Reluctance to Accept Alcohol Treatment by Alcoholic Liver Disease Transplant Patients: A Qualitative Study

Pharmacotherapy for alcohol use disorder among adults with medical disorders in Sweden

BACKGROUND

Alcohol-attributable medical disorders are prevalent among individuals with alcohol use disorder (AUD). However, there is a lack of research on prescriptions of pharmacological treatment for AUD in those with comorbid conditions. This study aims to investigate the utilization of pharmacological treatment (acamprosate, disulfiram and naltrexone) in specialist care among patients with AUD and comorbid medical diagnoses.

METHODS

This was a descriptive register-based Swedish national cohort study including 132,728 adults diagnosed with AUD (N = 270,933) between 2007 and 2015. The exposure was alcohol-attributable categories of comorbid medical diagnoses. Odds ratios (OR) were calculated using mixed-effect logistic regression analyses for any filled prescription of acamprosate, disulfiram or oral naltrexone within 12 months post AUD diagnosis.

RESULTS

Individuals with comorbid alcohol-attributable medical diagnoses had lower odds of filling prescriptions for any type of AUD pharmacotherapy compared to those without such comorbidities. Cardiovascular (OR = 0.41 [95% CI: 0.39-0.43]), neurological (OR = 0.52 [95% CI: 0.48-0.56]) and gastrointestinal (OR = 0.57 [95% CI: 0.54-0.60]) diseases were associated with the lowest rates of prescription receipt. The presence of diagnoses which are contraindications to AUD pharmacotherapy did not fully explain the low prescription rate.

CONCLUSION

There is a substantial underutilization of AUD pharmacotherapy in patients with AUD and comorbid medical disorders in specialist care. Increasing the provision of pharmacotherapy to this group of patients is essential and may prevent morbidity and mortality. There is a need to further understand barriers to medical treatment both from the patient and prescriber perspective.

Lung transplant recipients' experiences of and attitudes towards self-management: a qualitative systematic review

OBJECTIVE

The objective of this review was to identify lung transplant recipients' experiences of and attitudes towards self-management.

INTRODUCTION

Lung transplantation is an established treatment to improve the survival of patients with end-stage lung diseases and has been performed on over 40,000 patients worldwide. The current focus of care for lung transplant recipients is on their long-term management. Patients need to adapt and adhere to complex self-management tasks to prevent complications and to enable them to keep the transplanted graft as long as possible. However, to date, no qualitative systematic review exists that identifies lung transplant recipients' experiences of and attitudes towards self-management.

INCLUSION CRITERIA

This review included adults over 18 years of age who had received a lung transplant and were able to perform their self-management tasks independently. All studies that investigated lung transplant recipients' experiences of and attitudes towards self-management in any setting were included in this review. All types of studies that focused on qualitative data, including, but not limited to, phenomenology, grounded theory, ethnography, action research, and feminist research were considered for inclusion. Mixed methods studies were included only when qualitative data could be extracted separately, and if they reported results relating to the phenomena of interest. Studies published in English or German were considered for inclusion in this review.

METHODS

The search strategy aimed to find published studies from 6 databases from the database inception to March 2022. Methodological quality of studies was independently assessed by 2 independent reviewers using the JBI checklist for qualitative research. A standardized data extraction tool from JBI was used by 2 reviewers for data collection. Meta-aggregation was undertaken to synthesize the data, and the final synthesis of the findings was reached through discussion. Results were graded according to ConQual.

RESULTS

Ten studies with a sample size from 8 to 73 participants from North America and Central/Northern Europe were included in the review. The critical appraisal scores of the included studies varied from 3 to 9 out of 10. A total of 137 findings were extracted and aggregated to form 19 categories and the following 4 aggregated syntheses: i) Changes in routines, beliefs, and sense of responsibility are essential for better adaptation and self-management after lung transplantation; ii) Life after transplantation is characterized by both positive and negative feelings and experiences; iii) Better adjustment and self-management after a lung transplant require dealing with one's own feelings and beliefs; iv) After transplantation, engaging with relatives, friends, medical team and donors is essential to improve experiences and adapt to being a transplant recipient. Based on the ConQual scores, 2 synthesized findings were graded as moderate and 2 as low.

CONCLUSIONS

Nuanced emotional, social, relational, and psychological adjustment is required of lung transplant recipients to be able to successfully self-manage. Loved ones and health professionals contribute significantly to this process, but psychosocial or peer support may further facilitate this transition.

