Introduction

Continuous alcohol and tobacco use disorders present a significant challenge in addiction treatment, particularly in individuals with more than one medical condition [1]. Bariatric surgery, which is conducted for weight loss, can further complicate the treatment of substance use disorders due to modifications in metabolism and absorption [2]. Substance use disorders (SUDs) are chronic, relapsing conditions characterized by addictive and excessive behaviors despite harmful consequences [1]. Substances, including different types of alcohol, tobacco, opioids, and stimulants, pose negative impacts on physical, psychological, and social well-being [3]. SUDs can be diagnosed using criteria mentioned in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which includes impaired control, social impairment, risky use, and pharmacological criteria [1].

Tobacco use disorders are chronic, relapsing conditions that not only have a severe impact on physical health but also alter psychological and social well-being. Following bariatric surgery, the changes in the body's handling of substances can affect how tobacco products are metabolized. This alteration might influence nicotine cravings and the efficacy of pharmacological treatments designed to manage tobacco dependence [1]. The disorders occur through continuous use and withdrawal symptoms after concluding substance use, with unsuccessful attempts to quit or reduce substance use despite the negative consequences [4]. SUDs can also lead to psychiatric comorbidities such as anxiety, depression, and personality disorders, which further complicate treatment and comorbid medical conditions [5]. The treatment of SUDs can be achieved by administering drugs, behavioral interventions, and support services. Pharmacology plays a crucial role in the management of SUDs by targeting neurobiological mechanisms underlying medical conditions caused by addiction [6]. The management of SUDs through medications is available for various substances, including nicotine, alcohol, and opioids. Approved for the treatment of alcohol use disorder, medications like naltrexone, acamprosate, and disulfiram are known to reduce cravings and lower relapse rates [7]. Similarly, drugs such as methadone, buprenorphine, and naltrexone are utilized in opioid use disorder treatment, alleviating withdrawal symptoms and cravings while supporting long-term recovery [8]. Hence, behavioral interventions are fundamental components in SUD treatments, used to modify maladaptive behaviors, enhance coping skills, and promote sustained abstinence [9].

Post-bariatric surgery substance use disorder

Bariatric surgery, which includes procedures such as gastric bypass and sleeve gastrectomy, is often performed to achieve weight loss in obese individuals [10]. These surgeries modify the structure and physiology of the gastrointestinal tract, allowing the individual to consume less food and alter nutrient absorption and the hormone regulation system. Bariatric surgery has the advantage of promoting weight loss and improving obesity-related conditions; however, it can also have unintended consequences, such as modifying alcohol metabolism and absorption [11]. Post-bariatric surgery SUD refers to the development or expansion of substance use behaviors following bariatric surgery [12]. Several factors may contribute to the increased risk of SUDs in people, including modified neurobiological responses to substances, changes in reward pathways, and psychological factors, such as stress and anxiety [13]. Additionally, changes in alcohol pharmacokinetics post-surgery, including increased peak blood alcohol concentrations and prolonged intoxication, may contribute to the development of an alcohol use disorder [14].

Case presentation

A 39-year-old single Hispanic male who domiciled with his mother in a private residence in the Bronx has a history of alcohol and tobacco use disorders as well as anemia and underwent bariatric surgery 10 years ago. The patient has no substantial psychiatric history. The patient was referred from the Life Recovery Center (LRC) Inpatient Detox Unit to the LRC Addiction Outpatient Program, where he was admitted to the OPD on October 30, 2023. The laboratory findings and pathology report of the patient are shown in Table 1.

Table 1. Laboratory results of the patient characteristics.

Diagnosis

The patient has been diagnosed with multiple conditions such as moderate alcohol use disorder (ICD-10 CM F10.20), tobacco use disorder (ICD-10 CM F17.210), status post-gastric bypass for obesity (ICD-10-CM Diagnosis Code K91.1), and iron deficiency anemia (ICD-10-CM D50.9).

Abnormal presence

The patient exhibited abnormal laboratory results, including low levels of hemoglobin (HGB), hematocrit, mean corpuscular volume (MCV), vitamin D, serum ferritin, and folate (Table 2).

Table 2. Abnormal findings.

Substance use information

The patient reported that he first drank alcohol at the age of seven, claiming that he was “forced.” During his 20s, he began consuming hard liquor, particularly during national holidays. A notable turning point occurred after bariatric surgery a decade ago when his daily alcohol intake escalated, initially after indulging in a couple of beers with friends. A previous study has shown that alcohol intake and substance use increased in individuals after bariatric surgeries [15].

Subsequently, our patient had a progressively worsening history of alcohol consumption over the following eight years after surgery. The patient acknowledges a significant “drinking problem,” revealing that he consumed seven liters of whiskey weekly in addition to a few beers daily. His most recent drink occurred before seeking assistance at the BronxCare Hospital. Following a referral from the Jacobi Hospital, he was directed to BronxCare for inpatient detoxification. He also reports occasional blackouts after heavy drinking. The patient currently smokes, consuming approximately one packet of cigarettes per day. He denies intravenous drug use or using recreational substances.

