Alcoholic Liver

Ma nagement of Alcoholic Liver Dis eas e
Michael R. Lucey, MD, FRCPI
KEYWORDS  Alcohol  Alcoholism  Cirrhosis  Hepatitis  Abstinence

ADDICTION TO ALCOHOL

Addictions usually arise from pleasurable actions, and immediate gratification is the most common foundation for addiction. In the case of alcohol, the addictive state is divided into 2 classes within a spectrum: abuse, in whichdrinking is excessive but does not lead to many of the physical and social harmful consequences, and dependency, wherein drinking is continued despite physical and social injury. Ask an alcoholic person why they continue to drink, despite the obvious havoc alcohol is bringing to their lives and the lives of their family, and they will often say, ‘‘I drink because I like it.’’ The combination ofgratification from the substance with the unwanted effects of the treatment, such as inconvenience of attending psychological therapy, embarrassment, financial disincentives, and ambivalence about the addictive behavior, can all contribute to addiction persisting. Consequently, substance abuse and addiction are disorders of remission and relapse. Most reviews of alcoholic liver disease concentrate ontreatment of the liver disease and do not address the underlying addiction. In practice, understanding the addiction is the key to understanding the continuum from alcoholic fatty liver to alcoholic cirrhosis. Furthermore, abstinence leads to resolution of alcoholic fatty liver and alcoholic hepatitis,1,2 and, as shown by the classic studies of Powell and Klatskin, is associated with improvedsurvival in alcoholic cirrhotic patients with decompensated liver function (Fig. 1).3 Consequently, there is every reason to encourage alcoholic patients with liver disease to become abstinent. When counseling an alcoholic patient, addiction specialists distinguish between a slip and a relapse.4 A slip is a temporary return to drinking, which is recognized by the patient as potentially harmful, andleads to renewed efforts toward abstinence. A relapse suggests a more sustained resumption of drinking. These events are sometimes characterized as ‘‘harmful,’’ ‘‘abusive,’’ or ‘‘addictive drinking,’’ whereas the term ‘‘recidivism’’ is abjured on account of its pejorative connotations.

Section of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicineand Public Health, H6/516 CSC, 600 Highland Avenue, Madison, WI 53792, USA E-mail address: mrl@medicine.wisc.edu Clin Liver Dis 13 (2009) 267–275 doi:10.1016/j.cld.2009.02.003 1089-3261/09/$ – see front matter ª 2009 Elsevier Inc. All rights reserved. liver.theclinics.com

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Fig.1. Survival after diagnosis of alcoholic cirrhosis (n 5 278) and from onset of decompensation (n 5 233)according to continued alcohol use or abstinence. (From Powell WJ Jr., Klatskin G. Duration of survival in patients with Laennec’s cirrhosis. Influence of alcohol withdrawal, and possible effects of recent changes in general management of the disease. Am J Med 1968;44(3):406–20; with permission.)

Treatment of addiction is directed at establishing and maintaining abstinence from the addictivebehavior. Although continuing drinking that is less frequent or of reduced amounts is less than ideal, it is better than continuing harmful drinking. In contrast, in the world of hepatology, especially transplant, absolute abstinence is considered the only acceptable outcome, and any slip is judged to be a treatment failure. Many addiction specialists think that this is an unreasonable andunrealistic standard.4 Furthermore, some specialists believe that this preoccupation with complete abstinence works against the best interests of the alcoholic patient with liver failure, since the patient may be frightened to seek help when he or she experiences a slip.5 Recent long-term follow-up data suggest that relapse to harmful drinking affects survival after transplantation, whereas a history of a...