Given the strong connection between alcohol use disorder and liver diseases, researchers believe that making it easier for patients to receive care for both conditions under one roof could increase long-term survival.
Alcohol can adversely impact almost every organ in the body, particularly the liver—the organ tasked with metabolizing ethanol. For heavy drinkers, problems such as cirrhosis, acute hepatitis, and liver failure are increasingly common.
Yet historically, psychiatric screening and treatment have not been well integrated into alcohol-related liver disease care, according to G. Scott Winder, M.D., a clinical associate professor of psychiatry at the University of Michigan. Winder is also a transplant psychiatrist at Michigan Medicine’s transplant center; he was recruited in 2014 by hepatologists and surgeons concerned about the prevalence and severity of alcohol use disorder (AUD) in their patients.
As a single embedded psychiatrist, he could not provide all the mental health and substance use disorder care his patients required. But as he tried to get them connected to outside resources, he was often informed that patients’ severe physical illnesses meant they would not be appropriate for various clinics or hospitals.
“Several substance use treatment centers told me or the patients they were too sick to be admitted,” he told Psychiatric News.
To address this glaring treatment gap, Winder and colleagues at Michigan Medicine in 2018 established an integrated hepatology clinic where psychiatrists, psychologists, social workers, and liver specialists work with patients with alcohol-related liver diseases.
Beyond their own walls, this Michigan team, as well as other like-minded psychiatrists and hepatologists, have been beating the drum for more studies that examine the benefits of integrated liver care. And the right people seem to be listening.
Bringing Two Treatments Together
“Alcohol misuse has such a prominent role in liver disease, it just makes sense that we should bring the treatment of these two conditions together,” George Koob, Ph.D., told Psychiatric News. He is the director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
Since taking the helm at NIAAA in 2014, one of Koob’s imperatives has been to improve the screening and management of AUD across medical disciplines and settings. At the time, survey data indicated that only 1 in 6 adults had been asked by a doctor about their drinking, while less than 10% of those who had AUD received a prescription for an FDA-approved medication for treating the disease.
While attending a liver conference a few years back, Koob connected with many hepatologists who recognized the importance of screening patients for drinking problems and expressed an interest in incorporating AUD management into their clinics. “The doctors really took the initiative on this, and [NIAAA] worked to provide them the support they needed, such as grants, workshops, and other resources.”
Though the onset of COVID-19 slowed the momentum on this integration initiative, studies examining the relationship between alcohol, liver disease, and treating one or both conditions have started to yield data, Koob noted.
A 2021 analysis conducted by Winder’s colleagues at Michigan, for example, found that deaths due to alcohol-related liver disease are lower in states with more restrictive alcohol policies (for example, higher alcohol taxes, limited Sunday hours at liquor stores, and lower blood alcohol threshold for impaired driving). Also, a research team at Massachusetts General Hospital examined retrospective patient data and found that individuals with AUD who initiated medication therapy were over 60% less likely to subsequently be diagnosed with alcohol-related liver disease. Even among patients who already had cirrhosis, those who initiated AUD medication had a lower risk of liver decompensation (loss of functioning) than those who did not, the study found.
The findings “highlight that liver disease is not an unavoidable progression,” Koob said. “There are various points where if you stop drinking, then your health can stabilize.”
Abstinence or Stability?
Preliminary data from health centers that have developed integrated AUD-liver disease programs suggest that patients in these programs are receiving higher quality care (for example, more screening for substance use disorder, referrals for substance use therapy, and preventive measures such as hepatitis vaccines) than patients receiving usual care. In the short term, these integrated programs have also led to fewer hospital visits by the patients, but only time will tell if the integrated programs will help improve long-term outcomes for patients with AUD and alcohol-related liver disorders.
Integrating care for comorbid conditions does not always improve long-term outcomes, Winder acknowledged. For example, efforts to integrate depression care into cardiology clinics have found limited success at improving physical health outcomes for patients with heart disease. “But the link between AUD and liver disease is much closer than depression and heart disease, so I’m hopeful that this integrated model can succeed,” he said.
Winder told Psychiatric News that finding continued funding for integrated AUD-hepatology clinics is necessary to keep these programs running. “Addiction care, unfortunately, is not lucrative,” he said. One solution Winder proposed is to tie integrated patient care with liver transplants, which are a source of revenue for health care systems. If a hospital invests psychiatric resources for complex patients with alcohol-related liver disease and AUD, then they will have a more successful pool of transplant candidates and more opportunities to perform transplants.
A historical hurdle that people with AUD and liver disease face is that most hospitals follow a guideline that the transplant recipient must be abstinent from drinking for at least six months before becoming eligible for a liver transplant.
There are numerous factors that can trigger post-transplant AUD relapse beyond an arbitrary abstinence period, Winder said. “An individual with cirrhosis who has recently slipped back into drinking but otherwise has a healthy psychological profile, strong social support, and good insight could be a better candidate [for a transplant] than someone abstinent for a year but who frequents bars, has psychiatric comorbidities, and checks out of the hospital against medical advice.”
Koob also believes that the time has come to revamp such transplant rules. “[W]hy are we making people wait six months when acute hepatitis might kill someone within three?” he asked. He noted that the NIAAA’s definition of AUD recovery does not refer to abstinence. NIAAA has funded research to establish a large cohort of early transplant recipients and follow their outcomes over time.
Koob, like Winder, is optimistic that these efforts to change the clinical care of liver disease will bear fruit. “Integrating health disciplines is tricky, but I know the hepatology community is committed to this, and I think the psychiatrists are ready, too.”
Drs. G. Scott Winder, Anne Fernandez and Jessica Mellinger are all co-founders of the clinic.
Dr. Mellinger is the Director, Dr. Fernandez is an ALD psychologist and Dr. Winder is an ALD psychiatrist.