders.

Obesity and addiction: can a complication of surgery help us understand the connection?

Obesity is a multifactorial, chronic disease that has proven difficult to treat. An increased understanding of aetiological mechanisms is critical to the development of more effective obesity prevention and treatment strategies. A growing body of empirical evidence has demonstrated parallels between obesity, overeating and substance abuse, including shared behavioural, psychological and neurophysiological factors implicated in the excessive intake of both food and substances of abuse. Several different lines of research have recently emerged that hold the potential to shed light on the connection between obesity, food reward and addiction, with studies examining changes in alcohol use/misuse after weight loss surgery providing a particularly interesting perspective on these interrelationships. However, these lines of investigation have proceeded in relative isolation, and relevant research findings have yet to be integrated in a synthesized, comprehensive manner. To provide an opportunity to achieve such a synthesis, a scientific symposium was convened at the Radcliffe Institute in Cambridge, Massachusetts. Invited participants were researchers working in diverse domains related to the intersection between obesity and addiction. Extensive discussion was generated suggesting novel research directions. In this article, we summarize and synthesize the symposium participants' ongoing research in this area, incorporating additional relevant research holding potential clues regarding the connections between obesity, weight loss surgery and addiction.

Alcohol and other substance use after bariatric surgery: prospective evidence from a U.S. multicenter cohort study

BACKGROUND

Empirical evidence suggests Roux-en-Y gastric bypass (RYGB) increases risk of developing alcohol use disorder (AUD). However, prospective assessment of substance use disorders (SUD) after bariatric surgery is limited.

OBJECTIVE

To report SUD-related outcomes after RYGB and laparoscopic adjustable gastric banding (LAGB). To identify factors associated with incident SUD-related outcomes.

SETTING

10 U.S. hospitals METHODS: The Longitudinal Assessment of Bariatric Surgery-2 is a prospective cohort study. Participants self-reported past-year AUD symptoms (determined by the Alcohol Use Disorders Identification Test), illicit drug use (cocaine, hallucinogens, inhalants, phencyclidine, amphetamines, or marijuana), and SUD treatment (counseling or hospitalization for alcohol or drugs) presurgery and annually postsurgery for up to 7 years through January 2015.

RESULTS

Of 2348 participants who underwent RYGB or LAGB, 2003 completed baseline and follow-up assessments (79.2% women, baseline median age: 47 years, median body mass index 45.6). The year-5 cumulative incidence of postsurgery onset AUD symptoms, illicit drug use, and SUD treatment were 20.8% (95% confidence interval (CI): 18.5-23.3), 7.5% (95% CI: 6.1-9.1), and 3.5% (95% CI: 2.6-4.8), respectively, post-RYGB, and 11.3% (95% CI: 8.5-14.9), 4.9% (95% CI: 3.1-7.6), and .9% (95% CI: .4-2.5) post-LAGB. Undergoing RYGB versus LAGB was associated with higher risk of incident AUD symptoms (adjusted hazard ratio or AHR = 2.08 [95% CI: 1.51-2.85]), illicit drug use (AHR = 1.76 [95% CI: 1.07-2.90]) and SUD treatment (AHR = 3.56 [95% CI: 1.26-10.07]).

CONCLUSIONS

Undergoing RYGB versus LAGB was associated with twice the risk of incident AUD symptoms. One-fifth of participants reported incident AUD symptoms within 5 years post-RYGB. AUD education, screening, evaluation, and treatment referral should be incorporated in pre- and postoperative care.

Risk of psychiatric disorders, self-harm behaviour and service use associated with bariatric surgery

OBJECTIVE

To investigate psychiatric outcomes after bariatric surgery, including suicide, self-harm, psychiatric service use and substance misuse.

METHOD

Retrospective study on a Danish nationwide register-based cohort of 22 451 patients followed for 1 029 736 person-years. Data were analysed utilizing single- and multi-event Cox regression with non-operated controls with obesity and mirror-image analyses with the operated patient serving as their own controls.

RESULTS

We showed an increased ratio of self-harm (hazard ratio [HR] 3.23, P < 0.001; incidence rate ratio [IRR] 1.71, P < 0.001), psychiatric service use (admissions IRR 1.52, P < 0.001; emergency room visits IRR 1.70, P < 0.001), psychiatric diagnosis (organic psychiatric disorders HR 1.78, P < 0.001; substance use HR 2.06, P < 0.001; mood disorders HR 2.66, P < 0.001; neurotic, stress-related and somatoform disorders HR 2.48, P < 0.001; behavioural syndromes HR 3.15, P < 0.001; disorders of personality HR 2.68, P < 0.001; behavioural and emotional disorders HR 6.43, P < 0.001), as well as substance misuse utilizing Cox regression as well as mirror-image analyses, as compared to non-operated. We did not find an increased suicide rate (HR 1.35, P = 0.658) among operated as compared to non-operated.

