OBES SURG (2012) 22:1308–1314 DOI 10.1007/s11695-012-0668-2 CLINICAL RESEARCH “I Didn’t See This Coming.”: Why Are Postbariatric Patients in Substance Abuse Treatment? Patients’ Perceptions of Etiology and Future Recommendations Valentina Ivezaj & Karen K. Saules & Ashley A. Wiedemann Published online: 3 June 2012 # Springer Science+Business Media, LLC 2012 Abstract Background Recent evidence suggests that bariatric patients may be overrepresented in inpatient substance abuse treatment, but the reasons for this are unclear. Patients’ perceptions of this problem may be of heuristic value. Using a qualitative approach, the present study evaluated bariatric patients’ impressions of how their postsurgical substance use disorders emerged and their future recommendations for those working with bariatric patients. Methods Semi-structured interviews were conducted with 24 bariatric patients in an inpatient substance abuse treatment program. Seven prominent themes emerged, four referring to etiology of substance use (unresolved psychological problems, addiction transfer/substitution, faster onset or stronger effects from substances, and increased availability of pain medications) and three pertaining to future recommendations (counseling preand/or postsurgery, increased knowledge of the associated risks of substance use postsurgery, and greater “honesty”). Blind coders rated the presence or absence of each theme in each interview. Results Of the four etiology themes, 75 % of patients acknowledged unresolved psychological problems, 83.33 % identified addiction transfer/substitution, 58.33 % noticed The preparation of this manuscript was supported by the Eastern Michigan University Department of Psychology and the EMU Graduate School. V. Ivezaj : K. K. Saules : A. A. Wiedemann Psychology Department, Eastern Michigan University Ypsilanti, MI 48197, USA V. Ivezaj (*) Eastern Michigan University Psychology Clinic 611 W. Cross Street Ypsilanti, MI 48197, USA e-mail: valentina.ivezaj@gmail.com faster onset or stronger effects from substances, and 45.83 % identified increased availability of pain medications. For future recommendations, 41.67 % suggested counseling pre- and/or postsurgery, 70.83 % suggested increased education about the associated risks of substance use postsurgery, and 41.67 % identified a need for greater “honesty.” Conclusions Patient perceptions suggest that several common themes may be related to risk for the development of postsurgical substance use disorders. Keywords Bariatric surgery . Weight loss . Alcohol dependence . Alcohol abuse . Opiate dependence . Substance abuse . Addiction . Chemical dependence . Obesity Introduction Bariatric surgery is a cost-effective [1] and safe [2] treatment for morbid obesity. Bariatric surgery patients typically lose 60 to 80 % of their excess weight [3] during the first 2 years following surgery. In addition, bariatric surgery has been associated with improved quality of life [4], increased life expectancy [5], and reduced mortality rates [6]. Despite the positive outcomes that are commonly associated with bariatric surgery, burgeoning research suggests that a subgroup of bariatric patients may be at risk for developing substance use problems postbariatric surgery [7]. In fact, recent evidence suggests that postbariatric surgery patients may be overrepresented in substance abuse treatment, perhaps constituting as high as 6 % of inpatient treatment admissions [7]. When bariatric patients were compared to nonbariatric patients in that substance abuse treatment facility, bariatric patients were more likely to be women and were more likely OBES SURG (2012) 22:1308–1314 to consume greater maximum number of drinks per drinking day. Although the literature is mixed on the magnitude of this problem [7–11], these findings taken together suggest that there is a subgroup of individuals struggling with substance misuse following bariatric surgery. It has been speculated that physiological factors may confer risk for alcohol misuse following gastric bypass surgery, particularly given changes in alcohol absorption following surgery [12–14]. Specifically, when comparing gastric bypass surgery patients to nonsurgical patients, gastric bypass patients experience increased peak blood alcohol levels [12, 13] and take longer to return to baseline [12]. This finding was replicated even when comparing presurgical alcohol absorption to postsurgical alcohol absorption, using each patient as his/her own control [14]. The authors stated, “Patients feel different effects of alcohol intoxication postoperative, and this can lead to overindulgence to achieve the same symptoms of intoxication that they experienced before surgery” (p. 212) [14]. Given these concerning findings, the goal of the present study was to examine whether bariatric patients perceived their substance abuse as developing prior to or after bariatric surgery. A qualitative approach was used to evaluate the perceptions of postbariatric patients struggling with severe substance use disorders, of the magnitude warranting inpatient treatment. Utilizing a qualitative approach was ideal to generate hypotheses about this poorly understood phenomenon