April 2010
Reviewer: Jeff C. Huffman, MD
Significant reductions in drinking following brief alcohol treatment provided in a hepatitis C clinic
Psychosomatics 2010; 51(2):149-156
Background: Alcohol use is common among patients with Hepatitis C (HCV); 80% of HCV patients have a history of excessive drinking, and approximately one-third of patients presenting to HCV clinics have current overuse of alcohol. Alcohol use is particularly important in HCV patients because it is thought to hasten the development of cirrhosis (and potentially hepatocellular carcinoma) in this cohort.
Methods: The authors performed a retrospective chart review of patients consecutively evaluated in an HCV clinic between February 2003-April 2004 who, as part of the initial evaluation process, scored above the cutoff on an alcohol use disorders screen (AUDIT-C) or were considered by clinicians to meet DSM-IV criteria for alcohol abuse or dependence and were actively drinking.
In this clinic, all currently drinking patients underwent brief (5-10 minute) alcohol counseling visits from clinic physicians and nurse practitioners. The intervention consisted of an alcohol use assessment, feedback of personal risk, advice to change (cut back/abstain), and a follow-up appointment to monitor progress. These follow-up interventions, performed by a psychiatric clinical nurse specialist, were more complex and utilized principles of CBT and motivational interviewing; referral was also offered to patients at these 30-minute sessions.
Charts were then reviewed by the authors to assess (a) rates of abstinence, (b) >50% reduction of alcohol use, (c) mean drinking days, and (d) mean quantity of alcohol consumed per drinking day. These outcome measures were assessed at baseline, after the brief intervention, and over an 8–22 month follow-up period.
Results: Forty-seven patients (all male; mean age 51) met study criteria and had chart reviews. After the brief intervention, 9 (19%) reported abstinence and 13 (28%) reported reducing their alcohol use by 50%. Furthermore, reported mean drinking days in the last month were reduced from 17.3 (SD 10.1) to 10.6 (10.1) and the mean quantity of alcohol consumed per drinking day was also reduced after the brief intervention. A total of 34 of the 47 patients subsequently elected to receive follow-up treatment from the clinical nurse specialist; these patients had a mean number of 4.5 (SD 4.2) visits with this clinician.
On follow-up chart review (8–22 months after the intake), alcohol use had further declined, to 8.8 (SD 10.6) drinking days in the prior month and 3.8 (SD 4.2) drinks per episode. Overall, 17/47 subjects achieved or maintained abstinence, and 12 subjects achieved or maintained a 50% reduction in alcohol use, at the follow-up. Finally, there was a significant improvement in AST and ALT over the course of treatment.
Commentary: This trial has many limitations: it is a small, retrospective study of a somewhat varied clinical intervention that occurred in a single clinic, relied on self-report of alcohol use, and results could have been skewed by both regression to the mean and an expectation bias (e.g., patients felt compelled to report less alcohol use after having an alcohol intervention from their physician). However, it also has some real strengths—it "recruited" consecutive patients, represents real-world care, and subjects’ transaminases dropped concurrently with their lesser reported use (it would have been interesting to see the correlation between LFT change and reported alcohol use reduction).
This report is consistent with literature that has found that brief screening and intervention around problem alcohol use, performed by patients’ medical clinicians, can be quite effective. Such an intervention is low-cost, low-burden, and can have some substantial results (especially in populations such as this one, where alcohol use can combine with existing medical conditions to lead to significant risk). The high rates of patient follow-up with the co-located psychiatric clinical nurse specialists (and, notably, patients did not take advantage of referrals to outside clinics) further argues for having mental health and substance abuse interventions co-located with medical care for greater acceptability and utilization.
In short, this is not a definitive study in this area, but continues to bolster the literature that recommends brief alcohol screening/interventions and co-location of substance abuse follow-up services within the medical clinic.