Psychological interventions to treat alcohol use disorder in patients with liver disease.

Identifying and treating alcohol use disorder (AUD) are of paramount importance in the management of patients with alcohol-associated liver disease (ALD). Achieving long-term alcohol abstinence is a crucial factor in preventing harmful outcomes associated with ethanol consumption, such as increased liver-related mortality and the need for liver transplantation.1 In a real-life scenario, primary care doctors and gastroenterologist/hepatologists can detect patients with ALD that fulfills AUD criteria, who will benefit from referral to specialized addiction professionals.1 Likewise, alcohol addiction specialists may identify individuals that should be screened for ALD. For example, providers from primary care centers, emergency departments, and surgical units may screen for AUD by using the Alcohol Use Disorders Inventory Test (AUDIT) questionnaire and, in appropriate circumstances, advise them on steps to establish abstinence including referral to a specialized addiction unit. This clinical approach is often referred to by the acronym “SBIRT” for Screening, Brief Intervention, and Referral for Treatment. Indeed, providers can simplify this process by using a short form of the AUDIT questionnaire called AUDIT-C as the initial screening tool (Table 1). Moreover, an addiction counselor may identify liver fibrosis using Fibrosis-4 (FIB-4) index or other noninvasive tests, such as elastography, referring the patient to a physician to treat advanced fibrosis (Figure 1). Thus, high-risk patients with significant ALD detected either in the clinical setting or the counseling environment should be referred to the pertinent specialist and managed by multidisciplinary teams.3 TABLE 1 - AUDIT-C questionnaire as an initial screening tool for alcohol use disorder (AUD)2 0 1 2 3 4 How often did you have a drink containing alcohol in the past year? Never Monthly or less 2–4 times a month 2–3 times a week 4 or more times a week How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? 1 or 2 drinks 3 or 4 5 or 6 7–9 10 or more How often did you have six or more drinks on one occasion in the past year? Never Less than monthly Monthly Weekly Daily or almost daily FIGURE 1: Proposed workflow for patient referral to addiction and GI/liver specialists. Abbreviations: FIB-4, Fibrosis-4.Comprehensive management by a multidisciplinary team is currently considered the gold standard for the integrated management of AUD and ALD.4 Ideally, physicians should systematically apply the AUDIT both in general practice and specialist consultation for the detection of excessive alcohol consumption in patients with any kind of liver disease. When the AUDIT score is rated positive (>8), the patient can benefit from brief interventions, a technique that has been largely proven to be effective in other settings.5,6 Motivational interventions can be conducted by both physicians and addiction counselors. If patients have an AUDIT score >20, they should be transferred to an addiction clinic for alcohol dependence assessment. Addiction specialists and gastroenterologists/hepatologists can provide brief motivational interventions and suggest initiating pharmacological treatment, such as baclofen, acamprosate, and naltrexone.7 Alcohol pharmacotherapy must be carefully selected in patients with advanced ALD due to possible hepatoxicity. In this commentary, we address how to use psychological interventions including motivational techniques that can be applied in both general practice and specialist (GI/hepatology) consultations. A variety of psychological interventions can be used to promote healthy lifestyles and social interactions, and can be effectively combined with pharmacological therapies to achieve compliance.8 Pharmacological treatments of AUD should be specially considered for more severe cases since low-to-moderate AUD may initially benefit from a psychological approach alone. These techniques, both individually and as a group intervention, include Cognitive Behavioral Therapy, Motivational Enhancement Therapy, Motivational Interviewing, and the 12-Step Facilitation that is used by Alcoholics Anonymous.8 Mindfulness represents another potential technique that could be used in combination with other techniques, yet its efficacy needs to be proven.8 Although no studies have tested their efficacy in the setting of ALD, the use of these techniques in liver clinics seeing patients with AUD is recommended. Understanding these techniques can benefit physicians who want to incorporate psychotherapies in treating their patients. Cognitive Behavioral Therapy is a commonly used technique in patients with AUD and helps prevent relapse in patients by helping them to acquire self-control skills.9 Relapse prevention is favored by developing strategies for facing