Chris Kahler, PhD, is a professor of behavioral and social sciences, a professor of psychiatry and human behavior, and the director of the Center for Alcohol and Addiction Studies at Brown University.

Chris Kahler, PhD

Discussion between 3 subject matter experts on the impact of stigmatization on outcomes of alcohol-related liver disease.

HCPLive Alcohol Stigma Discussion Part 2

Shame derived from structural or self-stigma may inhibit patients from obtaining treatment for their 

. This could be because patients might downplay their drinking problems. By internalizing cultural norms surrounding 

, those with alcohol-related liver disease might fear being labeled as an “alcoholic.” 

The healthcare system was designed to separate addiction and hepatology care. Patients would see their alcohol or addiction specialist for alcohol-related issues and would see their hepatology specialist for liver problems. This contributes to patients feeling like they are the ones to be blamed—that their alcohol use was the sole reason they had developed liver disease.

However, this is not true. Although alcohol can lead to liver problems, other causes such as genetics or obesity can lead to liver issues, too.

Research suggests work needs to be done on de-stigmatizing alcohol-related liver disease. A 

 revealed limited usage of non-stigmatization language for AUD and alcohol-related liver disease, underscoring the need for more patient-centered language in transplant centers.

 special report, Hersh Shroff, MD, MPA, moderated a conversation between hepatology specialist Jay Luther, MD, and addiction specialist Chris Kahler, PhD, to discuss the stigmatization of AUD and how hepatologists and addiction specialists can work to collaborate to give patients improved care.

The first part of the report focused on the different types of stigma and how the stigma around AUD may contribute to delays in seeking care for liver disease. The second half of the discussion pivoted to how the collaboration between hepatology and addiction specialists may reduce the stigma surrounding alcohol-associated liver disease.

“To expect that the individual necessarily will have full control over their capacity to say, ‘I can stop drinking tomorrow’ is not realistic for many people,” Kahler said. “It involves not just the involvement of psychiatrists, but social workers, or psychologists, other people who can think about the social determinants of health because those are often driving factors both in alcohol use, but also in delays in seeking care.”

He added the importance of peer support or recovery coaches to share experiences with to reduce the stigma. He also said screening for unhealthy alcohol use is important, rather than a doctor telling their patient, “I think you need to quit drinking.” Kahler stressed the importance of referring the patient to a liver specialist so they can examine actual negative impacts instead of making assumptions.

“Catching patients early or getting patients in who are at high risk for developing disease, so they never develop disease… are critical pieces to the puzzle that…need more attention,” Luther said.

Check out the first half of the discussion: 

https://www.hcplive.com/view/recognizing-stigma-impact-care-alcohol-related-liver-disease

 a transplant hepatologist and an assistant professor of medicine at the University of North Carolina School of Medicine

 an assistant professor of medicine at Harvard Medical School and director of the Massachusetts General Hospital Alcohol Liver Center

 a professor of behavioral and social sciences, a professor of psychiatry and human behavior, and the director of the Center for Alcohol and Addiction Studies at Brown University

Shroff, Luther, and Kahler have no relevant disclosures.

Schomerus G, Leonhard A, Manthey J, et al. The stigma of alcohol-related liver disease and its impact on healthcare. 

. 2022;77(2):516-524. doi:10.1016/j.jhep.2022.04.026

Mahle R, Okanlawon A, Luther J, Louissaint J, Zhang W. Stigmatizing Language for Alcohol Use Disorder and Liver Disease on Liver Transplant Center Websites. 

. 2024;7(2):e2355320. Published 2024 Feb 5. doi:10.1001/jamanetworkopen.2023.55320

Brooks, A. The Power of Words: Liver Transplant Centers Continue to Use Stigmatizing Language. 

https://www.hcplive.com/view/the-power-words-liver-transplant-centers-continue-use-stigmatizing-language

Videos

The second segment of a special report stresses the importance of cross-specialty collaboration with hepatology and psychiatry when treating alcohol-related liver disease.

Addressing Stigma to Improve Outcomes in Alcohol-Related Liver Disease

Discussion between 3 subject matter experts on the impact of stigmatization on delays in diagnosis of alcohol-related liver disease.

