Critical misconceptions and knowledge gaps regarding alcohol cessation and risk of relapse in alcohol-related liver disease patients: A qualitative mental models study

INTRODUCTION

Despite the mortality benefits of alcohol cessation and alcohol treatment, few patients with alcohol-related liver disease (ALD) get such treatment. To understand reasons for low treatment rates, we performed a qualitative mental models study to explore how ALD patients understand factors influencing alcohol cessation, relapse and their liver health.

METHODS

Using a mental models framework, we interviewed experts in alcohol use disorder (AUD) and ALD to determine factors influencing alcohol cessation, risk of relapse and liver health. An expert influence diagram was constructed and used to develop a patient interview guide. We recruited participants with ALD enrolled in hepatology or transplant clinics at a single tertiary-care center. We conducted interviews either face-to-face or by phone, per participant preference. We transcribed all interviews verbatim and analyzed them using combined deductive coding schema based on both the interview guide and emergent coding.

RESULTS

25 (10 women, 15 men) participants with a mean age of 57 years completed interviews. 68 % had decompensated cirrhosis. Major omissions included gender (as a factor in alcohol use or liver disease) and the influence of benzodiazepines/opioids on relapse. Misconceptions were common, in particular the idea that the absence of urges to drink meant participants were safe from relapse. Conceptual differences from the expert model emerged as well. Participants tended to view the self as primary and the only thing that could influence relapse in many cases, resulting in a linear mental model with few nodes influencing alcohol cessation. Participants' risky drinking signals (i.e., elevated liver enzymes) differed from known definitions of hazardous or high-risk drinking, which largely emphasize dose of alcohol consumed irrespective of consequences. Finally, participants sometimes viewed stopping on one's own as the primary means of stopping alcohol use, not recognizing the many other nodes in the influence diagram impacting ability to stop alcohol.

CONCLUSION

Patients with ALD had critical misconceptions, omissions, and conceptual reorganizations in their mental models of the ability to stop alcohol use. Attention to these differences may allow clinicians and researchers to craft more impactful interventions to improve rates of alcohol abstinence and AUD treatment engagement.

Lifestyle of Patients with Alcoholic Liver Disease and Factors Leading to Hospital Readmission: A Prospective Observational Study

The objective of this study was to clarify the lifestyle characteristics of patients with alcoholic liver disease (ALD) who were readmitted to the hospital, and to identify the background factors associated with these characteristics. This was a prospective observational study. Over a period of 3 months following hospital discharge, we conducted structured interviews to investigate the following five lifestyle characteristics based on our previous research: dietary intake, alcohol consumption or abstinence, psycho-emotional status, regularity of life habits, adherence to treatment. We also collected data on background factors from medical records and questionnaires. The analysis was performed using conceptual cluster matrices, with participants divided into two groups (at-home recovery and readmission). Lifestyle, health status, and background factors were compared between the two groups. Of the 34 patients with ALD recruited, 21 completed the one-month follow-up and were included in the analysis-14 patients were in the at-home recovery group and 7 in the readmission group. The at-home group's lifestyle was characterized by controlled alcohol consumption, but with maintenance of regular life and eating habits and adherence to treatment. In contrast, irregular eating habits (p=0.006) and the development of irregular life habits or the discontinuation of treatment very quickly after hospital discharge characterized the readmission group's lifestyle. Experiences of loss were a lifestyle-related background factor that was associated with readmission (p=0.017). Based on these findings, supporting patients with ALD in maintaining regular eating habits and taking experiences of loss into consideration would be important in avoiding readmission over the short-term.

Understanding alcohol-related liver disease patients' illness beliefs and views about their medicine

BACKGROUND

people with alcohol-related liver disease require complex treatment plans that often include the need for medication for the rest of their lives. Between 30% and 50% of all patients do not take their treatment as prescribed, leading to a significantly increased risk of morbidity and mortality.

AIM

to consider the factors which influence beliefs held by patients with alcohol-related liver disease about their medication to provide an evidence base to support interventions to reduce medication non-adherence.

METHOD

an observational cross-sectional patient survey.

RESULTS

statistically significant associations were found between positive attitudes towards medication and the illness representation dimensions of 'illness identity' and 'illness comprehension'.

CONCLUSIONS

medication adherence in patients with alcohol-related liver disease is likely to be improved by an intervention that strives to improve the patient's understanding of their illness condition and their perception of their illness symptoms.

Histological parameters and alcohol abstinence determine long-term prognosis in patients with alcoholic liver disease

BACKGROUND & AIMS

Few data exist on predictors of long-term prognosis in patients with alcoholic liver disease (ALD). Most studies have only assessed short-term prognosis in patients with advanced ALD. We aimed to assess the prognostic impact of clinical, biochemical and histological parameters on long-term prognosis in patients with early/compensated and decompensated ALD.

METHODS

Consecutive patients (n=192) with biopsy-proven liver disease due to alcohol abuse were analyzed retrospectively. Prognostic factors were evaluated in patients with early/compensated ALD (n=60) and in patients with decompensated ALD (clinical decompensation and/or bilirubin >3mg/dl at entry) (n=132). Factors that predict long-term survival were identified using Cox regression models.

RESULTS

Liver-related mortality at 5years was 13% in early/compensated and 43% in decompensated ALD. In early/compensated ALD patients, long-term prognosis was determined by fibrosis stage, but not by clinical or biochemical variables. Severe fibrosis (F3/4) was present in 52% and had a major impact on 10-year mortality (F3/4: 45% vs. F0-2: 0%, p<0.001). In contrast, in decompensated patients, a combination of clinical features (sex), biochemical markers of liver failure (bilirubin, international normalized ratio [INR]), and histological features (pericellular fibrosis) predicted long-term survival. During follow-up, abstinence from alcohol was an important predictor of survival in both early/compensated and decompensated ALD.

