Reversing pandemic-era trends in alcoholic liver disease requires empathetic, multidisciplinary care

During a state-of-the-art conference at Digestive Disease Week 2022, Jessica L. Mellinger, MD, MSc, discussed how the COVID-19 pandemic has led to increased rates of alcohol consumption and associated liver diseases, as well as what can be done at clinical, societal and policy levels to address these trends.

During a state-of-the-art conference at Digestive Disease Week 2022, Jessica L. Mellinger, MD, MSc, discussed how the COVID-19 pandemic has led to increased rates of alcohol consumption and associated liver diseases, as well as what can be done at clinical, societal and policy levels to address these trends.

Mellinger, an assistant professor and hepatologist at Michigan Medicine, led the way by showing that mortality from alcohol use disorder (AUD) has been increasing in many areas for years, leading to an increase downstream in alcoholic disease. of the liver (ALD), which is now the leading cause of liver transplantation. These trends have intensified during the pandemic, as alcohol consumption peaked at the start of the pandemic and has only declined somewhat since, and waiting lists and transplant procedures have also increased dramatically. The complex reasons behind these trends include contextual factors, such as confinement, living alone or job loss, and individual factors, such as age, gender, race and consumption. other substances.

Given these disturbing trends, Mellinger devoted the majority of his talk to where we can go from now. The most important factor for survival in ALD is quitting alcohol, so she described what the public can do in their clinical practice and at organizational, community and policy levels.

At the individual level, the keys at the bedside are to detect alcohol use, diagnose AUD and refer 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 motivation for behavior change. Providing patients with liver-specific feedback about their alcohol consumption resulted in lower AUDIT scores 1 year later.

“It illustrates the power we have as liver doctors – people care about their liver; they care that their liver is diseased,” Mellinger explained. “They show up at your clinic and not the AUD clinic because of [stigma]so capitalize on that.

Once AUD is diagnosed, the next step is to refer the patient for treatment, but this is often complicated by barriers such as lack of insurance coverage, logistical difficulties and attitudes towards treatment. . Mellinger noted that this last item might be the most important, because the most common thing she hears in her clinic is that her patients don’t feel the need for AUD treatment. Rates of access to AUD treatment are low – around 10% to 14% – even among patients with ALD, but those who receive treatment experience better outcomes, such as lower rates of decompensation and mortality .

“It’s rare that we find interventions for this population that decrease mortality, … but they do,” Mellinger said. “So that’s the most important thing we can do for our patients is to connect them to alcoholism treatment.”

Clinicians hoping to make these connections must listen to the patient’s goals, consistent with the principles of motivational interviewing, and remain aware of the power of stigma, including self-stigma, as patients may feel that they don’t deserve help. They should also become familiar with the different types of addiction treatment – ​​not just residential programs, but also intensive outpatient clinics, counseling, self-help/12-step programs, and medications. Mellinger advised the clinician audience to mark the treatment Navigator and locator tools to help them direct patients to the right treatment.

The drugs, both FDA-approved for AUD and those used off-label, can be helpful in helping to “turn down the volume” of alcohol cravings, but Mellinger urged caution when prescribing because some types that are metabolized by the liver may not be suitable for patients with impaired liver function. Still, Mellinger cited data showing that AUD drug therapy works to prevent worse outcomes by reducing the risk of incident ALD and decompensated cirrhosis.

Beyond the role of the individual clinician, Mellinger also discussed what can be done from a healthcare organization perspective. She cited a study from a UK hospital that showed nurse-led screening of all patients with AUD was feasible to connect patients to a level of intervention commensurate with their risk. She also pointed to 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.

Integration of care across specialties is essential, and Mellinger encouraged the public to forge affiliations with addiction medicine providers, develop referral pathways, and “look to those interested in addiction medicine.” ALD”. His multidisciplinary ALD clinic at Michigan Medicine, “born out of great friendships and frustration,” brought together hepatology, psychiatry, psychology, addictions, social work, and nursing, resulting in a 50% reduction emergency room visits and readmissions after a clinic visit.

Finally, Mellinger addressed the potential of changes at the political level to effect change. For example, price levels are powerful in reducing alcohol consumption at the population level, as evidenced by the quantities of alcohol purchased which fell after Wales instituted a minimum unit price, although that this strategy is more complicated in the United States due to the patchwork of local and state liquors. , and federal liquor taxes.

In addition, she hopes that insurance companies will expand their coverage for alcoholism treatment; she and her colleagues have worked to demonstrate the cost-effectiveness of medication-assisted therapy and counseling in alcohol-related cirrhosis. She also cited the potential of mobile health apps to demonstrate return on investment.

A particularly concerning trend is the rise in alcohol consumption among young adults, compounded by social media, Mellinger said. She presented the results of a meta-analysis which found that greater participation in alcohol-related social media is associated with increased alcohol consumption and alcohol problems.

Above all, Mellinger said, we need more attention on ALD because the low priority of research and funding toward the disease is disproportionate to its high clinical burden.

Mellinger concluded that she hoped to have given the public “things that you can take home and do in your own clinic, that you can start advocating for in your own healthcare organizations, and hopefully that we can do as a larger organization to [the American Association for the Study of Liver Diseases] to have an impact on policy changes.

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