Behavioral Treatment for Patients with Alcohol‐Related Liver Disease

Review

Behavioral Treatment for Patients With Alcohol-Related Liver Disease: A Primer for Hepatologists Peng-Sheng Ting, M.D., * Jason Wheatley, M.S.W.,† and Po-Hung Chen, M.D.*

KEY POINTS Alcohol-related liver disease (ALD) can be protean in manifestation from simple steatosis to alcoholic hepatitis (AH) and cirrhosis, but its cause is straightforward and • Alcohol use disorder (AUD) in patients who develop al- dose dependent. In spite of our understanding of its cause, cohol-related liver disease or cirrhosis always warrants mortality from alcohol-related cirrhosis (AC) increased treatment for the AUD that underlies said liver disease. 18% from the year 2000 to 2013.1 Cirrhosis-related mor- • A multidisciplinary approach to AUD treatment, one tality increased by 10.5% annually from 2009 to 2016 in that involves both the hepatologist and the substance people aged 25 to 34 years and was primarily due to ALD, abuse specialist and includes both behavioral treat- resulting in unacceptable consequences to the labor force ment and pharmacological therapy, is quintessential in and society.2 preventing alcohol relapse. • We aim to delineate the practical evidence-based Patients who develop ALD or AC always warrant knowledge of behavioral treatment for hepatologists. treatment for AUD, and the importance of abstinence

Abbreviations: AC, alcohol-related cirrhosis; AH, alcoholic hepatitis; ALD, alcohol-related liver disease; AUD, alcohol use disorder; CBT, cognitive behavioral therapy; DSM-V, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; ESLD, end-stage liver disease; HE, hepatic encephalopathy; LT, liver transplantation; MET, motivational enhancement therapy; MI, motivational interviewing; RCT, randomized controlled trial; TAU, treatment as usual. From the * Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD; and † Department of Medical Surgical Social Work, Johns Hopkins Hospital, Baltimore, MD. Potential conflict of interest: Nothing to report. Received April 7, 2019; accepted June 7, 2019.

31 | Clinical Liver Disease, VOL 15, NO 1, JANUARY 2020 An Official Learning Resource of AASLD Review Behavioral Treatment for ALD Ting, Wheatley, and Chen cannot be overstated. In the Steroids or Pentoxifylline for multiple-session structured treatment integrated with the Alcoholic Hepatitis trial, the largest randomized controlled hepatology practice.4-6 trial (RCT) for the management of AH to date, only 37% The following subsections outline specific behavioral of its participants reported complete abstinence at 1-year 3 treatment strategies for ALD. follow-up. This observation underscores that we can do more to facilitate alcohol abstinence and AUD treatment. Nonpharmacological AUD treatment has a critical role in Cognitive Behavioral Therapy ALD and can be instrumental in inducing and maintaining Cognitive behavioral therapy (CBT) takes place over sev- abstinence. We aim to outline the major categories of behav- eral sessions and focuses on identifying and managing the ioral treatment as a primer for the practicing hepatologist. cues that lead to drinking to modify the thought processes underlying AUD. Specific CBT techniques include training BEHAVIORAL TREATMENT STRATEGIES coping skills, drug-refusal skills, and increasing nonuse-related activities.7 CBT is most consistently shown to increase The first step of AUD treatment is to screen for AUD and abstinence in AUD and is supported by an RCT and obser- to classify its severity (Table 1). In general, the degree of vational studies in ALD.5,8,9 AUD is important in selecting which behavioral treatment to use. More severe AUD requires more structured and sustained behavioral treatment regimens. Motivational Interviewing and Motivational Enhancement Therapy Behavioral treatment is a set of strategies (depicted in Motivational interviewing (MI) is a therapeutic coun- Fig. 1) led by health professionals in identifying individ- seling style aimed at evoking the patient’s own motiva- ual maladaptive behavior and in employing all available tion for change.10 It provides a method to focus on the resources to remain abstinent. The evidence underlying patient’s own circumstance and lessens the paternalistic different behavioral treatment strategies in ALD is scarce environment of the clinician’s office. Harm reduction is a and mainly observational, but the available evidence can core tenet of AUD treatment, and MI facilitates dialogue help prioritize strategies based on efficacy and accessibility. under nonjudgmental conditions. A few RCTs have evaluated behavioral treatment specifically in the context of ALD; we summarize these in Table 2. Motivational enhancement therapy (MET) is performed These RCTs are not consistently positive studies in favor of over several sessions where the therapist, similar to use behavioral treatment, but the key takeaway is that brief of MI, evokes self-motivated cessation strategies that are motivational interventions appear to be less effective than monitored and encouraged over time. MET has mixed

TABLE 1. CLASSIFICATION OF SEVERITY IN AUD AND CORRESPONDING TREATMENT STRATEGIES

No. of DSM-V Possibly Effective Behavioral Severity of AUD Criteria Treatment DSM-V Criteria for AUD

At risk <2 Brief intervention 1. Ended up drinking more or longer than you intended in one sitting. Mild 2 or 3 Brief intervention, mutual support 2. Wanted or tried to cut down but could not. Moderate 4 or 5 Mutual support, contingency 3. Spent a lot of time drinking or suffering from its aftereffects. management, MI/MET, CBT 4. Experienced a strong craving to drink. Severe ≥6 Mutual support, contingency 5. Found that drinking or being sick from drinking interfered with your family, management, MI/MET, CBT social, or professional responsibilities. 6. Continued to drink despite trouble with family/friends. 7. Had to decrease participation in activities that were important or interesting to you in order to drink. 8. More than once have gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex). 9. Continued to drink even though it was leading to depression, anxiety, exacerba- tion of another health problem, or after having had a memory blackout. 10. Had to drink much more than you once did to get the effect you want, or found that the usual number of drinks had much less effect than before. 11. Presence of withdrawal symptoms (i.e., trouble sleeping, shakiness, irritability, anxiety, depression, restlessness, nausea, sweating, or sensed things that were not there) as the effects of alcohol were wearing off.

