Integrating Treatments for Alcohol Use Disorder into Hepatology Clinics

ABSTRACT Deaths due to alcohol-associated liver disease (ALD), a serious consequence of alcohol use disorder (AUD), have risen substantially over the past two decades. Although reduction and cessation of alcohol use is a vital component of treating ALD, few patients with AUD and ALD receive treatment for AUD, including behavioral treatment or medications (MAUD), due to clinician, patient, and system-level barriers ranging from lack of familiarity to stigma. Treatment of AUD, including MAUD, is associated with liver-specific benefits in patients with ALD, such as reductions in complications including cirrhosis, or scarring of the liver, and hepatic decompensation, or severe deterioration of liver function. As such, guidelines on the treatment of ALD recommend AUD treatment be provided to patients with AUD and ALD, however little is known regarding which treatments may be of greatest benefit in this population and how to deliver them most effectively. There is a lack of data regarding the comparative effectiveness of different forms of MAUD among patients with AUD and ALD and limited consideration of the perspectives of patients with AUD and ALD with regard to receipt of AUD treatment. Finally, while multidisciplinary teams of co-located hepatology and addiction specialists to facilitate AUD treatment in patients with AUD and ALD have been described, these models of care are resource- intensive and not commonly available. Therefore, alternative strategies are needed to inform delivery of AUD treatment for patients with both AUD and ALD. Hepatology clinicians are well-positioned to provide integrated AUD treatment, such as MAUD and brief counseling, for patients with AUD and ALD in the context of routine hepatology care. Existing NIAAA resources, such as the Healthcare Professional’s Core Resource on Alcohol (HPCR) and Alcohol Treatment Navigator (ATN), are readily available but have not been tailored for implementation in hepatology clinics. Therefore, the Specific Aims of this work are to: 1) Determine the comparative effectiveness of different forms of MAUD among patients with AUD by liver disease severity, relative to no MAUD, 2) Elicit AUD treatment preferences among patients with AUD and ALD, particularly regarding integrated MAUD and brief counseling in hepatology clinics, and 3) Determine the feasibility and acceptability of a novel implementation intervention to promote MAUD and brief counseling in hepatology clinics using the HPCR and ATN with clinical decision support. As a board-certified hepatologist and addiction medicine specialist with training in health services research, I am well-suited to lead efforts to integrate AUD treatment into hepatology clinics. Guided by mentors with expertise in pharmacoepidemiology, mixed-methods research, clinical trials, and implementation science, this work will generate important foundational data and provide me with the opportunity to build methodological expertise in these complementary areas. This will be critical to achieve my goal of becoming an independent clinician-investigator dedicated to optimizing the care of patients with AUD and ALD.