CONCLUSION

Our study shows that undergoing bariatric surgery is associated with increases in self-harm, psychiatric service use and occurrence of mental disorders.

Prevalence of Psychoactive Substance Consumption in People With Obesity

OBJECTIVE

The aim of this study was to evaluate the prevalence and the kind of psychoactive substances consumed by people with obesity.

METHODS

Patients were included at their first visit for bariatric surgery. Socio-demographic characteristics, anxiety, depressive disorders and psychoactive substance consumption were assessed. The prevalence of psychoactive substance consumption was compared to that of the general population reported by the French National Institute of Prevention and Health Education.

RESULTS

One hundred (100) patients were consecutively recruited: 60 women (mean age 41 ± 14 years) and 40 men (mean age 46 ± 13 years). Sixty-seven percent of subjects consumed alcohol. Consumption rates of cannabis (21% vs. 10%), cocaine (7.0% vs. 0.8%) and amphetamine (6.0% vs. 0.3%) were significantly (p < .0001) higher in people with obesity than in the general population.

CONCLUSIONS

People with obesity have an excess risk of amphetamine, cocaine and cannabis consumption. This consumption may increase the risk of cardiovascular and psychiatric morbidity and should therefore be detected before surgery.

Long-term pharmacotherapy considerations in the bariatric surgery patient

PURPOSE

Pharmacists' role in optimizing long-term pharmacotherapy for bariatric surgery patients is detailed.

SUMMARY

Bariatric surgery patients provide a difficult challenge in terms of many pharmacotherapy issues, especially in the chronic care setting, where data on long-term effects of bariatric surgery are limited. The most common procedures are Roux-en-Y gastric bypass (RYGB), adjustable gastric banding, and sleeve gastrectomy. Sleeve gastrectomy has become the most common procedure in the United States, primarily because it has less overall chronic malabsorption effects than RYGB. Pharmacotherapy management is complicated by rapid weight loss combined with a number of pharmacokinetic changes, such as decreased absorption of some medications due to altered gastrointestinal tract anatomy and potentially increased concentrations of some medications due to a decreased volume of distribution resulting from weight loss. Nutritional and metabolic supplementation are of the utmost importance in order to limit deficiencies that can lead to a number of conditions. Many chronic diseases, including hypertension, diabetes, gastroesophageal reflux disease, and urinary incontinence, are improved by bariatric surgery but require close monitoring to ensure the effectiveness of maintenance pharmacotherapy and avoidance of adverse effects. Psychotropic medication management is also an important pharmacotherapy concern, as evidenced by antidepressants being the most commonly used medication class among preoperative bariatric surgery patients.

CONCLUSION

Pharmacists have an increasing role in the chronic management of the bariatric surgery patient due to their knowledge of medication dosage forms and expertise in disease states affected by bariatric surgery.

Substance use after bariatric surgery: A review

BACKGROUND

Prevalence of obesity has increased dramatically. Obese individuals may undergo bariatric surgery to lose excessive body fat and mitigate obesity-related comorbidities. However, bariatric patients are particularly vulnerable to substance use problems. We conducted a review to examine the prevalence change and factors associated with substance use and determine the association between substance use and health status after weight loss among bariatric patients.

METHODS

We searched peer-reviewed articles published between January 1990 and January 2015 in several databases (PubMed, PsycINFO, Cochrane Library, Google Scholar) using different keywords combinations. Studies that focused on pre-surgery substance use only or without reported effect measurements were excluded.

RESULTS

Overall, 40 studies were included in the review. Preoperative history of substance use was a reliable correlate of postoperative substance use. The prevalence of postoperative alcohol use was higher among patients with preoperative history of alcohol use than those without. Postoperative prevalence of alcohol use ranged from 7.6% to 11.8%. No significant prevalence change in cigarette smoking from pre-to postoperative period was observed. Time effect was not observed on smoking or drug use prevalence, while an increase in alcohol consumption was inconsistent across studies. The proportion of new-onset substance users among bariatric patients after surgery ranged from 34.3% to 89.5%.

CONCLUSION

Substance use is associated with poor health among bariatric patients. Preoperative assessment and postoperative follow-up should include interventions to reduce relapse among users and prevent substance use initiation.