from a unique population. Method Between July 2009 and February 2010, 24 postgastric bypass patients were recruited by medical staff upon admission to a voluntary, comprehensive substance abuse treatment program. Gastric bypass history is assessed as a routine part of the admission history and physical. When bypass patients were agreeable to research participation, hospital staff scheduled a meeting time, and participants completed a semi-structured interview (developed by the investigators) with a member of the research team. The interview covered presurgical assessment and education, postsurgical compliance, patients’ perceptions about the development of their substance use disorder, and patients’ recommendations about what could be done differently to help future bariatric patients avoid problems with substance abuse. Specifically, to assess substance abuse etiology, the following questions were asked: (1) Were you aware of or concerned that you might have a problem with drugs or alcohol before you had bariatric surgery? If yes, please tell me a bit about that. (2) Before your surgery, had other people expressed concerns about your use of alcohol or drugs? If yes, please tell me more about that. 1309 (3) Had you ever had alcohol or drug treatment before your surgery? If yes, please tell me more about your experiences with treatment. (4) Do you feel like your problems with alcohol/drugs began after you had bariatric surgery? If yes, please describe how you began or increased your use of alcohol/drugs, and how you became concerned that it might be a problem for you. (5) What do you think the relationship is between your eating behavior and alcohol/drug use? Are they connected in any way? Or, do you think they are unrelated types of problems? Please tell me about how you formed that impression. Of note, questions 1–4 were used to define “problematic substance use” pre- or postoperatively. To assess future recommendations, participants were asked (1) Are there any other thoughts, observations, or impressions you can share that might help us better understand why some people enter substance abuse treatment after they have had bariatric surgery? (2) Do you have any ideas about what might help postbariatric surgery patients avoid problems with alcohol or other drugs? Although the interview was structured to include the questions delineated above, comments about etiology and recommendations were also offered spontaneously at other junctures. As such, the full transcript of each interview was considered data for purposes of evaluating patients’ perceptions and recommendations. The qualitative methodology was based on the Grounded Theory approach developed by Glaser and Strauss [15]. Specifically, two of the authors highlighted material from the first 13 interviews focusing on etiology of substance use development and future recommendations. After preliminary coding of these interviews, saturation of themes occurred. Four themes emerged regarding substance use etiology, and three themes emerged regarding future recommendations. The four themes regarding substance use etiology were unresolved psychological problems, addiction transfer/substitution, faster onset or stronger effects from substances, and increased availability of pain medications. The three themes that emerged regarding future recommendations were counseling pre- and/ or postsurgery, increased knowledge of the associated risks of substance use postsurgery, and honesty on behalf of the patients and their bariatric treatment team. Thereafter, a coding scheme was developed to operationally define each theme so that the full set of interviews could be rated by two blind coders. For example, the definition of addiction transfer was “Any mention of replacing one behavior or substance with another. For instance, replacing food with alcohol or exercise.” Further operational definitions for each theme are presented in Table 2. The new, blind coders then reviewed the interviews identifying the presence or absence of each of these seven themes. Discrepancies were resolved by consensus at research team meetings. 1310 OBES SURG (2012) 22:1308–1314 Inter-rater agreement for the two blind coders was 77 % for the entire set of themes. Inter-rater agreement for each theme was as follows: 79.17 % for unresolved psychological problems, 87.5 % for addiction transfer, 83.33 % for increased effects of substances, 70.83 % for increased availability of pain medications, 83.33 % for counseling pre- and postsurgery, 75 % for increased knowledge of the associated risks of substance use postsurgery, and 62.5 % for honesty. Finally, inter-rater agreement for volunteering regret and determining whether the individual did or did not regret surgery was 91.67 and 79.17 % respectively. Results The sample consisted primarily of Caucasian women with a mean age (±SD) of 45.2 (±10.0), mean BMI (±SD) of 32.4 (±6.8), mean number of years since surgery (±SD) of 5.5 (±3.1)years, mean postsurgical weight loss (±SD) of 149.52 (±56.00)lbs, and mean percent excess weight loss (±SD) of 76.65 % (±SD 24.51 %). The 24 participants reported having had bypass surgery across a range of 21 different hospitals, 20 