CONCLUSION

Fibrosis stage is the main predictor of long-term survival in patients with early/compensated ALD, while clinical, biochemical and histological parameters predict survival in patients with decompensated disease. Promoting abstinence may improve survival in patients with both early and advanced ALD.

LAY SUMMARY

In this study, we evaluated long-term outcome in 192 patients with alcoholic liver disease who underwent liver biopsy: 60 patients with early disease (no symptoms) and 132 patients with advanced disease (jaundice, complications of cirrhosis). Importantly, half of the patients with 'early' disease already had severe fibrosis or cirrhosis on liver histology and dismal outcome (45% mortality at 10years). Abstinence from alcohol improved the prognosis in both early and advanced stages of the disease.

Risk of alcohol use relapse after liver transplantation for alcoholic liver disease

AIM

To investigate factors, including psychosocial factors, associated with alcoholic use relapse after liver transplantation (LT) for alcoholic liver disease (ALD).

METHODS

The clinical records of 102 patients with ALD who were referred to Nagoya University Hospital for LT between May 2003 and March 2015 were retrospectively evaluated. History of alcohol intake was obtained from their clinical records and scored according to the High-Risk Alcoholism Relapse scale, which includes duration of heavy drinking, types and amount of alcohol usually consumed, and previous inpatient treatment history for alcoholism. All patients were assessed for eligibility for LT according to comprehensive criteria, including Child-Pugh score, Model for End-Stage Liver Disease score, and psychosocial criteria.

RESULTS

Of the 102 patients with ALD referred for LT, seven (6.9%) underwent LT. One (14.3%) of these seven patients returned to heavy drinking, but that patient was able to successfully quit drinking following an immediate intervention, consisting of psychotherapeutic education and supportive psychotherapy, by a psychiatrist. A comparison between the transplantation/registration (T/R) group, consisting of the seven patients who underwent LT and 10 patients listed for deceased donor LT, and 50 patients who did not undergo LT and were not listed for deceased donor LT (non-T/R group), showed statistically significant differences in duration of abstinence period (P < 0.01), duration of heavy drinking (P < 0.05), adherence to medical treatment (P < 0.01), and declaration of abstinence (P < 0.05).

CONCLUSION

Patients with ALD referred for LT require comprehensive evaluation, including evaluation of psychosocial criteria, to prevent alcoholic recidivism.

Candidates for liver transplantation with alcoholic liver disease: Psychosocial aspects

In Europe, 30% to 50% of liver transplantations are currently due to alcoholic liver disease (ALD). In the United States, this percentage is 17.2%. Post-transplant survival and other predictors of clinical course do not differ significantly from those in other types of transplanted patients, as long as there is no relapse of drinking. However, 20%-25% of these patients lapse or relapse to heavy drinking post-operatively, which has been associated with an increased risk of liver damage and mortality. It is therefore crucial to design specific selection and follow-up strategies aimed at this particular type of patient. Several good and poor prognosis factors that could help to predict a relapse have been suggested, among them the duration of abstinence, social support, a family history of alcoholism, abuse diagnosis versus alcohol dependence, non-acceptance of diagnosis related to alcohol use, presence of severe mental illness, non-adherence in a broad sense, number of years of alcoholism, and daily quantity of alcohol consumption. In this article, we discuss these and other, more controversial factors in selecting ALD patients for liver transplantation. Abstinence should be the main goal after transplantation in an ALD patient. In this article, we review the several definitions of post-transplant relapse, its monitoring and the psychopharmacological and psychotherapeutic treatment.

Recidivism in Liver Transplant Recipients With Alcoholic Liver Disease: Analysis of Demographic, Psychosocial, and Histology Features

OBJECTIVES

Liver transplant for alcoholic liver disease requires identifying potential recipients at risk for recidivism. We sought to identify risk factors for recidivism and survival in recipients of liver transplant with alcoholic liver disease.

MATERIALS AND METHODS

Demographic, psychosocial, and histology features were evaluated as risk factors toward harmful recidivism in 148 recipients of liver transplant with alcoholic liver disease.

RESULTS

Based on the univariate analysis using Cox proportional hazards model, duration of alcohol abstinence 6 months (HR 3.74; P = .011, 95% CI: 1.36-10.3), non-alcohol related criminal history (HR 3.18; P = .032, 95% CI: 1.1-9.15), support from immediate family (HR 0.24; P = .0061, 95% CI: 0.09-0.67), and active smoking at the time of liver transplant (HR 2.74; P = .041, 95% CI: 1-7.53) were identified as significant predictors for recidivism. Older patients had less likelihood of alcohol relapse (HR 0.91; P = .0014, 95% CI: 0.87-0.97) on univariate model. In multivariate model older patients (HR 0.91; P = .004, 95% CI: 0.86-0.97) and patients who have immediate family support (HR 0.27; P = .012, 95% CI: 0.10-0.76) predicated against recidivism. Suggestive features of alcoholic hepatitis on liver explant did not predict recidivism or long-term survival. One-, three-, and five-year patient survival rates estimated by Kaplan-Meier survival model in the recipients that remained abstinent were 95%, 87%, and 80%, compared with 87%, 49%, and 49% for the recipients with recidivism (P = .001).

CONCLUSIONS

Recidivism is associated with earlier death after liver transplant. Older recipients and patients with immediate family support are less likely to have alcohol relapse, and have better long-term survival.

Opinions and beliefs held by Spanish teenagers regarding tobacco and alcohol consumption: a descriptive study

BACKGROUND

Preventive strategies are the most effective approach for dealing with issues of substance abuse, particularly in teenagers. Such strategies adapt well to this target population. Our objective was to reveal the opinions and beliefs held by teenagers about tobacco and alcohol as types of drugs, and their effects on health.

