Barriers to Pharmacotherapy for Alcoholism after Liver Transplant

Abstract

731 Alcoholic cirrhosis & hepatitis C either alone or together are the most common indications for liver transplantation in the USA. The benefits of standard alcoholism treatments have not been studied in the liver transplant population. Approximately 40% of alcoholic liver transplant recipients relapse to some alcohol use by 5 years post-transplant. Since many are too ill to tolerate treatment before transplant, we proposed a post-transplant intervention. Purpose: Our purpose was to pilot the safety/efficacy of naltrexone and an established brief alcoholism therapy, Motivational Enhancement Therapy. Methods: 60 recently transplanted, DSM4 alcohol dependent subjects were to be randomized to 6 months of double-blind naltrexone, 50mg. vs. placebo, and a third comparison group was to attend AA meetings only. Follow-up was 18 months. From 12/95 to 3/98, 31 alcoholic liver transplant recipients were screened and 25 were randomly approached or referred by nurse coordinators within 2 mos. of transplant. 8 refused, 7 were ineligible and 5 too ill. 5 were randomized and a further 7 died before they could be invited to participate. Results: Reasons for attrition were as follows (some gave more than one reason): Of the 8 who refused; 3 felt alcoholism was no longer a problem, and one denied ever being alcoholic; 2 lived too far; 4 were preoccupied with medical concerns and 1 cited financial stresses. Of 7 ineligible subjects, 4 were sober > 10 years and 3 had DSM4 alcohol abuse, not dependence. Of 5 who were too ill, most were weak and debilitated and 1 became severely depressed, had a heavy alcohol relapse and attempted suicide. Of the 5 active subjects, all were men. Of 3 randomized to medication, 2 dropped out due to worsening medical complications and 1 refused to take the study drug because of the fear of naltrexone induced hepatotoxicity. 2 subjects were randomized to the AA group, but did not attend AA. Both had significant depression and anxiety. All dropped out of the treatment phase within 2 months. One continued through 18 months of follow-up after stopping the study drug. No subjects reported any post-transplant drinking. Conclusions: In our center, established alcoholism treatments were not accepted or were poorly tolerated by liver transplant recipients. The most common reasons were; serious debilitation, preoccupation with daily matters or denying the need for alcohol treatment. All who began the study dropped out of the treatment phase within 2 months from medical or psychiatric problems. We found significant barriers to the acceptability of post-transplant alcoholism treatment. Given that relapse occurs after liver transplant and may result in significant health problems, we suggest alcoholism interventions need to be investigated prior to transplant.