Management of alcohol use disorder in alcohol-associated liver disease for nonaddiction specialists

Globally, excessive alcohol use is a leading cause of preventable death, accounting for more than 5% of total deaths.1 In the US, excessive alcohol use accounts for 3.6 million life-years lost and $249 billion in costs per year.2,3 Although alcohol is a causal factor for more than 200 diseases, alcohol-associated liver disease (ALD) has surged in the past decade to become the most common cause of alcohol-associated death.4,5 ALD accounts for 50% of liver-related deaths and is now the leading indication for liver transplantation.6,7 Given the growing burden of ALD on public health, improved management of alcohol use disorder (AUD) should be a critical priority for hepatologists. In this series of Clinical Liver Disease articles we aim to provide a clinically applicable overview of steps that providers (hepatologists, nurse practitioners, and so on) in a liver clinic can take to address AUD for their patients with ALD. This series is the result of a collaborative effort from a multidisciplinary team of authors, encompassing perspectives from primary care, addiction psychiatry, and hepatology, with a focus on what is realistic and practical for an everyday liver clinic, which can have variable resources and patient populations. Indeed, abstinence from alcohol is the strongest predictor of long-term survival in ALD.8,9 While evidence-based therapies for AUD exist to increase rates of abstinence and reduce rates of heavy drinking, <15% of patients with concomitant AUD and cirrhosis receive behavioral therapy, and <2% receive pharmacotherapy for AUD.10 The barriers to accessing AUD therapy among patients with ALD are likely multifactorial. Although the hepatology clinic represents a potential opportunity to provide therapy for AUD to improve clinical outcomes, this opportunity is not commonly leveraged. A recent survey11 commissioned by the American Association for the Study of Liver Diseases ALD Special Interest Group reported that the majority (71%) of hepatology providers never provide behavioral or pharmacotherapy for AUD, with the most common reason being low comfort (84%). Most (77%) reported low addiction education and 90% desired more training. We hope that this series will help to address these clinical gaps by educating our hepatology community and empowering them with the tools to deliver evidence-based interventions for AUD among patients with ALD in their liver clinic. The first 2 articles address the landscape of AUD and ALD through the lens of epidemiology, health equity, and stigma. Disparities in health care access are highly prevalent and complex, exacerbated by the stigma of alcohol and addiction among the lay public, medical professionals, and policymakers alike.12 Sedaros and Flemming13 propose potential solutions to bridge disparities and address the stigma that should be considered by the hepatology community. Next, the series moves directly into the clinic to impart essential bedside techniques. Kulkarni and Singal14 outline validated and efficient tools to screen for AUD and how to monitor for AUD using both clinical interviews and/or highly accurate biomarkers of recent alcohol use. Ravi and Bataller15 describe behavioral interventions (eg, cognitive behavioral therapy) that are evidence-based to treat AUD and can be learned and quickly applied by any hepatology provider even during a busy clinic visit. In parallel, Coe, Patel, and Lawrence16 detail how hepatology providers can safely prescribe AUD pharmacotherapy, including which medications to choose depending on the clinical scenario and to reduce alcohol use among patients with chronic liver disease. Finally, Winder and Clifton17 describe advanced AUD therapies that can only be applied outside the liver clinic in partnership with addiction specialists. ALD is already responsible for the majority of liver-related mortality and continues to grow at alarming rates. To best serve our community, hepatologists must become familiar and adept with the management of AUD. This series strives to provide a concise yet comprehensive reference that can be applied to address this need, by any medical professional regardless of formal addiction training, to better care for patients with concomitant AUD and liver disease.