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Substance Abuse and Addiction

Substance Abuse and Addiction. David B. Sarwer, Ph.D. Associate Professor of Psychology Departments of Psychiatry and Surgery Director of Clinical Services Center for Weight and Eating Disorders Perelman School of Medicine at the University of Pennsylvania.

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Substance Abuse and Addiction

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  1. Substance Abuse and Addiction David B. Sarwer, Ph.D. Associate Professor of Psychology Departments of Psychiatry and Surgery Director of Clinical Services Center for Weight and Eating Disorders Perelman School of Medicine at the University of Pennsylvania

  2. Dr. Sarwer’s research is supported by grants from the Ethicon Endo-Surgery and NIH. He discloses that he has a consulting relationships with Allergan, Baronova, EnteroMedic, and Ethicon Endo-Surgery. He also serves on the Board of Directors of the Surgical Review Corporation.

  3. Psychiatric Status and History of Bariatric Surgery Patients • 20-60% of bariatric surgery patients suffer from an Axis I disorder • Mood disorders are the most common diagnoses, seen in 19-60% of patients • Anxiety disorders have been found in as many as 48% of patients • Substance abuse disorders have been diagnosed in a sizeable minority (8% illicit drug use, 11% alcohol use) (e.g. Bocchieri et al., 2002; Greenberg et al., 2005; Herpetz et al., 2004; Sarwer et al., 2005; van Hout et al., 2006)

  4. Substance Abuse When repeated use of alcohol or other drugs leads to problems but does not include compulsive use or addiction, and stopping the drug does not lead to significant withdrawal symptoms . A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:  • Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home • Recurrent substance use in situations in which it is physically hazardous • Recurrent substance-related legal problems • Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

  5. Substance Dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:  (1) Tolerance, as defined by either of the following: (a) a need for markedly increased amounts of the substance to achieve intoxication(b) markedly diminished effect with continued use of the same amount of the substance  (2) Withdrawal, as manifested by either of the following:  (a) the characteristic withdrawal syndrome for the substance  (b) the substance is taken to relieve or avoid withdrawal symptoms (3) The substance is often taken in larger amounts or over a longer period than was intended  (4) There is a persistent desire or unsuccessful efforts to cut down or control substance use  (5) A great deal of time is spent in activities necessary to obtain the substance, use the substance , or recover from its effects  (6) Important social, occupational, or recreational activities are given up or reduced because of substance use 

  6. Lifetime and Current Axis I Disorders in Candidates for Weight Loss Surgery (N=288) Kalarchian et al. Am J Psych, 2007 *population base rate = 14.6%; **population rate 9%

  7. AACE/TOS/ASMBS Guidelines for Clinical Practice for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient (2008) • A psychosocial-behavioral evaluation, which assesses environmental, familial, and behavioral factors, should be considered for all patients before bariatric surgery. • Any patient considered for bariatric surgery with a known or suspected psychiatric illness should undergo a formal mental health evaluation before performance of the surgical procedure. • Current alcohol or substance abuse/dependence listed as a contraindication to bariatric surgery.

  8. Goals of the Psychosocial Evaluation To assess psychiatric status and history as potential contraindications to bariatric surgery (e.g. psychosis, severe major depression, substance abuse). To identify negative environmental influences that may have contributed to the development of extreme obesity. To evaluate maladaptive psychosocial factors and behaviors that may be associated with a poor postoperative outcome. (Wadden & Sarwer, 2006)

  9. Social/Psychological Factors • Current Psychiatric Status • Depression • Binge Eating Disorder • Bulimia (binge eating with purging or other compensatory behaviors) • Thought disorders • Substance abuse • Psychiatric History

  10. Psychiatric Treatment among Bariatric Surgery Candidates 16%-38.9% of bariatric surgery patients report current mental health treatment 50% of patients had a history of mental health treatment The most common form of treatment is psychiatric medications (often prescribed by primary care physicians) (e.g., Friedman et al., 2007; Sarwer et al., 2004, Larsen et al., 2003; Clark et al., 2003, Lang et al., 2002, Glinski et al., 2001)

  11. Results of Psychological Evaluations • Studies have suggested that mental health professionals unconditionally recommend 70%-90% of bariatric surgery candidates for surgery. (Fabricatore et al., 2006; Friedman et al., 2007; Pawlow et al., 2005; Sarwer et al., 2004; Zimmerman et al., 2007) • In 10%-30% of cases, the recommendation is to delay surgery until specific psychosocial and/or nutritional issues are resolved. • Many patients do not follow through on these recommendations (Friedman et al., 2007; Merrell et al., in press) • Those involved in outpatient mental health treatment (therapy or medications) and those with current or past alcohol abuse or dependence appear to be at greatest risk to not have surgery (Merrell et al., in press).

