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NCADD Addiction Medicine Update

The NCADD Medical-Scientific Committee is made up of physicians, psychologists and others to provide advice and guidance to the NCADD Board of Directors, staff and National Network of Affiliates on activities related to medicine, health and addiction to alcohol and drugs. The Committee develops NCADD position papers, advisories, and other public statements for approval by the Board which reflect the latest medical and scientific understanding of the disease of alcoholism and drug dependence.

Addiction Medicine Update

In Ontario, Individuals with Alcoholic Liver Disease Will Not Have to Wait Six Months for Liver Transplants

Ethical principles stand behind healthcare providers who withhold medical treatments that are “futile or pointless.” But withholding treatment can be controversial. For example, the family of a gravely ill patient might not agree with professionals that an unproven treatment is futile.

Even when scientific evidence in favor of a treatment accumulates, medical practitioners can be slow to embrace it. In Ontario, Canada, Debra Selkirk combined scientific reports with her powerful personal story, seeking to overturn the rule that individuals with advanced alcoholic liver disease must demonstrate six months of abstinence from alcohol to be eligible for a liver transplant.

Debra shares her account of that process below.

Subsequent research concluded that the post-transplant rate of return to heavy drinking is extremely low. Organ loss due to drinking is even more rare. In 2008, a comprehensive analysis of international data by a University of Pittsburgh team  established the return to heavy drinking at 2.5 percent in any given year. The study concluded, “The average rates of all outcomes we examined suggest that during any given year of observation, most transplant recipients with substance use histories will neither use substances nor become nonadherent to components of the medical regimen.”

Additional studies support similar conclusions, yet most transplant centers continue to deny transplants to ALD patients until they reach the 6-month benchmark. The policy remains intact, based largely on stigma against patients with alcohol use disorder, fueled by a fear that the public will be less likely to donate their organs if they think livers are being wasted by transplanting them into individuals with alcohol use disorder.

Some large transplant centers in the United States, including Johns Hopkins, New York Presbyterian, and University of Maryland—more in keeping with the evidence that the standard policy is out of date—have transitioned to a more compassionate approach, often incorporating addiction treatment into their transplant programs. 

On October 28, 2015, I filed a constitutional challenge against the 6-month wait in the Ontario Superior Court of Justice in Toronto, Canada. My goal was to end the 6-month waiting period that killed my husband in the hope that other families would not suffer a similar devastating loss. Alone, I studied legal cases and medical research, finally filing the court documents without the assistance of a lawyer.

In May 2016, University Health Network and Ontario’s Trillium Gift of Life Network asked me to put the court process on hold, and they went right to work on the review process they believed the court would have ordered in my case.

In August 2018, Ontario will become the first jurisdiction in North America to universally assess all patients with liver failure caused by alcohol use disorder for liver transplant without any period of sobriety. Each patient will be assigned to a specialized services team comprised of hepatologists, psychiatrists, addictions specialists, nurse coordinators, and social workers.

The initial length of the program is estimated to be three years. However, my expectation is that as the program produces results matching past low rates of return to drinking, the 6-month wait will be permanently suspended.

A Canadian news story on Debra and Mark Selkirk has photos of them both.

In the United States, the “6-month rule” remains embedded in the decision making of liver transplant selection committees, despite longstanding recognition that it is based on inconclusive evidence and more comprehensive criteria are needed.

Watch for additional NCADD Addiction Medicine Updates that highlight how subtle prejudice and stigma compromise the quality of medical care provided to individuals with addiction.

The NCADD Addiction Medicine Update provides NCADD Affiliates and the public with authoritative information and commentary on specific medical and scientific topics pertaining to addiction and recovery.

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