A matched comparison study of medical and psychiatric complications and anesthesia and analgesia requirements in methadone-maintained liver transplant recipients

✍ Scribed by Robert M. Weinrieb; Rebecca Barnett; Kevin G. Lynch; Maria DePiano; Alfred Atanda; Kim M. Olthoff

• Publisher: John Wiley and Sons
• Year: 2004
• Tongue: English
• Weight: 102 KB
• Volume: 10
• Category: Article
• ISSN: 1527-6465
• DOI: 10.1002/lt.20003

✦ Synopsis

Approximately 85% of patients receiving methadone maintenance therapy (MMT) for opiate dependence in the United States are infected with hepatitis C virus (HCV). MMT is significantly underrepresented in most liver transplant programs, but the number of patients receiving MMT is increasing and few data are available to guide treatment. We evaluated MMT in our program (27 pretransplant and 10 posttransplant cases) for medical and psychiatric complications and anesthesia and analgesia requirements. After transplant, 10 patients receiving MMT were compared with a matched control group of 19 patients who were not receiving MMT and not dependent on opiates. Fewer patients receiving MMT retained a spot on the transplant waiting list (65%) than patients not receiving MMT (80%); 30% of patients receiving MMT pretransplant used heroin, cocaine, or marijuana, and more than 25% were lost to follow-up. Liver disease according to mean Child-Turcotte-Pugh (CTP) score and transplant waiting times was similar between the 2 groups. Patients receiving MMT required significantly more intraoperative anesthesia and postoperative analgesia (mean fentanyl 3,175 g/d, SD ‫؍‬ 2,832; intravenous morphine 67.86 mg/d, SD ‫؍‬ 38.84, respectively) compared with patients not receiving MMT (mean fentanyl 1,324 g/d, SD ‫؍‬ 1,122; intravenous morphine 12.17 mg/d, SD ‫؍‬ 10.24, respectively). More patients receiving MMT had severe recurrent HCV infection (60%) and worse survival (60%) versus patients not receiving MMT (21% and 78.9%, respectively). Follow-up times did not differ between groups (MMT: mean 4.19 years, median 1.15 years, SD ‫؍‬ 7.6; non-MMT: mean 2.68 years, median 2.19 years, SD ‫؍‬ 1.73). Finally, patients receiving MMT required an average methadone dose increase of 60% from pretransplant to posttransplant. Postoperative analgesia guidelines are described. Posttransplant, 20% of patients receiving MMT used alcohol or illicit drugs. Data do not support withholding the provision of liver transplantation to patients receiving MMT, but larger, wellcontrolled studies are warranted. (Liver Transpl 2004;10: 97-106.)

S haring injection drug-use equipment among heroin addicts is the predominant medium for transmission of hepatitis C virus (HCV) in the United States. 1 The result is that approximately 85% of the approximately 179,000 patients receiving methadone maintenance therapy (MMT) for opiate dependence in the United States are HCV infected. 2 Because 20% of patients with chronic HCV infection will develop cirrhosis and 20% of cirrhotic patients will require liver transplantation, it is estimated that at least 6,000 patients receiving MMT will need liver transplantation in this country once they have progressed to the stage of decompensated liver disease. Despite the fact that HCV-related cirrhosis is the most common indication for liver transplantation in the United States, patients receiving MMT are significantly underrepresented in most liver transplant programs. 2,3 It seems likely that insurance reimbursement, stigma, insufficient knowledge of MMT, and fears about return to drug use after transplantation explain why only 10% of liver transplant programs surveyed in the United States had experience with more than 5 patients receiving MMT. [3][4][5] Furthermore, limited outcome data are available to guide transplant clinicians in treatment decisions affecting patients receiving MMT. Accordingly, the