PROJECT SUMMARY Project 2 of the Johns Hopkins DELTA Center for Alcohol Research focuses on studying and implementing evidence-based alcohol use disorder (AUD) interventions in the post-transplant setting. Alcohol-associated liver disease (ALD) is the leading indication for liver transplants (LT) in the United States. Our group and others have demonstrated comparable survival outcomes between recipients of early (ELT; <6-month abstinence) versus standard liver transplants (SLT; ≥6-month abstinence) for severe ALD. Therefore, we have advocated that transplant programs waive the arbitrary “6-month rule” to promote equity of access to LT for all patients with ALD. However, return to alcohol use remains a considerable concern for both ELT and SLT recipients; up to 40% report alcohol relapse and have 22% lower absolute cumulative survival by three years after LT. Furthermore, while most transplant programs have historically mandated or enforced pre-LT alcohol treatment, post-LT treatment services have received far less attention. We conducted a randomized controlled trial (RCT) during the previous funding cycle to assess technology-assisted, non-traditional AUD treatments integrated within routine clinical care during post-LT Year 1. The RCT initially encountered delays due to the COVID-19 pandemic. The trial’s progress has been promising since then, though it has also raised additional salient questions related to AUD treatment among LT recipients: Do LT-specific factors like surgical complications affect recipients’ engagement with alcohol treatment services? Does the addition of AUD pharmacotherapy by LT clinicians promote or discourage patient participation in concurrent psychosocial interventions (PSI)? How can transplant programs provide continued addiction support beyond the early post-LT period? The next phase of Project 2 will answer these and other questions related to the post-LT delivery of alcohol treatment services through a combination of observational studies and intervention trial that builds on our lessons learned during the previous funding cycle. The specific aims are (1) to ascertain the impact of pre- and post-LT factors on AUD treatment engagement, (2) to quantify the effect of AUD pharmacotherapy on participation in post- transplant PSI, and (3) to assess the benefit of peer support specialists on long-term post-LT alcohol outcomes. The proposed studies will systematically examine early and long-term approaches to increase LT recipients’ participation in AUD treatment, decrease alcohol relapse risk, and improve overall survival. Compared to co-located hepatology/addiction clinical models, which face many systems-level obstacles toward broad dissemination, our interventions are desirable given their greater ease of implementation. Our work will hold the potential to maximize the benefits of a scarce organ resource for society and improve the overall cost/benefit balance of LT for patients with severe ALD.