. 2022 Jan 31;12(4):1069–1082. doi: 10.1016/j.jceh.2022.01.010

Table 1.

Interprofessional Implications of ALD Pathophysiology Necessitating Integrated Care.

Clinical Domain	Description and Context	Interprofessional Implications
Acute alcohol-related hepatitis	• AAH has high short-term mortality²³ and any resumed drinking after severe AAH risks substantial mortality²⁴ • A standardized, consensus psychosocial approach to AAH evaluation and ongoing management is still emerging⁹ • OLT performed in AAH patients have recently increased²⁵ where psychosocial evaluations are crucial and team collaboration essential	• Hepatology training may not adequately prioritize addiction and mental health and psychiatric training may not provide adequate preparation for end-stage disease and OLT signaling the need for substantial, ongoing interprofessional education • Expert, at-the-ready psychiatric consultation may be sparse for liver teams • Post-discharge AUD treatment must be prioritized and integrated into follow-up planning given relapse and mortality risks • Psychosocial OLT evaluations should be prioritized in AAH; unfavorable influences on psychosocial evaluation include: ○ Prevalent patient AMS ○ Patient and family incentives to conceal or minimize psych history due to OLT access concerns ○ Compressed transplant and disease timetables
Gastrointestinal bleeding	• Commonly prescribed SRI medications may increase bleeding risk due to platelet function effects²⁶ prompting some to advise SRI discontinuation before liver procedures²⁷	• Risks and benefits of SRI medication use VS discontinuation must be carefully analyzed given competing medical and psychiatric needs ○ High psychiatric comorbidity in AUD/ALD (see later) ensures this will be a common clinical consideration for liver teams ○ Either choice (ongoing Rx use, therapeutic interchange, or taper/discontinuation) will necessitate interprofessional follow-up and coordination
Hepatic encephalopathy	• Insomnia is common in cirrhosis patients²⁸ and in alcohol users²⁹ increasing the likelihood that sedating medications may be prescribed to ALD patients which may, in turn, increase HE risk³⁰ • Cirrhosis patients are commonly prescribed BZD and opioids³¹ which are HE risk factors³⁰^,³²^,³³ • HE is a common and preventable reason for expensive cirrhosis hospital readmissions³⁴	• Collaboration is needed weighing the mental health risks of ongoing insomnia against the medical risks of using sedating medications • Opioids and BZD have numerous medical and psychiatric implications in terms of dose reduction and discontinuation • Lactulose titration problems are a common and preventable cause of expensive cirrhosis hospital readmissions³⁴ which could be precipitated by psychiatric or addictive disorders which can unfavorably affect treatment adherence
Visible Cirrhosis Stigmata (Ascites, Jaundice, Spider Angiomas)	• Ascites is a common reason for cirrhosis hospital readmission³⁴ • The discomfort and appearance of an ascitic abdomen is a common cause for psychological distress and physical pain which ALD patients may not be well-equipped to cope with and manage • Patients may report that others know when they have been drinking based on outward signs of their liver disease	• Fluid imbalances, poor diuretic management, and poor paracentesis planning are common preventable reasons for expensive cirrhosis hospital readmissions³⁴ which could be provoked by alcohol relapses and/or other psychiatric or addictive disorders which unfavorably affect treatment adherence • Visible signs of ALD may induce patient embarrassment and shame which can impact AUD treatment engagement which is already low²¹
Neuropathy	• Neuropathy is a common comorbidity in AUD and ALD patients³⁵ • Untreated neuropathy could lead to physical and psychological distress which, left untreated, could unfavorably influence relapse risks and mental health	• Gabapentin has literature supporting its off-label use for alcohol use disorder and related insomnia and negative affect;³⁶ it can be used in milder forms of alcohol withdrawal³⁷ • Pregabalin has some evidence for alcohol use disorder treatment and related anxiety; it has shown mixed results in withdrawal treatment³⁸ • Duloxetine is a commonly used Rx in neuropathy patients whose use in severe liver and kidney insufficiencies is discouraged • Thoughtful Rx selection can cover multiple clinical needs with fewer drugs
Overeating, obesity, and eating disorders	• Metabolic and alcohol-related liver injuries are closely related³⁹ • AUD and eating disorders are commonly comorbid⁴⁰ • Bariatric surgery patients are at risk for AUD and ALD⁴¹ • Many sober ALD patients find themselves newly drawn to unhealthy foods and feeding behaviors	• In their commitment to treating liver disease and compulsive behaviors, ALD clinicians must monitor not only SUD but also eating behaviors and weight • Topiramate, with its off-label use in AUD,⁴² renal clearance, and tendency to induce weight loss, may be an Rx consideration in ALD patients requiring AUD treatment amidst feeding and weight challenges
Polypharmacy	• The broad nature of ALD pathophysiology and its comorbidities increases the likelihood of patient polypharmacy • Number of medications is predictor of cirrhosis hospital readmissions³⁴	• ALD patients may receive Rx from numerous clinicians including PCPs, psychiatrists, and hepatologists, among others; without coordination, these regimens may be redundant and excessive • Peer-to-peer outreach and coordination among clinicians caring for ALD patients take extra effort and may reduce patient Rx side effect burden
