Liver transplantation for patients on methadone maintenance

Abstract

Most transplant programs require abstinence of at least 6 months from alcohol and illicit drugs before orthotopic liver transplantation (OLT). However, there are no published data regarding OLT outcomes in patients who are currently on methadone maintenance treatment (MMT) as part of the treatment of their heroin addiction at the time of OLT. The objective of this study is to evaluate our experience regarding the outcome of OLT in patients with end-stage liver disease (ESLD) who were on MMT at the time of OLT. Between March 1993 and May 1999, a total of 185 patients with ESLD underwent OLT at our center. Five transplant recipients (2.7%) had a history of heroin abuse and had undergone drug and alcohol rehabilitation, but could not be weaned off methadone. Pre-OLT status, drug history, perioperative course, compliance with medical therapy, post-OLT follow-up, and patient and allograft survival were analyzed in detail in these patients. All patients on MMT underwent uneventful OLTs. Their compliance with medications and follow-up was excellent. One patient was weaned completely off methadone after OLT. Post-OLT mean hospital stay in this group was 43 ؎ 25 days. Although the number of patients was small, long-term outcome of liver transplant recipients on MMT appears similar to that of patients not on MMT who underwent OLT during this period. Our results suggest cirrhotic patients on MMT should be considered for OLT if they meet the same psychosocial requirements as patients with alcohol abuse. Furthermore, it is not necessary for patients to be weaned off methadone before OLT. O rthotopic liver transplantation (OLT) is well established as an effective treatment for patients with end-stage liver disease (ESLD). One of the major challenges currently facing OLT is that the number of candidates far exceeds available organs. As of May 2000, a total of 15,258 patients were on waiting lists. Hepatitis C is the leading cause for OLT, followed by alcoholic liver disease; both are primarily substance abuse-related diagnoses. 1,2 Recipient selection is a critical aspect of OLT and involves a multidisciplinary approach. 3,4 Patients undergo an extensive psychosocial evaluation in addition to medical evaluation. Currently, patients actively using illicit drugs are excluded from consideration for OLT. 3-5 Methadone maintenance treatment (MMT) is routinely prescribed for patients during and after rehabilitation from heroin use. Patients on MMT appear to fare better with respect to social functioning, job rates, lower imprisonment, and human immunodeficiency virus infection compared with patients denied methadone after rehabilitation from heroin use. 6,7 Although patients fully rehabilitated from previous drug use are considered OLT candidates, there is a paucity of data regarding OLT in patients administered methadone at the time of OLT as part of MMT.Only 56% of transplant programs accept patients on MMT for OLT, and 32% of programs require discontinuation of MMT before OLT. 8 This apparent discrimination against patients on MM...

Survival and Risk of Recidivism in Methadone-Dependent Patients Undergoing Liver Transplantation

“…As a result, patients may be dissuaded from seeking proper health care or may place themselves at risk for opiate withdrawal or unanticipated drug-drug interactions through denial of methadone use. Although there has been a recent report of five MMT patients who underwent OLT successfully (9), there are very scant data regarding transplant outcome in patients on MMT.…”

“…Among methadone-dependent patients who have undergone OLT, little is known regarding their outcome and their risk for recidivism (1,9). Mount Sinai Medical Center's approach has been to evaluate patients on MMT and, if considered adequate candidates, to grant OLT.…”

Liver Transplantation for Methadone-Maintained Opiate Dependents: Making the Case for Cautious Optimism

“…Before this paper, the transplant physicians at Albert Einstein Medical Center in Philadelphia, PA (Kanchana et al) published the only other report of MMT LTX recipients; a case series of five recipients transplanted between 1993 and 1999 (2). Although their MMT LTX recipients had longer length of hospital stay, greater perioperative morbidity, and one death from myocardial infarction at 6 months posttransplant, the overall long-term patient and graft survival of the MMT LTX recipients were comparable to other LTX recipients at their center (2).…”

“…Although their MMT LTX recipients had longer length of hospital stay, greater perioperative morbidity, and one death from myocardial infarction at 6 months posttransplant, the overall long-term patient and graft survival of the MMT LTX recipients were comparable to other LTX recipients at their center (2). According to program reports, patient history and follow-up records, none of the five MMT patients reported illicit drug use following transplant (2).…”

“…Unfortunately, current knowledge of MMT transplant candidates is limited because of the lack of experience with such patients. Only 56% of U.S. liver transplant programs reported that they would even consider evaluating patients taking methadone and only 10% of these programs had experience with more than five such patients (2). Despite an abundance of evidence in stable nontransplant MMT patients showing that tapering methadone results in relapse to illicit opiate use in greater than 80% of patients (4) with consequently high rates of morbidity and mortality (5, 6), 32% of liver transplant programs required MMT patients to discontinue methadone for transplant eligibility (3).…”