Alcohol use is a common cause of death in the United States. According to death certificate data alcohol associated mortality doubled between 1999 and 2017 with the largest annual growth in white women. In addition, both alcohol use and its consequences skyrocketed during the COVID19 pandemic. Alcohol sales increased 54% in March 2020 compared to March 2019 with an increased in online sales of 262%! Parallel to alcohol sales, hospital admissions and liver transplantation rates for alcohol associated liver disease (ALD) also increased during the pandemic. My personal experience as a transplant hepatologist in a large academic institution corroborates these trends.
Yet, alcohol use disorder (AUD) is a treatable condition. Effective therapy should decrease morbidity and mortality. The failure to treat AUD occurs on multiple levels. First AUD must be recognized, as few patients are even screened. The US Preventive Services Task Force (USPSTF) recommends screening for unhealthy alcohol use in primary care settings for all adults aged 18 and older. Providers must also realize there is therapy for AUD. The USPSTF also recommends behavioral counseling intervention to reduce unhealthy alcohol use in those who engage in risk or hazardous drinking. A recent AASLD ALD special interest group survey found that only 61% of 408 providers (80% of which practice in a tertiary care hospital associated with a liver transplant center) routinely refer AUD patients for behavioral therapy and 71% have never prescribed any pharmacotherapy. The authors felt clinicians failed to prescribe AUD pharmacotherapy due to knowledge gaps.
Encouraging data helping to address these knowledge gaps was presented at the 2021 annual American College of Gastroenterology meeting. Patrick Twohig and his colleagues at the University of Nebraska Medical Center, retrospectively evaluated 115 patients who had been hospitalized for ALD and AUD. They also found low use of AUD pharmacological therapy (21%). However, those patients prescribed therapy had a lower 1-year mortality rate of 4.2% compared to 20.9% in those not prescribed therapy. They also found that those prescribed treatment for AUD were more likely to have been seen by an addiction specialist. The study clearly points to poor utilization of AUD treatments and better outcomes with multidisciplinary management.
It is equally important to recognize there are published guidelines to assist clinicians in management of patients with ALD and AUD. The 2019 AASLD Practice Guideline for Diagnosis and Treatment of Alcohol-Associated Liver Disease highlights the importance of referral to AUD treatment professionals as well as multidisciplinary integrated management of ALD and AUD. The guidelines also advocate for pharmacotherapy, advocating for the use of acamprosate or baclofen in the treatment of AUD in patients with ALD.
Unhealthy alcohol use continues to be a cause of liver disease across the globe. Demographics are shifting to a younger population with a striking increase in white women. Increasing awareness should result in better screening for AUD in primary care settings. However it is imperative that clinicians and patients realize that effective therapy for AUD exists and is proven to decrease mortality.
Dr. Reau is employed by Rush University Medical Center. She has recieved consulting fees, participation fees, or honorarium from AbbVie, Gilead, Xifaxan, Intercept, and Arbutus.
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