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Probabilities of relapse and abstinence among liver transplant recipients

Andrea DiMartini and her colleagues have provided prospectively gathered data on the course of alcohol use among liver transplant recipients during the first 5 years of postgraft living. Having worked with the difficult issue of alcohol use disorders and liver transplantation for a number of years now, I know the results of her study will be viewed in many ways. One frame of reference—that of the most exacting utilitarianism untroubled by the vicissitudes of human experience—might conclude, “There is nothing here that I can use. Alcohol-dependent people are likely to drink heavily: no surprise there. The investigators found no empirical cut point for pretransplant abstinence that we can use in selection: again, no help. And 1 in 4 alcoholic graft recipients were back drinking heavily within 5 years. How can I explain that when I’m talking with a donor parent of a child killed by a drunk driver?” This stance pays no attention to Sir William Osler’s conclusion that “Medicine is a science of uncertainty and an art of probability.” An opposite theoretical stance—one holding that technical idealism will save us all—might view Dr. DiMartini’s results and say, “Wow! Three out of 5 alcoholics didn’t drink any alcohol in 5 years, and 3 out of 4 never returned to pathological drinking in that time! Tom Starzl was right all those years ago when he said liver transplant is the cure for alcoholism. Maybe we should transplant every alcoholic we can find.” Osler’s words apply here too: A “cure,” as such, is likewise a matter of probability. In the complexities that fall day-to-day about the Aristotelian mean of human existence, that place where most of us live, what has Dr. DiMartini brought us? First, her data support the most carefully done outcome studies before her: Only a minority of even the heaviest drinkers returns to addictive alcohol use after liver transplant. It is easy to breeze by the fact that before transplant her subjects averaged 100 drinks per week, or about 14 drinks per day. Liver transplantation may not be “alcohol-acillin,” but something is going on here that resembles it. Several years ago I first thought that the high-abstinence/nonpathological drinking rates were due to the similarity between posttransplant care and George Vaillant’s predictors of sustained abstinence. And this may be true in part. But lately I’ve come to wonder whether the immunosuppressants themselves may have an affect on limiting alcohol use. Among hard-drinking mice, cyclosporine appears to do so. In any case, the high abstinence rates remain unexplained. Second, Dr. DiMartini pounds another nail of evidence in the coffin holding the 6-month rule of abstinence before transplant. Pregraft abstinence is a continuous variable. No cut point exists in nature, as she shows by the linearity of her receiver operating curve plotting the sensitivity and false-positive rates against each other in using pretransplant sobriety months to predict posttransplant abstinent months. As she points out, sensitivity and specificity are elastic here: The more you stretch one, the more the other shrinks. Osler would give her a gold star. More practically, any program still using the 6-month rule may want to show Dr. DiMartini’s report to their lawyers, who might have to defend the indefensible in court. Third, Dr. DiMartini’s detailed prospective study of return to drinking—among those who did so either as an experiment or as an addiction—demonstrates that posttransplant pathologic drinking resembles Mr. and Mrs. Mac Beth committing murder. If it occurs, it occurs quickly. In this study, the first few months after