I'm a CL psychiatrist over at Columbia, and I work with liver transplant patients, so I got sucked into the world of addiction. I think this has become my life's passion for the last 15 years. I worked at Mount Sinai Hospital, which saw a lot of liver patients, and now I'm for the last six years at Columbia. And I got to train Candice Hatton-Powell, who was a fellow last year at Columbia, who's now attending at Montefiore, so she's going to give the second talk, and then Marshall I got to meet because he does what I do at Cornell. We have a joint program, Columbia and Cornell, and it's really nice to learn from him because he is a real addiction psychiatrist. But I will try to, you know, if there's something I say that's incorrect, please, I'm here to learn from you as well. So nothing for us to disclose. We don't have that kind of, yet, those types of relationships, right? Okay. Yet. Get to get into that mindset. Maybe I want one of those relationships that I see everyone else have, okay, but not yet. For this session, really it's talking about, like, you should become a mini-expert in treating AUD in ALD patients, which you should know is about, you know, 50% of your patients with AUD will have some liver damage, and those patients get shuttled around because, you know, the idea is that they don't get treatment as well because of the ALD or the cirrhosis diagnosis. So recognize that there are treatments for them despite having ALD, and then some innovative stuff that Mashal is going to talk to you about in the form of technology-assisted interventions. So just a couple background slides, just so you know, I mean, the depth of this. Alcohol use is obviously very, very common. It's part of the social fabric of not just the United States, but of Europe and the rest of the world. And then, obviously, deaths from cirrhosis, if you don't already know. It maps pretty well to alcohol use around the globe, right? So we know that. We know that there's a dose response of alcohol with liver damage, right? So there's a, the one on the left, it's an older study, but this is the Million Woman Study from the UK, which, amazing how they do studies in the UK. One out of four women were assessed for diagnosis of cirrhosis and are getting, it's all self-report, but yeah, thanks. And there's a clear dose response, and when you get above two, you know, over two drinks a day for women and over four drinks a day for men, you start to see these sort of increase in liver damage that's persistent. Now, the reason I think they've invited us here is because of all the problems from alcohol use, cirrhosis stands out. It's the number one reason for death. So it's meaningful from us, from our perspective, and it's increasing. So alcohol-associated liver disease is increasing along with non-alcoholic liver disease, which is not called, so just so you know, this is an aside, it's not called metabolic-associated liver disease. So that, Masold, Masold, Masold, okay, Masold, it's kind of like your name a little bit. So it's not NAFLD anymore. So it's not, you know, it's not named by the absence of alcohol, and we're actually finding there's a lot of people in that in-between, which is metabolic ALD. So met ALD is like that in-between that people that do drink enough to cause damage, but they have another reason for having liver disease. So those are also increasing, but just the ALD by itself is increasing quite a bit, and it's projected to continue to increase, right? So we had the COVID, and we got the spikes, and then now we're going to have a new level of increase. So just a primer or primer, if you want, on ALD, there's a progression of steatohepatitis and steatopathology in fibrosis in patients with ALD, and it looks exactly the same as someone who has metabolic disease, right? It's fatty liver disease. It's just caused by alcohol. And as it progresses, it turns into fibrosis and bridging fibrosis according to the pathology, and then cirrhosis, which at the point of fibrosis, it can't go back. So if you find, I mean, there's actually, you want to do fibro scans, we want to give addiction psychiatrists fibro scans to like look at the liver. Have they gone past it? Can we reverse it? And this would be an extra, I mean, I'm not going to steal your thunder, but that's, so that's where it's going. And I just want to give you a little bit of a primer on ALD, meaning people talk about child PEW classifications, and then so we're going to be using this kind of nomenclature, the ABC, and then MELD score, which is the model for end-stage liver disease, which is kind of correlated to child PEW. So like these numbers will get thrown around. We'll repeat them so it's not confusing. But this matters to the medications. So because our hepatology colleagues always ask us, what are you doing? Why can't we fix this? So because they are very interested, and there's a lot of just clinical interest, research interest, but also financial interest to get these patients treated. And they're doing all the other things, right? They're going to, we're going to do the nutritional support, they're doing the, they're watching their LFTs, they're giving them good advice. But they're leaning on us for pharmacotherapy, and we're kind of leaning back on them to teach them how to do pharmacotherapy, but then we are also teaching them the whole concept of addiction, which they're clueless about, okay, just so you know. So a couple things at Columbia we developed a little bit, like I used to give this out as a, to patients, a brain science sort of tool to sort of like, this is a metaphor of driving a car, and some patients like it. It's not for everyone, but it's a sort of neuroscientific, you know, sort of metaphor for, the car analogy, if you like it, you can have it, it's out there. But I really use this quite more to think in terms, in my head, just going back to like operant conditioning, just what is it that is the cost and benefits to drinking, and then what are the costs and benefits to treatment. And I think this is part of my motivational interviewing spiel. These levers are in my head. I know Marshall told me not to put these things in because it looks like the acamprosate, like the gabaglutamate thing, but I hope you didn't get, it's basically looking at costs and benefits, Skinnerian, and that's how I kind of think about it. So I'm going to, so before I get to my talk, this is really important, which is that our patients are a little bit different than the patients in a general clinic. Our patients are very sick and they know they're going to die. So the consequence of death is looming. So that's what forces them to ultimately stop. I mean, that's their rock bottom. I'm sure you guys have all kinds of rock bottom stories, right? Like, and I'm sure, how many patients have like liver disease was their rock bottom? Yeah, right. So it's common, right? Even if you don't work in a transplant center, still liver disease is a rock bottom for a lot of patients. But there are so many other rock bottoms. And for us, I mean, just an aside, if someone keeps drinking after they hit their rock bottom of having severe decompensated liver disease, those are our most severe concerning patients that we really struggle with. Okay, so just so you kind of know where we're anchoring this. We do know that if you give them in, how many people here work in an inpatient setting? Oh, great, okay. So if our teams give them the AUD diagnosis in the hospital, it helps, right? This is the opportunity, the time to sort of intervene, and it reduces 30-day readmissions for the liver team. So all that being said, that's kind of background. We're going to cover three cases very quickly after each of our talks. I'm going to do pharma, Candice is going to do psychotherapies, and then Marshall's going to end off with some innovative interventions that are in the tech world. So we'll use these three cases. I'll bring them back up, and we'll talk through them in a second. But before we begin, does anyone have any questions? Any thoughts about this topic? Anything to just... Yeah, go ahead. I've been looking forward to this all weekend. Oh, wow. I work outpatient at Santa Barbara, and all my folks are low-income, they're uninsured, and they have no insurance. So I've been looking forward to this all weekend. I'm not sure, I have a lot of Hispanic populations books, and I have, I think, four patrons that are in their 50s, gentlemen, who are in, like, decompensated in their 30s, and Hannibal doesn't work, Galentine doesn't work, Pope Max doesn't work, and it's like, I want to know what the cost of analysis is of doing image control. Yes, we're gonna get there, go ahead. The literature supports some hepatotoxicity, but like not all of them. Yeah, no, we have to get there, yeah. Very good, I'm so glad you're here, and those are great stories, I think, where patients have liver disease, and they're still drinking, right? So those are like our folks, right? Those are the toughest folks. Anyone else have stories like that, where there's like the liver disease and they keep drinking? Yeah, yeah. No rural, dual diagnosis, I get admission decisions to make about, is this patient medically stable enough to be in our place, which is five miles from, really, really tiny, and not amazingly good hospital, not really sophisticated, can I handle it safely, can I not handle it safely, what do I watch out for, how do I protect the liver while they're with us? Yes, right, and these are the cases where the liver's already damaged beyond belief, right? Like if that's past just fatty liver, we're