SUPPLEMENTAL DIGITAL CONTENT

A German-language version of the abstract of this review is available as Supplemental Digital Content [http://links.lww.com/SRX/A46].

Treatment of alcohol use disorder in patients with alcohol-associated liver disease: Innovative approaches and a call to action

Alcohol-associated liver disease is currently the leading cause of liver transplantation and liver deaths both in Europe and the United States. Efficacious treatments exist for alcohol use disorder, but they are seldomly prescribed for patients who need them. Besides, the presence of liver cirrhosis can complicate pharmacological treatment choices. In this review, we discuss established and innovative treatment strategies to treat unhealthy alcohol use in patients with alcohol-associated liver disease. We also describe the experience of our own institutions, Hospital Universitari Germans Trias i Pujol in Badalona (Spain) and Yale-New Haven Health and Yale Medicine (Connecticut. United States of America).

Alcohol use disorder in alcohol-associated liver disease: Two sides of the same coin

Alcohol-associated liver disease (ALD) has emerged as the leading indication for liver transplantation (LT) worldwide, with 40% of LTs in the United States performed for ALD in 2019. The ALD-related health care burden accelerated during the COVID-19 pandemic, especially in young individuals. Alcohol use disorder (AUD), which focuses on the negative effects of alcohol on psychosocial, physical, and mental health, is present in the majority of patients with ALD, with moderate to severe AUD in 75%-80%. During the last decade, early liver transplantation (eLT) has emerged as a lifesaving treatment for selected patients with alcohol-associated hepatitis; these patients may have a higher risk of using alcohol after LT. The risk of alcohol use recurrence may be reduced during the pretransplant or post-transplant period with AUD treatment using behavioral and/or pharmacological therapies and with regular monitoring for alcohol use (self-reported and complemented with biomarkers like phosphatidylethanol). However, AUD treatment in patients with ALD is challenging due to patient, clinician, and system barriers. An integrated model to provide AUD and ALD care by hepatologists and addiction experts in a colocated clinic starting from LT evaluation and selection to monitoring listed candidates and then to following up on recipients of LT should be promoted. However, the integration of addiction and hepatology teams in an LT program in the real world is often present only during evaluation and candidate selection for LT. Data are emerging to show that a multidisciplinary integrated AUD treatment within an LT program reduces recurrent alcohol use after LT. If we want to continue using early liver transplantation for patients with severe alcohol-associated hepatitis, LT programs should focus on building integrated multidisciplinary care teams for the integrated treatment of both AUD and ALD.

Service-level barriers to and facilitators of accessibility to treatment for problematic alcohol use: a scoping review

Introduction

Services to treat problematic alcohol use (PAU) should be highly accessible to optimize treatment engagement. We conducted a scoping review to map characteristics of services for the treatment of PAU that have been reported in the literature to be barriers to or facilitators of access to treatment from the perspective of individuals with PAU.

Methods

A protocol was developed a priori, registered, and published. We searched MEDLINE®, Embase, the Cochrane Library, and additional grey literature sources from 2010 to April 2022 to identify primary qualitative research and surveys of adults with current or past PAU requiring treatment that were designed to identify modifiable characteristics of PAU treatment services (including psychosocial and pharmacologic interventions) that were perceived to be barriers to or facilitators of access to treatment. Studies of concurrent PAU and other substance use disorders were excluded. Study selection was performed by multiple review team members. Emergent barriers were coded and mapped to the accessibility dimensions of the Levesque framework of healthcare access, then descriptively summarized.

Results

One-hundred-and-nine included studies reported an extensive array of unique service-level barriers that could act alone or together to prevent treatment accessibility. These included but were not limited to lack of an obvious entry point, complexity of the care pathway, high financial cost, unacceptably long wait times, lack of geographically accessible treatment, inconvenient appointment hours, poor cultural/demographic sensitivity, lack of anonymity/privacy, lack of services to treat concurrent PAU and mental health problems.

Discussion

Barriers generally aligned with recent reviews of the substance use disorder literature. Ranking of barriers may be explored in a future discrete choice experiment of PAU service users. The rich qualitative findings of this review may support the design of new or modification of existing services for people with PAU to improve accessibility.

Systematic Review Registration

Open Science Framework doi: 10.17605/OSF.IO/S849R.

