Monday, June 15, 2015

How to Avoid Addiction Replacement after Bariatric Surgery.

Addiction Replacement (also referred to as Addiction Transfer) is when you quit one addiction and replace it with another.  Several recent studies have found that there is a substantial risk for developing alcohol use disorders after gastric bypass surgery.  The incidence is higher with gastric bypass than with other bariatric surgeries and is also higher in younger males than in other populations.  While most of the scientific studies have focused on alcohol use, anecdotal evidence (and common sense) suggest that other types of addictive behavior may also increase.  For instance, I was speaking at a conference recently and met a woman who after having bariatric surgery, then had back surgery where she was prescribed heavy-duty pain medication.  Not surprisingly, she became addicted to the pain pills.

If you think about it it makes sense.  Anyone who has reached the level of obesity that warrants bariatric surgery, has been using food beyond the need for physical sustenance and to serve another purpose.  They are food addicts.  Just like alcoholics or nicotine addicts use those substances to medicate their feelings, so too, food addicts abuse food in an attempt to "manage" their feelings.  But really, they are not managing their feelings, they are medicating them--trying to shove down the feelings or get rid of them temporarily. 

Bariatric surgery makes it more difficult (and dangerous) to overeat, but it doesn't take away your feelings and stressors.  So, if you don't find healthier ways of dealing with uncomfortable feelings, then you are more likely to try to repeat the same addictive behavior (either by overeating and risking serious injury, or turning to other addictions).  This is why many bariatric surgery facilities have intelligently started referring patients to therapists for psychotherapy before, during and after surgery.  So that, with the help of a therapist, patients can uncover and start to understand how they use food to deal with their feelings, and learn healthier ways of managing their feelings. The success rate and the safety of their patients (as well as the reputation of bariatric surgery) depends on patients finding healthier ways to tolerate feelings that don't involve addictive behaviors.  So really, this article should be entitled "Tolerating Feelings" since preventing Addiction Replacement requires learning to tolerate your full range of feelings, rather than trying to get rid of them or numb them out. 

What does that mean, to "tolerate feelings"?

You may have been taught that some feelings are "good" and others are "bad". Perhaps you have internalized messages from your parents or society that you are not "allowed" to feel certain feelings. "Boys don't cry," Girls who get angry are "B-tches". So we have to somehow manage those feelings without letting others know how we are feeling.

We all have feelings, pretty much 24/7, we have feelings of some kind. But certain feelings are more tolerable than others. For instance, "happy" is a feeling most people have little difficulty tolerating. In fact we'd often like more of that one. But other feelings we don't enjoy so much. Like for instance "stressed," "angry," sad," or "hurt"?
What happens when you have those uncomfortable feelings? You don't like that feeling, so you want to get rid of it, or make it stop.

We learn how to manage feelings, less by what our parents tell us, and more by watching how our parents and siblings handle their feelings. It may not be allowed to be "angry" but it may be accepted that people shove down their feelings until they "just explode." And that is the one rare exception when excuses are made for evacuating our feelings onto others. I just "lost it." But evacuating feelings can hurt us in our social and work lives. No one wants to be around a bully who's always evacuating his or her anger onto other people.

Maybe you've been taught that it's acceptable to "complain." "Misery loves company" as they say. But that also runs the risk of backfiring on you as you don't want to become "that" person who's always complaining or depressed or negative.

Another tactic people use is to shove the feelings down--with food, or alcohol, drugs, sex, etc. You may find that you do all of the above. When you stop using food to medicate your feelings, it's a pretty good bet that you'll start having a lot of those uncomfortable feelings coming up. You may find yourself getting angry with people (road rage is a great indicator that you are struggling with anger), or complaining a lot. Or as with addiction replacement, turn to other substances to try to shove down your feelings.

The problem with all of these is that in each case, we are trying to get rid of our feelings, by evacuating them onto other people through exploding, or complaining, or medicating them. But when you try to get rid of feelings, they don't stay "gone." They come back when another situation triggers them, or they rebound as other intolerable emotions, like shame, regret, self-doubt, and self-loathing. Which in turn need to be shoved down or gotten rid of, and the cycle comes around again.

Managing feelings in a healthy way requires Tolerating Feelings and not trying to get rid of them. So "how do I do that?" Here's how...

*Note, everything I know about tolerating feelings, I learned from my own analytic work with Dr. Diane Renk.   So she deserves even higher billing than a co-author on the following condensation of that work.*

Healthy Ways to Tolerate Feelings without Addictive Behavior

Managing feelings without self-medicating requires being able to tolerate uncomfortable feelings that may seem completely intolerable. Here are a few ways that you can tolerate feelings and deal with them in a healthy way.  

1. Use the Mental Muscle. All of the steps below are part of using your mental muscle, and they also require that you first use the mental muscle to slow down and allow yourself the time to work through these steps rather than just diving into and getting carried away with whatever intolerable feeling you are feeling. Like any muscle, the mental muscle will feel weak at first but get stronger the more you use it.

2. First you need to identify what you are feeling. If you've spent most of your life using food or other substances to medicate your feelings away, it may be hard at first to identify your feelings. Some people go straight to anger when they're really feeling sad or disappointed. And others go straight to sad when they're really feeling angry. Take a pause to figure out what are you feeling? Sad? Angry? Hurt?