talking about fibrosis, cirrhosis, it's not going back to normal. Some are acute hepatitis, but. Yeah, okay, okay, fine, right, so we can. Some are yellow with, Right, that's a great, so and now we're learning that medications, and that just came, that's hot off the press, that medications are associated with reduced incidence of new onset acute hepatitis, right? So people that get acute hepatitis from alcohol, yeah, sometimes it happens again, and it happens again, but I don't know if you guys see Tylenol, so I've seen a few where it's like the Tylenol overdose, and you're like, you tell them, don't do Tylenol like that, no, you can't, and then they keep doing it again, you have another Tylenol overdose, an accidental, you must be suicidal at this point, but so that's the thing, it's like some of those hepatitis patients you can kind of rescue completely, and they don't need a liver transplant, which is what we're looking for, but okay, those are good, I'm glad we brought those up. So, what I was going to do is kind of review this balance of safety profiles and efficacy. So that's what I was going to do, and then apply that evidence to the case. So this is from Scott Winder, who's my colleague at Michigan. And it's this idea, and you've seen this, this makes sense, it's like how do you balance safety with efficacy, right? And we have a paper coming out that's going to review all the medications and do exactly this, what we're presenting here. So let's start with disulfiram, which is something that I'm sure is used a lot within addiction. Like yesterday, when we talked, I asked how many people use disulfiram, and like almost everyone's arms shot up. So like a lot of disulfiram is used, which is great. Huh? Yeah, a lot of people have still used a lot of disulfiram. So we don't use it very much at all. And I'll tell you why. I mean, even though it's very effective, and it has, you know, and you know, this stuff in the background, and there's efficacy trials, which Roger Weiss came and gave us a talk on the efficacy of disulfiram and how he uses it with the patients and the conversations he has with the patient and the partner and how the partner is supposed to respond and this and that. And the back and forth is lovely. I was like, this is great stuff. But I cannot start it in good faith often, because of the potential for liver injury. So liver talks is your resource here. Just type in liver talks or pub, like into PubMed, or type liver talks into Google. And you'll see that the NIH has a really nice description of the toxicity of every drug we prescribe. Okay, it's so good. And they rate it by A, B, C, D, or E, right? So you have a sense. Now, liver talks gives us an A, which you'd think it's like, oh, that's great. It's not great. So it's a well known cause of liver injury. And the thing is that the whole effect of the aversive effect of disulfiram actually causes damage. So the acetaldehyde that's built up actually goes and so I think we're, I would love to prescribe this, but I struggled with this one. Now, I love to hear stories if people are using disulfiram with liver disease, but anyone using it? Like, yeah, it's tough. It's just it's kind of difficult. So I am not going to spend too much time even though the incidence is low. My colleagues would if there was one case where I caused the damage, they would be like, oh, what are you doing here? So that's my problem with it. I mean, I think in other settings, it works well. And yeah, so they've, right. So even in abstinent alcoholics, this is actually important, this Rossman paper, which is not cited here, but I can say so Rossman 2000, even if they're alcohol level zero, like talk through toxicology and not drinking, definitely not drinking, still, the acetaldehyde levels are higher. So you're causing kind of a low level damage oxidation. So it's not great. All right. Naltrexone, this is what we wanted to talk about, right? So Naltrexone, we know is efficacious. We know how it works. We're comfortable with it. But what is the data? All right. So the data is, the data is, we, yeah, yeah, yeah. The data is that it is, and then, so the Jonas paper from 2014 is a nice meta-analysis. But in just a month ago, they re-upped, they did a renewal of that same paper, same techniques, same meta-analysis with bigger, with more studies and similar results. So the number needed to treat was still about 12, which is a good number needed to treat. And it prevents heavy drinking days, right? So that's the effect of Naltrexone. And we know that, right? I think all the studies that we've read kind of say the same thing. Now what I wanted to talk about beyond just like how we use disulfiram, which is, you know, I think, you know, when you're talking about, I think, you know, what does it do? It reduces craving. But you know, there are some side effects associated with it, you know, sedation. But I want to talk about, there's one study that came out last year, which is with ALD patients, which is nice to see that they're finally studying Naltrexone with. And this is not Vivitrol. So we don't have that answer yet. But P-O-N-A-L-T-R-E-X-O-N-E, ALD is Alcohol Associated Liver Disease. Thank you. Sorry. Yeah. So this, I will say ALD like a million times, so thank you for that. And it used to be Alcoholic Associated Liver Disease, and now it's Alcohol Associated Liver Disease. We changed the nomenclature. We thought we were going to fix the world by changing that, but anyway. So the interesting thing with this study, only one case where the ALT went up, which is a sign of DILI, drug-induced liver injury. Just so you know, like AST, ALT, we love that, right? The AST goes up, the ALT doesn't go up as high. We're like, oh, that's probably the alcohol. Let's check the GGT. Oh, the GGT went up too. It's probably alcohol. It's very specific for alcohol. Good. So, but wait a second. This time the ALT went up and the AST is still down. What's that? I was like, maybe it's drug-induced liver injury. And this is something called High's Law that the hepatologists love. It's like, how do you assess for drug-induced liver injury? And an ALT going three times, five times above normal is your way. Well, that happened. Look, 25 to 124, and one case out of 160 went up. And what was the story? The story was that they stopped the naltrexone. But the story was that the ALT didn't go down. And that is not DILI. In DILI, drug-induced liver injury, the enzyme should go back down to normal for it to be a real case. And then it goes into their database. So it wasn't real DILI, plus the patient was still drinking. And it was one ER visit where the ALT was up, because it lost a follow-up. So it was tough. But they did track that one down, but it was not. So I mean, preliminarily with that one study, we're looking prospectively at a whole bunch of ALD patients, naltrexone looks safe. I mean, that's a prospective study, so that's good. Now, we know that there are other effects of naltrexone, and we have to reassure them like the sedation, the tiredness, but that's not liver injury. That being said, we still get LFTs at the beginning to check, even though they downgraded, you know, the FDA gave up the black box warning on naltrexone now. So we should also feel more comfortable, FDA's not breathing down our necks. Because the FDA's like, go for it, go for the naltrexone. So practically speaking, we shouldn't feel any concern about using it. So they downgraded it, and Livertox gives it an E, which is E is great. You should be prescribing any E to like any liver patient, all right? So that's kind of in a nutshell. And my take on transition to depo, and we really don't know, but some people say, okay, well, if you want to avoid that first pass metabolism, this is like voodoo science, who knows? But if you want to avoid that, maybe you can switch to the Vivitrol early, because you're going to get less impact on the liver. Any questions on that? Because that's all we know. Go ahead. Those, so, good, so those are high doses, um, and, so, also, AL, okay, so. So binge eating, it's a whole nother animal. We're not as precise, so I can't tell you that story of ASTALT with binge eating. Those patients, you've seen Super Size Me? The movie, it's like 20 years ago anyway. But it's like this movie where this guy goes in and he starts eating McDonald's every day, three times a day, and what happened to his LFTs? They went up. I mean, the doctor was like, why are you sick? You have fatty liver disease. But I just went to McDonald's every day and I told them to super size me. So that's what it is. Yeah. Go ahead. Yeah, okay, so this great question. Thank you so much because we do we just wrote the protocol for Columbia and Cornell and we did We wrote it for the our Nurse practitioners, and we didn't we wanted to make sure that They had some parameters so for child PUC or MELD scores that are over 20 I think it was 25 and so we had some cutoff where we said okay, let's review that one So would you be careful about that? So what are we going to talk about some sort of like follow-up plan? That's a little bit more specialized for a child PUC And then and look again more detailed at the cost-benefit analysis of that. Is it efficacious? But be a and B go for it, but see maybe like Kind of dance around a little bit talk to the patient share the decision-making a little bit with them How sick you know how meaningful is this? What are your other options that kind of stuff? Yeah? Yeah Oh, yeah, that's this is exactly it. Yeah, they're gonna reduce so they're gonna go from a who Drinking level of like the the three