Liver Transplantation and Alcoholism Rehabilitation.

In the excitement of finding a remarkably high rate of first-year abstinence among his alcoholic liver transplant patients (Starzl et al. 1988), Dr. Thomas Starzl, the pioneer of transplant surgery in this country, commented to the press that liver transplantation might be the ultimate cure for alcoholism.(1) His study of transplanted alcoholic patients was published with little comment on methods of patient selection or of posttransplant care. Five years later Starzl and colleagues presented data that argued the opposite case-that those with alcoholic hepatitis and cirrhosis show remarkably high rates of relapse to uncontrolled drinking despite having undergone liver transplantation (see Bonet et al. 1993). How can one find a rational approach between these two extremes? The best answer is a complex one, requiring a careful understanding of the methods of preoperative patient selection and of postoperative care. This article offers a brief overview of the topic; for more detail, see Lucey et al. 1994. Table 1 lists the data from four liver transplant programs.(Table 1 omitted) These programs have reported 1-year abstinence rates among liver transplant recipients who also suffered from preexisting alcohol addiction. All programs reported first-year abstinence rates that approximated 90 percent, a remarkably high frequency when compared with the 30- to 50-percent range reported in alcoholism treatment studies that did not involve a procedure as drastic as liver transplantation (Moos 1990; Vaillant 1983). On the surface, it is easy to conclude that a chronic life-threatening illness, followed by the extreme stress of a lengthy operation and its ensuing recovery, might deter a patient from future drinking. There is the added implication that the patient will not receive another transplant if drinking begins again and results in a second liver failure. A closer look at the programs reveals several common threads. Each program carefully selects and then follows those alcohol-dependent patients for whom the program will agree to provide a liver transplantation. Selection is based in part on the perceived risk that a particular patient will return to uncontrolled alcohol use. The University of Michigan' s liver transplant program has led in the development of selection procedures for alcoholic transplant candidates (Beresford et al. 1990), and each of the other programs incorporates some aspects of these procedures in their own formulations. However, the questions arise: Are there empirical guidelines for predicting long-term remission from alcohol dependence? In particular, does the transplant itself have a positive effect on maintaining abstinence? Currently, there are only partial answers to these questions, which are discussed below. PREDICTING ABSTINENCE Research has shown the following characteristics among patients who are likely to maintain long-term abstinence: (1) self-recognition of alcohol dependence and acceptance of it as a condition to be dealt with, (2) a socially stable living environment, (3) freedom from severe psychiatric disorders, and (4) available resources that facilitate continued abstinence (Beresford 1990; Lucey et al. 1994). Vaillant' s work(1983) is especially pertinent. In an 8-year prospective(2) study, he noted that alcoholics who had been abstinent for 3 years or longer had at least two of four clinical indicators. First, they structured their time with substitute activities that limited the potential time they could spend drinking. Second, they had developed a relationship with a person committed to their well-being who put clear limits on his or her toleration of their drinking. Third, they found a sense of hope or of improved self-esteem in some aspect of their lives that counteracted the often intense guilt they felt as a he result of their pathological alcohol use. Fourth, they suffered some noxious consequence of drinking, such as severe abdominal pain from pancreatic inflammation or an ethanol-disulfiram reaction(3) (see the article by Anton, pp. …