Who Gets a Liver? Transplant Centers Differ on Substance Abuse Abstinence Rules

Donor livers are scarce, donated organs are precious, and transplant surgeons make the final call on whether to transplant a particular patient.

The severity of illness is easy enough to measure. When the patient has a history of using marijuana, drinking too much alcohol, or even smoking tobacco comes up, the issue of who gets a liver can become tricky.

"You don't want to waste a liver, but you don't want to deny a patient a life-saving therapy either, just because he's a smoker," said David Riech

chief of multi-organ transplantation and hepato-pancreato-biliary surgery at Hahnemann University Hospital in Philadelphia, PA. "A lot of people who need liver transplants are smokers."

In a symposium presented at the Liver Meeting (AASLD) in San Francisco, panelists took up the questions of liver transplantation in patients with addictive disorders. The topic is complex, fraught with medical and ethical issues.

Even though the furor over "death panels" has died down in the national political arena, transplant committees are making such decisions, partly with rules, but too often with incomplete data on the impact of various addictions on transplant. The decision-makers are also prone to inserting personal bias into the process, panelists said.

Panelist Michael Lucey, MD, chief of the division of gastroenterology and hepatology at the University of Wisconsin School of Medicine in Madison, WI said he surveyed 134 transplant centers and got responses from 42 of them. Combined, these centers transplant about half of the livers transplanted in the US.

The survey's goal was to see how the centers' policies guided transplant decisions. He found the answers were all over the map.

Did they require a set period of abstinence from alcohol?, he asked.Twenty-four said yes, 15 said "it depends" and one said no. The same question for opiates drew a response of six-months abstinence from 27 centers and mixed results from others.

Few of the centers required patients to be in a smoking cessation program. Most had no policy on ceasing marijuana use. "There was no consistency across centers," Lucey said.

Instead, he described a system fraught with "team biases" that in some cases were likely to diminish some patients' access to transplant at a given center. Those addictions include illicit drugs, marijuana (still illegal under federal law), alcohol, and tobacco.

Obviously, giving a liver to an alcoholic is a risky proposition since that patient faces a danger of relapse and damaging the new liver. But assessing the risk of relapse is guesswork. Another medical issue is the fact that patients with opioid addictions will need extra doses of pain-relief medications to cope with post-surgical pain. Does that pose a risk to their recovery from addiction and the longterm outcome? Should that affect their chances of tranplantation?

Among the other medical issues: the anti-rejection drugs that must be taken post-transplant put patients at higher risk of getting cancer since the drugs dampen immune response. That means that smokers who get transplants and keep smoking face a increased risk of lung cancer. So these patients' longterm survival odds are not as good as a non-smoker. Should that hurt their chances of being approved for a donor liver?

Transplant center committees that weigh decisions have some guidance, but even the rules they currently play by may not be backed up by scientific evidence, Panelists who spoke said the rule that six months sobriety confers a better outcome post-transplant has never been put to an empirical test.

Relapse depends on a lot of factors, said Thomas Beresford, MD, a psychiatrist at the University of Colorado. It may take five years of sobriety to truly kick alcoholism.

Patients who have primary alcoholism and get substance abuse treatment are far less likely to relapse than patients who have alcohol and poly-drug addiction. "The first group is a happier group," he said, "The second group tends to have had unhappy childhoods and adult personality disorders" that make recovery harder.

But transplant committees generally are not required to weigh these factors. Team decisions are the usual rule, but teams may or may not include a substance abuse counselor.

.The problem, he said, is defining "active."

His program requires a half year sobriety from alcohol. But it has no fixed rules on smoking cessation or marijuana use. "We have a substance abuse counselor as part of our transplant team," Reich said. The counselor's recommendations are part of the mix but not the last word.

Hahnemann's transplant surgeon Reich said transplant policies generally do not allow active substance-abusers to get an organ

Marijuana use and its affect on the liver is virtually unstudied, the panelists agreed. With many states legalizing the substance, a few cases of aspergillosis in marijuana-smoking patients who got liver transplants have surfaced. So far there is no data on that risk.

Another understudied issue, Lucey noted, is the extent to which insurers influence these life-or-death decisions.Taken together, the questions call out for a new discussion on whether existing guidelines need a second look, Lucey said. .

He called on those with a stake in the debate--physicians, insurers, national policy-makers and patient advocates--need to talk about the issue of addiction and liver transplant. "We need a national dialog,"Lucey said.