Alcohol withdrawal and AUD relapses	• Short- and long-term AUD relapse rates vary between 20% and 80%⁴³ • Alcohol relapses occur in varying trajectories after OLT⁴⁴ • Access to specialized AUD treatment and Rx is low in ALD patients⁴⁵^,⁴⁶ • Some AUD medications should not be used in liver disease while others must be carefully monitored given risks in end-stage disease and LT⁴⁷ • Many hepatologists do not feel comfortable prescribing AUD medications⁴⁸ • Shorter periods of pre-OLT sobriety (<6 months) have been shown to predict post-OLT drinking,⁴⁹^,⁵⁰ but “6-month rules” are discouraged as numerous other factors should be considered⁵¹	• Withdrawal can precipitate or complicate any medical clinic and hospital ALD patient presentation • ALD teams will need to decide whether BZD (which carry risks of abuse, cognitive and psychomotor side effects) are indicated for withdrawal or if other agents should be used⁵² • Selection and follow-up of AUD Rx is optimal when psychiatric and medical professionals coordinate care given dosing adjustments in liver and kidney disease and OLT-related considerations⁴⁷ • ALD clinicians may understandably feel anger and resentment toward relapsing patients, sentiments which should be appropriately suppressed during clinical encounters and processed elsewhere if needed¹⁵ • MI is an invaluable communication skillset⁵³ to mobilize ALD patients toward change behavior; ALD patients uniquely trust their liver clinicians²¹ making their use of MI particularly important • Liver patients may conceal substance use, particularly if they require OLT; questionnaires and addiction consultation increase liver teams' accurate detection of drinking⁵⁴ • Along with clinical interviews, toxicology, used in accordance with guidelines,⁵⁵ is an important tool to corroborate patient reports since liver patients may misrepresent their use⁵⁶
Comorbid non-alcohol SUD	• Liver disease patients commonly have a history of polysubstance use⁵⁷ • Smoking is common in liver patients and may be increasing; tobacco use has been shown to predict post-LT alcohol relapse⁴⁹^,⁵⁰^,⁵⁸ • Marijuana use is common in ALD patients, increasing in the liver disease population, and associates with other psychosocial risk factors⁷^,⁵⁹	• ALD teams will frequently need to personalize SUD treatment to include Rx and psychotherapeutic interventions for substances other than alcohol • Several SUD medications may be used in ALD patients and require careful consideration in end-stage disease and OLT⁴⁷ • Substance policies in OLT vary widely⁶⁰ making interprofessional collaboration key to promote ethical treatment and organ allocation • Use of other toxicological markers may be indicated as part of ALD care
Medical and recreational marijuana	• Distinction between medical and recreational MJ use can be blurry⁶¹ • ALD patients have medical foci for pain, psychiatric comorbidities, and SUD meaning the risks and benefits of MMJ will be challenging to discern • Many OLT recipients use MJ and CBD⁶¹ • Transplant center policies regarding MJ are heterogenous⁶⁰	• Clinicians should have a working knowledge of MMJ formulations, dosing, and interactions and integrate the topic into their interviews and treatment plans • In cases where OLT patients are using MMJ, teams may opt to consult colleagues in the corresponding medical discipline (i.e. neurology when patients are treating neuropathy) to query if an MMJ regimen is optimal
Prescription benzodiazepines and opioids	• BZD and opioids (alone and in combination) are commonly prescribed in cirrhosis patients including in high doses³¹ • BZD and opioids have been associated with HE³⁰^,³²^,³³	• ALD clinicians must not only assess the medical necessity and risks of BZD and opioids but also the impact these drugs have on sobriety and other SUD risks • Any alteration or discontinuation of these drugs will have medical and psychiatric implications requiring careful interprofessional coordination and follow-up
Insomnia	• Insomnia is prevalent in the end-stage liver disease population⁶² • Insomnia can cause or exacerbate any number of psychiatric conditions and SUD and yet its pharmacological treatment risks worsening HE³⁰ or drug–drug interactions	• Treatment of insomnia will require ongoing interprofessional discussion given the ever-changing risks and benefits of Rx treatment given the dynamic natures of ALD and AUD • If available, non-Rx therapies, like CBTi may be prioritized for ALD patients⁶³
Suicidal ideation	• Alcohol is a predictive factor in developing suicidal ideation and is implicated in a high percentage of suicides⁶⁴^,⁶⁵	• Integrated ALD care entails screening for and responding to self-injurious behavior, SI, and SA meaning teams will benefit from suicide education and assessment training
Anxiety and mood disorders	• Anxiety and mood disorders are commonly comorbid with AUD⁶ • Depressive disorders have been shown to impact post-LT mortality⁶⁶ • Psychiatric comorbidity may predict post-OLT alcohol relapse in ALD patients⁵⁰	• As stated earlier, SRI medications treating mood and anxiety will need to have their benefits and risks scrutinized alongside other medical and psychiatric factors • Alcohol cessation and the stress of liver disease (and OLT) may unmask or worsen mood and anxiety which, in turn, risks alcohol relapse making ongoing psychiatric evaluation and treatment a priority