or four down to a two which According to them the data you're gonna reduce your risk of liver damage now if you're already at fibrosis Maybe they don't go to cirrhosis if you're if you're a fatty liver disease Maybe they don't go progress to fibrosis, but you've actually done your job. It's not plus. It's not this black and white It's just bringing them down one level because that's what naltrexone does it reduces heavy drinking days Yes I Made the pitch for getting the path to at the same time because as a different value, but I think you know Sneaking it in there and saying look. We're just we're just making sure your liver is okay There's a little bit of that's part of the treatment right. It's it's like is your liver fine today? Because I want to check this again to make sure that it's going to continue to be fine because this is the major impact For from drinking and everyone knows that everyone knows that alcohol causes liver damage So you know in there in their mind? Maybe it helps them yeah that has to be reframed I think blood blood testing is so important, so say is it. I don't know that's answers your question, but that's a kind of Give me data, right? Yeah, right, right? Yeah This is the last, uh, you know, round of the fan, then I will start a track zone. No, no barriers. No, good point. No, I understand what you're saying. Yeah, no, I get it. I get it. Yeah, you want to get them the treatment first. It's like treating for, like, you're not going to check vitamin deficiency. Just supplement them. Just give them the vitamin and let it go. All right, so we're going to swing through this because I didn't hear so much concern. So acamprosate, we know, you know, it's not studied in liver disease. Topiramate, not studied in liver disease, and because we're running out of time, there is some concern about some, you know, there's some incidents of some injury with topiramate, but it's not, it's not big. Gabapentin, not studying liver disease, but it's, you know, they're very limited data, but we can assume it's not causing liver damage. Baclofen is the one that I wanted to kind of touch on, which has been studied now repeatedly, and there's a meta-analysis now on using baclofen in alcohol-associated liver disease, and it shows efficacy and obviously safety, so I think it's... Anyone use baclofen for alcohol use disorder? Oh, cool, and is this... Yeah, I mean, look, so, right. That's fair. So there's maybe, so it might not be your Hail Mary at the end. Maybe it's a patient that has alcohol-associated liver disease that you don't feel, and they've got a lot of anxiety component, and maybe you're... Yeah, and the outcome is different, right? This is patients that are sober. They're trying to stay sober. We're talking about in that first few months. They're very anxious, and they keep coming back with anxious energy. Maybe that's the patient you start baclofen on. So, head-to-head, you're right. So naltrexone and acamprosate sort of continue to be that sort of high-level evidence. This is stuff you've seen before. The recent Jonas paper really just says the same exact thing, but this is in your notes. You have this, so... And then now hepatologists are studying this. This is like a big biobank at Mass General Brigham that looked at just prescriptions for MA, medication for alcohol use disorder, and incidents of liver damage over time, and there was strong association. So I think people are more and more interested in it. There's all this stuff that's coming out, but let's get to this case, and then in the interest of time, I want to get Candice up here because we're already down, but we've already had so many discussions about meds that I'm not going to delve into it. I'm just going to bring her up in the interest of time because I think my timer, this timer's not working. Okay, so hello everyone. I'm really happy to be here. Thank you to Akil for inviting me to participate in this talk. So I'm going to be talking about the psychosocial interventions in treating alcohol use disorder specific to people who have liver disease, and just as a little bit of an aside in two seconds, my interest in psychiatry was really largely shaped on my experience as a fourth-year medical student where I worked in an addiction psychiatry clinic, and so I really find this to be an integral part of psychiatry, even though I'm a consultation and liaison psychiatrist. I'm still doing very much addiction psych on my day-to-day. Okay, so the purpose of the talk, let me just, sorry guys, see. Okay. All right, so let me just review this with you guys. So this is basically the goals of my talk, and I hope to review the different modalities of treatment that exist out there. In general, the studies that are the types of psychotherapies that I've looked at are the five big ones that we think about. So CBT informed interventions, and I will say this does include the the third wave CBT interventions including like acceptance and commitment psychotherapy, dialectical behavioral therapy, etc. Then we have the motivational enhancement therapies. We have the brief advice and brief intervention modality, which was talked about pretty extensively actually at the symposium yesterday. So it's really an important area to focus. And then the peer support programs as well as relapse prevention. And then I wanted to focus on the efficacy of each of these within this patient population of liver disease. And then I don't know if we have time for a case, we'll go through it, but we may not. Okay. So in terms of the CBT informed interventions, so these can often be done in combination either with motivational enhancement techniques, or they can actually be just done solo. And they really focus on assessing the benefits and costs of alcohol use. So if you think about it, kind of really trying to explore with patients, what are they actually getting out of drinking? Are they trying to reduce their anxiety levels? Are they trying to maybe potentially dissociate or avoid a traumatic experience that they've had? What are the social contexts in terms of their use? Because there are so many different realms of our daily lives in which alcohol is really an integral part of the culture. And so understanding this is really important if we're going to try to help our patients to cut back. And then in terms of the costs of drinking, we want to think about the relationships lost, the opportunity costs that come along with this. Perhaps even like legal implications. People are sometimes arrested or getting DUIs. Things like that. So we really want to understand this with our patients as well to garner more motivation to change. And then we want to understand what are the barriers? What is getting in the way of them actually being able to cut back on their use. So this is the part where we kind of focus on the cognitive distortions that our patients are living with. So are they catastrophizing? Are they engaging in some all or nothing thinking? Like basically, if I have one drink, that means I might as well just give up on the road towards abstinence, basically. And then ultimately we want to work with our patients to set goals that are achievable and realistic. So things such as like the SMART goal tools that we may see can be really, really helpful in this context. And ultimately we want to really try to just improve the quality of the coping strategies people are already employing. Often, as I sort of alluded to, alcohol itself is one of the tools that people have to help them cope with things. And so we want to just expand that out and help them to see other ways to get through. And then last but not least, I sort of kind of think of CBT as like the modality of homework assignments. And so that's somewhat unpopular for patients. It's really important for them to understand why are we asking them to do things outside of their sessions. And really the purpose is to help remind them that what they're learning in therapy is actually applicable to their daily lives and they get to see that in practice in real time. Next, I wanted to talk about motivational enhancement therapy. And so there's a lot of overlap between this and sort of the assessing costs and benefits that I was just getting into with cognitive behavioral therapy modalities. But really the major difference here is it's informed by what the patient is bringing to you. Really want to take a patient-centered approach here and allow patients to share with you what are the goals, what are the values that they're associating with their alcohol use. And this is basically the main way that motivational enhancement therapy gets its buy-in and basically engages patients in the treatment process themselves. And so we also want to understand with our patients what are the experiences and the motivations behind their use, what is the background and the role that it plays in their daily lives. And sort of as I alluded to, there are so many family contexts in which it's really normative to have a glass of alcohol. There are times, like for example, sometimes births or weddings are really big times for drinking. Or even during the opposite end of the spectrum, when people are grieving, maybe wine or alcohol is an important part of that conversation as well. So understanding that. And then exploring with the patients what do they think they can get out of cutting back on their use or stopping. And I think I talk about cutting back a lot because at my core I'm a harm reductionist, but in the liver dysfunction population, really we want to try to aim for complete abstinence if at all possible. And