Developing an Efficient Screening Tool for Alcohol Use Disorder in Roux-en-Y Gastric Bypass Patients.

A lcohol use after Roux-en-Y gastric bypass (RYGB) is an important topic frequently discussed in the press and on social media platforms, yet clinicians are ill-equipped to readily identify bariatric patients at risk of harmful alcohol use behaviors. Alcohol use disorder (AUD), a spectrum disorder defined by the extent of symptoms of alcohol abuse and/or dependence, is poorly characterized in the RYGB population. Bypass patients are particularly at risk of alcohol-related sequelae due to alterations in metabolism and pharmacokinetics. Despite national guidelines recommending routine screening of RYGB patients for AUD, methodologies are not universal and rely heavily on self-reporting. Screening for AUD based solely on quantity or frequency of alcohol consumption may not accurately identify individuals at risk of developing harmful behaviors. This is magnified by patients potentially withholding information on addictive behaviors to assure they are qualified as surgical candidates. Alternatively, screening for AUD based on symptomatology lacks the efficiency and brevity of a routine tool for regular employment in the clinic. Most of our knowledge concerning alcohol use after RYGB comes from small, retrospective studies stymied by low response rates and variable definitions of alcohol abuse. Although alcohol consumption generally does not increase in the immediate postoperative year, its use may increase in subsequent years, and bariatric patients are accordingly overrepresented in admissions for substance abuse. Gastric bypass patients with previous AUD are at an increased risk of relapse after surgery, and select few without a history of AUD go on to develop the diagnosis postoperatively. Conflicting data from these previously published reports make it challenging to clearly define an individual’s risk of developing AUD after RYGB. Identifying those patients at risk of AUD is an essential component of the routine bariatric evaluation. In this issue of the Annals of Surgery, White et al evaluate the accuracy of an efficient screening mechanism for identifying female RYGB patients at risk of AUD symptoms. To do so, the authors examined 884 women enrolled in the longitudinal assessment of bariatric surgery-2 (LABS-2) multicenter, prospective cohort study. Participants in this study completed the AUD Identification Test (AUDIT), a comprehensive tool recommended by the United States Preventive Services Task Force for AUD screening in the primary care setting. This validated questionnaire assesses the frequency and quantity of alcohol consumption, as well as provides a global valuation of alcohol-related psychosocial problems. In the present study, the authors examine whether an abbreviated screening mechanism based on frequency and quantity of alcohol consumption could have a high enough sensitivity and specificity to serve as a surrogate screening tool to identify patients with symptoms of AUD. Ultimately, the authors demonstrate that the AUDIT-C score, derived from both frequency and quantity of alcohol consumption, yields the highest combined sensitivity and specificity for identifying patients exhibiting symptoms of AUD. However, with a post-RYGB sensitivity and specificity of 76.4% and 81.6%, respectively, these values fall short of those in the general female population as well as the authors’ predetermined threshold of 80%. Although the abbreviated screening tools in this study failed to meet the predefined sensitivity and specificity threshold, the resultant data offer some important insights into understanding alcohol consumption patterns and the development of AUD post-RYGB. Alcohol consumption after RYGB steadily increases over at least a 7-year postoperative period, and increased alcohol use is associated with an increased risk of alcohol-related problems. Of patients undergoing RYGB, at least 6.3% will develop alcohol-related problems, with 3.3% demonstrating symptoms of dependence and 5% reporting alcohol-related harm. The screening tool utilized in this study relies on self-reporting. A concern with this is that negative or disqualifying behaviors may be underreported, particularly during the preoperative evaluation for bariatric surgery. However, as the authors point out, underreported preoperative alcohol use would not account for the increasing use in the 7-year postoperative follow-up period.