HCPLive Alcohol Stigma Discussion Part 1

Recent years have seen a drastic increase in alcohol use in the United States. Alongside this growing prevalence has come an influx of severe morbidity and mortality linked to 

, with the National Institute on Alcohol Abuse and Alcoholism citing alcohol’s involvement in nearly half of all liver disease deaths among people 12 years of age and older in 2022 and labeling alcohol as one of the leading causes of preventable death.

Many cases of ALD are rooted in underlying 

, a medical condition involving frequent or heavy alcohol consumption that often requires an individualized treatment approach with a combination of medication, behavioral interventions, and mutual support groups. According to the 2022 National Survey on Drug Use and Health, 29.5 million people ages 12 and older had AUD in the past year. Of this group, 2.2 million received alcohol use treatment.

Although it is a mental health disorder, AUD’s role in the development and progression of ALD underscores the importance of its treatment alongside medical intervention for the liver and other potential negative physical impacts of alcohol use. However, it tends to fall by the wayside due to a number of patient, clinician, and system barriers, many of which are linked to the stigma surrounding AUD and its negative impact on patients’ willingness to seek care as well as clinicians’ ability to provide adequate care.

In this HCPLive special report, our moderator, Hersh Shroff, MD, MPA, is joined by Jay Luther, MD, and Chris Kahler, PhD, to discuss the stigmatization of AUD. The first segment of their conversation focuses on defining stigma, both at the public and structural level, and outlining its role in delaying and hindering care for these patients.

Shroff introduces the topic and poses a question to Kahler about the different forms and definitions of stigma and how public perception of AUD may contribute to delays in seeking care. Kahler responds by describing stigma as a “complex construct,” explaining its manifestation at both social structural levels and individual levels as well as how the stigma surrounding AUD may lead patients to underreport their alcohol consumption, avoid discussing concerns with their clinician, and hesitate to seek care from a specialist.

Shroff expresses agreement with Kahler’s response and poses a similar question to Luther, this time inquiring about how structural stigma in the health care system perpetuates disparities for patients with ALD. Similar to Shroff, Luther notes he agrees with Kahler’s response and mentions how certain aspects of this individualized stigma are also present at a greater structural level.

He goes on to describe how the disease has been labeled, pointing to inherent problems with the terms alcoholic liver disease and alcoholic hepatitis and how the term “alcoholic” contributes to the ongoing stigma in ways clinicians may not even realize. Structurally, Luther notes that there has been little to no overlap between the treatment of liver disease and the treatment of alcohol addiction, forcing patients to see different specialists and potentially making them feel as though they are being judged or blamed for their alcohol use.

However, Luther goes on to explain how some institutions, including his own, are taking strides to combat this structural stigma by incorporating what he calls a “team approach” with combined efforts from a hepatologist, an addiction specialist, and a social worker whose shared goal is to “get you feeling better to get you healthier.”

Check out the second half of the discussion:

National Institute on Alcohol Abuse and Alcoholism. Alcohol Use in the United States: Age Groups and Demographic Characteristics. Alcohol’s Effects on Health. 2023. Accessed April 30, 2024. 

https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-use-united-states-age-groups-and-demographic-characteristics

National Institute on Alcohol Abuse and Alcoholism. Alcohol and the Human Body. Alcohol’s Effects on Health. 2024. Accessed April 30, 2024. 

https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-and-human-body

Cleveland Clinic. Alcohol Use Disorder. Diseases & Conditions. June 2, 2021. Accessed April 30, 2024. 

https://my.clevelandclinic.org/health/diseases/3909-alcoholism

National Institute on Alcohol Abuse and Alcoholism. Alcohol Use Disorder (AUD) in the United States: Age Groups and Demographic Characteristics. Alcohol’s Effects on Health. 2023. Accessed April 30, 2024. 

https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-use-disorder-aud-united-states-age-groups-and-demographic-characteristics

In the first segment of this HCPLive special report, experts discuss the stigma surrounding alcohol use disorder and alcohol-associated liver disease.

Chris Kahler, PhD

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