then similarly, there's a lot of worksheets that are out there that just kind of help to guide the change and track over time. And so it's important to kind of compare the initial session with follow-up sessions. And the entire purpose of those follow-up sessions is to kind of weigh how things have gone after you've already established with the patients what are the values and goals that they have around their drinking and what are they hoping to change. And sometimes you find that you're able to reinforce what you've already decided and worked on with patients, but sometimes you've got to scrap and just start from the beginning and recreate a plan with your patient. And that's okay too because that's part of the process. So this is the brief intervention or brief advice, or sometimes in the literature it's better characterized as SBIRT interventions. And so this is really our opportunity to empower those of us who are not directly in behavioral health to really take charge of screening and providing some form of intervention for patients because this is where a lot of our patients are showing up to. Especially if they're already very sick, like in the liver dysfunction patient population. So really our medical colleagues often don't have a lot of time, even more pressed for time than those of us who are psychiatrists. So they really have 10, 15 minutes max to be able to talk with their patients. And so this is an intervention that is designed to be delivered in such a short period of time. It's also important to think about it as being a standardized practice. So you're able to keep all the pieces of information that you need and ensure that you're hitting the key points every time. And then I'm not gonna go through this in detail because of the interest in time, but really it's kind of like the rapid fire protocol that you might see in CBT, where you're assessing how much people are drinking, what is their risk for, or how dependent are they on alcohol? What's their risk level for a complicated withdrawal picture? These are the kinds of things that are high yield in the outpatient clinic setting, particularly the medical clinic. And ultimately they all serve as a way to kind of funnel people into substance use treatment more directly. Then in terms of the peer support programs. So as an aside, I have a background in psychodynamics. That is where my interest in psychiatry came from. So I think about 12-step programs is really important because alcohol, or other substances for that matter, can sometimes be thought of as like a transitional object. And so people sort of rely on this external object to help them through very difficult times or help them to regulate their emotions more carefully. But what we want to do with the peer support programs, the 12-step programs, is to help replace that object with a relationship. And so this is really kind of the frame in which I think about these modalities and find them to be really helpful because they directly counteract the areas of stigma that are associated with alcohol use. So we're normalizing here in the 12-step programs. We are helping to reduce the shame, the stigma around drinking. We're helping with loneliness. And so the other piece that's really important here is to think about the hope that's instilled by seeing people at different phases of recovery. And so this is like one of the major areas, I guess major reasons for why sponsorship is really important in these 12-step programs because it's really kind of someone holding your hand through the process. And last but not least, I just want to mention that although peer support programs really have a lot of emphasis on this higher power and in a Judeo-Christian America, people automatically associate that to like a religious practice being part of it. It's really not necessary. Anything can be a higher power and that's a message that we need to share with our patients who maybe don't identify as religious or spiritual. Last but not least, relapse prevention. And this is really basically like CBT targeted directly towards like the behaviors just preceding drinking, okay? And so I sort of think about this modality as thinking about with all of us, like there are different behaviors and things that we maybe do that are not ideal. And so this is how I kind of normalize and it sticks in my mind when I'm working with my patients. And so I think about that. What are the things that are leading me to do whatever the behavior is? What are the things driving craving? What are the mood states before, during, and after use? What are the different high risk situations? Here again, borrowing from peer support programs. What are the people, places, and things that are surrounding alcohol use? And then what are different coping strategies that people may engage in? How are they able to actually refuse drinks? We wanna often borrow from DBT here. There are a lot of nice tools that provide a lot of different coping strategies that maybe patients aren't able to think of on their own. And sometimes a helpful exercise can actually go through a list of coping strategies and help identify some that the patients find resonate with them. And then last but not least, expanding out the overall general health status. So if you focus on well-being, you're able to have a better ability to be flexible in your different coping styles. Okay, so I'm gonna have to speed up quite a bit. And so we're going to review the evidence that exists out there. So just to briefly mention treatment as usual. Often we're used to delivering our substance use treatment in kind of a separate behavioral health clinic without much in the way of medical, interaction with medical practitioners. And this is a real drawback for this patient population in particular. And so just to review, often patients who have chronic liver disease have a much heavier alcohol use. They have a more fragile relationship between the insight. When thinking about how they're drinking maybe causes the progression of the liver disease itself. They really can't make that association a lot of the time. And often they've tried a lot of the traditional modalities of treatment. So if you try to offer them, well, maybe we can try another 12-step program or maybe we can try referring you to a substance use program. They'll refuse and sort of say, nope, that hasn't worked for me. Why would it start to work for me now? And then last but not least, because they're so medically frail, they are in and out of the hospital a lot of the time or have many, many outpatient medical appointments that they need to attend to. So this sort of becomes an afterthought focusing on their substance use treatment directly. So I looked at two meta-analyses. There was one in 2016, and it really did focus on patients who had both AUD and ALD. So 3,000-ish studies were reviewed and only 13 actually met the criteria. So that should show to you guys how few people are actually looking at this in terms of what behavioral interventions are out there. And of the highest tier quality of evidence that we think of, RCTs, less than half of those 13 studies were actually RCTs. So this did look at a variety of different reasons for liver disease, so not just alcohol-related liver disease, but this is important because a lot of people who have liver disease for any reason are still drinking, and we know that if they're drinking heavily, they're actually increasing their risk of liver disease progression, regardless of what the underlying etiology is. And in terms of the outcomes that were measured, it was post-intervention alcohol abstinence as measured by biological markers, self-report, and collateral informants. So very briefly, this is four of the five RCTs that were looked at. Only the last one that I've highlighted here that integrated motivational enhancement therapy, CBT, and comprehensive medical care, so providing all of this in one location, showed a statistically significant reduction in, or sorry, increase in abstinence, I should say, in a very small N, so this is a real area for continued research. And then in terms of maintenance of abstinence, there really isn't any evidence that is strongly supportive of any particular modality. The one RCT that I found basically showed that at baseline, for people who were waiting for liver transplant, 90% were abstinent, but close to a majority of them relapsed, even though there was a slight decrease in the number of people who relapsed in the intervention group. So I think we still have work to do to figure out behavioral interventions that can help sustain behavior change. In terms of the observational studies that were looked at, so there were some cohort studies that compared with historical controls. Really the only one with any significance was one that showed weekly supportive psychotherapy given by a nurse within a medical clinic, actually showed, I think, 74% abstinence within two years. So this actually showed a sustained recovery, so having a supportive psychotherapy intervention within the medical clinic. And then, in terms of the pre-post designs that were done, so pre- and post-transplant, the one that had the most strong evidence was one that combined CBT and psychoeducation for the pre-transplant population, and about 31 to 45% of patients remained abstinent within the treatment interval, window interval that they were looking at. And then, for the post-transplant, those that used CBT, I think it was a 74% as well abstinence within that period. Okay, and then just very briefly, the systematic review of the RCTs in 2023, still not