high-risk situations.8 For instance, in conversations with patients, physicians can recommend minimizing exposure to scenarios that trigger cravings. Risky situations can include being among others who pressure the patient to drink, going to liquor stores, and attending events serving alcohol. The physician may recommend the patient attend self-help groups and avoid peer pressure. Another cognitive behavioral therapy technique that can further reinforce abstinence is “Contingency Management,” which uses negative and positive reinforcement.8 If patients do not have adequate social support to prevent relapse, a plan designed by both the physician and an addiction counselor can favor ways to ensure compliance with psychotherapies and pharmacological treatments. Community reinforcement can be combined with contingency management to support reinforcers8 This technique is focused on removing positive reinforcements associated with drinking while promoting positive reinforcements for abstinence.10 It can be used by physicians to promote the importance of developing new social skills and networks for their patients. This cognitive behavioral therapy technique can be useful for patients who do not have personal reinforcers (family and friends) and may benefit from developing new relationships to promote abstinence. Regular alcohol urine screening may help in monitoring patient’s compliance and to early detect relapse. Screening can also be expanded to other alcohol biomarkers, such as serum phosphatidylethanol.11 Internal motivation may be difficult for patients who are uncertain about pursuing therapies toward abstinence. Motivational Enhancement Therapy can be used by physicians to collaborate with the patient to solve the ambivalence (“the state of having two opposing feelings at the same time,” ie, continue drinking vs. abstinence). This technique increases the patient’s awareness related to the negative consequences of alcohol use, which can, in turn, increase the patient’s motivation to seek out the use of other therapies. In parallel, self-efficacy is promoted by motivational enhancement therapy.8,9 The combined use of this with other techniques could be useful (Figure 2).FIGURE 2: Psychological techniques potentially useful for the management of alcohol use disorder in patients with liver disease.Due to time constraints, Brief Interventions with motivational components are commonly used by clinicians to help patients understand the importance of abstinence and increase their self-efficacy. Using 5–10 minutes of time, hepatologists can educate patients and increase motivation.12 This technique can be most effective when repeated over multiple visits.12 Longer interventions did not show to be more effective.13 Training courses for Brief Interventions could be found here: https://www.niaaa.nih.gov/health-professionals-communities. If a patient is seen along with a partner or family member, physicians can use motivational interviewing to not only help the patient but also their support system.8 This technique is commonly used in Couples Therapy and can be useful if the use of alcohol is influential between partners. The coordinated work between the physician and addiction specialists to provide either pharmacological or psychological interventions is highly recommended (Figure 3). In fact, there is emerging evidence that the existence of multidisciplinary teams in liver centers, especially in those with a transplant program, results in improved outcomes in patients with ALD.19 Having these important parts connected to patient care may further promote abstinence from alcohol and, therefore, prevent negative outcomes.FIGURE 3: Different interventions in people with different degrees of AUD. High risk: alcohol consumption that exceeds the standard of moderate drinking and may increase the risk of medical or social consequences (in the United States, it is consuming more than 4 drinks per day in men and more than 3 drinks per day in women).14–17 Low risk: alcohol consumption below the limits of high-risk use.15–18 AUD severe = at least 6 symptoms presented. AUD moderate = 4–5 symptoms presented. AUD mild = 2–3 symptoms presented. Abbreviations: AUD, alcohol use disorder.Despite being a very prevalent condition, there is low access to treatment for AUD due to the lack of awareness and the presence of social stigma. Oftentimes, patients access specific therapy for AUD when they develop organ problems such as symptomatic ALD. The main pillar of AUD is psychotherapy and, more specifically, motivational interviewing and cognitive-behavior therapy. Pharmacological treatment for AUD is recommended in severe cases, alongside psychological approaches. Healthcare professionals (ie, liver specialists) must be trained to acquire skills and abilities to approach patients with AUD, so they promote access to specialized treatment.