Barriers and Facilitators of Alcohol Use Disorder Treatment for Alcohol-associated Liver Disease: A Systematic Review

Introduction: Individuals with alcohol-associated liver disease (ALD) have low engagement in alcohol use disorder (AUD) treatment. This study aimed to identify barriers and facilitators to AUD treatment in ALD patients and provide recommendations to improve recognition of need, treatment initiation, and care continuation. Methods: We conducted a mixed-methods systematic review to identify barriers and facilitators of AUD treatment. We combined quantitative and qualitative studies following the convergent integrated approach and performed directed content analysis based on the Capability, Opportunity, and Motivation–Behavior (COM-B) model. Results: Twenty-three eligible studies were analyzed. Discordance between patients and providers in the need recognition stage led to missed opportunities; patients recognized the need for AUD treatment during symptomatic ALD, but providers focused on it after immediate liver-related symptoms subsided. Liver transplant (LT) status influenced motivations for concealing alcohol use that hindered treatment initiation; LT candidates were confident in self-managing their alcohol use and feared reprimand or disqualification, while LT recipients felt shame in disclosing alcohol use. Low prescription and uptake of medications for AUD (MAUD) were linked to limited training and provider discomfort, along with patients’ misconceptions about MAUD. Care coordination and patient experience were key to care continuation. Conclusions: To increase AUD treatment in ALD, we suggest to: (1) Deepen patient and provider insights on AUD treatment during asymptomatic and symptomatic ALD, (2) Normalize AUD treatment for LT candidates and recipients, (3) Apply choice architecture and address misunderstandings about MAUD, (4) Improve collaborative care models accounting for patient preferences.