much, okay, so this, again, is a real area that we can do a lot more work in. So there was abstinence shown with motivational enhancement therapy peer support and integrated outpatient treatment. Referral to the peer support programs really showed a lot of decreased drinking and also, sorry, decreased relapse rates as well in the short term, and so basically, this is a way to kind of help patients feel a sense of self-efficacy. And then, last but not least, again, what we showed in this study was that patients who had integrated within medical clinic, CBT and motivational enhancement therapy had greater rates of abstinence and really an increased engagement just beyond their alcohol use disorder, but also helping with managing their liver disease, either slowing the progression or helping facilitate potentially the road towards transplant if necessary. Okay, so very briefly, most of the evidence was found for CBT and motivational enhancement therapy. Integrated treatment for both AUD and ALT, and again, integrated meaning within the medical setting, shows increased rates of abstinence, and really the type of therapy may not be as important. What may be the most important factor here is actually just having everyone in the same location so patients don't have to shop around for their treatment. And then, having as much follow-up where you're actually trending alcohol use and patterns is really critical as well. Okay. All right. I think we have a little bit of time, because I think we should probably review some of this. I mean, what are your, so maybe we can open it up. So a couple things I observed was that, that not a lot of studies, but there's not a lot of positive studies. So what is your thoughts about that? Like in this population with AUD in ALD, because I think we've heard from other, in other group in the symposium, that there's a lot of robust evidence for CBT and motivational enhancement therapy. Why not in this group? And I guess, any thoughts about that? Why it's not as effective? We were talking about that first six, yeah, go ahead. If I had to hypothesize, I see a lot of cognitive deficits in patients with Alzheimer's disorder, even from their TBIs. I was thinking the same thing. Yep. Hepatic encephalopathy, whatever chronic alcohol related changes. Right. They're not in the spot. Cognitively to be able to benefit. I totally, so there's hepatic encephalopathy, which is a concern. And this is a high burden population. So there might be some, like some more subacute cognitive changes. Absolutely. There's nutritional problems that are also subacute that take a while to, so that six months that you're hoping that you're gonna like give them the medication, you're gonna really direct them to stop and then wait till that change, that like lifestyle change and behavioral change happens. They're maybe not taking advantage of all this just as well as we'd hope that they are. So that's interesting. Okay. Anything else? Yeah. I was thinking maybe low home literacy. Yes. I have folks that, she said that everybody knows that alcohol can cause liver disease. They don't? Most don't. They don't? Okay. And their families don't. Really? They understand that correlation. How do we get that messaging out there? Okay. All right. So getting the message from different providers that they're dying, they're going to die of like a liver problem, like a fork that they don't even know about. Right. And they have another provider telling them that they should engage in them. Right. And therapy, it's tough to get by. Yeah, they're freaking out because their liver's failing and they're getting the symptoms of liver failure, which is like, which if, I mean, apart from the mind, I mean, they're swollen, they feel sick, they're tired. They can't, I mean, even if they don't have the mental capacity, maybe the physical fatigue of going in and being able to focus on this kind of stuff. Tough. It's tough. So I appreciate all that. So here's the case that we had for here. So, because there was some discussion about like, we're not, we're forgetting those patients that are, there's a lot of these patients that we're seeing that need liver transplants. These are patients who never stopped drinking and they just drank a bottle of wine for many years. And then all of a sudden, boom, it was like the straw that broke the camel's back. Then they have new onset decompensation in their liver. And they're like, what is going on? I just drank a bottle. And it's true. They just drank a bottle. And then there was no reason. Now, maybe in recent years, they're hiding the bottle because there was some sort of back and forth, especially when there's the medical doc, like they get seen by an internist or another good doctor who's like, tell him, oh yeah, you gotta cut down your drinking. And then there's like, ooh, there's a little bit of tension in the family. And they're like, so then their hiding happens. But I think, and it's stress-related drinking a little bit. So what are the psychosocial interventions for such a patient? Are they different than those other patients that have like that really severe alcohol use disorder where you're relapsing and remitting and can't control their use? How do you think about that? Do you think about their psychosocial care differently? I've used this word psychosocial because in the research, all these interventions are called just psychosocial. But what do you think? Yeah. So I had a patient kind of similar to this 45-year-old. She actually was a nurse practitioner and ended up having a liver transplant and the transplant was 15 because she was a nurse practitioner and was like, okay, I guess you don't have to be supportive before I get the transplant. And she had like- Free pass. Yeah, it was kind of hard to like, I consider myself a harm reductionist. I love motivational interviewing and I tried working with her when I started working with her, she was handed down by another physician, being like, maybe you can do something. So for months, I was seeing her PEP score in the thousands. She was denying alcohol use. So there was this deep, dense denial and unwillingness to admit that she was using, I think because of also the shame of drinking on top of a liver transplant. By the way, did she have a gastric bypass? No, she didn't have a history of it. So that thousand, when I hear that thousand and I hear a bottle of wine, I go, oh my God. It's like, maybe there's a little bit of discrepancy there. So she must be drinking maybe over. She was like, maybe I have four glasses a day or a week. Whoa! No. I don't think that's what you're talking about. But yeah, it was tough, it wasn't like, I finally ended up working with her husband and the patient as well and just being like, I just made the decision for her. I was like, you're going to treatment. That's it, you're going. No, and you need that. There's the directive, right? We have the very directive approach. Like you got to do this, I'm your doctor. I'm going to give you a direction here, but I'm also going to nurture you and I'm going to be here for you on the other end and like follow you through on this. So, but you need that direction. If it's just nurturing, it's never going to work. And so absolutely, you got to put your foot down, call the, okay, good. Also, and involving the husband too. Yes. It's like such a critical piece because I think, you know, especially for me as an early career psychiatrist, like there's often some hesitation about involving family and disclosing some pieces of their information there, but that is really how you're going to sustain change, having as many people on the team of the patient as possible. So. Yeah, and I think that was the thing that got her into treatment was she was saying, my husband is not okay with me taking more time off. You know, he's so under stress. And when I talked to the husband, he had no idea that she was drinking again. Exactly. So as soon as he heard that, he was like, go ahead. Do what you need to do. Yeah. Right. And there's that early stuff that you got to do, like just start the process, you know, go into an IOP or go into something where you're like, you're sequestered a little bit, but then there's the ongoing coming back and reintegrating week, you know, month two, three, four, and back at home. Cause I don't know if there's, so, you know, these are the patients that they don't go to this extended sober community. They just, they may do an inpatient stay and then they're back home. So, I mean, here, the whole life has changed, right? And you're replacing so many things that are lost in their life. And then like the transitional object that you mentioned, alcohol, cause then you dig into their history and you're like, whoa, no, actually there's a story with dad that drank and there's a whole thing about how alcohol was in their family and what alcohol means to this person. And then you get into that in month three, four, five, and you're like, whoa, there's like way more going on here. But I mean, replacing all these things and thinking, I like that with transitional objects. How do you replace all those objects? I mean, it's just really tough. The husband wants to go back to work and do what he has to do or the spouse, you know, any, it goes both ways. I mean, this is kind of a little bit stereotype case, but like there's so many, I have a lot of gay patients that are like, I mean, it's like, I'm not giving up my career for him, you know? And that's just what it is. It's like, we're like, okay, yeah, I mean, I get it, but where are you going to replace all the things