Alcohol use disorder in community management of chronic liver diseases

Abstract

Rising rates of alcohol use disorder (AUD) combined with increases in alcohol-related liver disease (ALD) and other liver disease have resulted in the need to develop alcohol management strategies at all levels of patient care. For those with pre-existing liver disease, whether ALD or others, attention to alcohol use treatment and abstinence becomes critical to avoiding worsening liver-related consequences. Modalities to help patients reduce or stop alcohol include screening/brief intervention/referral to treatment, various therapeutic modalities including cognitive behavioral therapy, motivational enhancement therapy and 12-step facilitation, and alcohol relapse prevention medications. Harm reduction approaches versus total abstinence may be considered, but for those with existing ALD, particularly advanced ALD (cirrhosis or acute alcoholic hepatitis), total abstinence from alcohol is the recommendation, given clear data that ongoing alcohol use worsens mortality and liver-related morbidity. For certain populations, alcohol cessation is even more critically important. For those with hepatitis C or NAFLD, alcohol use accelerates negative liverrelated outcomes. In women, alcohol use accelerates liver damage and results in worsened liver-related mortality. Efforts to integrate AUD and liver disease care are urgently needed and can occur at several levels, with establishment of multidisciplinary ALD clinics for fully integrated comanagement as an important goal.

Alcohol consumption and metabolic syndrome: Clinical and epidemiological impact on liver disease

“…125,137 It is crucial to assess drinking habits, including binge drinking, with standardized approaches (e.g., AUDIT-C or CAGE) for all patients with liver disease. 138 Moreover, continued alcohol consumption might impair the response to NAFLD drug therapies. Alcohol-use biomarkers, such as phosphatidylethanol, can assist in revealing undetected high-risk drinking.…”

“…In contrast, in steatohepatitis or advanced fibrosis, any alcohol use should be discouraged, due to the high absolute risks. 103,138 This distinction requires more active evaluations of liver fibrosis stage in the community. In cirrhosis, regardless of the main etiology, complete alcohol abstinence is important.…”

Alcohol use disorder: Recognition, testing, and initial management strategies

“…Other medications, such as ondansetron or varenicline, have shown some efficacy though their use for the treatment of AUD in patients with ALD has not yet been proven. [8,11] Table 3 summarizes the mechanisms, dosing, and contraindications of medications reviewed here.…”

“…The screening then identifies a specific behavioral characteristic that should be addressed during the intervention/treatment. [11] Interventions may occur anywhere from 1 to 5 times with the goal of educating patients on the harms of their alcohol use and increasing motivation to reduce their alcohol intake. [7] Brief treatments are recommended for patients who screen high risk and may involve more sessions with the goal of changing the current behaviors and to link with long-term care.…”

“…Motivational enhancement therapy and motivational interviewing are forms of therapy that help patients explore and resolve their lack of motivation toward changing their alcohol use. It can help examine the gaps between current actions and desired health outcomes and help motivate patients to make changes 8,11 …”