Post-Transplant Alcohol Use Disorder Resources Lacking at Most Centers, Survey Finds

New research is shedding light on perceived barriers to the effective management of alcohol use disorder (AUD) in patients with alcohol-associated liver disease (ALD) and severe alcohol-associated hepatitis (SAH) following liver transplantation.1

Survey responses from members of the American Society of Transplant Surgeons, the Association of Consult/Liaison Psychiatry Transplant Special Interest Group, and the American Society of Transplantation Liver and Intestine Community of Practice revealed that despite notable increases in the volume of liver transplants for both conditions, most centers have not made significant practice changes to accommodate this growing patient population.1

“As the LT community adjusts to the increasing burden of ALD and AUD in patients, it is important to better understand how providers view the resources for AUD at their centers, the need for additional resources, and how these views may differ across the multidisciplinary team,” Leigh Anne Dageforde, MD, MPH, a transplant surgeon at Massachusetts General Hospital and an assistant professor of Surgery at Harvard Medical School, and colleagues wrote.1

Although ALD represents the most common indication for liver transplantation in the United States, the lack of standardized recommendations to address mental health conditions and addictive disorders frequently observed in these patients complicates their care post-transplantation.2 The American Association for the Study of Liver Diseases recommends a multidisciplinary approach to the care of patients with ALD and AUD, but resources for implementing this type of care vary from center to center.3

To better understand current practice in the management and treatment of AUD in the post-LT setting and transplant providers’ perception of barriers to effective post-transplant AUD management, investigators administered a 45-item survey using open-link Research Electronic Data Capture between December 2021 and April 2022. Respondents who completed the survey were offered the opportunity to enter a de-identified random selection lottery for 1 of 3 $100.00 prizes.1

In total, 232 respondents from 70 liver transplant centers across all 11 United Network for Organ Sharing regions completed the survey, representing 59% of liver transplant centers nationwide.1

Respondents estimated high proportions of transplants for ALD at their centers (45%; interquartile range [IQR], 30%–60%), particularly alcohol-associated cirrhosis (45%; IQR, 30%–75%). Transplants for SAH represented 10% of center liver transplant volume (IQR, 5%–20%).1

Investigators noted most centers (84%) aimed for alcohol abstinence, as opposed to prevention of harmful drinking, for all post-transplant patients.1

For screening practices for AUD in the post-transplant setting, respondents identified social workers (29.9%) and hepatologists (19.9%) as the team members primarily responsible for discussing alcohol use and cravings with patients. Of note, 15.6% of respondents indicated this was not a clearly defined responsibility at their center.1

Survey responses revealed formal center protocols on medications for AUD were uncommon and did not significantly differ by center volume, with 62.1% reporting no center protocols for prescribing and 33.5% of individuals being unable to identify who on the transplant team would be responsible for prescribing.1

Additionally, most respondents reported no changes have been made to improve the care of patients with AUD at their center despite the need for additional resources (32.7%). They reported their primary needs as continued standardization and improvement of mental health management (51.5%), including hiring additional mental health professionals, dedicating specific staff to the care of patients with AUD, and standardizing psychiatric and psychological care in the transplant clinic.1

Investigators pointed out 3 main categories emerged as primary barriers to care and recovery: social support (39%), personal beliefs and barriers (38%), and resource availability (18%).1

Further analysis of free-response suggestions for resources that would be helpful in the care of posttransplant patients with AUD and SAH revealed 26% of respondents indicated a desire for increased interface between the patient and the transplant center, including better follow-up, especially with mental health professionals, more appointments, inpatient interventions for AUD, and medication and adherence checks. Additionally, 22% expressed a desire for increased staff training, including dedicated staff, specific protocols, and specialized providers.1

“Additional research efforts should focus on the best strategies to incorporate these interventions as well as patient-reported factors impacting outcomes, as there is a large proportion of LT patients across the country that may benefit from improved strategies for AUD care,” investigators concluded.1

References

1. Cote MP, Cloonan D, Li S, et al. Liver Transplant Provider Perspectives on Posttransplant Management of Alcohol Use Disorder. Transplant Direct. doi:10.1097/TXD.0000000000001766

2. Kwong AJ, Ebel NH, Kim WR, et al. OPTN/SRTR 2020 annual data report: liver. Am J Transplant. https://doi.org/10.1111/ajt.16978

3. Crabb DW, Im GY, Szabo G, et al. Diagnosis and treatment of alcohol-associated liver diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases. Hepatology. doi:10.1002/hep.30866