The patient has no prior history of seeking treatment or detoxification services for alcohol use except for the current inpatient detoxification administration. Notably, the patient has reportedly maintained sobriety for one year, from 2015 to 2016, which he claims was facilitated by avoiding serious relationships and refraining from socializing, while the only desire to drink was to prevent withdrawal symptoms. However, he did engage with a counselor at Montefiore earlier in 2023 for substance use disorder but had to discontinue due to work commitments. He actively participated in groups and Alcoholics Anonymous (AA) meetings and attended evening groups at LRC.

Chief complaint

The patient presented with the chief complaint, "I need help; I have a drinking problem."

Psychiatric history

The patient refused any prior inpatient psychiatric admissions, visits to Comprehensive Psychiatric Emergency Programs (CPEP), or any follow-up without a patient psychiatrist/therapist. There was no history of using other psychotropic medications. The patient denied experiencing hallucinations or delusions.

In 2020, the patient suffered a panic attack in his office upon realizing he was the sole occupant. Mistakenly perceiving symptoms of a heart attack, emergency services were summoned, leading to an emergency room (ER) visit. He was discharged after two hours without receiving any medication. Panic disorders are primarily associated with SUDs, with an odd ratio of 1.7 to 4.1 [16]. The patient shared the distressing information that a friend died by suicide in 2016, with whom he had spent time on the same night as the incident; this event has created feelings of guilt.

During his upbringing, the patient endured physical abuse from his mother's boyfriend. However, he denied exhibiting symptoms of post-traumatic stress disorder, such as hypervigilance, being easily startled, flashbacks, or nightmares. The patient denied symptoms of panic attacks, social anxiety, specific anxiety, major depressive disorder (MDD), or mania/hypomania. There were no reported prior suicide attempts or self-injury behaviors. Furthermore, the patient denied any historical or present issues with gambling.

While expressing overall well-being, the patient acknowledged job-related stressors, stating, "I have a stressful job; lots of people rely on me."

Medical history

The patient has no known allergies. The patient disclosed a history of bariatric surgery at the age of 29, when his weight had reached 400 pounds. After the surgery, he successfully lost 155 pounds and currently weighs 350 pounds with a BMI of 46. However, post-surgery, his alcohol intake notably increased, progressing from casual beer consumption to daily intake of hard liquor. Studies have indicated a potential increase in substance use following bariatric surgery due to changes in the body's ability to metabolize alcohol, often leading to quicker intoxication and a greater reinforcement of alcohol use [17]. A recent left ankle sprain was reported, along with concerns about a potential blood clot in his leg. His primary care physician conducted the evaluation and management. The patient's last follow-up occurred in March 2023. Additionally, the patient was under the supervision of a vascular surgeon, who, after a prior ultrasound, did not recommend any specific interventions or treatments.

Surgical history

The patient underwent billable/specific bariatric surgery 10 years ago. The patient was recommended to follow up with his dietician.

Family history

The patient denied any family history of mental illness or suicidal attempts but acknowledged that his oldest sister had an opioid use disorder. However, the patient currently has no contact with her. The patient underscored that they receive substantial support from their family, which motivates them to seek assistance. Additionally, the patient recognized the vital role played by a network of friends who provide valuable help and support. The patient experienced a significant impact due to family circumstances, undertaking numerous responsibilities during their childhood following their father's death. The dynamics within the family continued to affect the patient profoundly. The patient denied having any legal case against him.

Psychosocial history

The patient was born and raised in the Bronx, New York. He was single with no children. He was residing with his mother, having maintained the same living arrangement for the past two decades. The patient completed college and attained a master's degree. He denied participation in special classes or any history of vocational training. He supports himself financially through government employment. His prognosis is guarded but favorable.

Mental status examination

The patient is a Hispanic male, well-groomed, appearing his stated age, weighing 350 pounds (overweight), and appropriately dressed. He was fully conscious and fully oriented, ambulating independently. During the interview, he was cooperative and made appropriate eye contact. The patient had an appropriate affect and did not appear internally preoccupied. The speech was clear with normal rate and volume. No delusion was elicited. He currently denied suicidal/homicidal ideation. His intelligence and cognition were average. Memory and abstract thinking were within normal limits. He presented with fair-good insight and judgment.

