Impact of Alcohol Use Disorder Treatment on Clinical Outcomes Among Patients With Cirrhosis

Abstract

BaCKgRoUND aND aIMS:Despite the significant medical and economic consequences of coexisting alcohol use disorder (AUD) in patients with cirrhosis, little is known about AUD treatment patterns and their impact on clinical outcomes in this population. We aimed to characterize the use of and outcomes associated with AUD treatment in patients with cirrhosis. appRoaCH aND ReSUltS: This retrospective cohort study included Veterans with cirrhosis who received Veterans Health Administration care and had an index diagnosis of AUD between 2011 and 2015. We assessed the baseline factors associated with AUD treatment (pharmacotherapy or behavioral therapy) and clinical outcomes for 180 days following the first AUD diagnosis code within the study time frame. Among 93,612 Veterans with cirrhosis, we identified 35,682 with AUD, after excluding 2,671 who had prior diagnoses of AUD and recent treatment. Over 180 days following the index diagnosis of AUD, 5,088 (14%) received AUD treatment, including 4,461 (12%) who received behavioral therapy alone, 159 (0.4%) who received pharmacotherapy alone, and 468 (1%) who received both behavioral therapy and pharmacotherapy. In adjusted analyses, behavioral and/or pharmacotherapy-based AUD treatment was associated with a significant reduction in incident hepatic decompensation (6.5% vs. 11.6%, adjusted odds ratio [AOR], 0.63; 95% confidence interval [CI], 0.52, 0.76), a nonsignificant decrease in short-term all-cause mortality (2.6% vs. 3.9%, AOR, 0.79; 95% CI, 0.57, 1.08), and a significant decrease in long-term all-cause mortality (51% vs. 58%, AOR, 0.87; 95% CI, 0.80, 0.96).CoNClUSIoNS: Most Veterans with cirrhosis and coexisting AUD did not receive behavioral therapy or pharmacotherapy treatment for AUD over a 6-month follow-up. The reductions in hepatic decompensation and mortality suggest that future studies should focus on delivering evidence-based AUD treatments to patients with coexisting AUD and cirrhosis.

Practice Habits, Knowledge, and Attitudes of Hepatologists to Alcohol Use Disorder Medication: Sobering Gaps and Opportunities

“…A recent Veteran Affairs healthcare system study highlighted the extent of this deficiency, reporting that only 0.4% of AUD patients received pharmacotherapy alone and 1% received both behavioral and pharmacotherapy over a 180-day period after initial diagnosis. 17 Importantly, in this study, pharmacotherapy-based AUD treatment alone (versus no AUD treatment) was associated with a significant reduction in incident hepatic decompensation (5.5% versus 11.6%) and in mortality (0.6% versus 3.9%). 17 Further studies are needed to confirm this mortality benefit.…”

“… 17 Importantly, in this study, pharmacotherapy-based AUD treatment alone (versus no AUD treatment) was associated with a significant reduction in incident hepatic decompensation (5.5% versus 11.6%) and in mortality (0.6% versus 3.9%). 17 Further studies are needed to confirm this mortality benefit. The reasons for underutilization of AUD pharmacotherapy appear multifactorial, with a significant factor undoubtedly being the shortage of addiction specialist physicians in the United States.…”

Integrated Treatment of Alcohol Use Disorder in Patients With Alcohol‐Associated Liver Disease: An Evolving Story

“…However, we take hope from two papers in this issue of Hepatology that point to the future for better care for patients with ALD. ( 6,7 ) In the first study, Preoschold‐Bell et al compared Screening, Brief Intervention, and Referral to Treatment (SBIRT) with SBIRT and enhanced treatment of AUD, with an aim to reduce alcohol consumption in patients with hepatitis C virus (HCV) infection. ( 7 ) Subjects attending three out‐patient clinics from October 2014 to September 2017 were identified as candidates for the study using the AUD Identification Test questionnaire.…”

“…The study by Rogal et al provides a fascinating retrospective account of treatments of AUD in patients with cirrhosis in the U.S. Veterans Affairs (VA) integrated health system. ( 6 ) Among a cohort of almost 100,000 subjects with cirrhosis, 35,682 were identified with a new diagnosis of AUD. The authors showed that only 14% received treatment for AUD within 180 days of the index diagnosis of AUD, with 12% receiving behavioral therapy alone, 0.4% pharmacotherapy alone, and 1% both behavioral and pharmacotherapy.…”

“…Their data showed that treatment for AUD was associated with reduction in the hepatic decompensation by 37%, with 13% reducing long‐term all‐cause mortality. ( 6 )…”