When a patient’s alcohol use contributes to liver injury, the clinical response may appear straightforward: advise abstinence to prevent further damage. However, in hepatology and liver transplant care, clinicians routinely encounter patients whose liver disease is the direct result of a chronic, relapsing condition that impacts patients’ ability to limit or abstain from substance use. For patients with substance use disorder (SUD), continued use is not simply a behavioral choice, but a manifestation of a disease that impairs brain circuits involved in reward, impulse control, and decision-making—mechanisms that have significant implications for liver disease progression and transplant outcomes.
In the transplant setting, teams must weigh medical urgency, long-term graft success, and patient safety. But too often, care focuses narrowly on the damaged organ while the neurobiological condition contributing to liver failure remains under-treated. Addressing addiction alongside liver disease is crucial for providing comprehensive and effective care for patients with comorbid alcohol use disorder (AUD) and alcohol-associated liver disease (ALD).
Andrea Weber, MD, a clinical associate professor of Internal Medicine and Psychiatry, has spent her career working at this intersection through her specialization in addiction medicine. In a recent scoping review, “Integrated approaches to reduce alcohol use in people with liver disease: a scoping review of analysis,” Weber and chief resident Marcus Osman, MD, examined how clinical models that integrate addiction treatment into hepatology care could improve outcomes for patients with alcohol use disorder (AUD) and alcohol-associated liver disease (ALD).
Across studies included in the review, one finding emerged consistently: when liver care teams involved addiction medicine specialists in clinical care, patients with co-occurring AUD and ALD were more likely to reduce alcohol use, receive evidence-based medications, and remain engaged in hepatology care. In contrast, models in which addiction treatment and hepatology care remained siloed were associated with reduced treatment initiation and higher rates of returns to alcohol use.
For Weber and Osman, these findings reflect a broader trend in how medicine approaches alcohol-related disease. Hepatologists frequently care for patients whose alcohol use drives their liver disease, yet addiction treatment remains underutilized even in states of advanced illness.
“When you’re dealing with alcohol use disorder that’s a direct contributor to liver disease, patients benefit from access to these integrated care models, which manage both conditions at the same time,” Osman said. “A study we cited in our paper looked at VA patients in the US who had cirrhosis and alcohol use disorder. It was shocking to learn that less than 15% were receiving any treatment for AUD. These patients are medically complex, and without addiction medicine support, the liver disease is more likely to progress.”
Without a biobehavioral framework for understanding addiction, physicians may find patients’ return to alcohol use after an ALD diagnosis discouraging or even misinterpret this consumption as noncompliance. Weber emphasized that continued alcohol use in this population is not necessarily a failure of motivation or insight, but a predictable outcome of untreated addiction.
When intention is insufficient: the neurobiology of addiction
A growing body of neuroscience research supports understanding addiction as a chronic medical disease. With any substance use disorder, and in this context AUD, the organ undergoing pathological changes is the brain.
Addictive substances like alcohol produce large surges of dopamine in the brain’s reward pathways, reinforcing alcohol consumption far more powerfully than “natural rewards” like eating, exercise, or sex. In individuals at risk for developing an SUD, repeated exposure to an addictive substance induces long-lasting synaptic changes that shift dopamine signaling away from the substance itself and instead toward environmental cues associated with drinking. This cue-driven circuitry generates intense cravings while blunting overall dopamine release. Consequently, the prefrontal cortex—responsible for executive function, impulse control, and value-based decision-making—becomes impaired. This process limits a person’s capacity to translate knowledge of harm into sustained behavior change.
“Physicians, especially those of us in internal medicine, are very reason-oriented,” Weber said. “We tend to think that if we explain the risks clearly enough, behavioral change should follow. But if knowledge alone were enough to sustain behavior change, we would all be a lot healthier. And addiction, especially, doesn’t work that way.”
Rethinking treatment referrals
In the absence of addiction medicine expertise within hepatology clinics, physicians often consider residential treatment as the default solution for patients with advanced ALD. However, Weber points out that many residential treatment programs are ill-equipped to manage the medical complexity of liver disease.
Patients with decompensated cirrhosis or those undergoing transplant evaluation often require frequent medical monitoring, specialized medications, and multidisciplinary coordination—services that many residential facilities cannot provide. In practice, patients requiring aggressive medical interventions, including transplant evaluation, are frequently excluded from residential treatment programs altogether.
“These programs are designed for people with fully functioning organs,” Weber said. “Many of the patients we see in internal medicine simply don’t fit that model.”
Even when admission is possible, the structure of residential treatment poses barriers. Programming often features prolonged cognitive and behavioral therapy sessions, which can be difficult for patients with ALD-related cognitive impairment, fatigue, or hepatic encephalopathy. As liver disease progresses, patients may struggle to process information or meaningfully engage with long group sessions.
So rather than referring patients out, Weber’s work focuses on bringing addiction care into internal medicine settings.
Colocation: a pathway to improved care engagement
Several studies in the scoping review highlighted the benefits of colocation, which involves embedding addiction medicine specialists directly within liver clinics or transplant teams. In these models, patients received AUD treatment as a routine component of their hepatology care, reducing stigma and logistical barriers to engagement.
Weber has implemented this approach in practice. In a grant-funded project, she developed an integrated care team that included an addiction medicine physician, case manager, recovery coach, and counselor working alongside the liver and transplant services at UI Health Care. The liver and/or transplant team could refer patients through telehealth or in-clinic visits, ensuring continuity with providers they already trusted.
Weber and Osman’s review found that integrated care models like these significantly increased the likelihood that patients would receive evidence-based medications for AUD. Although historically under-prescribed, pharmacologic treatments are associated with reduced alcohol use. And while not every patient is responsive, Weber notes that the more prominent failure is that these medications are never offered at all.
“Integration changes that,” she said. “When addiction medicine treatment is part of the hepatology clinic workflow, patients actually have access to tools we know can help.”
Implications for transplant outcomes
Historically, liver transplant candidacy often requires documentation proving six months of sobriety, a standard increasingly recognized as a poor predictor of post-transplant outcomes. The literature Weber and Osman reviewed suggests that integrated addiction care may be a more meaningful determinant of transplant success.
When patients receive addiction treatment during transplant evaluation, they are more likely to remain engaged in care, proceed with transplantation, and reduce post-transplant alcohol use. Notably, Weber said that intensive outpatient or residential SUD treatment may even become more feasible after transplantation, when improvements in physical and cognitive health allow patients to better participate in programming.
Looking ahead
Weber and Osman’s review highlights the need for structural change in how health systems, specifically within hepatology and liver transplant care, address alcohol-related disease. Weber hopes to contribute to the literature on this matter through ongoing grant-funded work evaluating integrated care models within liver and cardiovascular clinics.
As she looks to the future of her current grant, Weber aims to provide other institutions with a practical framework for treating chronic medical conditions rooted in SUD, viewing them not as separate diagnoses, but as interconnected diseases requiring coordinated care.
For Osman, the implications of this work are both clinical and deeply personal, shaped by repeated encounters with patients whose liver disease reached advanced stages before meaningful addiction treatment was introduced.
“I often think of the dozens of patients I’ve taken care of who—if there had been interventions for their [AUD] at the medical or even community level—wouldn’t have faced premature death,” he said.
Integrated care models, he emphasized, allow Internal Medicine teams to intervene earlier—addressing AUD as a chronic, contributing medical condition to effectively treat its downstream effects on liver health. This approach gives patients the best chance to preserve liver function through engagement in SUD recovery, and in turn, improve overall quality of life.