With return-to-drinking rates within five years of transplant hovering around 50 percent in non-acute alcoholic hepatitis patients, incorporating a substance abuse nurse coordinator or addiction team would likely help reduce relapse.
Robert M. Weinrieb, MD, FACLP, Associate Professor of Psychiatry and Chief Psychiatric Consultant, Penn Transplant Institute, Philadelphia, PA, reviewed the latest treatment models for alcohol use disorders and alcoholic liver disease as part of Sunday morning’s Public Health SIG session “Alcoholic Liver Disease: Policy and Practice.”
“These patients take up a tremendous amount of energy and time from all of our nurse coordinators, and a lot of our coordinators either aren’t trained to deal with this or don’t want to deal with this, and I think that reflects into what the patients feel and how they move forward or backward in their care,” Dr. Weinrieb said.
The usual treatment recommendation today involves attendance at intensive outpatient program (IOP) and Alcoholics Anonymous (AA) meetings. But Dr. Weinrieb noted that the effectiveness of AA and IOP has not been well studied, but available results show a high dropout rate for AA participants because they don’t feel like they belong in that group and attendance can stimulate cravings. Some patients thrive in IOPs, but more patients attended individual sessions than group sessions in part, Dr. Weinrieb said, because many are afraid to attend group meetings because of social phobia or having had a traumatic experience that they fear sharing with people they don’t know.
“There’s a lot of complexity in what we’re dealing with in these patients that we’re not always aware of in the beginning,” he said. “It forces us to really put our countertransference in check and give the patients an opportunity to open up about what it is they’re dealing with.”
While the amount of studies is limited, Dr. Weinrieb said, the studies offer guidance about offering better treatment. Patients do best when receiving psychosocial interventions both before and after transplant and also getting a sufficient number of sessions, at least four. Embedding an alcohol treatment unit into the transplant group also yields good results, as do anti-craving medications when combined with psychosocial support.
Before Dr. Weinrieb’s presentation, Professor Sir Ian Gilmore, MD, Chair, Alcohol Health Alliance UK, discussed the influence of societal restraints on alcohol use and alcohol-related liver disease, saying that alcohol consumption and harm are driven by price, availability and promotion.
“We need to prioritize what works, we need to work with a wide range of stakeholders — but not with industry — and we need to persuade the government to use regulatory measures,” he said.
Taxation is the most common way to control alcohol pricing, and pricing or taxing drinks based on alcohol content does shift consumption to lower-strength drinks. Canada, Scotland and England are exploring minimum unit pricing, which targets the cheapest alcohol that heavy alcohol users and underage drinkers tend to buy.
While marketing controls have small effects on consumption, youth drinking is influenced by exposure to marketing and advertising. Education and information campaigns raise awareness but provide no effect on behavior.
Dr. Gilmore said that implementing restraints impacts liver disease quickly. When Soviet leader Mikhail Gorbachev instituted stricter alcohol controls in the 1980s, he said, cirrhosis mortality in Russian men decreased significantly but quickly increased after the controls were lifted in the 1990s.
“Even though it might take 10, 20 years to get cirrhosis, there are always people who are on the edge of the cliff, and you might be able to pull them back,” he said.