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Alcohol-Related Liver Disease: Treatment and Rehabilitation

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Alcohol-Related Liver Disease: Treatment and Rehabilitation ALCOHOL-RELATED LIVER DISEASE: TREATMENT AND REHABILITATION Introduction For people who cope with alcoholism, the specter of recovery relative to prevention of relapse and injury to the body is ongoing. Of significance liver injury, fibrosis or cirrhosis, is always a concern and can potentially severely impact the individual affected by an alcohol use disorder. Long-term alcohol use has been strongly connected to mental and physical disease states, and in the past few decades there has been a plethora of research related to patient education, treatments, disease management, and understanding the power of addiction in peoples’ lives. The medical condition of alcohol-related cirrhosis is a major area of research and concern for all members of the interdisciplinary health team. Liver transplant is the standard treatment for severe cases of alcohol use but this treatment may be limited. Relapsing episodes of alcohol use impacts an individual’s prognosis and treatment. Overview Of Alcoholism And Liver Disease There is a great deal of misunderstanding of the nature of alcoholism. For centuries, people who drank too heavily were considered weak or foolish. While alcoholism is now treated as a disease, clinicians are still struggling to fully understand alcoholism. The quandary confronting clinicians in dealing with alcoholic patients often entails not being able to accept why someone who requires medical treatment, possibly a transplant, to live would return to the very same behavior that led them to require treatment. This is the issue often facing clinicians as they struggle to cope with the high numbers 1 ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com of people who cope with alcoholism and complications, such as alcoholic liver disease (ALD). Alcoholism may not only be a psychosocial disease but also a neurological one, and it may also have a genetic component. The question clinicians are trying to answer is what is alcoholism? One of the most highly recognized and respected organizations in the U.S., addressing issues of alcohol use and addiction is the Substance Abuse and Mental Health Services Administration (SAMHSA). Another is the Centre for Addiction and Mental Health (CAMH) in Toronto, Canada. These two organizations engage in research, public awareness, individual education, and empowerment for people who cope with addiction. Alcoholism is an addiction.32,60 Alcoholism as a Neurobiological Addiction In March 2017, the Surgeon General of the U.S., published a report entitled Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. The report explored a number of key areas regarding alcoholism and other facets of addiction including the source of addiction itself. From the very first chapter, it acknowledges the neurobiological source of addiction. It states that a significant amount of research has been conducted to provide sufficient evidence to transform the way clinicians understand substance use disorders and its effects on the brain. With this knowledge, new ways of thinking about prevention and treatment of substance use disorders may be developed. Clinicians are learning how substances such as alcohol produce changes in brain structure and function that promote and sustain addiction and contribute to relapse. We also know that there are similarities and 2 ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com differences in how the various classes of addictive substances affect the brain and behavior.60 Breakthroughs in recent research are revolutionizing the ways in which clinicians now understand substance use disorders. Once they were viewed through the lens of a moral failing or character flaw but are now understood to be chronic illnesses characterized by clinically significant impairments in health, social function, and voluntary control over substance use. The latest research has aided clinicians to understand that while mechanisms may be different, addiction has many features in common with disorders such as diabetes, asthma, and hypertension. Each one of these diseases are subject to relapse, and influenced by genetic, developmental, behavioral, social, and environmental factors. They are all similar in that those individuals who cope with them may have difficulty in complying with the prescribed treatment. The fact that health clinicians now know addiction is affected and driven by neurological changes helps to reduce the negative attitudes and stigma associated with substance use disorders, and supports the integration of treatment for substance use disorders into mainstream healthcare. The research into the neurobiology of addiction has led to the development of new and effective medications not just for alcohol use, but also opioid and nicotine use disorders. All addictive substances have powerful effects on the brain. It is these