of which were in Michigan, and one of which was across the country. In terms of substance abuse history, 45.8 % were patients who reported some type of problematic substance use before surgery, whereas 54.2 % reported that they had not engaged in illicit drug use or experienced any alcohol problems prior to surgery. Only four patients reported previous substance abuse treatment. Two subjects reported seeking treatment as “teens,” another participant admitted to seeking treatment at age 21, and the fourth participant reported seeking treatment as an adult in 1995. With respect to substances of abuse upon treatment admission, 54.2 % were smoking cigarettes, 83.3 % were using alcohol, 12.5 % were using marijuana, 8.3 % were using cocaine, 66.7 % were using prescription opiates, 58.3 % were using benzodiazepines, and none were using amphetamines, heroin, or PCP. Additional demographic characteristics are listed in Table 1. Table 1 Bariatric patient characteristics Demographic variables Gender (% female) Race/ethnicity (% White or Caucasian) Years of education Relationship status (% married) Employment status (% working full time) Economic status (% earning 50,000–74,000) Values are expressed as M (SD) Participants (n024) 75 91.7 15.2 (2.5) 45.8 41.7 40.9 In terms of substance use etiology themes, 75 % of the sample acknowledged unresolved psychological problems, 83.33 % identified addiction transfer/substitution, 58.33 % identified faster onset or stronger effects from substances, and 45.83 % identified increased availability of pain medications. It is important to note, however, that of those taking pain medications, 69.23 % discussed the increased availability of pain medications theme. With respect to future recommendations themes, 41.67 % identified counseling pre- and/or postsurgery, 70.83 % identified increased knowledge of the associated risks of substance use postsurgery, and 41.67 % identified honesty. Finally, 41.67 % volunteered a discussion regarding bariatric surgery regret. Of those, 70 % indicated that they did not regret having surgery, 20 % reported that they did regret having surgery, while 10 % were ambivalent. Representative quotes and operational definitions of each theme for etiology and future recommendations are presented in Table 2 and Table 3, respectively. Discussion For the present study, postbariatric patients who were receiving treatment in an inpatient rehabilitation program for substance use disorders were interviewed to gain a better understanding of the development of their substance use disorder and future recommendations. Interestingly, participants in the present study had successful bariatric outcomes, at least with respect to their percentage of excess weight loss [3]. This is somewhat counterintuitive, given the potentially disruptive impact of severe substance use disorders on weight control efforts. Based on the patients’ perceptions, four themes emerged regarding the etiology of substance use disorders, namely unresolved psychological problems, addiction transfer, faster onset or stronger effects from substances, and increased availability of pain medications. Three themes emerged regarding future recommendations, namely counseling pre- and/or postsurgery, increased knowledge of associated risks of substance use postsurgery, and honesty. Finally, a theme of regret also appeared which will be discussed. In terms of the etiological themes, 75 % of the sample identified unresolved psychological problems as contributing to their substance development. This finding complements the extant literature on psychological issues among bariatric candidates including lifetime and current rates of major depressive disorders, anxiety disorders, eating disorders, and binge eating [16]. Bariatric surgery candidates are more likely to have Axis I disorders (anxiety, bulimia, and tobacco dependence) and Axis II disorders relative to community samples. In addition, bariatric surgery candidates are significantly more likely to have comorbid psychological OBES SURG (2012) 22:1308–1314 1311 Table 2 Themes regarding etiology of substance abuse development Unresolved psychological problems (75 %) Operational definition: Any mention of “deep-rooted issues” or underlying issues (e.g., depression, anxiety, identity issues) related to the development of their problems. “After losing weight, I was still left with issues. It was a roller-coaster of emotions…I was a fat person in a skinny person’s body.” Addiction substitution (83.33 %) Operational definition: Any mention of replacing one behavior or substance with another. For instance, replacing food with alcohol or exercise. “I gave up love for food, and compensated that with going out and drinking.” Faster onset or stronger effects from substances (58.33 %) Operational definition: Any mention of feeling the effects of alcohol or pain medications more quickly and/or more intensely. “A slam of wine felt just like a shot of heroin.” Increased availability of pain medications (45.83 % of full sample; however, 69.23 % of those with self-reported pain medication use endorsed this theme) Operational definition: Any mention of receiving pain medications after surgery. It