The Role of the Addiction Specialist in the Liver Transplant Setting

With increasing sophistication of medical knowledge and technology, the number of organ transplantations in the United States increases every year. With a high prevalence of substance use disorders among transplant candidates (1), the role of the addiction specialist in the evaluation and treatment of this population is increasingly relevant. According to data from the Organ Procurement and Transplantation Network, liver disease as a result of alcohol consumption is the second leading indication for liver transplantation, representing almost 50% of end-stage liver disease patients; however, these patients only account for 15%–20% of liver transplant cases (1–2). Addictive disorders can significantly affect candidacy selection and post-transplant outcome; hence, the involvement of an addiction specialist is essential for meaningful evaluation of the patient. Given the shortage of organs, the process of organ allocation has raised important bioethical questions, especially given the controversial subject of alcohol use disorder in the transplant community (1, 2). Liver transplantation programs vary in the selection criteria for candidates, but in general 3–6 months of abstinence is one of the main requisites (3). Many patients with alcohol use disorder and end-stage organ disease fail to meet selection criteria or die waiting for an organ.

The present article provides discussion of the challenges that the patient and the clinician will encounter throughout the pre- and post-transplant period. Additionally, it encourages psychiatrists to get involved in the process of evaluation of patients with alcohol use disorder and liver disease who are in need of a transplant.

Pre-Transplant Evaluation

Addiction specialists are beginning to play a more prominent role in the selection and preparation of patients for transplant. Many patients who develop alcoholic liver disease are at risk for comorbid substance use and mood disorders (1). This patient population experiences fewer cravings, which leads to an inflated sense of confidence and creates resistance to alcohol use disorder treatment; they are also less motivated to receive treatment than patients without end-stage liver disease (4). Additionally, for some patients, the assignment of an organ motivates their decision to become abstinent. The transplant community is invested in selecting patients who will be able to maintain abstinence. Studies have shown multiple predictors of relapse to drinking, including increased severity of alcohol use disorder, short abstinence maintenance prior to transplant, a positive family history of substance use, and lack of social support (5–7). The addiction specialist should provide a good assessment and recommend high-intensity treatment for patients with these factors to make sure they increase the probability that they will achieve abstinence and are considered for transplant.

During the assessment of eligibility for a liver transplant, if the candidate is found to have alcohol use disorder, the treatment should focus on enhancing the motivation toward abstinence. Close monitoring that includes urine samples, breath or blood toxicology and markers, collateral information from friends and family, and relapse prevention training is recommended (7, 8). Studies suggest that the longer the abstinence prior to transplant, the less likely the patient will relapse (1). Additionally, there is pharmacotherapy that helps patients achieve sobriety. Based on their pharmacologic profiles, acamprosate, topamax, and baclofen are generally safe treatment options with moderate efficacy for alcohol use disorder in this patient population. In a small retrospective study, baclofen was not only safe and efficacious in the treatment of alcohol use disorder in patients with alcoholic hepatitis, but it also improved their clinical profile, decreasing liver enzymes (9).

Post-Transplant Period

After transplant, treatment for alcohol use disorder, comorbid psychiatric conditions, and maintenance of motivation for recovery are essential to ensure treatment success. Ongoing alcohol use can interfere with the patient’s recovery by preventing treatment participation and also directly harming the graft (10). The inability to adhere to immunosuppressant regimens, which is common in the setting of alcohol use disorder, can lead to graft loss (up to 17%) (11). Alcohol use disorder and other comorbid substance use can be toxic to the graft and can also predispose patients to cardiovascular disease and can increase the risk of infections, which are common conditions in immunosuppressed patients. Transplant patients who relapse to drinking have also been shown to suffer from higher mortality rates due to cardiovascular disease and cancer (11, 12). Abstinence is critical in the post-transplant period to ensure good outcomes.

Up to 50% of patients will consume some alcohol after transplant, many within the first year (10). However, up to 70% will remain abstinent or have very minimal drinking (10). One study evaluated alcohol relapse after liver transplantation and its impact on survival; interestingly, while there was no significant association between relapse and poor outcomes in the first year, the 10-year survival rate decreased considerably among patients who relapsed (41% vs. 85%, p<0.01) (11). Another study found that alcohol use disorder patients had lower survival rates after transplant, even within the first year post-transplant (13).

Relapse reinforces the widely held perception that alcohol use disorder is a matter of willpower, a belief likely to dissuade potential donors from participating in organ donation (14). Given the shortage of organs and the risk of the surgery, as well as the cost of transplant, donors and others in the transplant community might want the organs to be allocated to patients that will adhere to recommendations and succeed medically.

Clinical Considerations

Transplant patients are a vulnerable and complex population. The role of the addiction specialist is very important at both a clinical level and an ethical level in an era in which the need far exceeds the availability of organs. This shortage of organs leads to an ethical mandate to select the candidates with the highest chances of a good outcome and survival. There is evidence that patients with addictive disorders, especially alcohol use disorder, are less likely to be listed for transplantation even when indicated (15). The role of educating other physicians and advocating for patients in the multidisciplinary team is essential throughout the evaluation for eligibility and management of the patients. Despite the high prevalence of alcohol use disorder in this population, abstinence rates are significantly higher when compared with patients without end-stage liver disease. The transplant team should not reject patients with alcohol use disorder before the appropriate addiction treatment is offered. Capitalizing on the patient’s motivation for consideration for transplant, we can promote abstinence and ensure better post-transplant outcomes and better quality of life for our patients.

Helping the medical community to conceptualize alcoholic liver disease as the byproduct of a complex disease with treatment can help destigmatize psychiatric patients to increase their chances of receiving the medical treatment that they need.

Key Points/Clinical Pearls