effects that result in a pleasurable feeling people experience when they engage in their initial use of alcohol or other substances, and these feelings motivate people to use those substances repeatedly, despite the risks for significant harm. The previous model for addressing substance use disorders was the criminal justice model. People were arrested and incarcerated for their use of alcohol 3 ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com and other drugs. This has led to what many term as the war on drugs but it has never been successful, and certainly does not address the neurobiological model, which informs clinicians on how addiction develops in an individual. ALD: Variables and Long-term Outcomes Alcoholic liver disease is predominantly observed in males; this does not imply women do not contract ALD but they do in far lower numbers. In fact, the male to female ratio of patients with alcoholic liver cirrhosis has been reported as 9:1. A nationwide study in the U.S., that assessed patients discharged from the hospital following a diagnosis of ALD found that 4.5 per 100,000 persons had acute alcoholic hepatitis. The male to female ratio was 1.83:1. In persons who have contracted chronic alcoholic hepatitis with cirrhosis, the male to female ratio is 2.64:1.61 Studies have also revealed a male predominance in the prevalence of NAFLD. An American study revealed that 58.9% of patients with NAFLD were male. Subsequently, a study was conducted in Japan which revealed that the male prevalence rates in NAFLD was 41.0% and 17.7% for females, respectively. Similar trends were observed in a study conducted in China. One of the most common causes for alcoholic liver disease or ALD is excessive consumption of alcohol. Alcoholic liver disease in turn may lead to advanced liver cirrhosis. Alcohol-related cirrhosis is the second most common indication for liver transplantation, after cirrhosis caused by viral hepatitis. Unfortunately, the high incidence of patients returning to heavy drinking is approximately 20% - 30% even after they receive the transplant.30 This is a subject of some controversy in the medical community, as there are so many people waiting for liver transplants. Some 4 ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com believe there must be protocols in place that put an emphasis on who receives transplants for ALD. The high relapse rate is crucial because alcoholic recidivism has a negative impact on post-transplant compliance and long-term outcomes of liver transplant recipients. When a person receives a new liver but then relapses back into drinking, this is strongly associated with increased damage to the transplanted liver and long-term outcomes may be poor for the patient. Thus, in evaluating candidates for liver transplant, there is a need for the clinician and patient to be clear and try to determine the risk of post- transplant relapse of alcohol use in patients with alcoholic liver disease.30 Alcohol-related Liver Disease Alcohol has been reported to substantially contribute to the global burden of disease and is responsible for significant disability-adjusted life-years and deaths. Moreover, alcohol has a negative effect on socio-economic activities and the annual cost of excessive social drinking has been estimated to be an excessive amount in high-income countries.8,32,60,61 Development of ALD The development of liver disease from alcohol ingestion depends on several factors. The first step is the person must reach a threshold regarding the duration of use and daily intake of alcohol. For someone drinking on a daily basis for 10–12 years with doses in excess of 40-80 g/day for males and of 20–40 g/day for females, these are the recognized thresholds. The truth is not all alcoholic beverages have the same content, and the threshold is different depending on the type of beverage. As an example, daily drinking of 3–6 cans (12 oz. each) of beer/day for males or 1.5–3 cans of beer/day 5 ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com for females for 10 years or longer can cause ALD.62 Even if a person has reached the threshold mentioned here, it does not imply they will develop liver disease. In fact, only 10–35% of heavy, long-term alcohol drinkers will develop alcoholic hepatitis and only 8–20% will develop cirrhosis. As implied by these statistics, host attributes (i.e., gender and polymorphism(s) of alcohol-metabolizing enzymes) and coexisting external factors (i.e., obesity and hepatitis C infection) combine to determine the likelihood of developing associated liver disease.62 The risk of serious liver disease always increases when the consumption of alcohol increases and in the presence of Hepatitis C infection. There are studies which reveal that women develop liver disease after exposure to lower quantities of alcohol and over shorter time periods. The correct diagnosis of ALD can usually be made on a clinical basis in conjunction with blood tests, and a liver biopsy is not usually required.
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