Incidence, clinical characteristics, and risk factors associated with recurrent alcohol-associated hepatitis

BACKGROUND

Alcohol relapse occurs frequently in alcohol-associated hepatitis (AH) survivors, but data on the frequency and course of recurrent alcohol-associated hepatitis (rAH) are sparse. We investigated the incidence, risk factors, and outcomes of rAH.

METHODS

Hospitalized patients with AH from 2010 to 2020 at a large health care system were followed until death/liver transplant, last follow-up, or end of study (December 31, 2021). AH was defined by NIAAA Alcoholic Hepatitis Consortium criteria; rAH was defined a priori as a discrete AH episode >6 months from index AH hospitalization with interim >50% improvement or normalization of total bilirubin. Multivariable competing risk analysis was performed to identify factors associated with rAH. Landmark Kaplan-Meier analysis was performed to compare survival between patients who did versus those who did not develop rAH.

RESULTS

Of 1504 hospitalized patients with AH, 1317 (87.6%) survived and were analyzed. During a 3055 person-year follow-up, 116 (8.8%) developed rAH at an annual incidence rate of 3.8% (95% CI: 2.8-4.8). On multivariable competing risk analysis, marital status [sub-HR 0.54 (95% CI: 0.34, 0.92), p=0.01] and medications for alcohol use disorder [sub-HR 0.56 (95% CI: 0.34, 0.91), p=0.02] were associated with a lower risk for rAH. On landmark Kaplan-Meier analysis, the cumulative proportion surviving at 1 year (75% vs. 90%) and 3 years (50% vs. 78%) was significantly lower in patients who developed rAH compared to those who did not develop rAH (log-rank p<0.001).

CONCLUSIONS

rAH develops in ~1 in 10 AH survivors and is associated with lower long-term survival. Medications for alcohol use disorder lower the risk for rAH and, therefore, could be a key preventative strategy to improve outcomes.

Testing a Digital Health App for Patients With Alcohol-Associated Liver Disease: Mixed Methods Usability Study

BACKGROUND

Alcohol-associated liver disease (ALD) is increasingly common and associated with serious and costly health consequences. Cessation of drinking can improve ALD morbidity and mortality; however, support for cessation is not routinely offered to those diagnosed with ALD, and continued drinking or resumption of drinking after diagnosis is common. Mobile health (mHealth) has the potential to offer convenient and scalable support for alcohol cessation to those diagnosed with ALD, but mHealth interventions for alcohol cessation have not been designed for or evaluated in a population with ALD.

OBJECTIVE

This study aims to understand how individuals with ALD would perceive and use an mHealth tool for alcohol cessation and to gather their perspectives on potential refinements to the tool that would allow it to better meet their needs.

METHODS

We interviewed 11 individuals who attended clinic visits related to their ALD to elicit their needs related to support for alcohol cessation and views on how mHealth could be applied. After completing initial interviews (pre), participants were provided with access to an mHealth app designed for alcohol cessation, which they used for 1 month. Afterward, they were interviewed again (post) to give feedback on their experiences, including aspects of the app that met their needs and potential refinements. We applied a mixed methods approach, including a qualitative analysis to identify major themes from the interview transcripts and descriptive analyses of use of the app over 1 month.

RESULTS

First, we found that a diagnosis of ALD is perceived as a motivator to quit drinking but that patients had difficulty processing the overwhelming amount of information about ALD they received and finding resources for cessation of alcohol use. Second, we found that the app was perceived as usable and useful for supporting drinking recovery, with patients responding favorably to the self-tracking and motivational components of the app. Finally, patients identified areas in which the app could be adapted to meet the needs of patients with ALD, such as providing information on the medical implications of an ALD diagnosis and how to care for their liver as well as connecting individuals with ALD to one another via a peer-to-peer support forum. Rates of app use were high and sustained across the entire study, with participants using the app a little more than half the days during the study on average and with 100% (11/11) of participants logging in each week.

CONCLUSIONS

Our results highlight the need for convenient access to resources for alcohol cessation after ALD diagnosis and support the potential of an mHealth approach to integrate recovery support into care for ALD. Our findings also highlight the ways the alcohol cessation app should be modified to address ALD-specific concerns.

Patient reflections, challenges, and supports related to early liver transplant for severe alcohol-associated liver disease

BACKGROUND

Transplant centers conventionally require at least 6 months of alcohol abstinence before offering liver transplants for alcohol-associated liver disease. However, early liver transplant (ELT)-proceeding with a transplant when clinically necessary without first meeting the conventional requirement-is increasingly gaining attention. In our study, we qualitatively assessed ELT recipients' perceived challenges and supports regarding alcohol-associated liver disease, transplant, and posttransplant survivorship.

