Liver transplantation in patients with alcohol and other substance use disorders.

It is unfortunate that LT is not the ultimate sobering experience. LT patients can and do relapse; however, relapse to alcohol or substance use should no more be considered a failure of LT than the recurrence of HCV after LT. It is a phenomenon of their addiction. As a group, the survival and outcomes of patients undergoing LT for ALD are not significantly different from those undergoing LT for other causes. The fact that few patients return to heavy and deleterious alcohol or substance use attests to the success of programs in selecting patients capable of caring for themselves and their livers after LT. In the pre-LT phase, establishing the correct addiction diagnosis is essential so that those at highest risk can be carefully monitored. Although information is emerging about other risk factors for relapse, the authors caution against considering patients with these characteristics as being categorically unfit for LT. Each individual is unique, and such factors should guide clinical decision making rather than being absolute contraindications. After LT, clinical interviews, preferably by a trained psychiatric physician or clinician, are essential to monitoring alcohol and substance use, and surveillance early on is required. Much work needs to be done with respect to substance use and relapse after LT because few studies have explored these issues. In addition, the special treatment needs of those who relapse has not been addressed. Treatment research is underway but has relied on traditional strategies that are not always applicable to LT recipients. Further areas to improve clinical care include improving health behaviors, specifically, smoking cessation. The authors anticipate that, in the near future, the ongoing work in this area will provide information and guidance to physicians and clinicians caring for these unique patients.