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Child Psychiatrist /Adult Psychiatrist

How to Treat Alcohol Use Disorder in Patients With Liver Disease

For many people navigating the stresses of the COVID-19 pandemic, temporary relief came in the form of a stiff drink. In the United States, the pandemic years were accompanied by the largest increase in alcohol sales in more than half a century and a surge in cases of alcohol-associated liver disease (ALD).


Alcohol

Yet the pandemic merely accelerated a trend that was decades in the making. Statistics from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) show that from 2000 to 2019, deaths due to alcohol-associated liver cirrhosis grew by 47%. Globally, ALD is now the leading cause of preventable liver-related morbidity and mortality.


"This increasing trend is due to a number of factors, including an increase in global alcohol consumption, increase in alcohol consumption and binge drinking among women, social media and increased exposure of youth to alcohol-related ads, more people using alcohol as a way to cope, among other reasons," Bubu Banini, MD, PhD, assistant professor in the Section of Digestive Diseases at Yale School of Medicine and a hepatologist at Yale Medicine, New Haven, Connecticut, told Medscape Medical News.


For gastroenterologists treating ALD, gaining an understanding of a patient's alcohol consumption is crucial for distinguishing it from other conditions and tailoring subsequent interventions.


"Unfortunately, there are no accurate diagnostic tests for ALD; thus, history and honest reporting of alcohol use are essential," Doug A. Simonetto, MD, associate professor of medicine and director of the Gastroenterology and Hepatology Fellowship Program at the Mayo Clinic, Rochester, Minnesota, told Medscape Medical News. "ALD and metabolic dysfunction–associated steatotic liver disease (MASLD) are indistinguishable biochemically and histologically. Many patients with ALD also have risk factors for MASLD, which highlights the importance of an accurate alcohol-use history."

Effectively treating ALD often means simultaneously treating alcohol use disorder (AUD), a common and chronic condition with varying grades of severity. The sooner AUD treatment can begin, the better the prognosis is for patients with ALD. A retrospective analysis of veterans with cirrhosis found that behavioral and/or pharmacotherapy‐based AUD treatment was associated with a significant reduction in incident hepatic decompensation and long‐term all‐cause mortality.


Yet, getting patients to openly and accurately discuss their alcohol consumption can be difficult.


"Research suggests that people tend to underreport their alcohol consumption, whether intentionally or not," George F. Koob, PhD, director of the NIAAA, told Medscape Medical News. "For instance, when people are asked to keep diaries of how much they drink, they tend to report more alcohol use in the diaries than when interviewed in person. This is particularly true for heavier drinkers."


Many gastroenterologists are falling short in addressing problematic drinking in patients with ALD. Survey results indicate that although nearly all hepatology and gastroenterology providers routinely ask patients about alcohol use, most don't regularly use validated screening questionnaires, are uncomfortable treating AUD due to a lack of addiction education, have suboptimal knowledge about AUD pharmacotherapies and are unlikely to prescribe them, and generally demonstrate low rates of adherence to practice guidelines.


Experts say that gastroenterologists can meet these challenges by adopting a few techniques for discussing and treating AUD.


Choose Brief, Effective Screening Tools


The American College of Gastroenterology's guidelines on ALD recommend that standardized screening for AUD be incorporated at every medical encounter.


The United States Preventive Services Task Force recommends the Alcohol Use Disorders Identification Test–Consumption, which consists of three questions related to drinking frequency and quantity, or the NIAAA's Single Alcohol Screening Question, which asks "How many times in the past year have you had (four for women, or five for men) or more drinks in a day?" When a patient screens positive, clinicians should follow-up with a more thorough risk assessment.


Experts also advise clinicians to incorporate into their screening practices biomarker tests that can detect alcohol across windows of time, spanning from hours (blood alcohol) to months (hair ethyl glucuronide). A 2021 systematic review found that biomarkers provided a substantially more accurate accounting of alcohol consumption than self-reporting among those with AUD.


Patients should be informed ahead of time they'll be screened with a biomarker assessment, so they don't feel as if the tool is a de facto lie detector test, said Ponni V. Perumalswami, MD, MS, associate professor of medicine in the Division of Gastroenterology and Hepatology at the University of Michigan, Ann Arbor, Michigan, and coauthor of a recent review on optimizing the care of ALD.