METHODS

In this cross-sectional study, participants completed a self-administered questionnaire based on the World Health Organization "Health Behaviour of School-aged Children" study. Our sample included 1,005 schoolchildren aged between 11 and 13 years, resident in the province of Córdoba in Spain. Descriptive and univariate analyses were performed using a chi-squared test.

RESULTS

Of respondents, 25% (95% confidence interval [CI]: 22.2-27.6%) and 61% (95% CI: 58.0-64.1%), respectively, did not consider tobacco or alcohol to be drugs. No relationship was found between tobacco and alcohol use, and the belief that these are drugs (p = 0.477 and p = 0.217, respectively). A total 98.2% of adolescents surveyed (95% CI: 97.3-99.1%) believed that tobacco causes physical damage, mainly to the lungs, heart, and to the developing fetus. Additionally, 92.4% (95% CI: 90.6-94.0%) believed that alcohol is detrimental to health and identified the liver as the organ most frequently damaged by alcohol consumption. The media was identified as the main source of information about these substances by 78.0% of respondents (95% CI: 75.4-80.6%).

CONCLUSIONS

Teenagers possess an acceptable level of knowledge and information about the negative effects of tobacco and alcohol on health; however, many of them do not consider these substances to be drugs.

Challenges in transplantation for alcoholic liver disease

Transplantation for the treatment of alcoholic cirrhosis is more controversially discussed than it is for any other indication. The crucial aspect in this setting is abstinence before and after liver transplantation. We established pre-transplant selection criteria for potential transplant candidates. Provided that the underlying disease can be treated, there is no reason to withhold liver transplantation in a patient suffering from alcoholic cirrhosis. Evaluation of the patient by a multidisciplinary team, including an addiction specialist, is considered to be the gold standard. However, several centers demand a specified period of abstinence - usually 6 mo- irrespective of the specialist’s assessment. The 6-mo rule is viewed critically because liver transplantation was found to clearly benefit selected patients with acute alcoholic hepatitis; the benefit was similar to that achieved for other acute indications. However, the discussion may well be an academic one because the waiting time for liver transplantation exceeds six months at the majority of centers. The actual challenge in liver transplantation for alcoholic cirrhosis may well be the need for lifelong post-transplant follow-up rather than the patient’s pre-transplant evaluation. A small number of recipients experience a relapse of alcoholism; these patients are at risk for organ damage and graft-related death. Post-transplant surveillance protocols should demonstrate alcohol relapse at an early stage, thus permitting the initiation of adequate treatment. Patients with alcoholic cirrhosis are at high risk of developing head and neck, esophageal, or lung cancer. The higher risk of malignancies should be considered in the routine assessment of patients suffering from alcoholic cirrhosis. Tumor surveillance protocols for liver transplant recipients, currently being developed, should become a part of standard care; these will improve survival by permitting diagnosis at an early stage. In conclusion, the key factor determining the outcome of transplantation for alcoholic cirrhosis is intensive lifelong medical and psychological care. Post-transplant surveillance might be much more important than pre-transplant selection.

Long-term survival after liver transplantation for alcoholic liver disease

Currently, alcoholic cirrhosis is the second leading indication for liver transplantation in the United States and Europe. The quality of life and survival after a liver transplantation (LT) in patients with alcoholic liver disease (ALD) are similar to those in patients with other cirrhosis etiologies. The alcoholic relapse rate after a LT varies from 10%-50%, and these relapse patients are the ones who present a reduced long-term survival, mainly due to cardiovascular diseases and the onset of de novo neoplasms, including lung and upper aerodigestive tract. Nearly 40% of ALD recipients resume smoking and resume it early post-LT. Therefore, our pre-and post-LT follow-up efforts regarding ALD should be focused not only on alcoholic relapse but also on treating and avoiding other modifiable risk factors such as tobacco. The psychiatric and psychosocial pre-LT evaluation and the post-LT follow-up with physicians, psychiatrists and addiction specialists are important for reversing these problems because these professionals help to identify patients at risk for relapse as well as those patients who have relapsed, thus enabling responsive actions.

[Psychosocial indication of liver transplantation for alcohol-related liver failure: current controversies and imminent issues in Japanese society]

Organ transplant therapy is becoming a usual practice also in Japan, which dramatically improves the length and quality of life in patients with end-stage organ disease. Liver transplantation was resumed in Japan much later than that in the West and is continued now under unique circumstances where more than 90% of grafts come from living donors. Nevertheless the number of liver transplantation for alcohol-related liver failure shows a sharp rise to the level comparable to the West, and not a few physical and/or psychosocial problems caused by recidivism after transplantation are coming up. To find appropriate solutions to how to predict recidivism and define psychosocial indication of liver transplantation in our society, and to how to monitor and support sobriety after transplantation, there is an urgent need for multidisciplinary management by hepatologist, transplant surgeon, psychiatrist, and dependence specialist. Life-saving therapy and dependence management are expected to work closely together from the viewpoints of transparency, equity, utility, and autonomy requested in transplant therapy, protection of living donors, and consideration for donor family and public emotion.

[Psychosocial aspects of liver transplantation indication criteria for alcohol-related liver failure]

OBJECTIVES

Consensus regarding psychosocial aspects relevant for the liver transplantation indication criteria in case of alcohol-related liver failure remains to be established. Thus we investigated the psychosocial aspects of candidates for liver transplantation for alcohol-related liver failure in order to determine the indication criteria.

SUBJECTS

We evaluated the psychosocial aspects of 19 candidates (14 male and 5 female patients) who met the physical liver transplantation indication criteria for alcohol-related liver failure at Nagoya University Hospital between 2004 and 2012.

RESULTS

Of the 19 subjects, 4 underwent liver transplantation (average follow-up phase: 42.3 +/- 36.5 months), and 3 were monitored without resuming alcohol consumption. One patient temporarily resumed alcohol consumption at 12 months after transplantation.