does not have to be bariatric surgery-related. For instance, it could be that a participant had an unrelated surgery or accident necessitating pain medications. “Pain pills seemed safe and innocent…I began to act the part of a patient who was in pain in order to get more pills.” disorders [17]. Morbid obesity is also related to even poorer health-related quality of life [18, 19], greater depression [20], and increased morbidity [19] relative to lower BMI classifications of obesity. Notably, there is research to support body image problems among the bariatric population, and weight loss does not necessarily correspond with more positive body image [21, 22]. Research has shown that gender (women), race (Caucasian), age (younger), and high BMI are associated with unrealistic weight loss goals postsurgery [23], which may lead to increased dissatisfaction postsurgery. One participant stated that: “Psychologically, I spoke to many people in my town who also had the surgery and they all said the same thing—you still don’t see yourself as thin. I still look in the mirror and see fat.” Thus, some patients voiced concerns about numerous psychological struggles including body image dissatisfaction, yet the magnitude, severity, and specific diagnoses of comorbid conditions of this sample are unknown. Future research should continue to investigate whether presurgical psychological distress relates to the development of substance abuse postsurgically. Given that unresolved psychological problems was a common theme for a majority of the patients, it is not surprising then that nearly half of the sample (roughly 42 %) recommended that bariatric patients should participate in counseling pre- and/or postsurgery. It is noteworthy, however, that postbariatric patients tend to report improved healthrelated quality of life [24] and reduced depression [25]. Based on that literature, one would not expect common endorsement of some of the themes mentioned among our sample (e.g., “unresolved psychological problems,” “need for more counseling/education”) by bariatric patients, in general. Therefore, although we lack a direct comparison group, the prominence of these themes appears rather high among our postbariatric substance abuse treatment sample, relative to what the literature would suggest more generally. In support of this, many of the study participants advocated for support Table 3 Themes regarding future recommendations Counseling pre–postsurgery (41.67 %) Operational definition: Any mention of needing counseling pre- or postsurgery in the form of therapy, support groups, counseling, etc. “People need to have therapy while they are losing weight because it is such a big transition. Just getting on a scale is stressful, whether you lose weight or not.” Increasing knowledge regarding associated risks of substance abuse postsurgery (70.83 %) Operational definition: Any mention that staff working with bariatric patients should have presented them with information about substance use problems postsurgery, or more information about why to completely eliminate alcohol postsurgery. Some participants say “I was told not to drink alcohol, but was not told why…People need to know why.” “There should be required readings, or readings on education related to addiction.” “Honesty” (41.67 %) Operational definition: Any mention of needing to be “honest” or “truthful.” “Get honest without fear of not getting surgery.” 1312 groups and counseling throughout the bariatric process. Below are illustrative quotes. “Early intervention is key.” “Nobody told me about an after plan. Or even to talk to a psychologist about the changes—physical changes.” Indeed, additional support and resources, particularly for those at risk for developing substance use disorders postbariatric surgery, are warranted. Given that standardized guidelines for bariatric surgery clearance [26] and procedures for follow-up care vary widely, future research should aim to identify at-risk individuals and develop appropriate after-care plans associated with their recovery and progress throughout the bariatric process. The second etiological theme that emerged was addiction transfer/substitution, with approximately 83 % of the sample discussing this issue. In the present study, addiction transfer refers to replacing intake of certain foods or overeating behavior, more generally, with intake of substances more traditionally regarded as being “addictive.” Kalarchian et al. [20] stated that “it is intriguing to speculate that substance and weight problems may also have a shared diathesis, and that substance abuse remits when eating behavior predominates” (p. 331). If this is the case, then it would be expected that the reverse may be true, namely that when eating behavior “remits” or reduces following bariatric surgery, that substance abuse predominates. Consistent with this theory, Macias and Leal [27] found that those who engaged in binge eating behavior prebariatric surgery had higher rates of alcohol abuse postsurgery. Thus, it seems that converging lines of research may provide evidence of addiction transfer; however, future research is needed to better understand the validity of this