Reversing Pandemic-Era Trends in Alcoholic Liver Disease Requires Empathetic, Multidisciplinary Care

During a State-of-the-Art Lecture at Digestive Disease Week 2022, Jessica L. Mellinger, MD, MSc, explained how the COVID-19 pandemic has driven increases in rates of alcohol use and associated liver disease, as well as what can be done at the clinic, societal, and policy levels to address these trends.

Mellinger, an assistant professor and hepatologist at Michigan Medicine, set the stage by showing that mortality from alcohol use disorder (AUD) has been rising in many areas for years, resulting in downstream increases in alcoholic liver disease (ALD), which is now the leading reason for liver transplant. These trends have intensified during the pandemic, as drinking peaked early in the pandemic and has only somewhat abated since, and transplant waitlists and procedures rose dramatically as well. The complex reasons behind these trends include contextual factors, such as lockdowns, living alone, or job loss, and individual factors, such as age, gender, race, and use of other substances.

Considering these worrying 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 she outlined what the audience can do in their clinical practice and at the organizational, community, and policy levels.

At the individual level, the keys at the bedside are to detect alcohol use, diagnose AUD, and direct patients to treatment, because “we cannot fix what we cannot detect,” Mellinger said. She recommended 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 on their alcohol use resulted in lower AUDIT scores 1 year later.

“It illustrates the power that we have as liver doctors—people care about their livers; they care that their liver is sick,” Mellinger explained. “They’re showing up in your clinic and not in the AUD clinic because of [stigma], so capitalize on that.”

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

“It is rare that we find interventions for this population that decrease mortality,…but this does,” Mellinger said. “So, this is the most important thing we can do for our patients is get them connected to alcohol treatment.”

Clinicians hoping to make these connections should listen to the goals of the patient, in accordance 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 familiarize themselves with the different types of substance use treatment—not just residential programs, but also intensive outpatient, counseling, mutual aid/12-step programs, and medications. Mellinger advised the audience of clinicians to bookmark treatment navigator and locator tools to help them connect patients to the right treatment.

Medications, both FDA approved for AUD and those used off label, can be useful in helping “turn down the volume” on alcohol cravings, but Mellinger urged caution when prescribing, as some types that are metabolized by the hepatic system may not be appropriate for patients with worse liver function. Still, Mellinger cited data showing that AUD pharmacotherapy works to prevent worse outcomes by reducing the odds of both incident ALD and decompensated cirrhosis.

Beyond the role of the individual clinician, Mellinger also discussed what can be done from the health care organization standpoint. She cited a study from a UK hospital that showed nurse-led screening of all patients for AUD was feasible in connecting 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 consults by a nurse practitioner and a hepatologist to patients with AUD who are at risk of ALD.

Integrating care across specialties is key, and Mellinger encouraged the audience to forge affiliations with addiction medicine providers, develop referral pathways, and “glom on to people who are interested in ALD.” Her multidisciplinary ALD clinic at Michigan Medicine, “born out of great friendships and frustration,” brought together hepatology, psychiatry, psychology, addiction, social work, and nursing, resulting in a 50% reduction in emergency department visits and readmissions after a clinic visit.

Finally, Mellinger addressed the potential of policy-level changes to effect change. For instance, pricing levels are powerful at reducing population-wide alcohol use, as demonstrated by amounts of purchased alcohol plummeting after Wales instituted a minimum unit price, although this strategy would be more complicated in the United States due to the patchwork of local, state, and federal taxes on alcohol.

Additionally, she hopes that insurance companies will expand their coverage of alcohol 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 a return on investment.

An especially concerning trend is the rise in alcohol use among young adults, compounded by social media, Mellinger said. She displayed findings from a meta-analysis that more engagement with alcohol-related social media is associated with increased alcohol use and alcohol problems.

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

Mellinger concluded that she hoped she had given the audience “some things that you can take home and do in your own clinic, that you can start to advocate for in your own health care organizations, and hopefully that we can do as a broader organization at [the American Association for the Study of Liver Diseases] to impact the policy-level changes.”