CONCLUSION

This retrospective study suggested the importance of pre-and post-transplant psychosocial evaluation. A prospective well-designed analysis is essential to determine psychosocial aspects regarding the liver transplantation indication criteria for alcohol-related liver failure.

[Alcohol liver disease patients and liver transplantation: a psychosocial approach]

One of the most common indications for Liver transplantation is Alcohol Liver Disease (ALD). Transplant recipients with ALD have a similar prognosis in terms of medical evolution and quality of life to those with other liver diseases. ALD is present when alcoholism (alcohol dependence /abuse) or heavy drinking coexists with chronic/acute liver disease. In the present article difficulties in establishing this diagnosis are debated. The main predictors of alcohol intake relapse after transplantation are: pre-transplantation abstinence (> 6m), social support, diagnosis acceptance, history of previous treatments, alcohol abuse VS dependence, Vaillant prognosis factors, good adherence (good prognosis); and family history of alcoholism, psychiatric history (psychosis, personality disorder), duration of alcoholism period, quantity of alcohol /day consumed (bad prognosis). Based in these factors we present a new evaluation scale. Diagnosis of alcohol relapse depends on the criterion used. Relapse rate is 5.6% /year. In the end of this article we discuss the different psychopharmacological and psychological methods used to treat pos-transplantation alcoholism relapse and some ethical aspects related to discrimination of patients with ALD.

A critical review of candidacy for orthotopic liver transplantation in alcoholic liver disease

The majority of candidates with end-stage alcoholic liver disease (ESALD) in the United States who are eligible for referral for liver transplantation (LT) are not being referred. There is a lack of firm consensus for the duration of abstinence from alcohol as well as what constitutes good psychosocial criteria for listing for LT. Evidence shows that the general public and the practicing physicians outside the transplant community perceive that patients with a history of alcohol abuse will make poor transplant candidates. However, physicians in the transplant community perceive selected patients with ESALD as good candidates. When considering patients for listing for LT, 3 months of alcohol abstinence may be more ideal than 6 months. Patients with a lack of social support, active smoking, psychotic or personality disorders, or a pattern of nonadherence should be listed only with reservation. Those who have a diagnosis of alcohol abuse as opposed to alcohol dependence may make better transplant candidates. Patients who have regular appointments with a psychiatrist or psychologist in addictions treatment training also seem to do more favorably.

Conceptual importance of identifying alcoholic liver disease as a lifestyle disease

The concept that alcoholic liver disease (ALD) is as a toxic disease does not mirror the exact nature of the disease. ALD should be defined as an alcohol-associated lifestyle disease, the predisposition to which is largely governed by gene-environment interactions, much like other chronic diseases such as diabetes, atherosclerosis, and neurodegenerative diseases. The epidemiology and pathogenesis of ALD need to be re-addressed from this viewpoint. Specifically, the interactions between alcohol and secondary risk factors (high-fat diet, iron, tobacco, medications, female gender) and comorbidities (viral hepatitis, diabetes) are of urgent epidemiological importance. Molecular characterization of the interfaces of these interactions is essential for revelation or acquisition of new pathogenetic, preventive, and therapeutic insights.

Severe alcohol-induced liver disease and the alcohol dependence syndrome

AIMS

To examine the hypothesis that patients who present in the UK to detoxification services differ from patients who present with severe alcohol-induced liver disease (ALD) with respect to severity of dependence on alcohol and other features of their drinking history.

METHODS

Levels of alcohol dependence were assessed in 34 patients with severe ALD, all of whom were cirrhotic, and 34 subjects from a residential alcohol detox centre in Southampton using the Severity of Alcohol Dependence Questionnaire (SADQ). During interview, various aspects of participants' alcohol consumption were recorded, including total monthly consumption, whom they usually drank with and where, and, if applicable, what caused them to start drinking heavily. Social circumstances were also noted, including participants' employment and marital status.

RESULTS

Among ALD patients, 58% scored none/mild on the SADQ, 32% moderate and 9% severe. In contrast, 76% of the detox group were graded severe and 34% moderate (P < 0.001). ALD patients were also significantly older, had lower scores on the Alcohol Use Disorders Identification Test, tended to drink less alcohol, were more likely to be in a stable relationship, were less likely to be unemployed and gave different reasons for starting to drink heavily. The ALD group were most likely to have started drinking heavily for social reasons, whereas subjects in the detox group were most likely to have started drinking heavily as a result of relationship or money problems.

CONCLUSION

Patients attending a liver unit and patients admitted to a detoxification unit were separate but overlapping populations of alcohol misusers. Perhaps these two populations of alcohol misusers are likely to require different approaches for effective detection, intervention and treatment.

Predictors of relapse to harmful alcohol after orthotopic liver transplantation

BACKGROUND

End-stage alcoholic liver disease (ALD) is a common indication for liver transplantation. Outcomes may be limited by return to harmful drinking. Previous studies have identified few predictors of drinking relapse.

AIM

This study examined novel postulated predictors of relapse to drinking.

METHOD

The case notes of all patients transplanted for ALD at the Royal Prince Alfred Hospital from 1987-2004 were reviewed. Pre-transplant characteristics were rated by a psychiatrist independent of the transplant team, blind to the outcome. Outcomes were rated by a second independent alcohol treatment specialist also blind to the pre-transplant ratings.

