WEBB FELLOW: Prescription Opioids and Liver Transplantation: Shining the Spotlight on a Slippery Slope

Document Type

Conference Proceeding

Publication Date

11-1-2025

Publication Title

J Acad Consult Liaison Psychiatry

Keywords

Psychiatry, Psychology

Abstract

Background: Pain management, both pre- and post-liver transplantation (LT), may be challenging and necessitate complex analgesic regimens and reliance on prescription opioids. Importantly, shared neurobiological pathways exist between pain and addiction (LeBlanc et al. 2015), and individuals with a preexisting alcohol use disorder (AUD) are at increased risk for developing opioid cross-tolerance and persistent opioid use after surgeries (Kent et al. 2019). Hence, it is imperative for transplant psychiatrists to be aware of opioid consumption patterns in the setting of alcohol-associated liver disease (ALD) and LT. The aim of this narrative review is to describe existing literature and gaps related to opioid use for pain in the peri-LT period. Methods: PubMed and Embase searches were completed using the terms “opioid” AND "pain” AND “(liver transplantation OR alcohol liver disease)”. The final set of references included 21 academic articles (systematic reviews, cohort studies, and expert commentaries) and 3 conference abstracts published between 2012 to 2025. Results: Results are thematically grouped as follows (1) problems associated with opioid use in cirrhosis and specifically in ALD; (2) prevalence of and risk factors for chronic post-LT use; and (3) proposed strategies to minimize opioid use for peri-LT related pain. Discussion: Over 40% of patients with an AUD may develop new-onset addictions to other substances (Ohtani et al. 2023). There have been significant efforts made to highlight challenges associated with chronic opioid use after LT, particularly in the setting of ALD. However, while emerging literature suggests buprenorphine can be effective for postoperative pain (Raffa et al. 2014), a notable gap exists for ways to effectively manage pain related to ALD and LT with buprenorphine. Based on the findings of this review and the known relative safety profile of buprenorphine, we designed a protocol to manage pain related to ALD and LT in an effort to minimize the risk for iatrogenic opioid dependence or the development of an opioid use disorder. Future efforts may include examining how a standardized buprenorphine protocol impacts post-LT alcohol relapse rates and chronic opioid consumption rates. Conclusion: It behooves psychiatrists to recognize the interplay between uncontrolled pain and addiction in the context of transplantation. Various strategies to effectively and safely manage pain in the peri-transplant period may be considered, but utilizing buprenorphine for pain, particularly for individuals with at least one underlying substance use disorder, warrants further attention.

Volume

66

First Page

2

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