that you've lost? So it's tough. All right, well, this is lovely. Thank you for, you know, I think, so we're gonna move along and we're gonna have Mashal Khan, who's our addiction psychiatrist and. Thank you everyone for your patience. So I'm gonna be going over technology assisted therapies and interventions, which is just a fancy way of saying anything that's, you know, a software or a hardware product that can enhance your, you know, the care that you deliver. And, you know, it encompasses a lot of things, you know, it includes mobile phone applications, web-based platforms, and neuromodulation is also included in that category. And the idea of this is to, you know, improve the quality of care or, and it's not to replace the standard of care, where it's to enhance things when needed. And especially when the standard of care cannot be delivered, sometimes these can step in as somewhat alternatives. And, but, you know, with anything, they do have their limitations. Each of them have their own unique limitations. Starting off with telehealth, something that we all had to adopt because of the lovely pandemic. You know, the silver lining there was that we were all forced to adopt it, but also the government had to adjust the laws and the insurance companies were forced to pay for our services appropriately, and we all got used to it. It really enhanced delivery of care in rural areas. And, you know, those of us that were avoidant of losing that, you know, the third dimension and just seeing patients on a two-dimensional screen and always thought that, you know, it wouldn't, therapy wouldn't work, med management wouldn't work, you know, you can't smell the alcohol off their breath, so on and so forth, for the most part, we were able to provide effective care. And there might be some qualitative differences, but, you know, it did assist us in delivering care quite a bit, especially in desperate times. Then, you know, mobile phone technologies, those, these have been around for a while, even before Apple phones and apps, you know, at the federal level and the state level, they were either NIDA or SAMHSA-led projects where you could, you could text on a number and if you were having cravings or you wanted to sort of speak to someone for support purposes or leave a voicemail saying, you know, I'm struggling with X, Y, and Z and with cravings and they would call you back with, for support. Those services have reduced since the advent of mobile health apps, however, still do exist to a lesser degree, though. Mobile health apps are, are, are, are basically very, nowadays quite popular, of course, and, you know, include, you know, things that enhance behavioral change through CBT, either gamification technique, utilize gamification techniques, focus on use reduction, you know, or progress tracking or help within the movement, cravings and whatnot, or, you know, offer access to peer support groups. And just to sort of go over each category and what that actually means, you know, absence trackers are great. You know, you can, they allow you to, you know, plug in how many hours you've been, since your last drink or how many days it's been and they reinforce abstinence by giving you these tokenized rewards or they sort of act as your cheerleader and enhance your motivation by, you know, just congratulating you on your first day of abstinence, congratulations on making it to your first week and they have these badges and awards, which really, you know, works for some people that, for which gamification really appeals. So then there are apps that focus on information and educational content and can have like daily affirmations or motivational content, or it can have, or they offer you access to educational videos or podcasts. And if you ever listen to the podcast material where people are going over their experiences, their struggles with alcohol or other substances, it's similar to, you know, what a lot of people attend AA for, where they want to learn from other people's experiences, their journey and apply those lessons to their own lives. And, you know, it doesn't really matter if you're sitting in AA getting that same, lesson versus if you're listening to, you know, a podcast that you click with, as long as it instills a state of change. And then there are peer support groups, which are in the form of public forums or messaging services or the 12 step groups, or even there's a social network that's focused on sobriety called Sober Grid, where people post their experiences, offer advice, and there's like an FAQ section, there's a, you know, ask an expert or ask someone in recovery section. And that really helps in sort of providing a de-stigmatized environment where people can actually engage with others that are going through the same journey or are more advanced in the journey and can learn from them. And then there are these habit tools, which, you know, focus on behavioral change, use, are basically CBT based apps. And in these apps, you take inventory of all the negative toxic habits that were associated with your use of alcohol. And the CBT app then guides you towards, you know, addressing these habits by forming healthier habits that will ward you away from alcohol use. So, and then there are these relapse prevention apps that are pretty cool, which, you know, you can, the minute you have a craving, you can open one up and it'll give you a list of things or a different, you know, depending on your, your archetype or your preferences will give you different options of how you can sort of overcome the craving or, you know, how you can distract yourself in different ways. So those are really helpful for people in early recovery. And then there are these apps that offer, you know, links to support groups, AA meetings, and connect you with other peer support groups and whatnot. There are, there are a number of FDA, there's, there are a limited number of FDA approved apps. Peer is one of them, or used to be one of them. Unfortunately, it is no longer in existence. But, but the good news is with anything nowadays, there are like a million clones of this app. So they've, you know, they're better, if not the same, they just don't have the FDA approval. It's literally the same product, but a bit more user friendly, if anything. Because, you know, somebody in Silicon Valley just decided to make a better version that appeals to people better. So, and then there are applications that are endorsed by NIDA and SAMHSA. CBD for CBT is a very popular one. It's gone through rigorous, you know, it's gone through eight independent randomized clinical trials where it's shown a lot of evidence that it's effective in behavioral change and promoting abstinence. And then Drinker's Checkup is a computer based app that, you know, focuses on brief motivational interviewing and also assesses alcohol use and figures out, you know, what type of problems you may have and has like this whole module that enhances motivation and, you know, identifies those, what kind of treatments you would benefit from. And that's also gone through randomized control trials and has an evidence base for reducing alcohol use by 50%. And then the other honorable mentions would include therapeutic education systems, which is a web-based interactive multimedia module based on community reinforcement. And with alcohol, I always try to address comorbid or co-occurring tobacco use. Because oftentimes those two things get paired together. If you don't treat them both at the same time, you are just inviting relapse into the picture. So Motivate and Project Quit are great apps that focus on tobacco abstinence and have a lot of data backing them as well. And then there are a number of web-based technologies that, you know, include all of these. And I'm going to be individually covering them. So Online AA has been, quite frankly, a game changer. And Akhil and I often recommend it to patients that we evaluate on the liver transplant team. These are patients that are very sick. They're admitted to the hospital. They need a transplant. Yet we, you know, they've been recently drinking. So they're still drinking. So we need to see if they are motivated for change, if they want to invest their time and energy, even when they're sick, towards getting better. So we often recommend at bedside that, hey, I know we reviewed the records and it shows like 10 times the ER or other physicians or your primary care mentioned that you should go to an IOP or attend AA or Smart Recovery. And you said you would, but you weren't able to for a number of reasons. Here's a QR code or here's a link that we're going to text you or email you and just click on it. And it's going to open up a bajillion meetings that are happening across the globe that you can join. One meeting every like five to 10 minutes. And each with its own theme, by the way. So if you're a veteran, if you're interested in a women's only group, if you're interested in the Lower East Side Click or whatever, it's so specific. And it gives you the choice of like choosing what themes you would want. And it has maybe 30 or 40 unique things that you could combine and gives you options and timings. And there was one example where we weren't able to find a Korean AA for one of our patients. And thank God for online AA, we were able to find one in South Korea and connect the individual there. Even though you'd imagine New York has K-Town and might have some services there, but they were in person, but they didn't have an online presence. So yeah, it connects everyone, connects everyone globally. And for those patients