Recognizing Stigma's Impact on Care for Alcohol-Related Liver Disease

Recent years have seen a drastic increase in alcohol use in the United States. Alongside this growing prevalence has come an influx of severe morbidity and mortality linked to alcohol-associated liver disease (ALD), with the National Institute on Alcohol Abuse and Alcoholism citing alcohol’s involvement in nearly half of all liver disease deaths among people 12 years of age and older in 2022 and labeling alcohol as one of the leading causes of preventable death.^1,2

Many cases of ALD are rooted in underlying alcohol use disorder (AUD), a medical condition involving frequent or heavy alcohol consumption that often requires an individualized treatment approach with a combination of medication, behavioral interventions, and mutual support groups. According to the 2022 National Survey on Drug Use and Health, 29.5 million people ages 12 and older had AUD in the past year. Of this group, 2.2 million received alcohol use treatment.^3,4

Although it is a mental health disorder, AUD’s role in the development and progression of ALD underscores the importance of its treatment alongside medical intervention for the liver and other potential negative physical impacts of alcohol use. However, it tends to fall by the wayside due to a number of patient, clinician, and system barriers, many of which are linked to the stigma surrounding AUD and its negative impact on patients’ willingness to seek care as well as clinicians’ ability to provide adequate care.

In this HCPLive special report, our moderator, Hersh Shroff, MD, MPA, is joined by Jay Luther, MD, and Chris Kahler, PhD, to discuss the stigmatization of AUD. The first segment of their conversation focuses on defining stigma, both at the public and structural level, and outlining its role in delaying and hindering care for these patients.

Shroff introduces the topic and poses a question to Kahler about the different forms and definitions of stigma and how public perception of AUD may contribute to delays in seeking care. Kahler responds by describing stigma as a “complex construct,” explaining its manifestation at both social structural levels and individual levels as well as how the stigma surrounding AUD may lead patients to underreport their alcohol consumption, avoid discussing concerns with their clinician, and hesitate to seek care from a specialist.

Shroff expresses agreement with Kahler’s response and poses a similar question to Luther, this time inquiring about how structural stigma in the health care system perpetuates disparities for patients with ALD. Similar to Shroff, Luther notes he agrees with Kahler’s response and mentions how certain aspects of this individualized stigma are also present at a greater structural level.

He goes on to describe how the disease has been labeled, pointing to inherent problems with the terms alcoholic liver disease and alcoholic hepatitis and how the term “alcoholic” contributes to the ongoing stigma in ways clinicians may not even realize. Structurally, Luther notes that there has been little to no overlap between the treatment of liver disease and the treatment of alcohol addiction, forcing patients to see different specialists and potentially making them feel as though they are being judged or blamed for their alcohol use.

However, Luther goes on to explain how some institutions, including his own, are taking strides to combat this structural stigma by incorporating what he calls a “team approach” with combined efforts from a hepatologist, an addiction specialist, and a social worker whose shared goal is to “get you feeling better to get you healthier.”

Check out the second half of the discussion:

Addressing Stigma to Improve Outcomes in Alcohol-Related Liver Disease

Our experts:

Hersh Shroff, MD, MPA, a transplant hepatologist and an assistant professor of medicine at the University of North Carolina School of Medicine

Jay Luther, MD, an assistant professor of medicine at Harvard Medical School and director of the Massachusetts General Hospital Alcohol Liver Center

Chris Kahler, PhD, a professor of behavioral and social sciences, a professor of psychiatry and human behavior, and the director of the Center for Alcohol and Addiction Studies at Brown University

Shroff, Luther, and Kahler have no relevant disclosures.

References:

1. ^{National Institute on Alcohol Abuse and Alcoholism. Alcohol Use in the United States: Age Groups and Demographic Characteristics. Alcohol’s Effects on Health. 2023. Accessed April 30, 2024. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-use-united-states-age-groups-and-demographic-characteristics}
2. ^{National Institute on Alcohol Abuse and Alcoholism. Alcohol and the Human Body. Alcohol’s Effects on Health. 2024. Accessed April 30, 2024. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-and-human-body}
3. ^{Cleveland Clinic. Alcohol Use Disorder. Diseases & Conditions. June 2, 2021. Accessed April 30, 2024. https://my.clevelandclinic.org/health/diseases/3909-alcoholism}
4. ^{National Institute on Alcohol Abuse and Alcoholism. Alcohol Use Disorder (AUD) in the United States: Age Groups and Demographic Characteristics. Alcohol’s Effects on Health. 2023. Accessed April 30, 2024. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-use-disorder-aud-united-states-age-groups-and-demographic-characteristics}