Alcohol use disorder (AUD) affects 7% of the world population and has a high health burden, including a high risk of acute and chronic pancreatitis. Over 80% of individuals with AUD also smoke, which is itself a risk factor for pancreatitis. Most centers require 6 months of sobriety before performing total pancreatectomy with islet autotransplantation (TPIAT), so patients require active counseling on remaining sober and abstinent from smoking. Studies of TPIAT rarely evaluate outcomes by etiology, but heavy alcohol consumption and smoking are both associated with an increased risk of postoperative complications. However, it is not clear whether light or moderate alcohol use is problematic or whether complete abstinence is needed for a successful TPIAT. Chronic pancreatitis is associated with an increased burden of psychological diseases, which are exacerbated by AUD; even those who achieve sobriety may be more prone to anxiety and depression after TPIAT and will need psychological support. Thus, the need to treat ongoing pain and distress from chronic pancreatitis with TPIAT or other procedures must be weighed against the risks inherent in treating patients with AUD.