10/26/15

Doubling Up Your Drinking

© willeecole | stockfresh.com

© willeecole | stockfresh.com

Would you like to be able to double the amount of alcohol that enters into your bloodstream when you drink? Let’s say you consume the equivalent of two standard drinks containing one ounce of alcohol. Your blood alcohol level (BAL) would double and you would likely exceed the legal driving limits in thirty minutes. Oh, and you would feel drunker as well. Does this sound crazy? Yet that is exactly what happens to someone who has had gastric bypass surgery.

A recent 2015 study, “Effect of Roux-en-Y Gastric Bypass Surgery,” published in JAMA Surgery evaluated the physical and subjective effects of ingested alcohol on individuals who had received a common from of gastric bypass surgery called Roux-en-Y gastric bypass. The find is from a small study of 8 obese women who had undergone the surgery and 9 obese women who had not yet had the surgery. All the women consumed the equivalent of two standard alcoholic drinks or two placebo nonalcoholic drinks in two 10-minute drinking sessions.

HealthDay reported that the researchers measured the blood alcohol concentration (BAC) levels of the participants. “Drunkenness” was measured by matching each participant’s behavior to an “Addiction Research Center Inventory.” BAC levels rose much faster in the bypass group and peaked at levels twice those seen in the non-bypass group. The BAC levels of the bypass group also exceeded legal driving limits for thirty minutes after consuming their second drink. “BAC levels never exceeded legal driving limits among the non-bypass group.”

Feelings of drunkenness were also greater in the bypass group. Using criteria developed by the U.S. National Institute on Alcohol Abuse and Alcoholism, the researchers concluded that just two drinks were the equivalent of a binge-drinking episode with the potential risk of an alcohol use disorder. Dr. Samuel Klein, one of the study’s authors, said:

This surgery literally doubles the amount of alcohol that immediately enters your bloodstream. . . . And it also increases the patient’s long-term risk for alcoholism, because the risk for a binge episode of drinking goes up. And we know that binge drinking increases the risk for going on to develop alcoholism in the future.

Although Klein and his team used a more rigorous methodology than had been used before, the study’s finding isn’t new. Dr. John Morton, chief of bariatric and minimally invasive surgery at the Stanford University School of Medicine, said this was a well-known phenomenon.  “It’s about physiology,” he said. There is an increased sensitivity to alcohol because the surgery removes alcohol receptors in the stomach. These receptors are also found in the liver. “And if you bypass and remove a portion of either of these, you have a change in blood alcohol levels.”

ScienceLine reported on a woman who lost 180 pounds within a year of her gastric bypass surgery in 2009. She started ordering wine in place of dessert at dinner so she wouldn’t sit there ‘”twiddling my fork” while others ate their dessert. The occasional glass of wine became more often and she spent the next two years fighting an alcohol use disorder. She began drinking at home alone, two bottles of wine per occasion. She began hiding bottles from her husband, driving while drunk and blacking out when drinking. She discovered injuries she didn’t remember getting.

A 2012 study, “Prevalence of Alcohol Use Disorders Before and After Bariatric Surgery,” found that while alcohol use disorder (AUD) symptoms were not significantly different one year after the surgery, they were significantly higher in the second postoperative year. The presence of an AUD in the year before surgery substantially increased the odds of an AUD in the first two postoperative years. “Regular alcohol consumption prior to surgery also independently increased the likelihood of postoperative AUD.” One in 8 participants reported consuming at least three drinks per typical drinking day; and 1 in 6 participant said they drank at a hazardous level in the second postoperative year.

A 2013 Swedish study, “Alcohol Consumption and Alcohol Problems After Bariatric Surgery” did a long-term follow up of over 2,00 obese patients who had three types of bariatric surgery: vertical banded gastroplasty (VBG), banding and gastric bypass. The follow up time of the study ranged from 8 to 22 years. Alcohol consumption standards established by the World Health Organization (WHO) were used to assess the risk levels of alcohol consumption during the follow up period.