Discussion

Medical history and clinical course

After discharge from the LRC Detoxification Center on September 24, 2023, the patient was sober for two weeks but admitted to having persistent urges to drink thereafter. His last episode involved one liter of whiskey and four beers over the last weekend in October 2023. However, he reported that he did not experience any pleasure from drinking but suffered from nausea, headache, and lightheadedness after drinking. Additionally, he noted that he sometimes drank to avoid withdrawal symptoms and also got anxious about missing work days due to his alcohol consumption. The patient also reported difficulty falling and maintaining sleep, sometimes waking up in the middle of the night with shortness of breath. He was encouraged to follow up with his primary care physician (PCP) for obstructive sleep apnea (OSA) evaluation. The review of the system and physical examination findings revealed unremarkable thyroid disorder, infectious disease, or any malignancy. According to the laboratory report, he has iron and vitamin D deficiencies and anemia.

The patient was educated about potential lifestyle changes; obesity is a risk factor for metabolic syndrome. Additionally, the patient was informed of nutritional deficiencies from chronic alcoholism following bariatric surgery.

The patient was interested in starting medications for his alcohol use disorder. We discussed different medications, including their potential side effects. Subsequently, the patient was prescribed naltrexone 50 mg oral tablet, folic acid 1 mg oral tablet, thiamine 100 mg oral tablet, multiple oral vitamin tablets, and ferrous sulfate 325 mg (65 mg elemental iron) oral tablet.

The combination of increased alcohol consumption and smoking post-bariatric surgery has had detrimental effects on the patient's weight management. Alcohol contains empty calories, which can contribute to weight regain, and smoking has been shown to alter metabolism, potentially complicating the maintenance of weight loss post-surgery [18]. His current weight was 350 pounds, with a BMI of 46, indicating that he has regained some of the weight lost post-surgery.

The increase in alcohol consumption and continued smoking after bariatric surgery significantly impacted the patient's weight management. Alcohol, rich in empty calories, contributes to weight regain, complicating post-surgery weight management [19]. Additionally, smoking has been linked to metabolic disturbances that can affect weight. Nicotine increases the metabolic rate, which might initially lead to weight loss but can disrupt long-term weight management strategies post-bariatric surgery by increasing appetite and caloric intake once smoking is ceased [20].

Conclusions

This case report demonstrates the effectiveness of personalized treatment, combining medication and therapy, in helping people with complex medical histories, such as those who have undergone bariatric surgery, to overcome SUDs. The improvements in their health and happiness highlight the power of tailored care and support. This experience underlines the need for further research to refine these methods and help more people in the future.

Introduction

Persistent alcohol and tobacco use disorders pose a considerable challenge in addiction treatment, particularly for individuals with co-occurring medical conditions. Bariatric surgery, a procedure for weight loss, can further complicate the management of substance use disorders due to its effects on metabolism and substance absorption. Substance use disorders (SUDs) are chronic conditions marked by compulsive and excessive behaviors despite harmful outcomes. Various substances, including alcohol and tobacco, negatively affect physical, psychological, and social well-being. The diagnosis of SUDs relies on criteria such as impaired control, social disruption, risky use, and pharmacological indicators. Treatment typically involves a combination of medication, behavioral therapies, and support services, with pharmacology targeting the neurobiological mechanisms underlying addiction.

Post-bariatric surgery substance use disorder

Bariatric surgeries, such as gastric bypass, alter the gastrointestinal tract's structure and function, impacting food consumption, nutrient absorption, and hormone regulation. While these procedures promote weight loss and improve obesity-related conditions, they can also unintentionally modify alcohol metabolism and absorption. Post-bariatric surgery SUD describes the emergence or increase of substance use following these procedures. Several factors may contribute to an elevated risk of SUDs in these individuals, including altered neurobiological responses to substances, changes in brain reward pathways, and psychological factors like stress and anxiety. Specifically, changes in alcohol processing post-surgery, such as higher peak blood alcohol concentrations and prolonged intoxication, may increase the likelihood of developing an alcohol use disorder.

Case presentation

A 39-year-old male with a history of alcohol and tobacco use disorders and anemia underwent bariatric surgery a decade prior. He was referred to an addiction outpatient program after completing inpatient detoxification. Laboratory results indicated low levels of hemoglobin, hematocrit, mean corpuscular volume, vitamin D, serum ferritin, and folate. The patient reported first consuming alcohol at age seven, with hard liquor use increasing in his twenties. Notably, his daily alcohol intake escalated significantly after bariatric surgery, eventually reaching seven liters of whiskey weekly in addition to daily beers, alongside a packet of cigarettes per day. He acknowledged a serious "drinking problem" and reported occasional blackouts. Despite a prior year of sobriety maintained by avoiding social situations, this marked his first formal treatment for alcohol use disorder. The patient has no significant psychiatric history beyond a panic attack in 2020 and feelings of guilt related to a friend's suicide. He reported job-related stressors but denied symptoms of other psychiatric conditions. Medically, he lost 155 pounds post-surgery but currently weighs 350 pounds with a BMI of 46. He reports a recent ankle sprain and has a family history of opioid use disorder in an older sister, though he receives substantial family and friend support. The patient is single, lives with his mother, holds a master's degree, and is employed by the government. During examination, he appeared well-groomed, cooperative, and oriented, with clear speech, appropriate affect, and good insight and judgment.