RESULTS

Of 100 patients, 6 died before discharge from hospital, 4 had <6 months follow-up, 18 relapsed to harmful drinking, 10 drank below harmful levels, and 62 remained abstinent after a mean of 5.6 years follow-up. Univariate analyses identified six potential pre-transplant predictors of return to harmful drinking. These were a diagnosis of mental illness (of which all cases were of depression), the lack of a stable partner, grams per day consumed in the years before assessment for transplant, reliance on 'family or friends' for post-transplant support, tobacco consumption at time of assessment, and lack of insight into the alcohol aetiology. Duration of pre-transplant abstinence and social class by occupation did not predict relapse. A multivariate model based on the above characteristics correctly predicted 89% of the outcomes.

CONCLUSION

A model based on readily defined behaviours and psychosocial factors predicted relapse to harmful drinking after transplant for ALD. This model may improve assessment and post-transplant management of patients with advanced ALD.

Liver transplantation in alcoholic patients

Alcoholic liver disease is one of the most common causes of cirrhosis and indications for orthotopic liver transplantation in Europe and North America. The reluctance to transplant alcoholics stems in part from the view that alcoholics bear responsibility for their illness. There is also the perception that the alcoholic person is likely to relapse into alcohol use after transplantation and thereby damage the allograft. In this review, we considered the evaluation for and outcome of liver transplantation in alcoholics with special attention to the specific risks of alcohol relapse, to show that alcoholism should be considered like other co-morbid states rather than as a moral flaw.

A pilot study of an alcoholic liver disease recurrence prevention education program in hospitalized patients with advanced liver disease

No systematic work has been completed to assess whether or not educational programming might exert lifestyle improvements among alcoholic liver disease (ALD) inpatients. The present pilot study sought to answer this question through the use of a small-scale two-group experiment (five-session education program versus standard care) at a state-of-the art Liver Unit that provided tertiary care of indigent patients with advanced ALD. A total of 44 patients were initially randomly assigned to program conditions, and 25 provided 3-month follow-up data (13 in the program condition, 12 in the control condition). Patients who received the program reported high receptivity to it, and showed greater learning of program material and reported greater lifestyle changes than the control patients. For those ALD inpatients that are able and willing to participate, the program shows promising effects on self-reported lifestyle change.

Cognitive performance and liver function among recently abstinent alcohol abusers

It has frequently been suggested that some of the enduring subtle cognitive impairments seen in sober alcohol-dependent persons may be a result of subclinical liver dysfunction. Cognitive performance and liver function among 85 recently abstinent alcohol-dependent persons were assessed by means of a neuropsychological examination and the GGT test of liver function. Unlike some previous studies, no relationships were found between the two areas of functioning. It is argued that lack of statistical power did not account for the failure to find an association between the two domains. The proposition that residual cognitive impairment in abstinent alcoholic persons is (partly) mediated by earlier liver dysfunction rests on slight empirical foundations and remains speculative.

II. Veterans Affairs Cooperative Study of polyenylphosphatidylcholine in alcoholic liver disease

BACKGROUND

Polyenylphosphatidylcholine (PPC) has been shown to prevent alcoholic cirrhosis in animals. Our aims were to determine the effectiveness of PPC in preventing or reversing liver fibrosis in heavy drinkers and to assess the extent of liver injury associated with the reduced drinking achieved in these patients.

METHODS

This randomized, prospective, double-blind, placebo-controlled clinical trial was conducted in 20 Veterans Affairs Medical Centers with 789 patients (97% male; mean age, 48.8 years) averaging 16 drinks per day (1 drink = 14 g of alcohol) for 19 years. A baseline liver biopsy confirmed the presence of perivenular or septal fibrosis or incomplete cirrhosis. They were randomly assigned either PPC or placebo. Liver biopsy was repeated at 24 months, and the main outcome measure was the stage of fibrosis compared with baseline. Progression was defined as advancing to a more severe stage.

RESULTS

The 2-year biopsy was completed in 412 patients. PPC did not differ significantly from placebo in its effect on the main outcome. Alcohol intake was unexpectedly reduced in both groups to approximately 2.5 drinks per day. With this intake, 21.4% advanced at least one stage (22.8% of PPC patients and 20.0% of placebo patients). The hepatitis C virus-positive subgroup exhibited accelerated progression. Improvement in transaminases and bilirubin favoring PPC was seen at some time points in other subgroups (hepatitis C virus-positive drinkers or heavy drinkers).

CONCLUSIONS

PPC treatment for 2 years did not affect progression of liver fibrosis. A trend in favor of PPC was seen for transaminases and bilirubin (in subgroups). One of five patients progressed even at moderate levels of drinking, and thus health benefits commonly associated with moderate drinking do not necessarily extend to individuals in the early stages of alcoholic liver disease.

Características de personalidad en pacientes alcohólicos candidatos a trasplante hepático

BACKGROUND AND OBJECTIVE

Although the characteristics of personality have been scarcely investigated in alcoholic patients who are candidates for liver transplantation (LT), a psychopathological evaluation is necessary in them.

PATIENTS AND METHOD

The personality questionnaire Mini-Mult was administered to 53 alcoholic and 20 non-alcoholic patients who were candidates for LT, and was re-administered to 18 alcoholic and 4 non-alcoholic patients at 1-3 months after LT.

RESULTS

Abnormal values in at least 1 of the 8 clinical Mini-Mult scales were observed in 62% of alcoholic patients. However, no significant differences were observed between alcoholic and non-alcoholic patients in relation to the intensity and frequency of abnormal Mini-Mult values. In those alcoholic patients re-evaluated shortly after transplantation, there was not a significant improvement in any of the Mini-Mult scales, with the exception of scale K (self-image).

CONCLUSIONS

Alcoholic patients candidates for LT show common alterations in some areas of the personality but the intensity is moderate and without significant differences with respect to non-alcoholic patients also evaluated as candidates for LT.