During the follow up time, 93.1% of the surgery patients and 96.0% of the controls reported alcohol consumption classified as low risk by the WHO. However, in comparison to the control group, the gastric bypass group had an increased risk of alcohol abuse diagnoses, alcohol consumption at least at the WHO medium risk level, and related alcohol problems. VBG also increased the risk of these conditions, while banding was not different from controls.

Another 2013 study, “Substance Use Following Bariatric Weight Loss Surgery,” looked at the course of substance use (alcohol, cigarettes, recreational drugs, and composite substance use), as measured by the Compulsive Behaviors Questionnaire. Participants completed questionnaires preoperatively and 1,3, 6, 12 and 24 months after surgery. There were no significant changes in participant’s reported frequencies of cigarette smoking or recreational drug use. However, there was a significant increase in alcohol use for participants who had undergone RYGB surgery, the same Roux-en-Y gastric bypass as reported above in the 2015 study by .

Because patients have a reduced tolerance for alcohol after RYGB surgery, they may experience the rewarding aspects of alcohol use sooner and more frequently, which may contribute to the increase in frequency of alcohol use after LRYGB surgery.

Steph Yin for ScienceLine noted that many patients are unaware of the risk of an alcohol use disorder when they get gastric bypass surgery. And scientists aren’t clear themselves on why the risk exists. An early theory was that of addiction transfer. People adopt new addictions after weight-loss surgery because they can no longer fulfill their food addictions. However, evidence like that above in “Effect of Roux-en-Y Gastric Bypass Surgery” suggests there may be an anatomical explanation. Namely that metabolic and hormonal changes triggered by gastric bypass leave patients particularly vulnerable to alcohol use disorders. It’s possible, said Yin, that both are right. Or maybe it’s something else entirely. We just don’t know at this point.

According to James Mitchell, a doctor and professor of neuroscience at the University of North Dakota, “Whether it’s addiction transfer or something else going on, we really don’t know at this point.” What is certain is that the high rates of alcohol use disorders in postoperative gastric bypass patients cannot be attributed to chance.

11/10/14

A “Cure” for Alcoholism

Stockfresh image by stevanovicigor

Stockfresh image by stevanovicigor

There is an alleged “cure” for alcoholism. Yes, “cure.” It’s called “The Sinclair Method.” It actually encourages individuals to drink, but only after taking naltrexone or nalmefene before they start drinking. Naltrexone and nalmefene are opiate agonists (drugs that blocks opioid receptors in the brain). The theory is their use before drinking will reduce the neurological “reward” after drinking. The “cure” claim is that this reduction eventually leads to the extinction of the person’s desire to drink because they no longer catch the same buzz when they drink.

This is not a joke. The Sinclair Method has its own facebook page; it is promoted in a new documentary, “One Little Pill,” which also has its own facebook page. The original research was done by David Sinclair, and published in the journal, Alcohol & Alcoholism in 2001. You can see the original article here or here. Sinclair believes that drinking alcohol is a learned behavior. Some individuals (partly for genetic reasons) get so much positive reinforcement from drinking, that the behavior becomes too strong for them to control. “They cannot always control their drinking; they cannot ‘just say “no”.’  And society calls them alcoholics.”

The use of the Sinclair Method is said to remove “the neural changes that have caused alcoholism—the over-strengthened pathways of neurons that have developed in the brain, causing alcohol craving and excessive drinking.” The basic premise of the treatment method is that addiction is a learned behavior that has become so entrenched that the addict can no longer control it. “Alcohol drinking produces reinforcement and is learned through that reinforcement.”

Sinclair’s method is the subject of a book by Roy Eskapa, The Cure for Alcoholism. Eskapa said the book’s title means what it says: “Addiction to alcohol can now be cured—not through abstinence, but by always taking a medication an hour before drinking alcohol.” The reduction in cravings is progressive, with the strongest effects in evidence three to four months after beginning to use the Sinclair Method. “The benefits continue increasing indefinitely so long as you take naltrexone if and when you drink.”