Discussion

After discharge from detoxification, the patient experienced persistent urges to drink, culminating in a relapse involving whiskey and beer. He reported no pleasure from drinking, only nausea, headache, and lightheadedness, along with anxiety about missing work and difficulty sleeping. He was encouraged to follow up for obstructive sleep apnea evaluation. Laboratory findings confirmed iron and vitamin D deficiencies and anemia. The patient was educated about lifestyle modifications, the link between obesity and metabolic syndrome, and nutritional deficiencies stemming from chronic alcoholism compounded by bariatric surgery. Expressing interest in medication for his alcohol use disorder, the patient was prescribed naltrexone, folic acid, thiamine, multivitamins, and ferrous sulfate. The combination of increased alcohol consumption and continued smoking post-bariatric surgery negatively affected the patient's weight management. Alcohol's empty calories contribute to weight regain, and smoking can alter metabolism, potentially complicating the maintenance of post-surgical weight loss.

Conclusions

This case report demonstrates the efficacy of a personalized treatment approach, combining medication and therapy, in supporting individuals with complex medical histories, such as those who have undergone bariatric surgery, in overcoming substance use disorders. The observable improvements in the patient's health and overall well-being underscore the impact of tailored care and support. This experience highlights the ongoing necessity for further research to refine these treatment methods and expand their reach to benefit a larger population.

Introduction

Substance use disorders (SUDs) involving alcohol and tobacco present considerable challenges in addiction treatment, particularly for individuals with other medical conditions. Weight-loss surgery, known as bariatric surgery, can further complicate SUD treatment due to changes in the body's metabolism and how substances are absorbed. SUDs are ongoing conditions marked by addictive behaviors and excessive substance use despite harmful outcomes. Substances such as alcohol and tobacco negatively impact a person's physical, psychological, and social well-being. These disorders are typically diagnosed using criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which includes signs like impaired control over substance use, negative social impacts, risky use, and physical dependence.

Tobacco use disorders are chronic, relapsing conditions that significantly affect physical health, as well as psychological and social well-being. Following bariatric surgery, changes in the body's processing of substances can alter how tobacco products are metabolized. This alteration might affect nicotine cravings and the effectiveness of medications used to manage tobacco dependence. SUDs develop through continuous substance use, often accompanied by withdrawal symptoms when use stops, and involve unsuccessful attempts to quit despite negative consequences. They can also lead to co-occurring mental health issues like anxiety or depression, which make treatment more complex. SUDs are managed through various approaches, including medications, behavioral therapies, and support services. Medications play a key role by targeting the brain mechanisms involved in addiction. For instance, naltrexone and acamprosate are approved for alcohol use disorder and can reduce cravings. Similarly, medications like methadone and buprenorphine are used for opioid use disorder to alleviate withdrawal symptoms and support long-term recovery. Behavioral interventions are also fundamental, helping individuals change harmful behaviors, improve coping skills, and maintain abstinence.

After bariatric surgery, which includes procedures like gastric bypass, the gastrointestinal tract's structure and function are modified. While these surgeries effectively promote weight loss and improve obesity-related conditions, they can also unintentionally alter alcohol metabolism and absorption. Post-bariatric surgery SUD refers to the development or increase of substance use behaviors following these procedures. Several factors may contribute to this increased risk, including changes in the brain's response to substances, altered reward pathways, and psychological factors like stress and anxiety. Additionally, changes in how the body processes alcohol after surgery, such as higher peak blood alcohol levels and prolonged intoxication, may contribute to developing an alcohol use disorder.

Case Presentation

A 39-year-old single Hispanic male, residing with his mother in the Bronx, had a history of alcohol and tobacco use disorders and anemia. He underwent bariatric surgery ten years prior. The patient had no significant psychiatric history and was referred from an inpatient detoxification unit to an outpatient addiction program in October 2023. Laboratory findings indicated low levels of hemoglobin, hematocrit, mean corpuscular volume (MCV), vitamin D, serum ferritin, and folate. The patient received diagnoses for moderate alcohol use disorder, tobacco use disorder, status post-gastric bypass for obesity, and iron deficiency anemia.

The patient reported first consuming alcohol at age seven. During his twenties, he began drinking hard liquor, especially during holidays. A significant increase in his daily alcohol intake occurred after bariatric surgery a decade ago, initially starting with a few beers. Over the following eight years post-surgery, his alcohol consumption worsened progressively. The patient acknowledged a significant "drinking problem," reporting consumption of seven liters of whiskey weekly in addition to daily beers. He experienced occasional blackouts after heavy drinking and reported smoking approximately one pack of cigarettes per day. He denied any intravenous drug use or use of recreational substances. His most recent drink was before seeking assistance at BronxCare Hospital for inpatient detoxification.

