Alan Bonder, MD, and Juan Ramos, PsyD, on Alcohol Use Disorder and the Pandemic: Part 2

In part 2 of this podcast Dr Alan Bonder and Dr Juan Ramos continue their discussion about the increasing incidence of alcoholic liver disease during the COVID-19 pandemic, dealing with relapse, and liver transplantation.

Listen to Part 1 here.

Alan Bonder, MD, is the medical director for liver transplantation at Beth Israel Deaconess Medical Center and an assistant professor of medicine at Harvard Medical School in Boston, Massachusetts. Juan Ramos, PsyD, is the transplant psychologist at Beth Israel Deaconess Medical Center and an instructor in psychology at Harvard Medical School.

TRANSCRIPT:

Welcome to part 2 of this podcast with Drs Alan Bonder medical director for liver transplantation at Beth Israel Deaconess Medical Center in Boston, and Juan Ramos, transplant psychologist at Beth Israel Deaconess, as they continue their discussion about the increasing incidence of alcoholic liver disease, dealing with relapse, and liver transplantation. 

Dr. Bonder:  You bring one, maybe a couple of key points. Number one is although alcohol is an addictive substance, again, we have to consider it as a chronic disease, and we should treat it as one.

Again, we don't discriminate on your liver disease. We give the opportunity if you meet criteria to be listed and evaluated for transplant, if you meet our psychological, psychosocial, and medical criteria to be listed for transplant.

One more thing, Juan, is people are concerned about organs that we're giving to people, and the relapses or slips. We can comment about what are slip and relapse, what's the difference between a slip and a relapse, but we can...

Once you comment on those, we need to emphasize that the mortality from those people coming into the hospital is higher even before getting a liver transplant. We should offer those patients a treatment option if they meet the criteria.

Juan, can you comment on what are rates? What is the difference between a slip, a relapse, and how do we address it? How do we treating those people who are after transplant?

Dr. Ramos:  Those are very good questions on very hot topics even among the addiction community. The definition of relapse or slip is—I think that there's not a clear definition across all centers. However, the way how we define it or we've been defining alcohol relapse —we're doing a huge effort to base that on objective measures. Now that we have certain toxicology screen that we can use to determine if the patient is drinking, and how much is the patient drinking, then we can have a more objective assessment of this process.

The way how we are defining alcohol slip, first, is if the patient has report or have a positive ethanol, and the amount of alcohol that they use is not similar to their previous level of drinking, let's say that they are in a wedding, and they have a glass of champagne or wine, that's considered a slip because the patient didn't return to the previous level of alcohol use.

We are using the PEth also. Usually, in those cases, the PEth is not necessarily positive, but if the patient reports this mild or minimal alcohol use, we work with them. Of course, they have to be engaged in alcohol‑relapse prevention treatment.

That's how we define alcohol slip. The amount of alcohol that is minimal, and the patient did not return to the previous level or previous behaviors similar to alcohol use, and all that.

With the relapse, we're talking about patients that engage in a consistent alcohol consumption. Even though there might be less amount of alcohol than pretransplant, but still engaged in this constant alcohol use, some episode of binge drinking, those patients usually have a positive PEth given the amount of alcohol that they're consuming. That's how we're defining this. Returning to an unhealthy, dysfunctional alcohol use with the confirmation of a PEth score.

I think that this is important, because if we focus on the level of treatment, at least in my opinion, no alcohol‑relapse prevention treatment is not an option. We will not let our patients go over with a chronic condition without treatment.

This difference in alcohol slips versus alcohol relapse helps us to make the determination of the level of alcohol‑relapse prevention care that they need. That can go from groups, individual therapy, individual psychiatric treatment, all the way to intensive outpatient programs, partial hospital programs, depending onthe severity of the relapse.

Dr. Bonder:  Closing our remarks, it is important to send a message out there that Beth Israel Deaconess in Boston as a transplant center is transplanting people coming in with acute alcoholic hepatitis who meet certain psychological/psychiatric criteria. We do have Juan, who is an essential part of our team who are doing those evaluations, commenting those patients who will basically meet criteria and will move forward with liver transplant.

I think one more thing before we close, Juan, is we need to be saying that it's important to seek psychological therapy because alcoholic use disorder is becoming more and more prevalent these days, more with a pandemic.

If you want to send a message to the public to say, hat would you use, or what will you do to try to treat or get help for this disorder, what would you say?

Dr. Ramos:  One of the most important message to our patients and to providers is to have a consistent message. We, as a team, as providers, we have to be clear that even though the patient is really willing to maintain their sobriety, it's unfair for the patient to ask them to maintain sobriety for life without treatment.

As providers, we have to be very consistent on that messages that, "Yes, we're doing pretty well, things are going well for you. We have to keep this going with professional help." And hat professional help is alcohol relapse prevention, mental health treatment if needed. That message has to be consistent across the board with all the specialists and across the transplant team.

I think that's essential because if we take this seriously, the patient and the family will take it as well. As serious as any other recommendation that we make to our patients.

Dr. Bonder:  I think one more message that we want to send. The psychosocial part of our evaluation is as important as a medical part, so we value the opinion of Juan and our social workers evaluating those patients. They're part of our team.

Again, sending the message that acute alcoholic hepatitis is currently an indication for transplantation. We will evaluate those patients here at our center, and we will decide if those patients are good candidates for liver transplant.

With that said, I would like to thank Dr. Ramos for his help. I work with him on a daily basis. It’s a pleasure to get to interact and know about all these alcoholic dependence and disorders that for us is so crucial in our day‑to‑day workday. Thanks so much for joining us in Gastroenterology Learning Network and hope we can have you here in the future to discuss good outcomes after what we're doing today.

Dr. Ramos:  My pleasure. Thank you so much.