PATIENTS AND METHODS

To diversify perspectives based on sex, race/ethnicity, age, time since ELT, and pretransplant abstinence duration, we purposively recruited ELT recipients and conducted semistructured interviews. Recruitment continued until data saturation. We analyzed transcripts using inductive thematic analysis.

RESULTS

We interviewed 20 ELT recipients between June and December 2020 and identified themes within 3 participant-characterized time periods. Three themes emerged in life before severe illness: (1) alcohol as a "constant" part of life, (2) alcohol use negatively affecting relationships and work life, and (3) feeling "stuck" in the cycle of drinking. Two themes emerged during the severe illness period: (4) rapidity of health decline and (5) navigating medical care and the 6-month abstinence requirement. Finally, in life after transplant, 4 themes emerged: (6) feelings of shame or stigma and new self-worth, (7) reconnecting with others and redefining boundaries, (8) transplant as a defining point for sobriety, and (9) work-related challenges. Overall, participants expressed gratitude for receiving a gift of life and acknowledged their responsibilities to the new liver.

CONCLUSIONS

ELT recipient experiences reveal complex psychosocial challenges related to addiction, inadequate support system, and stigma, particularly in the posttransplant period. The care of ELT recipients would be incomplete if focused solely on optimizing patient or graft survival.

The stigma of alcohol-related liver disease and its impact on healthcare

People with alcohol-related liver disease (ALD) experience stigma and discrimination. This review summarises the evidence on stigma in healthcare and its implications for people with ALD, drawing from the literature on the stigma associated with mental illness and, specifically, alcohol use disorder (AUD). Public stigma, self-stigma and structural stigma all contribute to failure to seek help or delays in seeking help, inferior healthcare, and negative health outcomes, which increase the overall burden of ALD. Stigma can be experienced, but also anticipated and avoided, with both scenarios negatively impacting on ALD healthcare. Blaming people with ALD for their condition is central to the stigma of ALD. Stigma affects ALD healthcare at all stages, from prevention, early detection and intervention, to allocation of scarce resources in liver transplantation. People with lived experience need to be empowered to lead action against the stigmatisation of patients with ALD. Promulgating a dynamic model of individual and social responsibility for AUD, a continuum model of harmful alcohol use, and establishing training on ALD-related stigma for healthcare professionals are strategies to address stigma. Integrating addiction and ALD services, providing stigma-free prevention, and overcoming the frequent separation of addiction services from general healthcare are necessary. Beyond healthcare, addressing social inequality, the social dimensions of ALD risk and outcomes, and ensuring equal access to services is necessary to improve outcomes for all people with ALD. More research is needed on the stigma of ALD in low- and middle-income countries and in countries with restrictive drinking norms. Interventions to reduce the stigma of ALD and facilitate early help-seeking need to be developed and evaluated.

Liver transplantation for alcohol-related liver disease in the UK: revised UK Liver Advisory Group recommendations for referral

Liver disease, of which liver cirrhosis is the most advanced stage, constitutes the fourth most common cause of life-years lost in men and women younger than 75 years in England, where mortality rates from liver disease have increased by 25% in the past decade. Alcohol consumption is the most common modifiable risk factor for disease progression in these individuals, but within the UK, there is substantial variation in the distribution, prevalence, and outcome of alcohol-related liver disease, and no equity of access to tertiary transplantation services. These revised recommendations were agreed by an expert panel convened by the UK Liver Advisory Group, with the purpose of providing consensus on referral for transplant assessment in patients with alcohol-related disease, and clarifying the terminology and definitions of alcohol use in liver injury. By standardising clinical management in these patients, it is hoped that there will be an improvement in the quality of care and better access to liver transplant assessment for patients with alcohol-related liver disease in the UK.

Diagnosis and Management of Alcohol Use Disorder in Patients with Liver Disease: Lights and Shadows

Alcohol use disorder is the most common cause of advanced liver disease in the Western world. Diagnosis of alcohol use disorder can be difficult because patients with liver disease tend to deny alcohol intake for the fear of being excluded from treatment and because available biomarkers of alcohol intake have poor specificity in these patients. Alcohol abstinence is the cornerstone of the therapy in these patients. However, pharmacological treatments for alcohol use disorders have not been formally tested in patients with advanced liver disease, except for baclofen. Psychosocial intervention became crucial in these patients considering the limited pharmacological choice. However, psychosocial approach and an appropriate team to manage these patients are not still well defined. In this review, we critically discuss the diagnosis and the management of alcohol use disorder in patients with liver disease.