theory. This theme was also endorsed by the majority of the patients in this sample. One participant reported: “I think I drink more now because I can’t eat. You know, [I'm an] emotional eater, [I] can’t eat so I drink.” It may be the case that certain bariatric candidates are at risk for “transferring addictions.” However, whether or not “addiction transfer” is occurring remains an empirical question. Addiction transfer is, however, how the patients in the present study described their impression of how the problem developed. Therefore, identifying adaptive coping skills for managing this potential problem, both in preparation for surgery and after surgery, may be an area that psychologists can contribute by helping to improve postbariatric outcomes. The third etiological theme focused on increased effects of substances postsurgery. Fifty-eight percent of the sample mentioned this as a contributor to the development of their substance use disorder. Increased sensitivity to alcohol after bariatric surgery has been supported in the literature [28]. Researchers have documented that alcohol absorbed differently OBES SURG (2012) 22:1308–1314 among gastric bypass patients [12, 14]. Specifically, gastric bypass surgery patients exhibited increased peak blood alcohol levels relative to nonsurgical patients [12, 13], and gastric bypass patients took longer for blood alcohol levels to return to baseline [12]. Furthermore, Woodard et al. [14] matched preoperative and postoperative gastric bypass patients, highlighting that patients felt more intense effects of alcohol intoxication postsurgically. In fact, they reported that when postgastric bypass patients consume even one glass of wine, they may be over the legal limit to drive. Additionally, these authors reported that bariatric patients’ bodies respond differently to alcohol after surgery. This was evidenced in the present study as well, which is illustrated by the following quotes. “After surgery it [alcohol] was like a high.” “It [alcohol] affects you differently. The highs are different, a better high, and no hangovers.” “I respond very differently to pills now. It used to take 1/2 an hour to feel the effects. Now I feel the effects within 10–15 minutes. The effects are more intense but they don’t last as long, so you have to take more to get that euphoria.” Taken together, it appears that both quantitative and qualitative approaches to examining alcohol effects postbariatric surgery have yielded similar results indicating that alcohol, and perhaps other substances, are absorbed differently postsurgery, particularly among gastric bypass patients. Additionally, a recent study [29] found that alcohol absorption was also changed in a group of 12 morbidly obese patients who underwent laparoscopic sleeve gastrectomy. Future research should investigate if certain bariatric procedures confer greater risk for developing a substance use disorder based on absorption alterations. In addition, future research should examine whether other substances are absorbed differently following bariatric surgery, especially pain medication and benzodiazepines, both of which were used by a large proportion of the study sample. Given these findings, it is not surprising that over two thirds of the sample recommended that there should be increased knowledge regarding the associated risks of substance abuse postsurgery. Patients reported that there was not enough education, if any, on the risks of substance use following bariatric surgery. Below are two representative quotes. “They didn’t give me a reason not to drink. Maybe they didn’t know.” “I don’t know if there is an exact link. Doctors should mention the possible link. If I was told there was a possible connection, I would have watched my drinking. They never said how bad it was.” OBES SURG (2012) 22:1308–1314 Consistent with these findings, almost half of the participants reported a theme of honesty. For instance, one patient said: “Get honest without fear of not getting surgery.” Despite the emergence of an “honesty” theme among this sample, only one participant admitted to lying about substance (pain medication) use, allegedly upon the advice of her psychologist, who reportedly told her that she should not admit to her substance use, or surgery would not be authorized. No one else reported lying about substance use during presurgical screening because they either were not using or it was in their distant past. Therefore, it is essential that continued monitoring and education are provided for postbariatric patients. Although our understanding of postsurgical psychological outcomes is in its infancy, it appears that patients are requesting information about the current literature on substance use and bariatric surgery, which should be implemented in a standardized method. The final theme regarding etiology was availability of pain medications, with about 46 % of the sample identifying this theme as a source of their substance use disorder. Of those who self-reported pain medication use, however, about 69 % identified this theme. Bariatric surgery patients may be at an elevated risk of needing pain medications due to postsurgical complications necessitating