The patient had no prior history of seeking treatment or detoxification services for alcohol use before his current admission. He notably maintained sobriety for one year, from 2015 to 2016, attributing it to avoiding serious relationships and social gatherings, with his only desire to drink being to prevent withdrawal symptoms. He did engage with a counselor for SUD earlier in 2023 but discontinued due to work commitments. He actively participated in group and Alcoholics Anonymous (AA) meetings during his outpatient program. His chief complaint upon presentation was, "I need help; I have a drinking problem."

The patient denied any prior inpatient psychiatric admissions or visits to emergency psychiatric programs. He had no history of using psychotropic medications and denied experiencing hallucinations or delusions. In 2020, he had a panic attack at work, mistakenly perceiving heart attack symptoms, leading to an emergency room visit where he was discharged without medication. He shared that a friend died by suicide in 2016, an event that created feelings of guilt as he had spent time with the friend on the same night. Although he endured physical abuse during childhood, he denied symptoms of post-traumatic stress disorder, panic attacks, social anxiety, major depressive disorder, or mania. He reported no prior suicide attempts, self-injury behaviors, or gambling issues. While expressing overall well-being, the patient acknowledged job-related stressors.

The patient had no known allergies. He reported undergoing bariatric surgery at age 29, when his weight reached 400 pounds. After surgery, he lost 155 pounds, but his current weight was 350 pounds with a BMI of 46. Post-surgery, his alcohol intake increased significantly, progressing from casual beer consumption to daily hard liquor. A recent left ankle sprain and concerns about a potential blood clot in his leg were evaluated by his primary care physician and a vascular surgeon, who did not recommend specific interventions. The patient's last medical follow-up was in March 2023. He was recommended to follow up with his dietitian after bariatric surgery.

The patient denied any family history of mental illness or suicide attempts but acknowledged his oldest sister had an opioid use disorder, with whom he currently had no contact. He highlighted substantial support from his family, which motivated him to seek assistance, and recognized the vital role of his friends. The patient experienced a significant impact from family circumstances, undertaking numerous responsibilities during childhood after his father's death. He denied any legal cases against him.

The patient was born and raised in the Bronx, New York. He was single with no children and resided with his mother, maintaining this living arrangement for the past two decades. He completed college and attained a master's degree, supporting himself financially through government employment. His prognosis was considered guarded but favorable. During the mental status examination, the patient appeared well-groomed and his stated age, despite being overweight. He was fully conscious, oriented, cooperative, and maintained appropriate eye contact. His affect was appropriate, and he did not appear preoccupied. His speech was clear with normal rate and volume. No delusions were elicited. He denied current suicidal or homicidal ideation. His intelligence and cognition were average, with memory and abstract thinking within normal limits. He presented with fair-to-good insight and judgment.

Discussion

After discharge from the detoxification center, the patient maintained sobriety for two weeks but subsequently experienced persistent urges to drink. His last episode involved consuming one liter of whiskey and four beers over a weekend. He reported not experiencing pleasure from drinking but suffered from nausea, headache, and lightheadedness. He also noted that he sometimes drank to avoid withdrawal symptoms and became anxious about missing work days due to alcohol consumption. The patient reported difficulty falling and maintaining sleep, sometimes waking up with shortness of breath, prompting encouragement to follow up with his primary care physician for obstructive sleep apnea evaluation. A review of his systems and physical examination found no remarkable thyroid disorder, infectious disease, or malignancy. Laboratory reports confirmed iron and vitamin D deficiencies and anemia.

The patient received education on potential lifestyle changes, including the risk of metabolic syndrome associated with obesity, and nutritional deficiencies resulting from chronic alcoholism following bariatric surgery. He expressed interest in starting medications for his alcohol use disorder. Various medications and their potential side effects were discussed, leading to prescriptions for naltrexone 50 mg oral tablet, folic acid 1 mg oral tablet, thiamine 100 mg oral tablet, multiple oral vitamin tablets, and ferrous sulfate 325 mg (65 mg elemental iron) oral tablet.

The increased alcohol consumption and continued smoking after bariatric surgery significantly impacted the patient's weight management. Alcohol contributes empty calories, which can lead to weight regain, and smoking is known to alter metabolism, potentially complicating the maintenance of weight loss post-surgery. His current weight of 350 pounds, with a BMI of 46, indicated that he had regained some of the weight lost after his surgery. While nicotine can initially increase metabolic rate, it may disrupt long-term weight management by increasing appetite and caloric intake once smoking ceases.

Conclusions

This case report highlights the effectiveness of a personalized treatment approach, combining medication and therapy, for individuals with complex medical histories, such as those who have undergone bariatric surgery, who are also overcoming substance use disorders. The improvements observed in the patient's health and well-being demonstrate the importance of tailored care and support. This experience underscores the ongoing need for further research to refine these methods and assist more individuals in the future.