I. Veterans Affairs Cooperative Study of Polyenylphosphatidylcholine in Alcoholic Liver Disease: Effects on Drinking Behavior by Nurse/Physician Teams

BACKGROUND

This multicenter prospective, randomized, double-blind placebo-controlled trial was designed to evaluate the effectiveness of polyenylphosphatidylcholine against the progression of liver fibrosis toward cirrhosis in alcoholics. Seven hundred eighty-nine alcoholics with an average intake of 16 drinks per day were enrolled. To control excessive drinking, patients were referred to a standard 12-step-based alcoholism treatment program, but most patients refused to attend. Accordingly, study follow-up procedures incorporated the essential features of the brief-intervention approach. An overall substantial and sustained reduction in drinking was observed. Hepatic histological and other findings are described in a companion article.

METHODS

Patients were randomized to receive daily three tablets of either polyenylphosphatidylcholine or placebo. Monthly follow-up visits included an extensive session with a medical nurse along with brief visits with a study physician (hepatologist or gastroenterologist). A detailed physical examination occurred every 6 months. In addition, telephone consultations with the nurse were readily available. All patients had a liver biopsy before entry; a repeat biopsy was scheduled at 24 and 48 months.

RESULTS

There was a striking decrease in average daily alcohol intake to approximately 2.5 drinks per day. This was sustained over the course of the trial, lasting from 2 to 6 years. The effect was similar both in early dropouts and long-term patients, i.e., those with a 24-month biopsy or beyond.

CONCLUSIONS

In a treatment trial of alcoholic liver fibrosis, a striking reduction in alcohol consumption from 16 to 2.5 daily drinks was achieved with a brief-intervention approach, which consisted of a relative economy of therapeutic efforts that relied mainly on treatment sessions with a medical nurse accompanied by shorter reinforcing visits with a physician. This approach deserves generalization to address the heavy drinking problems commonly encountered in primary care and medical specialty practices.

Liver transplantation for alcoholic liver disease

In many patients, long-term heavy drinking leads to chronic liver disease, liver failure, and even death. Orthotopic liver transplantation (OLT) is the only definitive treatment for end-stage liver disease, including alcoholic liver disease (ALD). Because of a shortage of donor organs, OLT for ALD patients remains controversial out of concerns that patients may resume drinking, thereby harming the transplanted organ. Therefore, transplant centers conduct careful screening procedures that assess patients' coexisting medical problems and psychosocial status to identify those patients who are medically most suited for the procedure and who are most likely to remain abstinent after OLT. Studies assessing the outcomes of ALD patients after OLT found that the survival rates of the transplanted organ and the patient were comparable to those of patients with nonalcoholic liver disease and that relapse rates among the ALD patients were low. Similarly, ALD patients and patients with other types of liver disease had comparable rates of compliance with complex medication regimens after OLT. Enhanced efforts to identify risk factors for relapse among OLT candidates with ALD and to target interventions specifically to those patients who are at high risk of relapse may further improve patient outcome and enhance the acceptance of OLT for alcoholic patients in the general population.

Long-term medical and psycho-social evaluation of patients undergoing orthotopic liver transplantation for alcoholic liver disease

The major concern in transplanting patients with alcoholic liver disease (ALD) is the high rate of alcohol recidivism. Our aim was to assess the long-term outcome of liver transplantation (OLT) in a group of ALD patients in terms of post-OLT alcohol recidivism and its relationship with pre-OLT psychosocial variables and medical follow up. Fifty-one ALD patients underwent strict medical and psychosocial evaluation before and after OLT. Alcohol abuse was recorded in 60% and alcohol dependence in 40% of patients before OLT. The 5-year survival was similar to the one observed in non-ALD transplanted patients (64 vs 56%). Alcohol recidivism was observed in 33% of transplanted patients, 64% of whom were occasional and 36% were heavy drinkers. The admission of alcoholism by the patient and his/her family prior to OLT significantly predicted abstinence after OLT. A multidisciplinary approach evaluating medical and psycho-social variables before OLT and a close follow up after OLT are mandatory for ALD patients.

Recidivism and return to work posttransplant. Recipients with substance abuse histories

The purpose of this retrospective survey was to describe posttransplant recidivism and return to work rates for adult liver transplant recipients with histories of alcohol-related liver disease (ARLD) or ARLD and polysubstance use. Recidivism from alcohol was the primary substance analyzed. One hundred and twenty-two adult liver transplant recipients comprised the convenience sample; 98 had histories of ARLD and 24 had both ARLD and polysubstance use. Using a mailed survey, the recipients were asked about their drug and alcohol use (both prior to and following the transplant); family and social issues; and whether they were working posttransplant. The two subgroups of recipients differed with respect to the variables gender, age, and years posttransplant with the ARLD/polysubstance using recipients more likely to be male, younger, and more recent transplant recipients than those with ARLD, alone. Recidivism and return to work rates differed for the two subgroups.

Patterns of alcohol consumption after liver transplantation

BACKGROUND

Uncertainty exists about the extent and consequences of a return to alcohol consumption after liver transplantation for alcoholic liver disease (ALD).

AIMS

To determine the prevalence and consequences of alcohol consumption in patients transplanted for ALD.

METHODS

A retrospective case controlled study of all patients transplanted for ALD at the Queen Elizabeth Hospital, Birmingham, between 1987 and 1996.

RESULTS

Seventy patients with ALD were transplanted, of which 59 survived more than three months; 56 were interviewed. Twenty eight had consumed some alcohol after transplantation; for the nine "heavy drinkers" (HD), the median time to resumption of alcohol intake was six months and for the 19 "moderate drinkers" (MD) it was eight months. There was no significant difference in episodes of acute rejection or compliance with medication between those who were abstinent, MD, or HD. Histological evidence of liver injury was common in ALD patients who had returned to drink. Mild fatty change was found in 1/11 biopsy specimens from abstinent patients but moderate to severe fatty change and ballooned hepatocytes were seen in 3/5 MD and 2/5 HD specimens. Two HD patients had early fibrosis. One HD patient had died of alcohol related complications.