  12. Postoperative Psychosocial Status • Significant reductions in depression and anxiety in the year following surgery. • Significant improvements in health and weight-related quality of life. • Majority of patients report improvements in body image and sexual functioning. (Bocchieri et al., 2002; Herpetz et al., 2004; Sarwer et al., 2005; van Hout et al., 2006)

  13. Does a History of Substance Abuse Impact Postoperative Outcomes? • Two studies have demonstrated larger weight losses among persons with a history of substance abuse as compared to those without a history of substance abuse (Clark et al., 2003; Heinberg & Ashton, 2010) • Persons who are successful at controlling their addiction history may be using the same behavioral self-management skills to promote success after bariatric surgery. (Bocchieri et al., 2002; Herpetz et al., 2004; Sarwer et al., 2005; van Hout et al., 2006)

  14. History of Substance Abuse is Related to Larger Postoperative Weight Loss(Heinberg & Ashton, 2010)

  15. Alcohol Consumption after RYGB • Accelerated alcohol absorption (Klockhoff et al., 2002) • Higher maximum alcohol concentration (Hagedorn et al., 2007; Klockhoff et al., 2002; Woodard et al. 2011) • Longer time to elimination (Hadedorn et al., 2007; Woodard et al. 2011).

  16. Alcohol Use after Surgery • 83% of RYGB patients reported drinking alcohol postoperatively • 28% reported a “problem controlling alcohol” • (Buffington, 2007) • 13-15 years following RYGB: • 5% reported alcohol abuse (v. 3% preoperatively) • 3% reported alcohol dependence (v. 10% preoperatively) • (Mitchell et al., 2001)

  17. Substance Abuse and “Addiction Transfer” There is also some concern, particularly in the mass media, that patients can experience “addiction transfer” postoperatively—transferring their “addiction” to food to another addiction such as drugs, alcohol, shopping or sex.

  18. Substance Abuse and “Addiction Transfer” Gastric Bypass Surgery and Alcoholism June 01, 2008 Trading One Addiction for Another April 9, 2007 “After Gastric Bypass Surgery, These Patients Found It Hard to Abuse Food—So They Turned to Other Out-of-Control Behavior”

  19. Criticisms of “Addiction Transfer” “Addiction transfer” is not an accepted clinical diagnosis There is no scientific consensus that food is an addictive substance or eating is an addictive behavior There is little support for the notion that addictive behaviors can switch unless the psychological basis for the original problem is resolved. Nevertheless, it is possible that bariatric surgery patients (particularly those with a history of addiction) could be at increased risk for substance abuse postoperatively. (Sogg, 2008)

  20. Substance Abuse and Bariatric Surgery: Next Steps • Need for additional research on mechanisms of action (alcohol and other substances) • Need for additional study of clinical populations (LABS and Teen-LABS) • Additional emphasis on preoperative screening (Heinberg et al., in press).

  21. Screening for Substance Abuse • National Institute on Alcohol Abuse and Alcoholism (NIAAA) • Alcohol Use Disorder Identification Test (AUDIT) • Special Preoperative Education Groups (Heinberg et al., in press). • Special Consent Forms (Heinberg et al., in press)

  22. Correspondence Dr. David B. Sarwer Perelman School of Medicine at the University of Pennsylvania Department of Psychiatry Center for Weight and Eating Disorders 3535 Market St. Suite 3026 Philadelphia, PA 19104 dsarwer@mail.med.upenn.edu

  23. National Institute on Alcohol Abuse and Alcoholism (NIAAA)(6 Question Set) Question 1 - (asks about frequency of past 12 month drinking) During the last 12 months, how often did you usually have any kind of drink containing alcohol? By a drink we mean half an ounce of absolute alcohol (e.g. a 12 ounce can or glass of beer or cooler, a 5 ounce glass of wine, or a drink containing 1 shot of liquor). Choose only one. Every day 5 to 6 times a week 3 to 4 times a week twice a week once a week 2 to 3 times a month once a month 3 to 11 times in the past year 1 or 2 times in the past year(IF RESPONDENT GIVES ANY OF THE ABOVE RESPONSES, GO TO QUESTION 2)I did not drink any alcohol in the past year, but I did drink in the past (GO TO QUESTION 1A) I never drank any alcohol in my life (GO TO QUESTION 1B)