Introduction

Dealing with ongoing alcohol and tobacco use issues is a major challenge in addiction treatment, especially for people who have other health problems. Weight loss surgery, also known as bariatric surgery, can make treating substance use disorders even more complex because it changes how the body processes and absorbs substances. Substance use disorders (SUDs) are long-term conditions where individuals continue to engage in addictive behaviors, even when these behaviors cause harm. Substances like different types of alcohol, tobacco, opioids, and stimulants can negatively affect physical, mental, and social well-being. SUDs are diagnosed based on specific criteria, including a loss of control over substance use, problems in social life, risky use, and physical dependence.

Tobacco use disorders are long-lasting conditions that severely impact not only physical health but also mental and social well-being. After bariatric surgery, the body's changes in how it handles substances can affect how tobacco products are processed. This change might influence nicotine cravings and how well medications for tobacco dependence work. These disorders develop from continued use and withdrawal symptoms once substance use stops, often with failed attempts to quit despite harmful effects. SUDs can also lead to other mental health conditions like anxiety, depression, and personality disorders, which further complicate treatment and existing medical conditions. Treatment for SUDs often involves medications, behavioral therapies, and support services. Medications are important in managing SUDs by targeting the brain pathways involved in addiction. There are medications to help manage SUDs for various substances, including nicotine, alcohol, and opioids. For alcohol use disorder, medications like naltrexone, acamprosate, and disulfiram can reduce cravings and lower the chance of relapse. Similarly, drugs such as methadone, buprenorphine, and naltrexone are used to treat opioid use disorder, easing withdrawal symptoms and cravings while supporting long-term recovery. Behavioral therapies are also a key part of SUD treatments, helping individuals change harmful behaviors, improve coping skills, and maintain sobriety.

Post-bariatric surgery substance use disorder

Bariatric surgery, which includes procedures like gastric bypass and sleeve gastrectomy, is often done to help people with obesity lose weight. These surgeries change the structure and function of the digestive system, causing individuals to eat less and altering how nutrients are absorbed and how hormones are regulated. While bariatric surgery is good for weight loss and improving health problems related to obesity, it can also have unintended effects, such as changing how alcohol is processed and absorbed in the body. Substance use disorder after bariatric surgery refers to new or increased substance use behaviors that happen after the surgery. Several factors might lead to a higher risk of SUDs in these individuals, including altered brain responses to substances, changes in how the brain experiences reward, and psychological factors like stress and anxiety. Additionally, changes in how alcohol moves through the body after surgery, such as higher peak blood alcohol levels and longer periods of intoxication, can contribute to the development of an alcohol use disorder.

Case presentation

A 39-year-old single Hispanic male, who lives with his mother in the Bronx, has a history of alcohol and tobacco use disorders, along with anemia. He had bariatric surgery 10 years ago and has no major past mental health issues. The patient was sent from an inpatient detox unit to an outpatient addiction program, where he was admitted on October 30, 2023. Laboratory tests showed low levels of hemoglobin, hematocrit, mean corpuscular volume (MCV), vitamin D, serum ferritin, and folate. His diagnoses included moderate alcohol use disorder, tobacco use disorder, a history of gastric bypass for obesity, and iron deficiency anemia. He stated his main problem was needing help for his drinking.

The patient reported that he first drank alcohol at age seven. In his twenties, he began drinking hard liquor, especially on holidays. A major shift occurred after his bariatric surgery a decade ago, when his daily alcohol intake increased significantly, starting after a few beers with friends. Studies have shown that alcohol and substance use can increase in individuals after bariatric surgeries. Over the next eight years after surgery, his alcohol consumption steadily worsened. He admitted to having a serious "drinking problem," consuming seven liters of whiskey weekly in addition to a few beers daily. His most recent drink was before he sought help at a hospital. He also reported occasional blackouts after heavy drinking. Currently, he smokes about one pack of cigarettes per day but denies using injected drugs or other recreational substances.

The patient had not sought treatment or detox services for alcohol use before this current inpatient detoxification. He reported staying sober for one year, from 2015 to 2016, which he felt was due to avoiding serious relationships and social activities, and his only desire to drink was to prevent withdrawal symptoms. He did see a counselor earlier in 2023 for his substance use disorder but stopped due to work commitments. He actively participated in group therapy and Alcoholics Anonymous (AA) meetings.

Regarding his mental health, the patient denied any past inpatient psychiatric admissions, emergency psychiatric visits, or follow-up with a psychiatrist. He had not used any psychotropic medications and denied experiencing hallucinations or delusions. In 2020, he had a panic attack at work, believing he was having a heart attack, which led to an emergency room visit. He was discharged without medication. Panic disorders are often connected to substance use disorders. He also shared that a friend died by suicide in 2016, and he felt guilty because he had spent time with his friend on the night of the incident. While he endured physical abuse from his mother's boyfriend during childhood, he denied symptoms of post-traumatic stress disorder, such as being hyper-alert, easily startled, flashbacks, or nightmares. He also denied symptoms of panic attacks, social anxiety, general anxiety, major depression, or mania. There were no reports of past suicide attempts or self-harm. He also denied any history of gambling problems. While he generally felt well, he acknowledged job-related stress, stating that many people rely on him.

