==== Front Hepatol Commun Hepatol Commun HC9 Hepatology Communications 2471-254X Lippincott Williams & Wilkins Hagerstown, MD 37378631 HEP4-23-0444 10.1097/HC9.0000000000000202 00021 3 Editorial Medications for alcohol use disorder among patients with alcohol-associated cirrhosis: An underutilized intervention that could save lives https://orcid.org/0000-0002-5475-2713 Wakeman Sarah E. swakeman@partners.org Department of Medicine, Massachusetts General Hospital, Mass General Brigham, Office of the Chief Medical Officer Harvard Medical School, Boston, Massachusetts, USA Correspondence Sarah E. Wakeman, 55 Fruit Street, Austen 860 Boston, Massachusetts 02114. Email: swakeman@partners.org 7 2023 28 6 2023 7 7 e0020222 5 2023 22 5 2023 Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Study of Liver Diseases. 2023 https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0/ OPEN-ACCESSTRUE Read-alongYES ==== Body pmcIn a recent issue of Hepatology Communications, Rabiee et al1 present findings from an evaluation of the impact of medications for alcohol use disorder (MAUD) on all-cause mortality among people with alcohol-associated cirrhosis. This study utilized a data set of veterans from 2008 to 2021, who had a diagnosis of alcohol use disorder (AUD), alcohol-associated cirrhosis (ARC), and a recorded AUDIT-C of 8 or higher in the year before their cirrhosis diagnosis. They then examined the impact of newly initiated acamprosate or oral naltrexone on all-cause mortality. MAIN FINDINGS Among 9131 included individuals, fewer than 1 in 10 were treated with MAUD for a week or longer in the year after ARC diagnosis, which speaks to the tremendous treatment gap for AUD. MAUD treatment rates did increase over the study time period, from 4% in 2008 to 23% after 2017, which is a positive sign of increasing treatment access. Treatment duration was overall relatively short, with 61% treated for <3 months with MAUD. As with other types of substance use disorder (SUD) treatments, such as medication for opioid use disorder, disparities were seen in who was treated with MAUD, with the odds of MAUD in White patients 1.5 times higher than in Black patients. Hospitalization for AUD was associated with MAUD initiation, and an inpatient diagnosis code for AUD was the variable most strongly associated with receipt of MAUD. In contrast, those with decompensated cirrhosis were less likely to receive MAUD. Using propensity-matched cohorts, the authors found that, in the intention-to-treat analysis, MAUD treatment in the first year after ARC diagnosis was associated with a 20% reduced mortality. Duration of MAUD treatment was associated with a greater reduction in mortality. Treatment for >3 was associated with a 27% reduced hazard of dying. MAUD IS LIFESAVING These findings demonstrate the lifesaving potential for MAUD among people with ARC and the urgent need to close the remaining treatment gap, particularly for those with liver disease. Amidst rising alcohol-associated mortality among younger individuals, the need for standardized approaches to ensure treatment for AUD has never been more urgent.2,3 The finding that only 1 in 10 individuals with a potentially fatal alcohol-associated health condition, who were accessing health care regularly and were known to have AUD, was treated speaks to the lack of integration of AUD treatment into general medical settings. Prior research has found that almost half of individuals with ARC have had previous health care touchpoints for alcohol-associated diagnoses.4 Each of these represents a reachable moment, where clinicians have an opportunity to initiate effective treatment including MAUD, irrespective of whether the individual came in expressly asking for AUD treatment. MAUD IS UNDERUTILIZED The low rates of treatment in this study are similar to those of others demonstrating underutilization of MAUD with only 4%–12% of individuals with AUD treated with pharmacotherapy.5 Clinicians miss opportunities to address alcohol use even when patients bring it up. For example, a study of primary care physicians found that patients share information about their alcohol use frequently, and yet, physicians often do not explore that information when shared, and when they do advice is vague compared with how physicians respond to tobacco use.6 Patients also share that they would feel comfortable discussing alcohol use with a physician they trust. For example, in a qualitative study on the topic a patient shared, “I’m very comfortable with my provider. That’s why I told her about what was going on. And so [in the appointment] I’m starting to open up to her and tell her the specifics of [my drinking] and … she listened, and was very compassionate, as always. [She] has been my care provider for the past 3 years, so … I’m very comfortable with talking to her about this subject”7. Although hepatologists frequently care for individuals with alcohol-associated liver disease, discomfort and lack of uptake around offering MAUD remain a challenge. A previous study looking at MAUD treatment among hepatologists found that, although 60% had treated a patient with MAUD, only 16.8% treated more than 20% of their active AUD population with MAUD.8 HOW TO INCREASE MAUD INITIATION In this study, prior inpatient AUD code and hospitalization were associated with higher odds of MAUD use. This emphasizes the importance of making MAUD standard practice