that are less spiritually inclined have experienced AA and are not that much interested in going back to it, Smart Recovery is awesome. It's very data, evidence-based. And also their digital platform has a bunch of awesome tools that can help with self-assessment of alcohol use. And you come across a person that's like, I don't believe you doctor, you're lying. I don't have use disorder. Well, do it yourself. And then it gives you this cost benefit analysis tool as well that guides you through different interventions and it has cognitive behavioral and motivational exercises and modules for alcohol. It's awesome. So try it, if you haven't seen it, check it out. So, and then with online peer support groups, there's so many benefits. There's a diversity of online available groups that I was raving about earlier. And there's a convenience of just logging in. Oftentimes we hear about like, doc, I can't go, I can't take like a 10 minute train ride to the next, or I can't leave my job and walk down the block to, take a 10 minute walk down to the nearest AA meeting. However, they can log in on their phone and just find a private corner and spend like half an hour to 45 minutes in investing their time towards their abstinence. There's increased anonymity. You don't actually even have to show your face. You can actually apply a virtual emoji and become a bear or a dolphin or whatever. So, and it's anonymity to that level. And that's where it's going. I personally advocate for it, it's pretty cool. So, and then you connect with the global crowd and there's decreased stigma, of course. However, so it's not all roses and butterflies. There's also the perception of social disconnectedness and the inequity of access to technologies. If somebody, and it's a little less common nowadays, but there are people that don't have, for example, the unhoused, don't have, people from very lower socioeconomic strata may not have mobile technologies that allow them to connect or be online for as long as they'd like to be. And then there's also this fatigue associated with repeated online video conferencing as well. So those are the negative dings around it, but I think all the positives make up for it. So, oh, that's just my opinion. So, web-based contingency management models, Motivate that I mentioned earlier is one of them, as with all contingency models, the same limitation applies to this, which is the sustainability and lack of funding, unfortunately, but it is effective to work, and most of it has been applied towards tobacco abstinence. So this is pretty cool. So there are two digital tracking tools that I wanted to bring up, and I hope that you can integrate into your practice. Soberlink is this breathalyzer that has a facial recognition tool and sends an email blast to all the people that you've added to the list. So it really helps in building back trust and accountability. And people used to use Antabuse for those purposes, where you have the partner join into the treatment, and they administer the anti-abuse, and you're sort of building accountability and trust by that manner. It's great in the forensic world where forensics and alcohol use disorder overlaps. It's great in our world where alcohol liver disease, and we're trying to monitor closely if they're abstinent and they're not able to often come in for testing. And the other tool that's really cool, but it's sort of in the early stages, is this digital tracking wearable. So this wearable that sort of tells you if you have basically categorical blood alcohol content. Either you have low, mid, or high blood alcohol content. So the use case for it is the individuals that we often find have the highest failure rate, the ones that want to reduce their use, that want moderation, that want to aim for moderation. They have this sort of biofeedback mechanism with this wearable. So from that perspective, it's pretty new. It's getting better and more specific, and the hope is in the future it'll be able to tell you the exact blood alcohol content, which currently the current models are not able to, but in the past four years it's advanced so much that I'm hopeful in the next two, three years that we'll get there. Fiberscan, something that briefly Akhil mentioned, is something that we often used with individuals that are interested in data, actually understanding what's going on with their livers. The limitations around Fiberscan, which is basically a very advanced ultrasound machine, is that if you're actively drinking, it won't give you an accurate amount of how much scar tissue you have in your liver. You need to be abstinent for four to six weeks, roughly, in order for it to accurately gauge the scar tissue accumulation in your liver. But it has worked wonders in individuals that are very concrete about, you know, well, tell me how much my liver is suffering, I want to know the exact number, and it really enhances their motivation for change, especially if you give them the spiel that we can recover a lot of this. Your liver can recompensate, you can do well with 70-80% of your liver, you know, 20% scarage isn't that bad, but it is going in a direction where it may get very bad. And then artificial intelligence, you know, I was talking to Rick Rosenthal, who's a big name in research and alcohol use disorder in New York, works in Long Island now. Machine learning's been around for ages, and, you know, he's been using machine learning to predict the likelihood of relapse. And within a three-month window, the accuracy or the predictive ability is going to improve as artificial intelligence, which is, by the way, the same thing as machine learning, just a sexier term, it's going to become more predictive, more accurate, and it's going to use a lot of patient data, such as texting data, their health records, and whatnot. And then there are already, you can program your chat GPT, which has been in the news and everywhere, it's been all the rave in the past year, you can actually program your chat GPT to become a chatbot. The prompts are all over Reddit if you want to use them, but there are actually these AI chatbots that are independent of that, if you don't want to do it manually, that are actually, in their early stages, they're a little bit clunky. I've used a few of them just to play around with them. They tend to go off track a little bit, but I'm afraid we're going to lose our job. But hopefully we won't. And then, just wanted to mention these briefly, because you guys have been in these general sessions and they've been talking about neuromodulation, both the non-invasive type, not the invasive type, but TMS and transcranial direct current stimulation. There's a lot of evidence in support of TMS, especially the one that's deeper and targeted. It is helping with reducing cravings and reducing alcohol consumption. And when it comes to direct current stimulation, with that, the older studies from 2013 showed mixed results and actually increased rates of relapse, but the newer ones from Philip et al. showed that there was reduced craving for alcohol consumption. But majority of the work has been done towards tobacco craving reduction and cigarette use. There was a lot of supporting data for that. Deep brain stimulation. By the way, none of these things are FDA approved. And this is just data for you to consider. I don't know if anybody is aware of what Neuralink is. It's this very invasive attempt to make us cyborgs, which is entering into its human trials. It actually just started a few weeks ago. And part of their agenda is to also help with treating mental illness and addictive disorders. I just wanted to tie those two things in, that deep brain stimulation has shown to effectively reduce alcohol use and alcohol cravings in a variety of studies. And most likely, when Neuralink becomes commercialized and we're all a bunch of cyborgs and don't have any mental illness and use disorders, that might be the approach where they're just poking our neck and amygdalas and whatnot. So this is a very typical case that both Akhila and I see on at least once or twice a week for urgent evaluations. A middle-aged man with a history of alcohol use disorder, alcohol liver disease, and possibly past pancreatitis episodes comes in with decompensated liver disease with an episode of jaundice and ascites, has a mild to 28 acute child's PUC. They have a history of consuming half a liter of vodka, never received any history, any treatment for alcohol use disorder, and have been hiding their alcohol use from their spouse. So based on the things that we've learned or gone over today, how would you apply any of these things to an individual such as this that has admitted to the inpatient or is interfacing with you? I guess just lay out the facts, like, all right, this is what's going on. It could be worse. You can come and make it better, but you're confused with the options. And, like, as it is, you find all these options, and you're found to be bad. I don't know. That way it works. Yeah, yeah, absolutely. And, you know, we often, my go-to, or what has become my go-to, is now after we've been consulted, we obviously assess for what severity of use disorder they have and whether or not they need a liver transplant or whatever is happening with them. I would always connect them to online AA. I would also offer them resources for online trackers. I would try to connect them to someone that is able to provide them virtual care that is there, you know, accepting insurance or if they don't have insurance, if there's a free clinic that has virtual AA, sorry, virtual telehealth