Ramon Bataller, head of Hepatology at the Hospital Clínic (Barcelona) and a world-renowned researcher on the damage that alcohol causes to the liver, needs only a pen and a piece of paper to summarize in three lines the great challenge he faces. his speciality.
“Alcohol is the leading cause of hospitalization and death from liver disease,” he writes in the first.
“The only measure that can save patients' lives is to stop drinking;
It doesn't matter what you give them, if they don't, in the medium term, the disease will progress to forms that lead to high mortality," says the second.
“With this simple equation, it seems obvious that the most important thing for a hepatologist is to get the patient to give up alcohol.
But the reality is that we don't know how to do it well," he summarizes in the third as a conclusion before adding out loud: "We have few tools and some, like the medications available, we don't know how to use at all well.
And we work too far from psychologists and psychiatrists, who are our great allies to be successful.”
Bataller writes his reflections on a page of the program of the 49th edition of the Annual Congress of the Spanish Association for the Study of the Liver (AEEH), the meeting in which the country's specialists shared experiences and scientific advances last week in Madrid.
A forum that in the last decade has witnessed great recent successes in medicine, such as treatments that cure hepatitis C, but which continues to be resisted by a problem almost as old as humanity: the toxic effects of alcohol.
Every year, more than 15,000 people die in Spain from causes attributable to this legal drug, according to a report from the Ministry of Health published in 2021. 9% of the population aged 15 to 64 drank daily during the 30 days prior to taking the test. the 2023 AGES survey of the National Drug Plan.
6.4% of citizens admit to having gotten drunk in the last month (8.5% of men and 4.2% of women), while 15.4% (20.3% and 10.4%, respectively) ) has engaged in the so-called “binge drinking”, consisting of drinking five or more alcoholic drinks in less than three hours in the case of men and four in the case of women.
Boxes of two medications used to stop drinking, Antabus and Lioresal, in a pharmacy in Madrid.Álvaro García
These percentages, experts warn, show the enormous challenge posed by the fight against alcohol use disorder.
“I tell my patients that they have to learn to say no.
And this may seem very simple, but it is terribly complicated for a person with a serious dependency problem in a society in which alcohol is so ingrained and linked to important moments of social and family life.
We need more tools and make better use of the ones we already have,” says Gloria Sánchez Antolín, head of the Hepatology unit.
from the Río Hortega Hospital (Valladolid).
There are many factors—socioeconomic, genetic and cultural—that influence whether a person develops dependence on alcohol and suffers from one of the 200 diseases that the World Health Organization (WHO) relates to this substance.
For this reason, experts point out, there is no single way to address all cases, although there are two key pillars in many cases: “Psychological-social and pharmacological support,” adds Sánchez Antolín.
Experts regret that, unlike other addictions such as tobacco, in recent years there have been no new medications that provide substantial improvements against alcoholism.
“We have not seen a Champix come onto the market, we have been left behind or somewhat neglected by the pharmaceutical industry,” they lament in reference to the well-known smoking cessation therapy.
New research presented at the AEEH congress, however, reveals the potential of a drug that has been available for years and that, for various reasons, is not always used.
It is baclofen, a muscle relaxant marketed under the brand Lioresal and indicated for pain and certain types of spasticity (stiffness and hardening of the muscles) that has also been shown to be helpful for alcohol use disorder.
“We have obtained very good results with a pilot study that we now want to expand over time and with more hospitals,” explains Jordi Sánchez, hepatologist at the Parc Taulí hospital (Sabadell) and principal investigator.
The work has followed the evolution of 40 patients, 85% of whom suffered from liver cirrhosis, who also received psychosocial care.
After three months, 50% were still not drinking and 22.5% had reduced consumption.
At six, 45% of the patients under follow-up were still abstaining and 20% were drinking less.
The doses used are low, up to 30 milligrams per day in three doses - the technical information sheet provides for up to 80 milligrams per day - so side effects are usually minor (mainly drowsiness) and manageable by adjusting the doses.
Jordi Sánchez, hepatologist at the Parc Taulí hospital in Sabadell, at the AEEH congress.
Samuel Sanchez
The good results obtained come up against, however, a shocking obstacle highlighted by the study itself: “There is little experience with the use of baclofen in our area.
Prescription by specialists, both in hepatology and psychiatry, is low.”
In fact, and although the possible use of the molecule against alcoholism is known, this indication is not included in the technical sheet.
Much of the reluctance to use the drug is explained by the complexity of treating patients with advanced liver diseases.
“These are patients with very damaged livers, so the use of any drug is very limited.
There is fear when prescribing them due to the potential adverse effects,” explains hepatologist Cristina Solé, co-author of the work with Berta López, both from the Parc Taulí Hepatology service.
Jordi Sánchez confesses that one of the reasons for starting this investigation was “frustration.”
“We have experienced great progress against hepatitis B and C and we almost have no income from it.
The vast majority of hospitalized people are now hospitalized due to alcohol.
And although we see that the most important thing is to achieve abstinence, that is where hepatologists intervene the least.
So we said to ourselves: why don't we take a step forward? ”He relates.
This medication is not the only one available to help patients who want to quit alcohol.
Another is Antabus, probably best known because it makes patients who take it feel terribly ill if they drink.
The reason is that its active ingredient, disulfiram, interrupts the alcohol metabolization process in the body.
This increases the concentration of acetaldehyde in the blood—a toxic compound—which causes the patient to suffer very unpleasant symptoms (facial redness, headache, tachycardia...) if they drink a drink.
“Antabus is effective in patients who do not suffer liver damage, but it is contraindicated in those who do.
And this represents a significant risk, because many times liver ailments occur asymptomatically.
This has led to several cases of serious adverse effects and death,” says Bataller.
This specialist insists on the need to perform a liver elastography - a test similar to an ultrasound that confirms the good condition of the liver - on all patients before starting treatment with Antabus.
Naltrexone, also used for opioid addiction, and acamprosate, which reduces the risk of relapse, are other treatments used for alcohol use disorder, although Bataller highlights what he believes are the best alternatives available. : “You have to study the case of each patient.
If it has been proven that there is no liver damage, Antabus is a good option.
But baclofen is effective, safe, cheap and has the strongest evidence in people who have already developed cirrhosis.
It is the only one with a randomized and double-blind trial [those that provide better evidence] published in a journal of the level of
The Lancet
for this type of patients
. ”
All the experts consulted highlight the need to advance the integration of the work of hepatologists and addiction experts (psychiatrists, psychologists...).
“I tell all my patients that they have to go to the Addictive Behavior Unit, but then the majority don't even go.
It is true that many find it difficult to accept that they have to take the step, but we do not make it easy for them either.
We should be able to approach the patient from a single consultation,” explains Bataller, who will soon participate in a trial to elucidate whether Ozempic, indicated for diabetes but widely used for weight loss, is also useful for curbing alcohol abuse.
At the Parc Taulí hospital they agree on the need to integrate the work of hepatologists and mental health experts.
“We insist to the patient that he has to go to the Dependency Care and Monitoring Center (CASD), but less than half end up going.
They think that they are going to go to a place with a profile of patients, such as heroin addicts, with which they do not feel identified.
The stigmas continue to weigh heavily.
That is why the involvement of psychiatrists from the first moment is key, that they go through the service and that there is already a connection with the patient,” concludes Jordi Sánchez.
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