further surgery (e.g., hernia repairs, strictures, gall bladder, nicked nerves, and cosmetic surgery), which were similar to the complications reported by some of the patients in the present study. Due to the altered substance absorption previously mentioned and increased need for pain medication following surgery, the medical community should be aware and cautious of distributing pain medications without proper education and follow-up care for their bariatric patients. Future research should investigate the impact of behavioral interventions for pain among bariatric patients. Evidence suggests that cognitive behavioral interventions may impact mood and coping strategies among those with acute and/or chronic pain [30]. As such, the role of psychologists working in integrated primary care settings may be an important factor in helping ameliorate postsurgical outcomes, especially related to pain among bariatric patients. Of note, about 42 % volunteered a discussion regarding regret of surgery. Of those, 70 % indicated that they did not regret having surgery, 20 % did regret, while 10 % were ambivalent about having bariatric surgery. Below is a quote representing ambivalence about the surgery. “Two other women here don’t regret the surgery. I do. I would rather be a fat social drinker than a thinner alcoholic/addict.” Later she stated “I don’t regret getting the surgery, I regret becoming an alcoholic.” Thus, most patients did not regret having bariatric surgery even when they associated their substance use problems with the surgery. It is also important to note that a little more than half of the sample denied a history of substance abuse at any 1313 point in his/her life prior to having bariatric surgery, while almost 46 % of the sample described some form of substance abuse relapse following bariatric surgery. From our perspective, it is less interesting that 45.8 % of the sample relapsed, as relapse is the norm, rather than the exception with substance use. What is compelling is that over half of the sample reported problematic use beginning at some point after bariatric surgery, which is a theme that is emerging from other data from our lab as well [31, 32]. Future research is needed to determine unique treatment needs of those who develop substance abuse postbariatric surgery. Limitations of the Present Study There are a few limitations to the present qualitative study. First, interviews were not taped and transcribed; rather each interviewer took notes with an attempt to capture direct quotes. Second, participants' hospital stays sometimes overlapped; as such, it is conceivable that they may have interacted in ways that could have influenced their responses to our interviews. Although this is possible, many of the admission dates did not overlap. Third, the findings may not generalize to all bariatric patients who engage in substance use given the severity of substance use disorders in this sample. Fourth, lack of a control group is a major limitation of the study; however, it would be difficult to obtain an appropriate control group. For instance, it would be very difficult to recruit enough participants who had lost a comparable amount of weight and were enrolled in inpatient substance abuse treatment. Last, but not least, future research should develop improved methods for assessing addiction transfer postbariatric surgery so that answers are not potentially biased by way questions are posed. Conclusion/Future Directions In summary, there appears to be a subgroup of individuals who struggle with substance use disorders postbariatric surgery. We lack a good understanding of who is at risk for developing problems and what care is needed for this unique population. Future research should identify risk factors for the development of substance use disorders among postbariatric surgery patients. It would be interesting to identify the level of concern related to substance use and bariatric surgery both pre- and postoperatively. Additionally, psychologists may play an imperative role in treating psychosocial factors that may influence success of bariatric surgery patients. Future research is needed to determine unique treatment needs of those who develop substance abuse postbariatric surgery. Finally, to expand our understanding of the parallels between eating and addictive behavior, more generally, future studies might address the relationship between eating and addictive disorders among nonbariatric patients as well. 1314 Acknowledgments We would like to thank Melissa Whelan and Rosa Quezada of Brighton Hospital for their assistance in participant recruitment and the EMU Graduate School for supporting graduate student co-authors. We would also like to thank Alisha Serras for her considerable assistance with data collection and data entry, and Kendra Clark and Bethany Feldman for their assistance with data coding. Conflict of Interest All contributing authors, Valentina Ivezaj, Karen K. Saules, and Ashley A. Wiedemann, declare that they have no conflict of interest. References 1. Picot J, Jones J, Colquitt JL, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. 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