for hospitalized patients with AUD. This is consistent with current consensus for other types of SUD, most notably opioid use disorder, where superior outcomes are observed when patients are started on medication during hospitalization or emergency department encounters and linked directly to ongoing care without interruption in pharmacotherapy.9,10 That model can and should be employed for AUD. Increased MAUD initiation could be encouraged in 4 ways. First, MAUD initiation should be tracked as quality and contract performance measures. Second, addiction medicine education should be incorporated into all levels of undergraduate and graduate medical education to ensure that all physicians—hepatologists included—leave training with basic competency in treating AUD as they do for other prevalent health conditions. Third, clinical decision support should be built into electronic health records to make it easy for clinicians to do the right thing. Finally, and most importantly, to increase the likelihood that hepatologists, and all physicians, will offer MAUD to a patient with AUD, we need to address the issue of AUD exceptionalism.11 The approach to AUD is no different than for any other chronic, treatable health condition physicians deal with regularly. We need to screen for it, diagnose it, start treatment expeditiously, and seek out expert care for more complex cases. Yet, study after study has demonstrated the many barriers that physicians and other healthcare clinicians identify when asked about treating AUD. The barriers cited for AUD treatment mirror those for other types of SUD and include worries about administrative burden, care interruptions, multimorbidity, and limited time to deliver direct care to patients.11 However, those barriers exist for all medical conditions that we treat, are not unique to AUD, and are rarely cited as a reason to not manage hypertension or HIV or cirrhosis. The major challenge that we need to overcome is the ideology that we have all been exposed to as members of a society that is stigmatized toward SUD. As physicians, we have all been exposed to these biases, including the idea that people with AUD are to blame for their medical complications. Therefore, even when we start to talk about AUD as a health condition, we continue to treat people living with it as if it is an issue of bad behavior. One only has to look as far as our differential approaches to NAFLD compared with ALD to see the impact of these societal stereotypes. I have lost count of how many individuals I have personally seen declined for transplant and die from ALD in the hospital, while I have yet to see the same for someone with NAFLD. This study adds to the growing body of evidence that, while ALD is a brutal public health and medical challenge to tackle, we have effective, lifesaving tools to utilize. MAUD has the potential to save lives. In the year 2023, offering it in all care settings should be the standard of care. CONFLICTS OF INTEREST The author has no conflicts to report. Abbreviations: ARC, alcohol-related cirrhosis; AUD, alcohol use disorder; MAUD, medication for alcohol use disorder; SUD, substance use disorder. ==== Refs REFERENCES 1 Rabiee A Mahmud N Falker C Garcia-Tsao G Taddei T Kaplan DE . Medications for Alcohol Use Disorder improve survival in patients with hazardous drinking and alcohol related cirrhosis. Hepatol Commun. 2023;7 :e0093.36972386 2 Spillane S Shiels MS Best AF Haozous EA Withrow DR Chen Y . Trends in alcohol-induced deaths in the United States, 2000-2016. JAMA Netw Open. 2020;3 :e1921451.32083687 3 Tapper EB Parikh ND . Mortality due to cirrhosis and liver cancer in the United States, 1999-2016: observational study. BMJ. 2018;362 :k2817.30021785 4 Askgaard G Kjær MS Tolstrup JS . Opportunities to prevent alcoholic liver cirrhosis in high-risk populations: a systematic review with meta-analysis. Am J Gastroenterol. 2019;114 :221–32.30353053 5 Williams EC Matson TE Harris AHS . Strategies to increase implementation of pharmacotherapy for alcohol use disorders: a structured review of care delivery and implementation interventions. Addict Sci Clin Pract. 2019;14 :6.30744686 6 McCormick KA Cochran NE Back AL Merrill JO Williams EC Bradley KA . How primary care providers talk to patients about alcohol: a qualitative study. J Gen Intern Med. 2006;21 :966–72.16918743 7 CucCucciare MA Lewis ET Hoggatt KJ Bean-Mayberry B Timko C Durazo EM . Factors affecting women’s disclosure of alcohol misuse in primary care: a qualitative study with U.S. military veterans. Womens Health Issues. 2016;26 :232–239.26341569 8 Cotter TG Ayoub F King AC Reddy KG Charlton M . Practice habits, knowledge, and attitudes of hepatologists to alcohol use disorder medication: sobering gaps and opportunities. Transplant Direct. 2020;6 :e603.33134483 9 D’Onofrio G O’Connor PG Pantalon MV Chawarski MC Busch SH Owens PH . Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313 :1636–44.25919527 10 Liebschutz JM Crooks D Herman D Anderson B Tsui J Meshesha LZ . Buprenorphine treatment for hospitalized, opioid-dependent patients: a randomized clinical trial. JAMA Intern Med. 2014;174 :1369–76.25090173 11 Joudrey PJ Oldfield BJ Yonkers KA O’Connor PG Berland G Edelman EJ . Inpatient adoption of medications for alcohol use disorder: a mixed-methods formative evaluation involving key stakeholders. Drug Alcohol Depend. 2020;213 :108090.32559667