Assessment of Alcohol and Other Substance Use in Patients With Chronic Liver Disease

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Background

Alcohol and substance use are common among the general US population and are highly prevalent in patients with chronic liver diseases (CLD) (Table 1). ¹ , ² The prevalence of alcohol and substance use in CLD is likely underestimated in the literature, due to low‐sensitivity measures, threshold definitions of alcohol use disorder (AUD) and substance use disorder (SUD) that underestimate the true prevalence in administrative datasets, and patient non‐disclosure (discussed below). The high prevalence and negative impacts of alcohol and substance use on patients with CLD ³ , ⁴ , ⁵ , ⁶ necessitate effective AUD/SUD evaluation and linkage to care, which are critical components of high‐quality hepatology care. ² , ⁷ The purpose of this review is to describe the prevalence and evaluation of alcohol and substance use in people with CLD.

TABLE 1.

Prevalence of Substance Use in Patients With Cirrhosis, HCV, and NAFLD

Substance	Cirrhosis	HCV	NAFLD
Marijuana	3%‐10% 31 , 32	26%‐29% 33 , 34	8% 35
Opioids	4%‐5% 3 , 32	22% 34 , 36	18% 37
Alcohol	32% 32	21%‐55% 34 , 36 , 38 , 39	21%‐58% 37 , 40
Cocaine	5% 32	26% 34	–

Definitions

Unhealthy alcohol use encompasses a spectrum ranging from drinking above recommended limits to meeting criteria for AUD. Drinking above recommended limits is defined as >7 drinks per week (average of >1 per day) for women or 14 drinks per week for men OR engaging in heavy drinking episodes (sometimes called “binge” drinking), defined as consuming 4 or more drinks in one sitting for women and 5 for men. ⁸ , ⁹ However, the American Association for the Study of Liver Disease (AASLD) specifies that there is no level of alcohol consumption that is considered to be “safe” for people with CLD. ¹⁰

Unhealthy substance (or drug) use is defined by the U.S. Preventive Services Task Force (USPSTF) as “the use of illegal drugs and the nonmedical use of prescription psychoactive medications (i.e., use of medications for reasons, for duration, in amounts, or with frequency other than prescribed or use by persons other than the prescribed individual).” ¹¹

Unhealthy alcohol or substance use increases the chances of developing an AUD/SUD. The Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM‐5) defines both AUD and SUD as a constellation of symptoms that fall into four main categories: loss of control, increased focus on the substance (e.g., cravings/strong desire), use of the substance despite risks or consequences, and physical symptoms such as tolerance and/or withdrawal. ¹² A DSM‐5‐defined diagnosis is made when the patient endorses at least 2 of 11 possible symptoms, with 2‐3 symptoms defined as mild, 4‐6 symptoms defined as moderate, and 7+ symptoms defined as severe AUD/SUD. ¹² This definition acknowledges that AUD and SUD are on a spectrum, similar to consumption and use itself. Terms sometimes deemed stigmatizing, such as “dependence” and “abuse,” are no longer used when making a diagnosis.

Basic Principles of Evaluating Alcohol and Other Substance Use

The USPSTF recommends screening all adults for unsafe alcohol and drug use, which is also recommended by the AASLD. ⁸ , ¹⁰ , ¹¹ Such assessments can be self‐reported (e.g., on a written survey or tablet) or elicited by clinical interview, and there are advantages and disadvantages to both. Regardless of assessment, introducing the measure in a straightforward and non‐judgmental manner is important for collecting accurate information. This includes explaining the item content (e.g., defining terms such as a “standard drink”), providing a rationale as to why the questions are being asked (e.g., in order to know how to best improve one’s health), and expressing a desire for patients to respond as accurately as possible. Furthermore, patients endorsing unhealthy substance use should receive a brief counseling intervention performed by a medical professional (e.g., MD, RN). For patients whose use appears moderate‐severe, referral to specialty substance use care may also be warranted (i.e., implementing an evidence‐based process known as “SBIRT”). ¹³

Creating an open and safe environment is important to address barriers to disclosure. Patients are often hesitant to disclose alcohol and substance use, due to low trust, provider stigma, and perceived low‐efficacy of AUD/SUD treatments. ¹⁴ In patients with CLD, the rules of transplantation that require complete abstinence may create a conflictual relationship between patients and provider that incentivizes incomplete disclosure of alcohol and substance use, which complicates reliable assessment.

Being cognizant of the other people in the room can also help to ensure that people can openly discuss sensitive topics. Asking caregivers to step out of the room during an exam can often provide a window to ask questions about substance use. Conversely, caregivers and family may provide more accurate assessments of substance use, particularly in the context of encephalopathy or other neurocognitive deficits.

A caveat of routinely assessing for unhealthy alcohol or substance use is that the clinic and provider must be aware of and offer evidence‐based services for patients screening positive. Services offered can either be embedded within hepatology practices (e.g., performing a brief counseling intervention for unhealthy alcohol use, prescribing medication for AUD/SUD) or sourced out via providing a list of referrals ideally tailored to the patient population (e.g., by offering a range of treatment options in the surrounding counties near the clinic). Finally, as mentioned earlier, the USPSTF cautions screening for substance use when a positive screen could be tied to punishment. Thus, hepatologists can emphasize that the goal of asking is to increase eventual transplant eligibility (by encouraging early connection to alcohol and substance use treatment), rather than withholding services such as transplant or hepatitis C treatment.