"We want patients to feel aligned and that we are working together to provide all-around support," Perumalswami told Medscape Medical News.


Engage in Open, Supportive Discussions With Patients


Once AUD has been identified via screening, clinicians can rely on practical communication strategies to move patients toward the most-appropriate interventions.


Clinicians should determine whether patients have any special considerations holding them back from fully disclosing alcohol consumption, said Lewis Nelson, MD, MBA, DFASAM, an addiction medicine specialist and chair of Emergency Medicine at Rutgers New Jersey Medical School, Newark, New Jersey.


"There may be issues of insurance, with people in their family finding out, or religious implications, among other things, that keep people from discussing this," he said.


Simonetto advised taking a compassionate, empathetic approach in these initial conversations.


"It's important to avoid stigmatizing words such as 'alcoholic' or 'alcoholic liver disease' to create a supportive, nonjudgmental environment and to ask clear, direct questions," he said. "It's also important to respect patients' autonomy and to accept resistance without confrontation."


Banini recommended putting the disease in a clinical context when talking with patients.


"Setting the tone and having patients understand that AUD is a common medical condition that can happen to anyone and that there are personalized, evidence-based treatment options that can be helpful in recovery might make them more comfortable in opening up about their alcohol use," she said.


The NIAAA's Koob pointed to the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model as an evidence-based approach that clinicians can adopt to identify and work with patients "who may be using alcohol in ways that are harmful to their health." Information on SBIRT and other materials are available in the NIAAA Healthcare Professional's Core Resource on Alcohol, he noted.


Get Comfortable With AUD Therapies


A 2019 analysis of over 66,000 patients with alcohol-associated cirrhosis found that only 10% had undergone face-to-face visits with mental health or substance abuse specialist, and just 0.8% received a US Food and Drug Administration (FDA)–approved relapse prevention medication.


"There's no prescribing restrictions around treatment for AUD," Perumalswami said. "This begs the question: Can we get more providers engaged in this space to be offering these medications with growing comfort? There's a lot of discussion in the gastroenterology and hepatology fields about wanting to see us collectively as a group be offering more."


The FDA has approved three medications for AUD, namely, naltrexone, disulfiram, and acamprosate, Koob said.


"Given the possibility of hepatotoxicity with disulfiram, it is not recommended for patients with ALD. Use of the other two medications should be made after careful consideration of the risks for an individual patient," he added.


Timing is of the essence in offering these treatments, as patients with ALD can still reap their benefits even after disease onset, Koob said. A 2022 retrospective cohort study of patients with AUD found that addiction pharmacotherapy significantly decreased the incidence of hepatic decompensation among a subset of those with cirrhosis, he noted.


Best practice is for patients to have at least one alcohol-related follow-up within 30 days of starting an AUD medication and to be reevaluated on a quarterly basis thereafter.


Build Relationships With Other Providers


The management of psychiatric and behavioral therapies can be more complicated.


"It isn't realistic for us to ask all gastroenterologists and hepatologists to have these behavioral skills and do all of this themselves," Perumalswami said. "This should be about figuring out your comfort level, building your capacity if you're interested, but also having relationships with behavioral health providers and asking them to be important parts of our practices and systems."


Here too, the need for greater intervention is clear. AUD is among the most undertreated psychiatric disorders. A 2023 review article estimated that 40%-60% of patients with AUD have concurrent mental illness.


Partnering with an addiction specialist is recommended to formally evaluate these patients and to determine the proper psychiatric care pathway and whether it entails outpatient, residential, or medically managed inpatient service.


However, gastroenterologists should maintain realistic expectations for their patients with ALD who seek these treatments, said addiction medicine specialist Nelson.


"Remember that the very definition of addiction is compulsive use despite harm," Nelson told Medscape Medical News. "I'm not trying to minimize our roles. It's a big step. But addiction physicians have no magic bullet to get people to stop drinking. You simply present them with information about the risks of continued use and their treatment options, which they need to use to make a decision. You just hope that you can get through to them."


Gastroenterologists may want to partner with or refer patients to psychiatric/behavioral care providers. The NIAAA's Alcohol Treatment Navigator and the Substance Abuse and Mental Health Services Administration's FindTreatment.gov offer tools to help find substance providers and programs.



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