Eskapa claimed that the Sinclair Method does not need to be done in conjunction with “extensive counseling.” He based this on his understanding of a study called Project COMBINE. “As a result of this study, naltrexone is no longer just for large clinics specializing in alcohol problems; now, any licensed doctor can ethically and safely prescribe naltrexone for problem drinking.” Citing clinical trials in Finland and the U.S., he said that naltrexone treatment was only effective when it was taken at the same time that alcohol was being drunk. “Until now, most doctors and addiction experts were unaware that to cure alcoholism, one has to drink alcohol while naltrexone is in the bloodstream.”

What the COMBINE study actually found was that all treatment groups experienced a large increase in the percentage of abstinent days, a factor of three times greater. The treatment groups for naltrexone alone, treatment alone and the combination of treatment and naltrexone had comparable outcomes. It did not conclude that treatment wasn’t needed.  What it said was: “Medical management of alcohol dependence with naltrexone appears to be feasible and, if implemented in primary, and other, health care settings, could greatly extend patient access to effective treatment.”

Before you seek out a doctor to prescribe naltrexone (nalmefene is not approved by the FDA for use in the U. S. at this time), let’s look at this alleged “cure.” First, alcoholism is reductionistically conceived as a learned behavior. And the treatment or “cure” is the systematic application of a behavior modification technique known as extinction. Now, the science behind extinction, and the reduction in drinking by using the Sinclair Method is clear. When you positively reinforce a behavioral stimulus, the individual person (or hamster) will do the behavior more. When you stop positively reinforcing the behavior, it will decrease in frequency. This systematic decrease is extinction. Here is a short YouTube primer on the four basic elements of classical conditioning, if you’re interested.

So here’s the kicker. The “cure” is contingent upon continuing the extinction process. In other words, you need to continue taking the medication an hour before you plan to drink . . . forever. But you can resume drinking for the positive reinforcement of the high simply by not taking your pill. So the “cure” is also contingent upon the motivation level of the potential drinker to take the drug before drinking. This is not a “cure” for alcoholism in my way of thinking.

Alcohol in high enough concentrations in the blood stream can cause unconsciousness, stop your breathing leading to cardiac arrest and other physical problems. The physiological effects from alcohol in your blood stream continue to occur even if the neurological reward for drinking is neutralized. The Sinclair Method does not stop these other effects from occurring. It simply neutralizes the reward from drinking and gradually extinguishes the cravings to drink. It does not metabolize the alcohol in your system.

Understanding what is actually treated by the Sinclair Method is slippery. Eskapa’s book title says it’s a “cure” for alcoholism. But he speaks about “alcohol drinking” being positively reinforced to the point that some individuals (excluding those with a genetic predisposition) cannot control their drinking and are called alcoholics.  Alcoholism is more than just a learned behavior or an out-of-control behavioral reinforcement strategy. It’s not something that pharmacological extinction can remove or cure. “It’s like a switch, clickin’ off in my head. Turns the hot light off and the cool one on, and all of a sudden there’s peace”  (“Brick” from: Cat on a Hot Tin Roof).

 

08/1/14

It Bites Like a Serpent

Because it gives such a vivid picture of compulsive drinking, Proverbs 23:29-35 is a favorite passage of mine.

image credit: iStock

image credit: iStock

29 Who has woe? Who has sorrow? Who has strife? Who has complaining? Who has wounds without cause? Who has redness of eyes?

30 Those who tarry long over wine; those who go to try mixed wine.

31 Do not look at wine when it is red, when it sparkles in the cup and goes down smoothly.

32 In the end it bites like a serpent and stings like an adder.

33 Your eyes will see strange things, and your heart utter perverse things.

34 You will be like one who lies down in the midst of the sea, like one who lies on the top of a mast.

35 “They struck me,” you will say, “but I was not hurt; they beat me, but I did not feel it. When shall I awake? I must have another drink.”