  24. National Institute on Alcohol Abuse and Alcoholism (NIAAA)(6 Question Set) 1A - During your lifetime, what is the maximum number of drinks containing alcohol that you drank within a 24-hour period? (asked here only of those who did not drink any alcohol during the past 12 months) 36 drinks or more 24 to 35 drinks 18 to 23 drinks 12 to 17 drinks 8 to 11 drinks 5 to 7 drinks 4 drinks 3 drinks 2 drinks 1 drink (DONE WITH ALCOHOL QUESTIONS)1B - So you have never had a drink containing alcohol in your entire life. (asked only of those who say they never drank alcohol in their lives) Yes, I never drank. (DONE WITH ALCOHOL QUESTIONS) No, I did drink (GO BACK TO QUESTION 1 AND REPEAT)

  25. National Institute on Alcohol Abuse and Alcoholism (NIAAA)(6 Question Set) Question 2 - (asks about number of drinks on typical drinking day in past 12 months) During the last 12 months, how many alcoholic drinks did you have on a typical day when you drank alcohol? 25 or more drinks 19 to 24 drinks 16 to 18 drinks 12 to 15 drinks 9 to 11 drinks 7 to 8 drinks 5 to 6 drinks 3 to 4 drinks 2 drinks 1 drink

  26. National Institute on Alcohol Abuse and Alcoholism (NIAAA)(6 Question Set) Question 3 - (asks about maximum drinks in a 24 hour period in past 12 months) During the last 12 months, what is the largest number of drinks containing alcohol that you drank within a 24-hour period? 36 drinks or more 24 to 35 drinks 18 to 23 drinks 12 to 17 drinks 8 to 11 drinks 5 to 7 drinks 4 drinks 3 drinks 2 drinks 1 drink

  27. National Institute on Alcohol Abuse and Alcoholism (NIAAA)(6 Question Set) Question 5 - (asks about frequency of binge drinking in past 12 months) During the last 12 months, how often did you have 5 or more (males) or 4 or more (females) drinks containing any kind of alcohol in within a two-hour period? [That would be the equivalent of at least 5 (4) 12-ounce cans or bottles of beer, 5 (4) five ounce glasses of wine, 5 (4) drinks each containing one shot of liquor or spirits - to be provided by interviewer if asked.] Choose only one. Every day 5 to 6 days a week 3 to 4 days a week two days a week one day a week 2 to 3 days a month one day a month 3 to 11 days in the past year 1 or 2 days in the past year

  28. National Institute on Alcohol Abuse and Alcoholism (NIAAA)(6 Question Set) Question 4 - (NEW QUESTION FOR 6 ITEM SET - NOTE ORDER CHANGE - NEW QUESTION IS #4) (asks about frequency of maximum drinks in last 12 months) During the last 12 months, how often did you drink this largest number of drinks? Choose only one. Every day 5 to 6 times a week 3 to 4 times a week twice a week once a week 2 to 3 times a month once a month 3 to 11 times in the past year 1 or 2 times in the past year

  29. National Institute on Alcohol Abuse and Alcoholism (NIAAA)(6 Question Set) Question 6- (asks about maximum drinks in 24 hours in lifetime) During your lifetime, what is the largest number of drinks containing alcohol that you drank within a 24-hour period? 36 drinks or more 24 to 35 drinks 18 to 23 drinks 12 to 17 drinks 8 to 11 drinks 5 to 7 drinks 4 drinks 3 drinks 2 drinks 1 drink

  30. Alcohol Use Disorder Identification Test (AUDIT) 1. How often do you have a drink containing alcohol? (0) Never [Skip to Qs 9-10] (1) Monthly or less (2) 2 to 4 times a month (3) 2 to 3 times a week (4) 4 or more times a week 2. How many drinks containing alcohol do you have on a typical day when you are drinking? (0) 1 or 2 (1) 3 or 4 (2) 5 or 6 (3) 7, 8, or 9 (4) 10 or more

  31. Alcohol Use Disorder Identification Test (AUDIT) 3. How often do you have six or more drinks on one occasion? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily Skip to Questions 9 and 10 if Total Scorefor Questions 2 and 3 = 0 4. How often during the last year have you found that you were not able to stop drinking once you had started? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

  32. Alcohol Use Disorder Identification Test (AUDIT) 5. How often during the last year have you failed to do what was normally expected from you because of drinking? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

  33. Alcohol Use Disorder Identification Test (AUDIT) 7. How often during the last year have you had a feeling of guilt or remorse after drinking? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily 8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

  34. Alcohol Use Disorder Identification Test (AUDIT) 9. Have you or someone else been injured as a result of your drinking? (0) No (2) Yes, but not in the last year (4) Yes, during the last year 10. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down? (0) No (2) Yes, but not in the last year (4) Yes, during the last year

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