3. Accept that this is how you are feeling right now, and just allow it to be present in your inner world without trying to shove it away, deny it, evacuate it, or act on it in any way. Just let it be there. Remember, all feelings are temporary. This too shall pass.

4. Don't hurt yourself. Remember, diving into a bottle or a pint of ice cream is not taking care of yourself, it is hurting yourself. So why would you hurt yourself when you're already having such a hard time?

5. Pay close attention to your Self-Care when you are dealing with uncomfortable feelings. Think of it as taking good care of the you that's having a really hard time right now. Take care of yourself as if you were feeling your best! Just a few self-care items might be:
  • Keep tracking your food
  • Don't veer from your meal plan at all
  • Get up on time--don't oversleep or stay up too late
  • Keep exercising
  • Keep up healthy cleaning rituals--ie don't let the dishes stack you can feel good living in a clean place.
  • Keep up your hygiene--take showers, wash your hair.

6. Don't make things worse. Evacuating your feelings on someone else will likely do more damage to your life than just sitting with the feelings and letting them be your own. Similarly, taking substances or shutting down will also cause you to lose time, may damage your relationships at work and home, and damages your self esteem and confidence in your own ability to deal with life. If you're having intense feelings, it's best not to do anything at all.

7. Talk to a therapist or other trained professional. Therapy can give you someone safe with whom to discuss your feelings. This person is objective, and can help you identify your feelings and why they are so intense, and also help you manage them. Sharing with a friend or family member may leave you feeling empty and alone because the other person doesn't know how to help or has their own agenda. Also, depending on how you share your feelings, you run a higher risk of damaging relationships if you evacuate on your friend or spouse, or lash out and say hurtful things. A therapist is trained to deal with the full range of emotions and can help you work through things in a safe environment.

8. Get some Peace by taking care of your spiritual needs. This is different for everyone. But it helps to have some sort of spiritual life, whether that is religion, your personal relationship with your idea of a higher power, meditation, yoga, etc. Sometimes praying for peace of mind or just calming yourself by sitting quietly in meditation can allow you to quiet down the noise in your mind and allow you to get some peace with the feelings that you are feeling.


King WC, Chen J, Mitchell JE, et al. "Prevalence of Alcohol Use Disorders Before and After Bariatric Surgery." JAMA.2012;307(23):2516-2525. doi:10.1001/jama.2012.6147. CONCLUSION: the prevalence of AUD was greater in the second postoperative year than the year prior to surgery or in the first postoperative year and was associated with male sex and younger age, numerous preoperative variables (smoking, regular alcohol consumption, AUD, recreational drug use, and lower interpersonal support) and undergoing a Roux-en-Y gastric bypass procedure.

Svensson PA1, Anveden Å, Romeo S, Peltonen M, Ahlin S, Burza MA, Carlsson B, Jacobson P, Lindroos AK, Lönroth H, Maglio C, Näslund I, Sjöholm K, Wedel H, Söderpalm B, Sjöström L, Carlsson LM, " Alcohol consumption and alcohol problems after bariatric surgery in the Swedish obese subjects study." Obesity (Silver Spring). 2013 Dec;21(12):2444-51. doi: 10.1002/oby.20397. Epub 2013 May 31... CONCLUSION: Alcohol consumption, alcohol problems, and alcohol abuse are increased after gastric bypass and VBG.

Ostlund MP1, Backman O, Marsk R, Stockeld D, Lagergren J, Rasmussen F, Näslund E. Increased admission for alcohol dependence after gastric bypass surgery compared with restrictive bariatric surgery. JAMA Surg. 2013 Apr;148(4):374-7. doi: 10.1001/jamasurg.2013.700. CONCLUSIONS AND RELEVANCE: Patients who had undergone GBS had more than double the risk of inpatient care for alcohol abuse postoperatively compared with patients undergoing a restrictive procedure, highlighting a need for healthcare professionals to be aware of this for early detection and treatment.

Mitchell JE1, Steffen K2, Engel S2, King WC3, Chen JY3, Winters K4, Sogg S5, Sondag C2, Kalarchian M6, Elder K7. Addictive disorders after Roux-en-Y gastric bypass.Surg Obes Relat Dis. 2014 Nov 13. pii: S1550-7289(14)00432-8. doi: 10.1016/j.soard.2014.10.026. [Epub ahead of print] CONCLUSION: These data add to a growing literature suggesting there is a substantial risk for the development of AUD after bariatric surgery. Understanding the risk for nondrug-related addictive disorders requires more data from larger studies before clear conclusions can be drawn.

Coker Ross, Carolyn, MD, MPH, "Weight-loss Surgery and Cross Addiction: A Look at Binge Eating Disorder."

Poladian, Charles, "Gastric Bypass and Addiction Transfer - One Woman's Story." Medical Daily, Jun 11, 2012 03:07 PM.

BT Online Editor, "Transfer of Addiction and Considerations for Preventive Measures in Bariatric Surgery."  Bariatric Times.  April 26, 2007.

Yin, Steph, "Alcoholism after gastric bypass: Is it in your mind or gut?"  From  January 9, 2015.

The Mental Muscle Company.

Dr. Noel Blundell's Mental Muscle.

Alex Hutchinson, "How to Build Mental Muscle."  Runners World, September 16, 2013., "Learning to Tolerate Difficult Feelings," by Crystal.


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