Assessment Tools

Several existing assessments are recommended for reliably and validly identifying unhealthy alcohol and substance use. The selection of which tool to use depends on several factors, including practicality, acceptability to the population, and validity. Below are several examples of validated tools concerned with identifying unhealthy alcohol and substance use, with a focus on those that are most practical to implement in a busy clinic. Assessments in clinics can be done in triage or by providers in the encounter. Alternatively, longer assessments can be sent to patients in advance of the appointment or given to patients in the waiting area.

Alcohol. The gold‐standard screening instrument for assessing unhealthy alcohol use in medical settings is the 10‐item Alcohol Use Disorder Identification Test (AUDIT). ¹⁵ , ¹⁶ , ¹⁷ This 10‐item instrument evaluates past‐year consumption, symptoms suggestive of AUD (e.g., morning drinking), and negative consequences of alcohol use. The abbreviated, validated, user‐friendly, 3‐question AUDIT‐C ¹⁸ (Fig. 1) has a score range from 0 to 12, with scores over 3 in women or >4 in men suggesting unhealthy alcohol use. Those screening positive on the AUDIT‐C can then be assessed with either the full AUDIT (which suggests cutoff scores >7 as likely meeting criteria for AUD) or clinical interview to determine likelihood and/or severity of AUD. ¹⁹ Other validated measures include the CAGE questionnaire (Box 1), which is simple to administer and well known among clinicians but does not quantify alcohol use, limiting its utility in hepatology clinics. ²⁰ Conversely, longer, validated instruments (e.g., The Michigan Alcohol Screening Test, The Timeline Follow‐back) are more specific but likely impractical in busy clinical settings. ²¹ , ²² For any scored instrument, it is important to note that, while lower scores are reassuring in general populations, any use of alcohol is concerning in patients with CLD. Thus, cutoff scores for “screening positive” may be lower in this population.

FIG 1.

AUDIT‐C screening tool for unhealthy alcohol use (Bush et al. ¹⁸ ).

Box 1. CAGE Questionnaire (Ewing, 1984).

Have you ever felt you needed to Cut down on your drinking?

Have people Annoyed you by criticizing your drinking?

Have you ever felt Guilty about drinking?

Have you ever felt you needed a drink first thing in the morning (Eye‐opener) to steady your nerves or to get rid of a hangover?

Substance use. While there is not a gold standard for the evaluation of unhealthy substance use, several screeners are recommended by the Centers for Disease Control and the National Institute of Drug Abuse (NIDA). ²³ Single question screeners (Box 2) have been assessed and validated and are similar in sensitivity and specificity to the longer Drug Abuse Screen Test (DAST‐10) or interviews. ²⁴ , ²⁵ , ²⁶ , ²⁷ More comprehensive and valid assessments include the NIDA‐Modified ASSIST (NMASSIST) and the Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) Tool. ²⁸ Both the NMASSIST and the TAPS first ask about past year frequency of: alcohol, tobacco, prescription drugs for non‐medical reasons, and illegal drug use using the NIDA Quick Screen. ²⁹ If the patient endorses any use, the NMASSIST goes on to inquire about lifetime and past 3‐month use of other substances and then probes for SUD symptoms. A resulting risk‐level score ranging from low (score 0‐3), moderate (score 4‐26), and high risk (score ≥ 27) is provided, along with feedback to the provider on what level of intervention may be necessary given the patient’s responses and corroborating risk level (e.g., ranging from reinforcing abstinence to providing feedback and arranging a referral to specialty substance use care). The TAPS assessment asks about past 3‐month substance use if the patient screens positive on the NIDA Quick Screen. ²⁸ A total score is then generated, ranging from 0 to 2+, with 0, 1, and 2+ corresponding to “No use in the past 3 months,” “Problem use,” and “Higher risk,” respectively. Both the NMASSIST and the TAPS can be administered via self‐report or clinical interview. The TAPS appears to have acceptable sensitivity and specificity for most substances, particularly at high risk levels, although may have low sensitivity for moderate‐risk use of illicit drugs (in addition to cannabis) and non‐medical prescription medications. ³⁰ However, the TAPS is shorter than the NMASSIST, making it a possibly more feasible routine assessment in hepatology practices. ³⁰

Box 2. Single‐Item Screening Questions (SISQs) for Alcohol and Drugs (McNeely et al., 2015).

Alcohol: How many times in the past year have you had X or more drinks in a day?* (X = 5 for men, X = 4 for women).

Other substances: How many times in the past year have you used an illegal drug or used a prescription medication for non‐medical reasons (for example, because of the experience or feeling it caused)?*

*Positive screen is any answer >0

Conclusions

In summary, alcohol and other substance use are common and underassessed in patients with CLD, despite USPSTF guidelines that recommend routine assessment in all patients. Evaluation of alcohol and substance use includes inquiring about typical use, risky behaviors related to use, and consequences of one's use. Simple, validated screening tools for alcohol and other substance use can feasibly be implemented in hepatology clinics. It is imperative that screening occur in a judgement‐free, supportive environment and that clinicians link patients who screen positive to further evaluation and care. Longer assessments not reviewed here are more applicable in specialty substance use clinics and/or research settings.