Physical, sexual, and emotional trauma	• PTSD patients are at higher risk of developing AUD; the two conditions are highly comorbid and treatment-seeking rates are low⁶⁷^,⁶⁸ • Many traumatized patients wait years to disclose past trauma which delays treatment and increases distress⁶⁹^,⁷⁰	• Integrated ALD treatment will often include patients disclosing their history of abuse and/or trauma, sometimes for the first time; it is crucial that clinicians receiving such disclosures attentively listen, believe the patient, and authentically provide support⁷¹ • Trauma could be a primary etiology and perpetuating factor of ALD making its ongoing pharmacological and psychotherapeutic treatment a priority
Personality disorders	• AUD co-occurs with challenging PD characterized by impulsivity and affective dysregulation⁷² • The patient-provider therapeutic alliance in OLT is already complicated by the need for clinicians to advocate for patients while maintaining stewardship over donor organs	• PD in ALD can be challenging and may require teams to regularly meet for mutual support and emotional processing, stress and burnout management, and clinical collaboration, similar to a DBT consultation team⁷³ • Interprofessional education around PD and their management may be required • Addressing PD earlier in the ALD course may increase the likelihood of future patient success in OLT given the challenges PD pose in medical and transplant care⁷⁴^,⁷⁵
Patient deception, defensiveness, ambivalence, denial, and poor insight	• Misrepresentation of substance use in OLT candidates has been documented⁵⁶^,⁷⁶ • Fear related to transplant access and death may motivate OLT patients to conceal their psychiatric and substance use history • Deception can elicit strong emotions in clinicians and may unfavorably affect how they perceive, interact with, and advocate for patients • ALD patients tend to have moderate to severe AUD⁷ which may correlate with lower levels of alcohol insight and higher defensiveness • Ambivalence is a common obstacle in any person's journey toward change • Clinicians desire to fix problems and commonly feel a “righting reflex”⁵³ which can manifest in the overuse of an overly directive style which is often ineffective or counterproductive • “Insight” is a commonly used term and parameter in ALD and OLT clinical decision making but remains a poorly defined term	• MI training is a valuable skillset whose “spirit”⁵³ is a helpful guide for rapidly allying with ALD patients: ○ Partnership—collaborative conversation and joint decision-making recognizing that change is done “with” the person, not “to” them ○ Acceptance—empathy, affirmation, valuing, and unconditional positive regard for the patient as they are ○ Compassion—actively promote the other's welfare and give priority to their needs ○ Evocation—patients often already have much of what is needed to change, clinicians must aid in activating their strengths and resources • Observation and critique of teammates' interviews can train, hone skills, and avoid pitfalls like blaming, “gotcha,” or overly paternalistic approaches • ALD and OLT teams should agree on a shared meaning of subjective terms like “insight” given its potential impact on decision-making and outcomes • A warm team culture facilitates clinicians can acknowledge their frustration with patients, seek and receive colleague support, and accept feedback or correction on their approach to deceptive patients
Low social support	• Social problems arising from alcohol use impact QofL,⁷⁷ AUD recovery,⁷⁸ and aspects of transplant adherence and outcomes⁷⁹ • Poor social support may predict post-OLT alcohol relapse⁴⁹^,⁵⁰	• ALD teams may recommend that family members consider their own MH treatment and/or seeking support in communities like Al-Anon • The 12 steps of AA address aspects of repairing and strengthening relationships • Teams must be mindful of particularly mindful of relationship dynamics as ALD patients seek LDLT from their social networks
Stigma and terminology	• Stigma among clinicians and the public toward alcohol patients needing OLT has been documented⁸⁰ • The liver community has called for nomenclature adjustments to reduce stigma⁹ • Concerns about alcohol relapse and graft damage have been shown to be the public's main concern about OLT in AAH patients⁸¹ • A majority of survey respondents were at least neutral in their perceptions of AAH patients receiving OLT⁸¹	• ALD clinicians can model respectful terminology in their case discussions and documentation • With warmth and patience as well as a robust understanding of current scientific literature, ALD clinicians can work to correct stigmatized attitudes and policies they encounter in their institutions and workplaces • ALD clinicians will encounter alcohol and addiction stigma in themselves and the minds of patients and families which they can carefully address as part of clinical care

AA, alcoholics anonymous; AAH, acute alcohol-associated hepatitis; ALD, alcohol-related liver disease; AMS, altered mental status; AUD, alcohol use disorder; BZD, benzodiazepines; CBD, cannabidiol; CBTi, cognitive behavioral therapy for insomnia; DBT, dialectical behavioral therapy; HE, hepatic encephalopathy; LDLT, living donor liver transplantation; MH, mental health; MI, motivational interviewing; MJ, marijuana; MMJ, medical marijuana; OLT, orthotopic liver transplant; PCP, primary care physician; PD, personality disorders; QofL, quality of life; Rx, prescription; PTSD, post-traumatic stress disorder; SA, suicide attempts; SI, suicidal ideation; SRI, serotonergic reuptake inhibitor; SUD, substance use disorder; VS, versus.