Stimulants for the Control of Hedonic Appetite

The focus of this paper is treatment of obesity in relation to the management of hedonic appetite. Obesity is a complex condition which may be potentiated by excessive reward seeking in combination with executive functioning deficits that impair cognitive control of behavior. Stimulant medications address both reward deficiency and enhance motivation, as well as suppressing appetite. They have long been recognized to be effective for treating obesity. However, stimulants can be abused for their euphoric effect. They induce euphoria via the same neural pathway that underlies their therapeutic effect in obesity. For this reason they have generally not been endorsed for use in obesity. Among the stimulants, only phentermine (either alone or in combination with topiramate) and bupropion (which has stimulant-like properties and is used in combination with naltrexone), are approved by the United States Food and Drug Administration (FDA) for obesity, although dexamphetamine and methylpenidate are approved and widely used for treating attention deficit hyperactivity disorder (ADHD) in adults and children. Experience gained over many years in the treatment of ADHD demonstrates that with careful dose titration, stimulants can be used safely. In obesity, improvement in mood and executive functioning could assist with the lifestyle changes necessary for weight control, acting synergistically with appetite suppression. The obesity crisis has reached the stage that strong consideration should be given to adequate utilization of this effective and inexpensive class of drug.

A Systematic Review of the Application And Correlates of YFAS-Diagnosed 'Food Addiction' in Humans: Are Eating-Related 'Addictions' a Cause for Concern or Empty Concepts?

The proposition of so-called 'food addiction' (FA) in the scientific literature has stimulated a recent surge in research and debate. The concept of FA is controversial, and opinion is divided. Many of the findings depend upon the use of a single instrument called the Yale Food Addiction Scale (YFAS). This review systematically examined FA, as defined by the YFAS, reported in 40 experimental human studies published in or after 2009. The results indicated that much of the literature makes the supposition that food addiction is an accepted neurobiological disease, consistent with substance use disorders; an interpretation based on very limited data. This raises the question as to whether those individuals who meet the YFAS criteria for diagnosis are truly 'addicted' to food or if they experience significant impairment to their psychological wellbeing and quality of life as would be expected in clinically recognised addictive disorders. At the present time, little research has investigated the extent to which a psychometric self-assessment of FA symptomatology can elucidate a harmful relationship with target foods in the diet. A positive YFAS diagnosis is usually positively associated with BMI and strongly linked with the presence of binge eating, but certain exceptions within the literature were revealed. Further clarification is required as to whether so-called FA is sufficiently different to existing conditions and traits to warrant classification as a distinctive disease phenotype rather than an expression of strong habits and preferences.

Alcohol and Drug Use Among Postoperative Bariatric Patients: A Systematic Review of the Emerging Research and Its Implications

BACKGROUND

Emerging research suggests that some bariatric surgery patients are at a heightened risk for developing substance use problems, especially alcohol use problems.

METHODS

An exhaustive literature review was conducted in January 2015 to investigate all articles published that included data on postoperative alcohol use, alcohol use disorders, and illicit drug use among bariatric surgery patients.

RESULTS

Twenty-three studies reported on alcohol and/or substance use among bariatric patients. Six studies longitudinally assessed alcohol use behaviors; 3 of these studies found an increase in alcohol use following surgery. Six studies were cross-sectional, and 2 studies assessed medical records. Five studies investigated the prevalence of admissions to substance abuse treatment, and 3 studies combined alcohol and drug use data in a single index. Six studies reported on illicit drug use and reported low-postoperative use. The studies' samples were primarily non-Hispanic white females in their upper 40s, and only 11 of the 23 studies utilized validated assessment instruments.

CONCLUSIONS

Studies employing longitudinal designs and large sample sizes indicate that bariatric patients who had the gastric bypass procedure are at an elevated risk for alcohol use problems postoperatively. Research also indicates that bariatric surgery patients might be overrepresented in substance abuse treatment facilities. Risk factors for problematic postoperative alcohol use include regular or problematic alcohol use presurgery, male gender, younger age, tobacco use, and symptoms of attention deficient and hyperactivity disorder. As a whole, however, studies indicate bariatric surgery patients demonstrate a low prevalence of problematic alcohol use, and studies about gastric bypass patients are not entirely conclusive. Prospective, longitudinal studies are needed, utilizing standardized and validated alcohol assessment instruments that follow postoperative bariatric patients well beyond 2 years, and account for types of bariatric procedure. Finally, study samples with greater racial/ethnic diversity and wider age ranges are needed.