Integrating Treatments for Alcohol Use Disorder into Hepatology Clinics

摘要 酒精相关肝病(ALD)死亡，这是酒精使用障碍(AUD)的严重后果， 在过去的二十年里大幅上升。尽管减少和停止饮酒是至关重要的 作为ALD治疗的组成部分，少数AUD和ALD患者接受了AUD的治疗，包括行为 治疗或药物(MOUD)，由于临床医生、患者和系统层面的障碍，从缺乏 对污名的熟悉。AUD的治疗，包括MOUD，与患者的肝脏特异性益处有关 使用ALD，例如减少并发症，包括肝硬变或肝脏瘢痕形成，以及肝脏 失代偿，或肝功能严重恶化。因此，ALD的治疗指南 建议为AUD和ALD患者提供AUD治疗，但对哪种治疗知之甚少 治疗在这一人群中可能是最大的好处，以及如何最有效地提供这些治疗。有一个 缺乏关于不同形式的MOUD在AUD和AND患者中的比较有效性的数据 AUD和ALD患者在接受AUD方面的观点的有限考虑 治疗。最后，在多学科团队共同部署肝病和成瘾专家的同时，促进 AUD和ALD患者的AUD治疗已被描述，这些护理模式是资源- 密集的，不常见的。因此，需要替代战略来通知澳元的交付 AUD和ALD患者的治疗。肝病临床医生处于有利地位，可以提供完整的 AUD治疗，如MOUD和短暂咨询，在常规情况下为AUD和ALD患者提供咨询 肝病护理。现有的NIAAA资源，例如医疗保健专业人员关于酒精的核心资源 (HPCR)和酒精治疗导航器(ATN)，可随时获得，但尚未为其量身定做 在肝病诊所实施。因此，这项工作的具体目标是：1)确定 根据肝病严重程度比较不同形式的MOUD在AUD患者中的疗效 相对于非MOUD，2)在AUD和ALD患者中引起AUD治疗偏好，特别是 关于肝病临床综合咨询和短期咨询的问题，以及3)确定可行性和 一种新的实施干预措施促进MOAD和短期咨询在肝病中的可接受性 使用HPCR和ATN的诊所提供临床决策支持。作为一名经过董事会认证的肝病专家和瘾君子 医学专家，受过医疗服务研究方面的培训，我非常适合领导整合澳元的努力 把治疗送进肝病诊所。在具有药物流行病学专业知识的导师的指导下，混合方法 研究、临床试验和实施科学，这项工作将产生重要的基础数据和 为我提供了在这些互补领域建立方法专长的机会。这将是 对于实现我的目标至关重要，成为一名独立的临床医生-研究员，致力于优化护理 在AUD和ALD患者中。

ABSTRACT Deaths due to alcohol-associated liver disease (ALD), a serious consequence of alcohol use disorder (AUD), have risen substantially over the past two decades. Although reduction and cessation of alcohol use is a vital component of treating ALD, few patients with AUD and ALD receive treatment for AUD, including behavioral treatment or medications (MAUD), due to clinician, patient, and system-level barriers ranging from lack of familiarity to stigma. Treatment of AUD, including MAUD, is associated with liver-specific benefits in patients with ALD, such as reductions in complications including cirrhosis, or scarring of the liver, and hepatic decompensation, or severe deterioration of liver function. As such, guidelines on the treatment of ALD recommend AUD treatment be provided to patients with AUD and ALD, however little is known regarding which treatments may be of greatest benefit in this population and how to deliver them most effectively. There is a lack of data regarding the comparative effectiveness of different forms of MAUD among patients with AUD and ALD and limited consideration of the perspectives of patients with AUD and ALD with regard to receipt of AUD treatment. Finally, while multidisciplinary teams of co-located hepatology and addiction specialists to facilitate AUD treatment in patients with AUD and ALD have been described, these models of care are resource- intensive and not commonly available. Therefore, alternative strategies are needed to inform delivery of AUD treatment for patients with both AUD and ALD. Hepatology clinicians are well-positioned to provide integrated AUD treatment, such as MAUD and brief counseling, for patients with AUD and ALD in the context of routine hepatology care. Existing NIAAA resources, such as the Healthcare Professional’s Core Resource on Alcohol (HPCR) and Alcohol Treatment Navigator (ATN), are readily available but have not been tailored for implementation in hepatology clinics. Therefore, the Specific Aims of this work are to: 1) Determine the comparative effectiveness of different forms of MAUD among patients with AUD by liver disease severity, relative to no MAUD, 2) Elicit AUD treatment preferences among patients with AUD and ALD, particularly regarding integrated MAUD and brief counseling in hepatology clinics, and 3) Determine the feasibility and acceptability of a novel implementation intervention to promote MAUD and brief counseling in hepatology clinics using the HPCR and ATN with clinical decision support. As a board-certified hepatologist and addiction medicine specialist with training in health services research, I am well-suited to lead efforts to integrate AUD treatment into hepatology clinics. Guided by mentors with expertise in pharmacoepidemiology, mixed-methods research, clinical trials, and implementation science, this work will generate important foundational data and provide me with the opportunity to build methodological expertise in these complementary areas. This will be critical to achieve my goal of becoming an independent clinician-investigator dedicated to optimizing the care of patients with AUD and ALD.