78. Treating Alcohol Use Disorder in Patients with Severe Liver Disease78. Treating Alcohol Use Disorder in Patients with Severe Liver Disease
Addiction Medicine Journal Club
Two addiction specialists review a large study on medications for alcohol use disorder in people with severe liver disease and reflect on how the findings challenge their own clinical habits. They also touch on the opioid crisis, low treatment uptake, and new feedback on injectable buprenorphine in pregnancy.
33:29•29 Jun 2026
Why Sickest Patients With Alcohol-Related Liver Disease May Gain Most From Medication
Episode Overview
- Medications for alcohol use disorder were associated with significantly better one- and three-year survival in patients with severe alcohol-related liver disease, even though treated patients were sicker at baseline.
- Longer duration of medication use and combining up to three alcohol use disorder medications correlated with lower mortality and very low numbers needed to treat.
- Use of these medications remained low nationally, with cultural barriers, stigma, and limited clinician familiarity highlighted as key reasons.
- The hosts challenge therapeutic nihilism in very ill patients, arguing that those with end-stage liver disease may stand to benefit most from treatment.
- Feedback from researchers on injectable buprenorphine in pregnancy underscores that buprenorphine and methadone are both considered standard of care and that safety data are continuing to evolve.
“The sicker you are, actually, the more benefit you get from some of these interventions.”
What insights can experts and survivors share about addiction? This instalment of Addiction Medicine Journal Club brings together research, clinical experience, and a healthy dose of dry humour as Dr. Sonya Del Tredici and Dr. John Keenan talk through how to treat alcohol use disorder in people with severe liver disease. Aimed squarely at clinicians in addiction medicine and general practice, the chat keeps things practical.
They walk through a JAMA Network Open study of 1,309 patients with severe alcohol-related liver disease referred for liver transplant. The headline finding is hard to ignore: medications for alcohol use disorder used for more than three months were linked with markedly better survival, even though the treated patients were actually younger and *sicker* at baseline. As John puts it, the groups were basically “sicker and sicker,” yet the medicated group still did better.
You’ll hear them unpack the numbers: higher MELD scores, more hepatic complications, and still a big survival advantage with medication. They highlight the striking number needed to treat — down to 4 when three medications for alcohol use disorder are combined — and reflect on how rarely they themselves have gone beyond one drug at a time. That leads to some honest self-audit around therapeutic nihilism and fear of side-effects in patients with decompensated cirrhosis.
The conversation also touches on low national uptake of alcohol use disorder medicines, age-related differences in clinician comfort, and ongoing fallout from the opioid crisis, including the dissolution of Purdue Pharma. Later, they revisit feedback from researchers about injectable buprenorphine in pregnancy, openly correcting and clarifying earlier comments.
If you’re a busy clinician wondering whether it’s “too late” to treat alcohol use disorder in someone with end-stage liver disease, this discussion strongly questions that assumption and may nudge you to rethink your prescribing habits. How might your approach change if you treated these patients as having the *most* to gain from medication, rather than the least?
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