services, giving them resources for that. And it's a real game-changer because the one theme that we picked up on is we spoke to a lot of ER physicians, hepatologists, or inpatient providers was that we have given them resources time and time again for attending in-person AA, walk-in clinics, all that stuff. But, you know, life happens, and they're not able to connect. But at least you're removing that physical barrier from people, especially in people like this individual that have health comorbidities that prevent them from, they're not as robust as they used to be. So, you know, they have things, their ability to go about and, or the energy bandwidth that they have is now very limited. So this can really be a good start for them and motivate them. And, you know... Before we get to the next, just another piggyback on that. Yeah. You know, we don't have a lot of evidence with AA because it's AA, and there's not a lot of studies, right? So you can't, we don't have a capacity to show you the numbers, but from anecdotally, from what we see in the hospital, because we basically have them download the app in the hospital, and we watch them get, you know, find a group. So, I mean, almost everyone finds a group, right? Because we're mandating that they find a group. We're coming back the next day to see if they found a group. We have a log sheet. They put down the leader's name from the AA group, and, you know, when they attended, and, you know, we follow up in two or three days and see what their progress is. We inform the team that that's what our recommendation was. The team also reinforces that message so that it's not a message in a silo. Right. So that's our anecdotal. I mean, the only one that I, was an Albanian patient. It was very tough to find an Albanian in Albania, so we didn't find it. But, you know, has anyone tried this? Like, and then followed up to see, are they engaged in a group? Because I was curious, is that something that people are doing outside? Because here we're captive audience. They're in the hospital for weeks, and the only way we can interrogate their motivation for joining a group, it's not, because they're not getting to it yet, is to see them engaged in this virtual AA. So I don't know if anyone else has had experience with that. I definitely encourage people to follow up and get, you know, various reports where people are not interested versus somebody just last week who finally engaged and ended up in a WhatsApp chat group and getting all kinds of great support and feedback, and so, you know, when people jump into it. But with the evidence, I'd at least like to just recall that when Kelly, 2020, caught a review on AA12 snap, which was pretty decent evidence. Yeah, that's true. Yeah. But it was sort of, that was pre-pandemic, so it's, but I'd like to see a virtual one like that. Oh, yeah. Yeah. Sure. Yeah. Sir, you had a question. Yeah, the, is this a patient you would expect to discharge to home? Because we get calls saying, our attending has decided this morning that he has to go home today, or has to leave today, and he's not ready, so we want him on residential by this afternoon. This is the kind of call we get from hospitals. Yeah. I mean, if you have access to a residential that would accept it, it might be a great option, but typically, we try and work with the team, especially when they're the nearest surgery team, and they're very eager to get them out, or something to that effect, because our patient population sometimes has falls and hurts themselves. I mean, you can see the future. If you can't get them to residential, the future could be you hand the family member the breathalyzer, and the AA link, and because they're going to be at home, they're starting at home, they're too sick to go anywhere else, and yes, you can order, you can also order blood flow to the house, too, right? So this is a little world where you can do that. Yeah. So you have, but they have the breathalyzer, and then, and then, and so that everyone's kind of calm and easy, like you said, you're doing a little bit of that. But things like CBT, for example, we, in the past, we've always depended on a therapist or someone that's trained in that field to educate our patients or get them acquainted with CBT, at least with these mobile technologies, we've removed that barrier. If you're working in rural parts, you've removed the barrier that my car isn't working, or it's too far, and I don't want to travel 45 minutes to see my doctor, or to go to the nearest AA meeting, or whatever their rationale is. And a lot of our patients are not in good health, they may have encephalopathy, they cannot drive, safely drive at least, without killing a few people on the way. So if we're lucky, it's a deer. But anyway, so I think with all this stuff becoming integrated into our practice, we're really going to help a lot of people, it's just a matter of becoming comfortable as healthcare providers to suggest that, or to recommend that to our patients. Yes. It's a subscription thing, so it's like $100 a month subscription, it's not covered by insurance. A lot of my forensic or legal work patients, where there's one partner's concerned about their use, and they want data to support abstinence, or the patient themselves wants to take away their partner's alleged allegations, or the power from them for continuing to allege that they're using, this can be a great tool. Go ahead. We do have access to peer support specialists, nurses, through a grant, and they can go to bedside and interact with patients. Oh, and they should have these resources to give to the patient directly. Yeah. Yeah. They already do. We just started it up in our healthcare system. All right, good. One thing that made everyone's life really easy is some of our residents came up with a QR code, you know, one of those dotty things that you just put a camera on and it just opens up a webpage with all these options. So, I mean, that's been really cool. As long as you have a functional phone that has a camera, you just point at it and, yeah. We gave all of our peer coaches a business card with a QR code. Nice. It's been super- Oh, that's good. Right? It's a business card. Isn't it game changing? People in the ED all have those. Nice. Yeah, yeah. Business card with QR code, that's good. Yeah, let's do that. Yeah, yeah, yeah. I was going to ask you a question. Is there any app where you can put money, whatever money you'd be spending on alcohol, into a sort of bank account, a mini bank account? And you only get access to it, it's like a lockbox, if you make your six months or three months- That's a great idea, but I'm not aware of it. And then you take your time. Sorry, are you in the back? I love that. I just have a comment. That wrist technology that you were showing, I think that Apple should buy that once it's developed so that our colleagues, our family members, anyone who drinks knows whether or not they can drive home. Yeah. So hopefully you can- By the way, it uses the same technology, the green light that blinks at the bottom, it uses the same one that checks blood oxygen levels. It's just tuned at a different frequency. We'll be able to see that for sure. The Apple Watch will do the Apple ALC. It'll come out soon. I think he said it out loud, right? I think all that will be ready for production. Yeah, but also I was really curious, you know, with this patient population with liver disease and how I feel like sometimes I have the same experience going through med after med after med where just like nothing is really making that big of a difference. Do you guys know if there are any studies looking at psilocybin or psychedelic use in this population? I know it's used palliative care wise, so these guys are just as sick as the palliative people. Yeah. In the ALD population? So yeah, unfortunately I came across a few. I don't know if that's good or bad. But in New York there are a bunch of kidney infusion clinics and you can actually now buy psilocybin chocolate bars at a random head shop. It's not, you know, kosher to do it, but it's available under the table. You just need to ask. So a lot of people have been microdosing and we are learning from, you know, just anecdotal reports are that yes, especially with kidney infusions, I presented a case actually last week, that this individual's use went down significantly after they, and they became abstinent without realizing it or intending it. They had other use, like cannabis use was still ongoing with their every Q2 weekly infusions. But, you know, we did notice that. And they did then later on recognize that that was the case. This is going to happen. We're going to, and it's the question about do you need a coach, do you need a therapist with the experience? Is it microdosing? What's the dose? No, it's not been studied. Microdose is always edging to macrodose essentially. So I've worked with a lot of people in the finance area that start off with using microdosing because it has that stimulant effect. And before you know it, they start off with like 0.5 gram and now they're at a macrodose of like 3 grams. And they're sort of almost like tripping, but not tripping and having some hallucinogenic effect. So it's not... On an ongoing basis? Yeah. Are they doing well in finance? I mean they're seeing me as if there must be something. Yeah, they're paying for the cure. Crazy. Okay. I don't know how sustainable is that. No, it's not. We'll be the losers. Yeah. This is great. Thank you so much for coming. I think we're good. Thank you.

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