Abstract
Introduction:
Alcohol-related liver disease (ALD) is a leading cause of advanced liver failure worldwide and is associated with a high mortality. Complete alcohol abstinence is the hallmark of medical treatment. The only effective treatment option for non-responders with advanced disease is liver transplantation with excellent long term outcomes in carefully selected patients. Relapse to harmful alcohol use post-transplant can occur and is associated with increased mortality. Thorough patient assessment, monitoring for and addressing relapse risk represent significant clinical challenges. Treatment of comorbid Alcohol Use Disorder (AUD) is complex and requires active patient participation and behaviour modification, which is complicated by the severity of the underlying medical condition. An integrated clinic was established at Royal Prince Alfred Hospital to address these issues.
Timeline of Practice change
A consult liaison psychiatry service was integrated into the Australian National Liver Transplant Unit in 1986. The Drug Health Service was involved from 1998. Research conducted in 2013 demonstrated striking reluctance in pre-transplant patients to accept AUD diagnosis and treatment.1. An integrated clinic was established in 2018. The clinic is led by a hepatologist with transplant and addiction experience and is comprised of an alcohol counsellor with occupational therapy experience, a psychiatrist and an addiction specialist. 94 patients have been referred and followed to date (Figure 1).
Aim and Theory of change
ALD patients referred for transplant are reluctant to attend traditional AUD treatment due to associated stigma and prioritisation of competing medical care. Expressing risk of relapse to AUD as negligible may facilitate selection for transplantation but may paradoxically compromise treatment for this disorder. Patients also report ongoing psychological stress and poor health-related quality of life post transplantation which increases relapse risk. This is compounded further by unresolved childhood trauma, affect dysregulation and limited social supports.
An integrated clinic allows for coordinated treatment which embodies the principles of involved disciplines, minimising contradictory approaches and development of a patient-centred treatment plan. Interventions include coordination of medical and psychiatric reviews, biomarker monitoring, psychoeducation, motivational interviewing, relapse prevention, trauma-informed care and wellbeing groups and individual counselling focusing on quality of life and function.
Figure 1: Integrated clinic pathway
Targeted population
· Patients with advanced ALD referred for transplantation
Stakeholders
· Australian National Liver Transplantation Unit
· Drug Health Services
· Consult liaison psychiatry
Highlights
· Integration of relapse prevention into routine medical pre and post-transplant care
· Highly specialised team
Outcomes
· Extending criteria for transplantation
· Prevention, early identification and treatment of relapse
· Increased uptake of counselling by patients
Comments on sustainability
Funding was allocated for a hepatologist and alcohol counsellor within DHS/ANLTU.
Transferability and Conclusions. A significant shift in clinical practice led to an integrated model of care tailored to the biopsychosocial needs and capabilities of ALD patients. This model could be replicated with other medical disorders where self-management is required.
Reference
1. Heyes,C.M, Schofield, T, Gribble,R, Day, CA and Haber, PS. Reluctance to Accept Alcohol Treatment by Alcoholic Liver Disease Transplant Patients: A Qualitative Study. Transplant Direct, 2016; 2 (10): e104. DOI: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5068203/