Insights Into the Experience of Liver Transplant Recipients With Alcoholic Liver Disease: A Descriptive Qualitative Study

Background.

Alcoholic liver disease (ALD) due to alcohol use disorder (AUD) is the primary cause of liver transplantation (LT) in the United States. Studies have found that LT recipients experience a range of physical and emotional difficulties posttransplantation including return to alcohol use, depression, and anxiety. The aim of this study is to better understand the experiences of LT recipients with ALD because they recovered posttransplant to inform the development of a patient-centered intervention to assist patients during recovery.

Methods.

Using qualitative methods, researchers conducted semi-structured interviews with 16 ALD LT recipients. The primary topics of the interview were physical recovery, mental health, substance use including alcohol and tobacco use, and financial experiences. Common patient themes were identified and coded.

Results.

Within the domain of physical health, patients stressed that undergoing LT was a near-death experience, they were helpless, changes in weight influenced their perception of their illness, and they have ongoing medical problems. In the domain of mental health, patients described cognitive impairments during their initial recovery, difficulty in processing the emotions of having a terminal condition, ongoing depression, anxiety, and irritability. The patients also described their perception of having AUD, the last time they used alcohol and their attitude to AUD treatment posttransplant. Patients also described their reliance on one member of their social support network for practical assistance during their recovery and identified one member of their medical team as being of particular importance in providing emotional as well as medical support during recovery.

Conclusions.

The patient’s description of their lived experience during the months following transplant informed the development of a patient-centered intervention that colocates behavioral health components with medical treatment that helps broaden their social network while addressing topics that emerged from this study.

Liver Transplantation for Alcoholic Liver Disease: An Update

Alcoholic liver disease is a serious and increasing contributor to the global liver disease burden. Extensive selection criteria, including a minimum abstinence period, has previously been used to secure good outcomes but new research questions the effectiveness of abstinence periods and has recommended changes in integrated alcohol use treatment to effectively prevent relapse. Patients have unique health concerns, including posttransplantation risks of malignancy and metabolic complications, but overall very good long-term outcomes. Severe alcoholic hepatitis has been increasingly treated with early transplantation without a set sobriety period, with overall favorable outcomes, even with respect to recidivism.

Misconceptions, preferences and barriers to alcohol use disorder treatment in alcohol-related cirrhosis

BACKGROUND

While alcohol cessation improves mortality in alcoholic liver disease (ALD), many patients struggle to achieve abstinence. Our aim was to characterize ALD patients' preferences, misconceptions, and barriers to alcohol use treatment options.

METHODS

This mixed-methods study included outpatients with a history of alcohol-related cirrhosis or alcoholic hepatitis recruited from a hepatology clinic for a survey or an in-depth semi-structured interview. We purposefully sampled men and women, compensated and decompensated patients to ensure adequate representation of gender and severity of liver disease for the qualitative interviews.

RESULTS

123 patients completed surveys among which 50% reported having at least one drink within the past year while only 20 patients were in any form of current alcohol treatment. Of the 23 patients reporting drinking within 3 months, only 3 were in AUD treatment currently. 17% had at least one misconception about alcohol use or treatment. An additional 22 ALD patients (10 women, 12 men) completed phone interviews of which two-third self-reported alcohol abstinence. All 22 interview participants had awareness of some form of alcohol treatment, but 13 felt that they did not need treatment with several characterizing it as ineffective or a "waste of time." Misconceptions included inaccurate perceptions of relapse medication side effects, beliefs that the presence of advanced liver disease symptoms means it is too late to treat alcohol use, and a lack of understanding about the chronicity of alcohol use disorders. The most common barriers to treatment included unwillingness to be in treatment, financial/insurance and transportation barriers.

CONCLUSIONS

Alcohol use treatment was underutilized in many ALD patients, despite active drinking in many. Tailored education and preference sensitive treatment engagement may overcome barriers to alcohol use treatment and promote abstinence.

Lung transplant recipients' experiences of and attitudes towards self-management: a qualitative systematic review protocol

REVIEW QUESTION

The question for this review is: what are lung transplant recipients' experiences of and attitudes towards self-management?