The patient has no known allergies. He had bariatric surgery at age 29, when he weighed 400 pounds. After surgery, he lost 155 pounds, but now weighs 350 pounds with a BMI of 46, indicating some weight regain. Following the surgery, his alcohol intake increased significantly, progressing from casual beer drinking to daily hard liquor consumption. Studies indicate that substance use might increase after bariatric surgery due to changes in how the body processes alcohol, leading to quicker intoxication and a greater urge to drink. He also reported a recent left ankle sprain and concerns about a potential blood clot in his leg, which his primary care physician evaluated. His last follow-up was in March 2023. A vascular surgeon had previously evaluated him and did not recommend any specific treatments. He was advised to follow up with his dietitian after his bariatric surgery 10 years ago.

The patient denied any family history of mental illness or suicide attempts, but his oldest sister had an opioid use disorder, though he no longer has contact with her. He emphasized strong family support, which motivated him to seek help, and recognized the valuable support from his friends. Family circumstances significantly impacted him, as he took on many responsibilities in childhood after his father's death. These family dynamics continued to affect him deeply. He denied having any legal issues.

The patient was born and raised in the Bronx, New York. He is single with no children and has lived with his mother for the past two decades. He completed college and earned a master's degree. He did not participate in special classes or vocational training. He supports himself financially through government employment. His outlook for recovery is cautious but hopeful. During his mental status exam, he appeared well-groomed, his stated age, and was overweight. He was fully aware and oriented, moving independently. He was cooperative during the interview and made appropriate eye contact. His emotions seemed normal, and he did not appear preoccupied. His speech was clear with a normal rate and volume. He had no false beliefs and denied current thoughts of harming himself or others. His intelligence and thinking abilities were average, and his memory and abstract thinking were within normal limits. He showed fair to good understanding of his situation and good judgment.

Discussion

After being discharged from the detox center on September 24, 2023, the patient remained sober for two weeks but admitted to having strong urges to drink afterward. His last drinking episode involved one liter of whiskey and four beers during the last weekend of October 2023. He reported that he did not get any pleasure from drinking but suffered from nausea, headache, and lightheadedness. He also noted that he sometimes drank to avoid withdrawal symptoms and became anxious about missing work due to his alcohol consumption. The patient also reported difficulty falling and staying asleep, sometimes waking up in the middle of the night with shortness of breath. He was advised to follow up with his primary care physician for an evaluation of possible obstructive sleep apnea (OSA). A review of his body systems and physical examination found no issues with his thyroid, infections, or any cancer. According to his lab report, he has iron and vitamin D deficiencies and anemia.

The patient was educated about potential lifestyle changes; obesity is a risk factor for a group of conditions that increase the risk of heart disease, stroke, and type 2 diabetes (metabolic syndrome). He was also informed about the nutritional deficiencies that can result from long-term alcoholism after bariatric surgery.

The patient was interested in starting medications for his alcohol use disorder. Various medications and their possible side effects were discussed. Subsequently, he was prescribed naltrexone 50 mg oral tablet, folic acid 1 mg oral tablet, thiamine 100 mg oral tablet, multiple oral vitamin tablets, and ferrous sulfate 325 mg (65 mg elemental iron) oral tablet.

The combination of increased alcohol consumption and smoking after bariatric surgery negatively affected the patient's weight management. Alcohol contains empty calories, which can lead to weight regain, and smoking has been shown to alter metabolism, possibly making it harder to maintain weight loss after surgery. His current weight of 350 pounds and BMI of 46 indicate that he has regained some of the weight he lost after surgery. The increase in alcohol use and continued smoking after bariatric surgery significantly impacted his weight management. Alcohol, high in empty calories, contributes to weight regain, making post-surgery weight management more difficult. Additionally, smoking has been linked to metabolic changes that can affect weight. Nicotine increases the body's metabolism, which might initially cause weight loss but can interfere with long-term weight management strategies after bariatric surgery by increasing appetite and calorie intake once smoking stops.

Conclusions

This case report shows how effective personalized treatment, combining medication and therapy, can be in helping individuals with complex medical histories, like those who have had bariatric surgery, overcome substance use disorders. The improvements in their health and happiness highlight the power of care and support tailored to individual needs. This experience emphasizes the need for more research to improve these methods and help more people in the future.

Introduction

Having problems with alcohol and tobacco use is a big challenge, especially for adults who also have other health issues. Weight-loss surgery, called bariatric surgery, can make treating these problems harder. This is because the surgery changes how the body handles substances.

