Alcohol-associated liver disease (ALD) is a major driver of liver-related morbidity and mortality across the world. There are 2.4 billion alcohol users (950 million heavy alcohol users) and between 1 in 10 and 1 in 20 people abuse or misuse alcohol. Combined, alcohol-associated cirrhosis and liver cancer account for 1 out of every 100 deaths worldwide.
Alcohol use spiked significantly during the COVID-19 pandemic. A study published in March in the Journal of the American Medical Association found that alcohol-related deaths in the United States increased nearly 26 percent in 2020, the largest year-over-year increase in decades. To address this growing disease burden, Baylor University Medical Center (Baylor Dallas), part of Baylor Scott & White Health recently established a multidisciplinary clinic program to help patients dealing with both their liver disease and alcohol abuse, the first of its kind in North Texas.
In 2019, Baylor Dallas and Baylor Scott & White All Saints Medical Center – Fort Worth convened a consensus conference titled Liver Transplantation in Acute Alcoholic Hepatitis. The conference brought together experts from around the world to develop guidelines on how to manage patients with this severe form of alcoholic liver disease. In addition to physicians, the more than 130 participants included addiction specialists, social workers, nurses, transplant coordinators, transplant program representatives and insurance company representatives.
“Many programs are starting to transplant these patients before the traditional six-month sobriety period, but everyone has different rules,” says Sumeet Asrani, MD, MSc, medical director for the Center for Advanced Liver Disease at Baylor Dallas. “Our goal at Baylor Scott & White Health was to get all the experts together to develop a consensus among the transplant community and develop the metrics that all programs need to follow. We need to be fair in allocating a scarce resource, which is liver transplant.”
Criteria were established to determine candidacy for liver transplant for patients with alcoholic hepatitis:
(1) Patients with alcoholic hepatitis presenting for the first time with decompensated liver disease who are non-responders to medical therapy without severe medical or psychiatric comorbidities
(2) A fixed period of abstinence prior to transplantation is not required
(3) Assessment with a multidisciplinary psychosocial team, including a social worker and a mental health professional with addiction and transplantation expertise.
“We wanted to make sure we built an appropriate infrastructure, so that we can support patients before and after transplant,” Dr. Asrani says. “We treat not only the liver disease but also the alcohol use disorder.”
Potential transplant candidates go through an extensive, multidisciplinary assessment by a hepatologist, an abdominal transplant surgeon and a clinical psychologist. If the group reaches consensus, they then recommend the patient undergo a liver transplant evaluation.
“People are dying every day because of the shortage of organs. Part of our job is to evaluate patients to make sure they are appropriate for transplant, and this requires a multidisciplinary team approach,” says Suzie Lee, MD, abdominal transplant surgeon on the medical staff at Baylor Dallas. “In the transplant evaluation, we make sure their anatomy is appropriate for transplant and that they have adequate social support to recover after transplant surgery. Patients must also have the financial resources to pay for their anti-rejection medications, or the transplant will fail.
“In this new clinic, we also try to assess how well patients understand their alcoholism and their history of alcohol abuse, as well as provide resources to help them with abstinence,” Dr. Lee continues. “Sometimes patients don’t identify as alcoholic because it doesn’t match how a stereotypical ‘drunk’ is portrayed in the media. I think it is very important that they have insight into their alcohol use and how it contributed to their liver disease, as well as insight into how they can stay sober post-transplant. Part of our job is to help patients identify when they might be struggling with sobriety and be able to step in with resources to keep them from using alcohol again.”
During evaluation of the patient, the clinical psychologist takes a biopsychosocial approach, which considers biological, psychological, and social factors of the patient’s unique situation. The patient’s medical issues and lifestyle factors like diet and exercise patterns are considered to ascertain if they understand their illness.
The psychological aspect looks at general personality traits, neurocognitive issues, such as confusion or delirium that could result from hepatic encephalopathy or other underlying conditions. The patient’s mental health history, substance use and family’s substance use is reviewed, and they are screened for current symptoms such as anxiety, depression or PTSD. The social evaluation records the patient’s education level, employment record, any legal issues due to substance use or abuse and level of social support.
“After I gather all this data, I educate patients about the integrative care we provide to address their alcohol use disorder,” says Stephanie Vega-Molina, PhD, clinical psychologist in the program. “Every patient is different and has different goals for their health and their future. We want to assess them as early as possible to develop individualized treatment plans according to their needs, their willingness to engage in therapy and address potential barriers.”
While patients are awaiting transplant, the clinical psychologist follows up on a biweekly or monthly basis to monitor for symptoms, such as cravings, and help the patient stay in consistent communication with the hepatology team. A combination of cognitive behavioral therapy, motivational interviewing and contingency (relapse) management will be used to continue to address the alcohol use disorder after transplant. Post-transplant care also involves monitoring of risk of relapse and relapse prevention, routine blood testing, as well as meeting with the team closely for six to 12 months.
“We want to give patients all the tools and support they need to succeed. By assessing their risk for relapse and overall complexity, we can help them connect with an addiction counselor or attend recovery groups, such as AA, NA, and Smart Recovery,” says Dr. Vega-Molina
To date, 18 patients have been evaluated and five patients have undergone liver transplant. All are receiving post-transplant support. Another three to four patients are in the evaluation process. Based on its success so far, the ALD multidisciplinary clinic will expand to the Baylor Scott & White transplant program in Fort Worth and to patients with liver disease in the greater Austin area.