Addiction specialist's role in liver transplantation procedures for alcoholic liver disease

Abstract

Although liver transplantation (LT) is performed increasingly for patients with end-stage alcoholic liver disease (ALD), the topic remains controversial. Traditionally, the role of an addiction specialist focused on the screening and identification of patients with a high risk on relapse in heavy alcohol use. These patients were in many cases subsequently excluded from a further LT procedure. Recently, awareness is growing that not only screening of patients but also offering treatment, helping patients regain and maintain abstinence is essential, opening up a broader role for the addiction specialist (team) within the whole of the transplant procedure. Within this context, high-risk assessment is proposed to be an indication of increasing addiction treatment intensity, instead of being an exclusion criterion. In this review we present an overview regarding the state of the art on alcohol relapse assessment and treatment in patients with alcohol use disorders, both with and without ALD. Screening, treatment and monitoring is suggested as central roles for the addiction specialist (team) integrated within transplant centers.

Confidentiality and the Role of the Addiction Specialist Team in Liver Transplantation Procedures. Commentary on Donnadieu-Rigole et al., 2017, Follow-Up of Alcohol Consumption After Liver Transplantation: Interest of an Addiction Team?

“…Ideally, both screening for relapse risk and the provision of active substance abuse treatment should be implemented within the transplant procedures. However, at this point, in many transplant centers, a much stronger emphasis is placed on the identification of relapse risk, while much less effort invested in providing addiction treatment and posttransplantation follow‐up (Addolorato et al., ; Dom and Peuskens, ; Dom et al., ). Potentially, this might result in excluding a number of patients from a life‐saving intervention, who otherwise would be suitable candidates if greater effort had been made to help them cope effectively with their alcohol use problem.…”

“…This accounts for the use of the “gold standard” 6‐month abstinence rule, which has increasingly been criticized (Hartl et al., ; Rice and Lucey, ). Furthermore, the outcome following transplantation may be affected by many other factors, such as chronic misuse or overdose of acetaminophen and continued cigarette smoking, which are often not considered (Dom and Peuskens, ; Lucey, ). Overall, the fact that clinical criteria only modestly predict relapse in LT patients comes as no surprise, insofar as these findings parallel those from studies of the course of alcohol use disorders (AUDs), outside of the context of LT.…”

“…Such studies in both the general population and clinical samples show that, although many clinical variables have been identified as predictors of relapse and other alcohol outcomes, none stands out as decisive. Rather, each of these shows at most low‐to‐moderate predictive power and is not always consistent (Boschloo et al., ; Dom and Peuskens, ). These findings may reflect the great clinical heterogeneity of AUDs.…”

“…Thus, increasingly, there is a growing awareness that, in addition to efforts at pre‐LT screening of patients, effective interventions need to be identified and integrated into current transplant practices, by actively helping patients to reach stable abstinence before transplantation and maintain control over alcohol use afterward (Dom and Peuskens, ). These should include better monitoring of alcohol use and offering psychosocial interventions to address addictions both before (during waiting‐list periods) and after transplantation (Addolorato et al., ; Dom et al., ).…”

“…Although no health economic studies have yet been done in this area, it can be argued that, given the importance of correct decision making during the initial assessment phase and the likely positive effects on future alcohol use following these extremely costly and procedures, which carry the risk of serious medical complications, the costs of involving addiction specialists can be readily justified. The cost offset is also accompanied by an ethical obligation to provide these patients with addiction treatment (Dom and Peuskens, ; Dom et al., ).…”