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

Abstract

Background: The prevalence of alcohol use disorder (AUD) and alcohol-associated liver disease is increasing in the United States. Efficacious AUD pharmacotherapies, while available, are, for protean reasons, underutilized. Hepatology providers may be in a position to bridge the pharmacotherapeutic gap between availability and utilization of AUD pharmacotherapies. Our aim was to ascertain the current practice, knowledge and attitudes of hepatology physicians in the United States, and identify opportunities on how to increase AUD medication prescribing. Methods: A web-based survey, developed by an expert panel, was administered to hepatology physicians working at all transplant centers in the United States. Results: The survey response rate was 131/658 (20%). There was significant support (two-thirds of respondents) for hepatology providers prescribing AUD medications; however, only 1 in 4 was comfortable prescribing these medications. The majority felt additional education is needed to prescribe AUD medications. The practice of hepatology providers prescribing AUD medications is common, with >50% of respondents having done so. Baclofen was the most popular medication prescribed. Hepatology providers perceived suboptimal ancillary addiction services. Although AUD prescribers had higher rates of AUD pharmacotherapy knowledge compared with nonprescribers, approximately 50% still had inadequate knowledge. Conclusions: AUD medication prescribing is a common practice among hepatology providers who appear eager to increase this practice through more education as they attempt to bridge the pharmacotherapeutic gap. This informative survey provides guidance for professional societies on how best to disseminate the requisite education required to optimize the care of patients with AUD.

Clinicians’ perspectives and perceived barriers to caring for patients with alcohol use disorder and cirrhosis

“…A prominent finding of this study was the relative lack of training clinicians receive about caring for patients with AUD. This is congruent with data suggesting that less than 16% of clinicians report receiving adequate addiction medicine training either in medical school [ 28 ] or in their fellowship programs [ 21 ]. A report by the National Centre for Addiction and Substance Abuse at Columbia University has advocated for more addiction training “at every level—in medical school, residency training, continuing education and in practice” to prepare current and future clinicians to deal with all aspects of substance use disorder management [ 29 ].…”

“…Though there have been several studies of clinician practices, knowledge, and attitudes towards patients with cirrhosis and AUD [ 21 , 22 ], to our knowledge our study is the first to qualitatively explore the experiences of clinicians working with this group of patients. The participants in our study described a number of challenges, and recognized the importance of providing person-centered, continuous care considerate of the medical complexity, motivation, and support systems available to the patient.…”

“…To date, there have only been two studies that have explored clinicians’ experiences in managing AUD in patients with cirrhosis [ 21 , 22 ]. Using a survey-based approach, key findings have included the lack of adoption of a standardized approach to AUD management, and low reported knowledge and comfort around pharmacotherapy for relapse prevention.…”

Integrated Care of Alcohol-Related Liver Disease

“… Alcohol relapses occur in varying trajectories after OLT (40)  Access to specialized AUD treatment and Rx is low in ALD patients (41,42)  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 used (48)  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 considerations (43) J o u r n a l P r e -p r o o f  Some AUD medications should not be used in liver disease while others must be carefully monitored given risks in end-stage disease and LT (43)  Many hepatologists do not feel comfortable prescribing AUD medications (44)  Shorter periods of pre-OLT sobriety (<6 months) have been shown to predict post-OLT drinking (45,46) but "6-month rules" are discouraged as numerous other factors should be considered (47)  ALD clinicians may understandably feel anger and resentment toward relapsing patients, sentiments which should be appropriately suppressed during clinical encounters and processed elsewhere if needed (11)  MI is an invaluable communication skillset (49) to mobilize ALD patients toward change behavior; ALD patients uniquely trust their liver clinicians (30)…”

Bridging the Gap: Dual Fellowship Training in Addiction Medicine and Digestive Diseases

“…Barriers to addiction treatment from the patients’ perspective include motivation, lack of transportation, financial limitations, perceptions that addiction treatment may not be effective, and a fear of being stigmatized [ 29 , 30 ]. Furthermore, providers may feel ill-equipped to deliver or facilitate addiction care [ 7 , 31 ]. Efforts to bridge this implementation gap through addiction medicine training and integrated care can help gastroenterologists and hepatologists deliver and facilitate SUD treatment in the form of behavioral and pharmacotherapies more routinely, directly, and consistently for patients with co-occurring SUD and liver disease, increasing the likelihood that patients may benefit from these life-saving interventions.…”