Substance use disorders (SUDs) are ongoing health problems. People with SUDs keep using substances too much, even when it causes them harm. This includes different kinds of alcohol and tobacco. These substances can hurt a person's body, mind, and social life. Doctors can tell if someone has an SUD by looking for signs like not being able to control use or having problems because of it.

Tobacco use disorders are also ongoing health problems that harm a person's body and mind. After bariatric surgery, the body handles tobacco differently. This can change how much a person wants tobacco and how well medicines to help them quit might work. Treatments for SUDs include medicines, special talks to change behavior, and support services. Medicines can help reduce cravings for alcohol or opioids. Learning new ways to act and getting support are also very important for stopping substance use for good.

Substance Use After Weight-Loss Surgery

Bariatric surgery, like gastric bypass, helps people lose weight when they are very overweight. These surgeries change how the stomach and gut work. They make a person eat less and change how the body takes in food and other things. While bariatric surgery helps with weight loss, it can also change how the body handles alcohol.

Sometimes, people start or increase their substance use after weight-loss surgery. This can happen because of changes in the body and brain. It can also be due to feelings like stress or worry. After surgery, alcohol might affect the body more quickly and for longer. This can make a person more likely to develop an alcohol use problem.

Case Presentation

A 39-year-old single man lives with his mother. He has long had problems with alcohol and tobacco use and also has anemia. He had weight-loss surgery 10 years ago. Doctors diagnosed him with moderate alcohol use disorder and tobacco use disorder. Lab tests showed he had low levels of important things in his blood, like iron and some vitamins. He was sent to a program for help with his addiction.

The man said he first drank alcohol at age seven. In his 20s, he began drinking hard liquor. After his weight-loss surgery a decade ago, his daily drinking greatly increased. He reported drinking seven liters of whiskey weekly, plus a few beers daily. He sometimes experienced blackouts after heavy drinking. He smokes about one pack of cigarettes per day. He had not sought help for alcohol use before, except for his current treatment. He did manage to stay sober for one year from 2015 to 2016. He also met with a counselor earlier in 2023 but had to stop due to work. He is now actively taking part in group meetings and Alcoholics Anonymous (AA) meetings.

He told doctors, "I need help; I have a drinking problem."

He has no past history of mental health hospital stays or ongoing therapy. He had a panic attack in 2020 at work, thinking he was having a heart attack. He felt guilty because a friend died by suicide in 2016, and he had been with that friend shortly before. He denies having signs of trauma from physical abuse he endured from his mother's boyfriend as a child. He also denies feeling overly anxious or sad, but he does feel stressed at his job because "lots of people rely on me."

The man had his weight-loss surgery at age 29 when he weighed 400 pounds. After the surgery, he lost 155 pounds, but now weighs 350 pounds. Doctors noted that his alcohol drinking greatly increased after surgery. Studies show that alcohol can be handled differently by the body after this surgery, which can lead to drinking more. He also reported a recent ankle sprain and worried about a blood clot in his leg, but doctors found no major concern.

His family has no history of mental illness, but his oldest sister had an opioid use disorder, though he no longer sees her. He said his family and friends give him a lot of support, which motivates him to get better. As a child, he took on many duties after his father died, which affected him deeply.

The man was born and grew up in New York City, is single with no children, and lives with his mother, as he has for 20 years. He completed college and has a master's degree, supporting himself through government employment.

During his interview, the man looked clean, dressed well, and appeared his age. He was aware of his surroundings, walked without help, and was cooperative. He made good eye contact, his mood seemed normal, and he spoke clearly. He denied thoughts of harming himself or others. His thinking was normal, and he seemed to understand his problems well.

Discussion

After leaving a detox center, the man was sober for two weeks. But he then felt strong urges to drink. His last drinking incident involved one liter of whiskey and four beers. He said he felt no joy from drinking but got sick with nausea, headache, and dizziness. He also sometimes drank to avoid feeling bad from withdrawal and worried about missing work. He had trouble sleeping and sometimes woke up short of breath. Doctors told him to see his doctor about possible sleep problems. Tests showed he had low iron and vitamin D. He learned about how his weight affects his health and about how drinking a lot after weight-loss surgery can lead to not getting enough nutrients.

The man wanted to start medicines for his alcohol use disorder. Doctors talked with him about different medicines and their possible side effects. He was given medicine to help with alcohol cravings, along with vitamins and iron pills.

Both his increased alcohol use and continued smoking after weight-loss surgery made it hard for him to keep the weight off. Alcohol has empty calories that can lead to weight gain. Smoking can also change how the body handles food and make it harder to maintain weight loss after surgery. He now weighs 350 pounds, which means he has gained back some of the weight he lost after his surgery.

Conclusion

This case shows how well a treatment plan that uses both medicine and counseling can work. It helped a person with a complicated health history, including weight-loss surgery and substance use problems, get better. The improvements in his health and happiness show that when care is made just for one person, it can really help. This story also means we need to study more to make these treatments even better for more people in the future.