Many At-Risk Bariatric Patients Missed by Alcohol Screening Tools
While typical screening tools for problem drinking focus on quantity and frequency of alcohol consumed, these tools may be ineffective for bariatric surgery patients, due in part to changes in the way their bodies process alcohol postoperatively.
“Candace” underwent Roux-en Y gastric bypass (RYGB) eight years ago, a surgery that significantly reduces stomach size and changes connections with the small intestine. While the surgery led to major weight loss and remission of her type 2 diabetes, several years later, she began drinking alcohol after experiencing a major personal loss.
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One day, she went home and fixed herself a drink and said she liked how it made her feel. “I was completely wasted after just one drink, and I started drinking every night,” Candace told Psychiatric News. Although she never drank more than three drinks, the alcohol created outsize problems: she suffered frequent blackouts and felt regret when reading drunken texts from the night before. She has experienced severe falls and injuries, sometimes having no memory of what happened. Once she woke up covered in blood with a broken nose and three broken fingers, requiring setting by an orthopedic surgeon; another time she suffered a severe burn. Also, she was sexually assaulted while incapacitated by alcohol.
“Since having the surgery, I don’t need much to get drunk,” she said. When she wakes up the next day, she experiences no hangovers, and most compelling to her, drinking alcohol keeps her weight in check. Despite Candace’s hospital visits for her injuries, “nobody ever asked me about my drinking,” she said. Although her drinking is under better control now, she still vascillates between periods of sobriety and periods of relapse. “The longest I’ve gone sober since I began drinking is about a year,” she said.
Screening Tools Inadequate for Bariatric Patients
Among the bariatric procedures performed in the United States, RYGB is the most common, and while it is associated with many impressive long-term health outcomes, it also raises risk for vitamin deficiencies, accidents, self-harm, and alcohol use disorder (AUD), explained Gretchen E. White, Ph.D., senior research analyst in the University of Pittsburgh’s School of Medicine Department of Surgery.
A study that White led followed 1,500 RYGB patients for up to seven years post-op and discovered that participants who drank significantly increased the average frequency and quantity of alcohol use in the years after their surgery, according to the report, which was published in the Annals of Surgery. In addition, traditionally recommended screening tools—which focus on consumption alone—miss many women at high risk for alcohol-related problems, according to the study.
“Rather, specific symptoms of alcohol use disorder, such as being unable to remember or failing to meet normal expectations because of drinking, should be assessed” in this population, explained Wendy C. King, Ph.D., a research associate professor of epidemiology at the University of Pittsburgh Graduate School of Public Health.
The association with AUD may be at least partially explained by pharmacokinetics: after undergoing RYGB surgery, individuals experience higher peak alcohol concentrations and slower elimination compared with presurgery or people who haven’t had the procedure. In particular, previous research has shown that with a standard dose of alcohol, peak blood alcohol content is about two times higher postsurgery than presurgery, White said.
“In other words, drinking three drinks for someone who has undergone RYGB is the equivalent of drinking six drinks for someone who hasn’t had the surgery,” White said, and moreover, the surgery’s alcohol-enhancing effect seems to be permanent.
For the study, the researchers put three recommended screening tools to the test, administering one that focused on frequency of alcohol use, one that focused on number of drinks per drinking day, and the AUDIT-C score (Alcohol Use Disorder Identification Test-Consumption), a three-question assessment that combines both measures. These are the screening tools recommended by the U.S. Preventive Services Task Force for use by primary care clinicians.
Researchers also gave participants the AUDIT, a 10-item test assessing alcohol-related problems. It asks participants if they have been unable to stop drinking once starting, failed to meet normal expectations, felt guilt or remorse, been unable to remember, or injured someone or elicited concern due to their drinking.
Researchers found that all three screening tools, despite being validated as effective in the general population, had lower than expected ability to detect alcohol-related problems following RYGB. On average, the tools had lower than 80 percent sensitivity, meaning they missed at least 1 in 5 of participants who were experiencing alcohol-related problems after their surgery.
One-Fourth of Patients Not Identified
While the AUDIT-C performed the best of the three recommended alcohol screening tools assessed, it still missed nearly one-quarter of women who were experiencing problems with alcohol after RYGB. One reason for this lack of sensitivity may be that the AUDIT-C assesses frequency of occasions of consuming six drinks on one occasion, which in a post-RYGB patient is equivalent to drinking 12 drinks, a level of consumption likely to be rare, the report noted.
The study also found the three screening tools were even less effective at detecting problem alcohol use in this population prior to their undergoing RYBG, failing to detect 1 in 3 women experiencing alcohol-related problems presurgery.
Women made up about 80 percent of the study participants, and not enough men completed the postsurgery alcohol assessments to draw scientifically accurate conclusions about their alcohol use or related problems, the researchers noted. However, they wrote, there is no reason to believe the findings wouldn’t also extend to men who have undergone RYGB.
“Clinicians should be aware that even the AUDIT-C will fail to correctly identify many patients with alcohol-related problems both before and after surgery, so additional screening for alcohol-related problems, such as the full AUDIT or other screening tools that assess symptoms of alcohol-related problems should be conducted in this population,” White and colleagues concluded.
The study was funded by the National Institutes of Health. ■
“Alcohol Use Thresholds for Identifying Alcohol-related Problems Before and Following Roux-en-Y Gastric Bypass” can be accessed here.
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Published online: 4 December 2018
Published in print: November 17, 2018 – December 7, 2018
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