CONCLUSIONS

Moderate to heavy alcohol consumption occurs in patients transplanted for ALD. Patient recall of abstinence advice is unreliable, and patients return to alcohol mainly within the first year after liver transplantation. Return to alcohol consumption after liver transplantation is associated with rapid development of histological liver injury including fibrosis.

Health Locus of Control in problem drinkers with and without liver disease

The purpose of this study was to investigate whether patients who developed alcoholic liver disease have more awareness of the link between their behaviour and subsequent health than patients with non-alcoholic liver disease and people with drink problems with no liver disease. This study included three groups of patients, alcoholic liver disease (ALD) (n=57), non-alcoholic liver disease (n=77), and problem drinkers with no liver disease attending a London community day treatment centre (ACCEPT) (n=115). Health locus of control differentiates people into two groups, health externals who are individuals who maintain that their health is largely determined by external factors, as opposed to health internals, who believe that their behaviour plays a major role in determining their subsequent health or illness. The results of the Health Locus of Control (HLC) scale administered to the above subjects suggested that the ALD group had limited insight into the relationship between their drinking and subsequent liver disease, compared to the ACCEPT group. It is suggested that alcoholic liver disease patients receive counselling as part of their total management.

Does liver dysfunction explain neuropsychological status in recently detoxified alcohol-dependent clients?

In the search for explanation of persistent cognitive impairment associated with alcohol dependence, the possible role of liver disease has aroused considerable interest. However, review of the relevant literature provides only ambiguous support for any general relationship between neuropsychological status and laboratory tests of liver function. We tested the general hypothesis, and also two specific hypotheses relating particular liver function parameters (gamma-glutamyl transferase and serum albumin) to mental ability in a sample of 54 recently detoxified alcohol-dependent people. Despite adequate design power, we failed to obtain evidence for general or specific correlations between mental ability and liver function. We conclude that the accumulated data do not provide direct support for the hypothesis that liver disease plays a part in the genesis of chronic alcohol-related brain impairment in clients without cirrhosis.

Long-term changes of markers of alcoholism after orthotopic liver transplantation (OLT)

Both physical rehabilitation and the course of the alcoholism improve after orthotopic liver transplantation (OLT) in patients with end-stage alcoholic liver cirrhosis. In the present study including 17 alcoholics and 14 nonalcoholics, after OLT, three of the alcoholic patients resumed their pre-OLT alcohol drinking habits, 4 consumed alcohol occasionally, 10 remained abstinent over the observation period of 13 to 36 months. The laboratory parameters before OLT did not discriminate alcoholics from nonalcoholic patients. Furthermore, the blood levels of two so-called alcogens (harman and norharman) were determined to investigate whether they discriminate between the two groups. Alcogens are natural compounds that are presumed to induce alcohol abuse in predisposed individuals. Both alcogens measured were elevated in plasma from nonalcoholics and alcoholics before OLT, suggesting a disturbance in inactivation in end-stage liver disease. Following OLT, the alcogens normalized but in the alcoholics this process was slower with respect to harman. The present exploratory study suggests that the normalized metabolic capacity of the liver after OLT causes a normalization of the levels of alcogens, for which harman and norharman are representative. These changes could contribute to the observed benefit to the outcome in alcoholics with respect to the alcohol dependence.

The use of alcohol home delivery services by male problem drinkers: a preliminary report

Alcohol home delivery services (AHDS) provide convenient and confidential access to alcohol, yet little is known about their use. The purpose of this report is to present preliminary data describing the use of AHDS by problem drinkers. We surveyed 174 males regarding social and demographic characteristics, alcohol use history, and use of AHDS. Use of AHDS was most common among problem drinkers. When statistically controlling for the effects of demographic and social characteristics, regular drinkers without a history of alcohol problems were significantly less likely to have had alcohol delivered than problem drinkers, p = .0036. Contrary to expectation, medically ill alcoholics with advanced and disabling medical complications of heavy drinking were not more likely than other problem drinkers to have alcohol delivered. Living in an urban area and not having a vehicle available were associated with the use of AHDS. The public health and safety considerations of alcohol availability via home delivery are discussed.

Assessing gender interactions in the prediction of mortality in alcoholic men and women: a 20-year follow-up study

This study investigates the predictors of mortality in 259 male and female alcoholics who were psychiatrically hospitalized between 1967 and 1968 and followed for > 20 years. The findings showed that, in addition to age, marital status, medical complications, and non-antisocial personality comorbidity were important independent predictors of time to death. Data pointed to gender interactions, in that marital disruption tended to be a stronger predictor of mortality in men, and delirium tremens tended to be a stronger predictor of mortality in women. Knowing and understanding that certain events and processes may differentially affect the survival of male and female alcoholics will allow for the development of more individualized and gender-specific therapeutic interventions.

Alcohol use, abuse, and alcohol-related disorders among ethnic groups in Hungary. Part I: Csángós from Egyházaskozár Region

This paper reports the results of a study on alcohol drinking habits, alcohol-related acute symptoms, and alcohol abuse among Csángós, an ethnic minority in Hungary. The demographic data revealed their social characteristics: growing old, low education, endogamous marriages, early maternal age at birth of the first baby, and a high child number per family. Alcohol use survey revealed that alcohol consumption of the Csángós is considerably high; more than half of Csángó males and more than one-quarter of Csángó females are heavy drinkers. While all kinds of alcohol are consumed by males, wine drinking is more common among females. Acute reactions to a moderate dose of alcohol evoked a series of physical and physiological symptoms including facial flushing, higher pulse rate, tachycardia and euphoria among at least one third of the probands. There was a distinct gender difference in response to alcohol drinking. While a higher percentage of females reported intense skin flush (34%), a greater percentage of males reported symptoms such as sleepiness, euphoria and aggressiveness. The distribution of clinical chemical markers of alcohol abuse in the sera of the individuals under study confirmed heavier alcohol consumption among males than among females. Alcohol-related mortality data indicate liver cirrhosis and liver cancer as the leading cause of deaths among Csángó males. A high alcohol consumption among Csángó ethnic group reflects the acceptance of alcohol use in the community as an integral part of their lifestyle.