Not only does this passage truly capture the out-of-control drinking of an alcoholic, it also displays the rich imagery of biblical Hebrew in the process. The description of unmanageability and negative consequences would fit right in with the personal stories in the AA Big Book or on one of the modern recovery blogs.

The passage begins with a series of rhetorical questions that lays out the unmanageability suffered by alcoholics and problem drinkers throughout the ages: woe, sorrow, strife, complaining, wounds without cause and red eyes. Who has all things? “Those who tarry long over wine.” The litany of questions also suggests someone who is familiar with the negative consequences from “tarrying over wine.” It seems that the author knew of what he wrote from personal experience.

According to R. Laird Harris in the Theological Wordbook of the Old Testament, wine was the most intoxicating drink known in ancient times. The reference to mixed wine suggests a process of first evaporating wine with a high sugar content; then mixing it with more wine to get a higher alcoholic content in the “mixed wine.” Even in Old Testament times problem drinkers knew how to maximize their high with the “hard stuff.”

The imagery of verse 31 is wonderfully seductive: red, red wine that sparkles in your cup and goes down smoothly. But watch out! It bites like a serpent and stings like an adder. The message then and the message today is the same for an alcoholic. The seductive appeal of sparkling wine is just as dangerous as a biting serpent.  And if you do not listen to the warning , you could end up dead.

Now we enter into the heart of a drunken stupor: your eyes see strange things; your heart utters perverse things. Watch this YouTube video of Robin Williams describing how alcoholics “see strange things and utter perverse things.” Nothing much had changed there.

The imagery in verse 34 is of being on a ship in the midst of a storm. Tossed about by the waves, one minute you are in the midst of the sea; the next at the top of the mast. In Psalm 107:27, sailors in a storm are said to be reeling like drunken men. Drunkenness is feeling like you are on a storm tossed ship. Can anyone relate? Like a storm, drunkenness must be “ridden out;” endured until the end. And you are powerless to calm the seas and end the storm.

The drinker says that he was struck, but not hurt (35a); beaten, but he did not feel it (35b). When you’re drunk, pain fails to register. Sometimes you don’t even remember what hit you. The terror of the strange things seen and perverse things uttered is like a dream: when will he awake? And if he does, more wine becomes the goal: “I must have another drink.”

Wine leads to negative consequences for those who pursue it; and the aftermath of a drunken storm leads right back to wine. A bleak, hopeless circle is depicted. The main point of the passage is then: Do not look at wine; it bites like a serpent and leads to an unending circle of sorrow.

So why do we do it? Why do humans turn to wine and other intoxicants? Ronald Siegel suggested in his book, Intoxication, that pursuing intoxicants is a “fourth drive,” following hunger, thirst and sex.

“History shows that we have always used drugs. In every age, in every part of this planet, people have pursued intoxication with plant drugs, alcohol, and other mind-altering substances. . . . This ‘fourth drive’ is a natural part of biology, creating the irrepressible demand for drugs.”

I think Leo Tolstoy is closer to the truth. In his essay “Why Do Men Stupefy Themselves?” he said:

“For man is a spiritual as well as an animal being. He may be moved by things that influence his spiritual nature, or by things that influence his animal nature. . . . People drink and smoke, not casually, not from dullness, not to cheer themselves up, not because it is pleasant, but in order to drown the voice of conscience in themselves.”

In the end, the apostle Paul had it spot on. In Romans 7:21-23 he said: “So I find it to be l law that when I want to do right, evil lies close at hand. For I delight in the law of God, in my inner being, but I see in my members another law waging war against the law of my mind and making me captive to the law of sin that dwells in my members.”

Why do you think humans get high? Is there a universal drive for mind-altering substances?