Reversing epidemiological trends in alcoholic liver disease requires compassionate multidisciplinary care

During a recent lecture at Gastroenterology Week 2022, MSc Jessica L. Mellinger explained how the COVID-19 pandemic has increased rates of alcohol use and related liver disease, as well as what can be done at the clinic, community, and policy level to address these trends.

During a recent lecture at Gastroenterology Week 2022, MSc Jessica L. Mellinger explained how the COVID-19 pandemic has increased rates of alcohol use and related liver disease, as well as what can be done at the clinic, community, and policy level to address these trends.

Mellinger, assistant professor and hepatologist at Michigan Medicine, paved the way by showing that deaths from alcohol use disorder (AUD) have been rising in many areas for years, leading to downstream increases in alcoholic liver disease (ALD), which It has now become the main reason for liver transplantation. These trends intensified during the epidemic, as drinking peaked early in the epidemic and has only subsided somewhat since then, and waiting lists and transplant procedures have skyrocketed as well. Complex causes behind these trends include contextual factors, such as being closed, living alone, or losing a job, and individual factors, such as age, gender, race, and other substance use.

Given these troubling trends, Mellinger devoted the majority of her lecture to where we can go from here. The single most important factor for survival in ALD is alcohol cessation, so I outlined what the public can do in their clinical practice and at the organizational, community, and policy levels.

On an individual level, the keys to the bedside are detecting alcohol use, diagnosing AUD, and directing patients to treatment, because “we can’t fix what we can’t detect,” Mellinger said. She recommended the use of the AUDIT-C screening tool and noted the power of liver disease as a motivator for behavior change. Providing patients with liver-specific feedback on their alcohol use resulted in lower review scores after one year.

“It shows the power we have as hepatologists — people take care of their livers; they care about liver disease,” Mellinger explained. [stigma]So take advantage of that.”

Once AUD has been diagnosed, the next step is to direct the patient to treatment, but this is often complicated by barriers including lack of insurance coverage, logistical difficulties, and attitudes toward treatment. Mellinger notes that this last ingredient may be the most important, as what she hears most in her clinic is that her patients don’t feel the need for AUD treatment. Access rates for AUD treatment are low—about 10% to 14%—even in patients with ALD, but those who do receive treatment reap improved outcomes such as lower rates of decompensation and mortality.

“It’s rare that we find interventions for this population that reduce the death rate, … but it does,” Mellinger said. “So, this is the most important thing we can do for our patients is connect them to alcohol therapy.”

Clinicians hoping to make these connections must listen to patient goals, according to motivational interviewing principles, and stay aware of the power of stigma—including subjective stigma, where patients may feel they do not deserve help. They should also learn about the different types of substance abuse treatment – not only residential programs, but also intensive outpatient programs, counseling, mutual aid/12-step programs, and medication. Mellinger advised the clinician audience to bookmark treatment navigators and locators to help them connect patients to the right treatment.

The drugs, FDA-approved and used off-label, can be helpful in helping to “reduce volume” in alcohol cravings, but Mellinger urged caution when prescribing, because some types that are metabolized by Hepatic system may not be suitable for patients with poor liver function. However, Mellinger cited data showing that AUD pharmacotherapy prevents poor outcomes by decreasing the odds of both incident ALD and decompensated cirrhosis.

In addition to the role of the individual physician, Mellinger also discussed what can be done from the point of view of the health care organization. She cited a study from a UK hospital which showed that a nurse’s examination of all patients for AUD was possible in associating patients with a level of intervention commensurate with their risk. She also noted early data from the ALivE Service at Massachusetts General Hospital, which provides inpatient liver consultations by a nurse practitioner and hepatologist to patients with AUD who are at risk for ALD.

Integrating care across specialties is key, and Mellinger encouraged the public to form associations with addiction medicine providers, develop referral pathways, and “depression for people interested in ALD.” “Born of Great Friendships and Frustrations,” Michigan Medicine’s ALD multidisciplinary clinic combined hepatology, psychiatry, psychology, addiction, social work, and nursing, resulting in a 50% reduction in emergency department visits and post-clinic readmissions.

Finally, Mellinger addressed the potential of policy-level changes to bring about change. For example, pricing levels are robust in reducing alcohol use at the population level, as evidenced by the lower amounts of alcohol purchased after Wales established a minimum unit price, although this strategy would be more complicated in the United States due to a mixture of, and federal taxes on Alcohol.

Additionally, she hopes insurance companies will expand their coverage for alcohol treatment; She and her colleagues have worked to demonstrate the cost-effectiveness of drug-assisted treatment and counseling in cases of alcohol-related cirrhosis. She also noted the potential of mobile health apps to demonstrate a return on investment.

A particularly worrying trend, Mellinger said, is an increase in alcohol use among young people, as well as social media. They presented the results of a meta-analysis that more interaction with alcohol-related social media is associated with increased alcohol use and alcohol problems.

Above all, Mellinger said, we need to pay more attention to ALD, as the low priority of research and funding toward the disease is out of proportion to the large clinical burden.

Mellinger concluded that she hopes it has given the public “some of the things you can take home and do in your own practice, that you can start advocating for in your healthcare institutions, and that we hope we can do as a broader organization in the future.” [the American Association for the Study of Liver Diseases] to influence policy-level changes.”

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