Psychiatric outcome in alcoholic liver transplant patients

We investigated drinking behaviour and psychiatric outcome of patients with alcoholic liver disease after liver transplantation, to help assess the advisability of the procedure in these patients. English-speaking patients (n = 20) transplanted for alcoholic liver disease and informants, and patients transplanted for non-alcoholic liver disease (n = 54), were assessed by semi-structured interviews and standardized questionnaires 1-6 years following transplantation. All alcoholics were abstinent for several months after transplantation, but only one patient remained totally abstinent. Sixteen of the 20 alcoholics later returned to regular drinking; the mean daily alcohol consumption was 3.5 units. Forty percent of the group were drinking above the recommended safe levels for the general population and over 50% were 'binge' drinking intermittently. The alcoholic liver transplant patients did not have higher levels of psychiatric or physical morbidity than controls. Patients with alcoholic liver disease return to drinking after a period of abstinence following liver transplantation, although at lower levels than before. Their vulnerability to alcohol abuse is not explained by higher levels of physical or psychiatric morbidity.

Occupational risk factors in patients with alcoholic or non-alcoholic liver disease

The present study examines the presence of specific occupational risk factors in a group of patients suffering from alcoholic liver disease compared with a group of patients with non-alcoholic liver disease. The first group was more dependent on alcohol, with fewer social or psychological alcohol-related problems. The majority of them were employed, although more likely to be employed in traditional 'high risk' occupations. They showed lower job satisfaction, and the total sum of all previously reported occupational risk factors was highly significant. This was the first empirical evidence in support of the importance of the specific occupational risk factors previously postulated.

Liver transplantation and alcohol: who should get transplants?

Medical selection criteria should be the same for all patients with end-stage liver disease and should aim for an acceptable outcome of the liver transplant procedure in matter of survival and quality of life, taking the scarce resources into account. The psychiatric selection criteria should aim at avoidance of recidivism of alcohol use in alcoholic patients. At least 6 mo of sobriety should be required. The patient must have a stable and supportive environment and should participate in an alcohol counseling program. A multicentered trial using uniform scoring criteria such as the Alcohol Prognosis Scale is needed to better define the selection of patients with alcoholic liver disease and long-term outcome of alcoholism after transplantation.

Predicting recidivism after orthotopic liver transplantation for alcoholic liver disease

With appropriate selection criteria, patients with end-stage alcoholic liver disease who undergo orthotopic liver transplantation have similar graft and patient survivals as patients undergoing transplantation for other causes. However, because of the possibility of recidivism after orthotopic liver transplantation there is still reluctance to transplant alcoholic patients. This study examined the association between pretransplant psychosocial variables and the risk of recidivism after orthotopic liver transplantation. At our institution, 43 patients received orthotopic liver transplantation for the referral diagnosis of alcoholic liver disease from February 1, 1988 to May 1, 1991. This represented 17% of all first transplants (43 of 257) performed during this period. Patients were interviewed before orthotopic liver transplantation by a single psychiatrist and responses to a defined set of questions were entered into a clinical database. All 43 patients diagnosed with alcoholic liver disease and a comparison group of patients transplanted for diagnoses other than alcoholic liver disease received a postoperative questionnaire regarding past and present alcohol use. Patients enrolled in the study all had at least 7 mo of follow-up, with the median follow-up being 21 mo. Eighty-six percent of alcoholic liver disease patients (37 of 43) and 86% of patients in the comparison group (37 of 43) of ALD patients agreed to participate in the study. Nineteen percent of alcoholic liver disease patients (7 of 37) and 24% of patients in the comparison group (9 of 37) admitted to having used alcohol after orthotopic liver transplantation, wtih 8% (3 of 37) and 11% (4 of 37) currently using alcohol, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

The association between severity of DSM-III-R alcohol dependence and medical and social consequences

This paper describes the relationship between severity of dependence and medical and social consequences in a clinical sample. Respondents constitute a sample of 219 men and 162 women interviewed in nine alcohol programs in a Northern California county. Results suggest that the number of dependence indicators reported by respondents is a valid indicator of severity of alcohol dependence, and that there is a positive relationship between the number of indicators and the number of medical and social consequences reported by respondents. When specific medical and social consequences are examined, an analysis restricted to men only, the number of dependence indicators is associated with stomach, heart and liver problems, DTs, hallucinations, public drunkenness, family arguments and serious accidents, but it is not associated with drunk driving arrests and job problems.

[Diagnosis of alcohol dependence]

The dependence syndrome has gained central importance in diagnosing alcohol abuse disorders, as shown by its incorporation in ICD-10 and DSM-III-R. After dealing with historical concepts of alcoholism, the concurrent and predictive validity of the dependency syndrome is discussed in relation to aspects of typology and comorbidity, and to neurobiological variables. Diagnostic instruments are assessed and research perspectives indicated.

Psychiatric aspects of liver disease

This paper reviews the literature on the effects of liver disease on mental health, a topic which has been relatively neglected in the recent psychiatric literature. It discusses both the encephalopathy which may be associated with liver disease of almost any type and the psychological consequences of specific liver disorders. Also considered are the effects of liver disease on sexual function; the relationship between alcohol and hepatic disorder in causing mental disturbance; the effects of childhood liver disease; psychiatric aspects of liver transplantation; and the use of psychotropic drugs in patients with hepatic dysfunction.