32 | Clinical Liver Disease, VOL 15, NO 1, JANUARY 2020 An Official Learning Resource of AASLD Review Behavioral Treatment for ALD Ting, Wheatley, and Chen

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TABLE 2. rCTS EVALUATING BEHAVIORAL TREATMENTS IN ALD

Patient Intervention Control Lead Author Year Population (No. of Patients) (No. of Patients) Findings

Weinrieb6 2011 AC, LT candidates MET (46) TAU (45) 1. Similar proportions of relapse in both groups (26% in MET and 24% in TAU) 2. MET group had significantly less frequency and quantity of drinks than TAU group, after excluding one outlier Willenbring5 1999 AC or AH, not LT Integrated CBT TAU (53) Statistically significant (P = 0.02) lower proportion of relapse in the candidates and MET (48) MET group (26%) than the TAU group (52%) Kuchipudi4 1990 AC, not LT 2-Hour MI (59) TAU (55) Similar proportions of relapse in both groups (32% in brief MI and candidates 28% in TAU) at 10-16 weeks after counseling results in RCTs in terms of abstinence in ALD, but appears environment” where the patient can enjoy positive associ- to decrease the frequency and quantity of drinks.5,6 ations with social experiences that do not include alcohol. Specific examples include Alcoholics Anonymous, Smart Recovery, and religious group meetings, which are acces- Contingency Management sible therapies in terms of cost and expertise.8 Mutual sup- Contingency management is based on the theory of report has the added benefit of social support that is not as inforcement where patients are rewarded to reinforce ab- prominent in CBT and MI/MET. Mutual support is often the 9 stinence. Examples of rewards can range from housing for standard of care for AUD and is the cornerstone of usual the homeless to mitigation of sentences in alcohol-related care in most RCTs. offenses. To date, contingency management has not been studied specifically in ALD. Brief Intervention In a brief intervention, a physician or therapist identifies Mutual Support alcohol use, sets a goal with the patient, and teaches a The strategy of mutual support is based on creating behavioral modification technique to promote abstinence. a reliable, healthy social network that fosters a “sober Although less time-consuming and more intuitive, there is

33 | Clinical Liver Disease, VOL 15, NO 1, JANUARY 2020 An Official Learning Resource of AASLD Review Behavioral Treatment for ALD Ting, Wheatley, and Chen little evidence for brief interventions in moderate-to-severe emphasize evoking and maintaining motivation with MI/ AUD. Compared with more structured sessions, brief inter- MET as the cornerstone of behavioral treatment together ventions are less likely to help in ALD.8 with other behavioral treatment modalities. At the same time, aggressive medical treatment for HE and other com- plications of ESLD should be a focus because it reduces TREATMENT INTENSITY cognitive disability and demoralization.

Behavioral treatments are used in many settings, often Two important differences in AUD treatment for LT in a multimodal approach. The setting is most analogous candidates can be discerned from available literature and to the “level of care” in medicine; it can involve inpatient should be applied to practice whenever possible. First, treatment, residential rehabilitation, intensive outpatient behavioral treatment programs integrated with the hepa- program, peer-support groups, or individual counseling. tology practice, rather than those referred to outside practi- Furthermore, there are methods that combine behavioral tioners, correlated with improved abstinence and mitigated treatments in a structured program such as reinforcement- severity of relapse.6,13 Second, behavioral treatment contin- based treatment, which incorporates contingency man- ued after LT is associated with a decreased risk for relapse.14 agement and components of CBT. Fig. 2 summarizes a decision flowchart in deciding behavioral treatment strategies for referral according to severity of AUD. CONCLUSION Our ultimate goal is to help patients realign their so- LIVER TRANSPLANT CANDIDATES cialization with a common cause rather than with drinking; with that in mind, we should incorporate methods Patients with end-stage liver disease (ESLD) or severe AH to include patients’ social network and support in main- who are candidates for liver transplantation (LT) should re- taining a sober environment. Although we listed all of the main completely abstinent. If LT is ultimately performed for earlier-mentioned strategies individually, in reality they are ALD, alcohol relapse is associated with an increased rate of often used simultaneously and at different levels of care allograft loss and fibrosis.11 Historically, hepatic encepha- (inpatient versus outpatient). AUD treatment is most effec- lopathy (HE) and lack of motivation were considered ob- tive when clinicians use a sustained multidisciplinary and stacles in the behavioral treatment of AUD before LT.12 Our structured approach. It is particularly important in the LT approach for the treatment of AUD in LT candidates would population for whom the stakes are highest.

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FIG 2 Decision flowchart for behavioral treatment strategies according to severity of AUD: What can you do? *Multidisciplinary approach entails substance abuse specialist will be involved, and multimodal means there at least should be mutual support plus CBT, contingency management, or MET.

34 | Clinical Liver Disease, VOL 15, NO 1, JANUARY 2020 An Official Learning Resource of AASLD Review Behavioral Treatment for ALD Ting, Wheatley, and Chen

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35 | Clinical Liver Disease, VOL 15, NO 1, JANUARY 2020 An Official Learning Resource of AASLD