Recognizing Addiction in GI and Hepatology Practice, With Hyundam (Dami) Gu, MD, MPH

Addiction and disorders of the gastrointestinal (GI) tract and liver are deeply interconnected, yet the relationship remains underrecognized in routine clinical practice.

In discussing this issue, Hyundam (Dami) Gu, MD, MPH, a postdoctoral research fellow at the Stravitz-Sanyal Institute for Liver Disease and Metabolic Health at Virginia Commonwealth University School of Medicine, emphasized that for gastroenterologists and hepatologists, substance use disorders (SUDs) are not peripheral concerns. Rather, they are central drivers of morbidity, mortality, and transplant need in the United States.

From a hepatology standpoint, she noted that alcohol-associated liver disease (ALD) is now one of the leading causes of chronic liver disease and the leading indication for liver transplantation, with unhealthy alcohol use directly injuring the liver through toxic metabolites, oxidative stress, and activation of inflammatory and immune pathways.

However, Gu was careful to distinguish alcohol use disorder (AUD) from ALD. While the 2 frequently overlap, they are not identical entities.

“We still do not have the clearest picture of what subset of AUD patients or ALD patients develop the other disease and why,” she explained.

Further complicating the identification and management of these patients is the widespread stigmatization of alcohol use, with emerging research suggesting greater levels of stigma surrounding ALD compared with non-alcohol-related liver disease, acting as a barrier to care and causing frequent delays in diagnosis among these patients.

Gu also highlighted the impact of opioid use disorder (OUD) on GI and liver health. Injection drug use continues to drive hepatitis C transmission, contributing to chronic liver disease. In addition, chronic opioid exposure disrupts GI motility, leading to esophageal dysfunction, gastroparesis, constipation, and narcotic bowel syndrome. Heavy cannabis use, she added, is strongly associated with cannabinoid hyperemesis syndrome, and synthetic cannabinoids have been linked to hepatotoxicity.

Despite these well-established connections, Gu identified underrecognition as the primary clinical challenge.

“Many patients are not routinely screened for substance use in GI and hepatology settings, and as a result, unhealthy substance use often goes unidentified until significant organ damage has already occurred,” Gu said.

She also noted that clinicians often rely heavily on self-report, which may be influenced by stigma or concerns about transplant eligibility. Although structured screening tools and objective biomarkers exist, they are not uniformly used.

Importantly, Gu stressed that the issue is not a lack of effective treatments. Rather, it is the failure to identify patients early and integrate addiction care into routine GI and liver practice. Fragmented systems, limited specialist training in addiction medicine, and uncertainty about medication safety in cirrhosis further complicate care.

Ultimately, she argued that integrated, multidisciplinary models are essential. Treating liver disease without addressing substance use does not improve long-term outcomes. Coordinated care, embedded addiction services, and early identification represent a high-impact opportunity to improve survival and organ-specific outcomes.

Editors’ note: Gu reports no relevant disclosures.

References

1. Deutsch-Link S, Byers IS, Gu H, Arab JP. Addiction in Gastrointestinal and Liver Disorders. Am J Gastroenterol. Published online January 21, 2026. doi:10.14309/ajg.0000000000003925

2. Hillenbrand A. Stigma Around Alcohol-Related Liver Disease Poses Major Barrier to Care. HCPLive. November 7, 2025. Accessed March 4, 2026. https://www.hcplive.com/view/stigma-alcohol-related-liver-disease-poses-barrier-care