For people infected with HCV, alcohol use has a direct negative impact on the liver, increasing the risk and progression of hepatocellular carcinoma and liver fibrosis, which can lead to liver failure and death. Despite these health implications, studies have shown that adults with HCV are 3 times more likely than uninfected persons to consume more than one alcoholic drink per day (35% vs. 14%) and almost 8 times more likely to consume more than 3 drinks per day (19% vs. 2%) (3
). In this study, we developed and manualized an integrated behavioral-medical treatment model for patients with HCV who drink alcohol.
The goal of the treatment program was abstinence, and 44% of patients achieved this objective at the end of the treatment. Natural history studies have demonstrated survival benefits among patients with HCV infection who become abstinent from alcohol even after the development of cirrhosis (25
). In addition, ASI alcohol composite scores decreased by nearly half between baseline and 6 months. This reduction in ASI alcohol scores is comparable to changes found following behavioral intervention studies in alcohol-dependent individuals (26
). Notably, alcohol scores did not significantly differ by HIV status, race, gender, age, or income, indicating that the treatment model may be equally beneficial for diverse HCV-infected patients.
For patients who did not become abstinent, ASI alcohol scores decreased by 26.8% between baseline and 6 months. Natural histories support benefits to both abstinence and reductions in alcohol use. Poynard and colleagues observed that the median rate of fibrosis progression was highest (0.167 units/year) among patients consuming greater than 50 grams or more of alcohol per day compared with 0.143 units per year among those consuming 1 to 49 grams of alcohol per day and 0.125 units per year among the abstinent patients (4
). Others have found a relationship between heavy alcohol consumption and developing cirrhosis faster (5
) and increased risk of developing hepatocellular carcinoma (28
). Thus, in addition to the 44% of study patients who became abstinent, it is likely that the decreased alcohol use found in other study patients, even when shy of abstinence, will benefit their health.
HCV-infected persons with advancing liver disease can be treated with HCV antiviral therapy, which offers the possibility of being cured. Alcohol use may negatively impact HCV treatment response in terms of degree of fibrosis and intrahepatic HCV replication (6
). Treatment guidelines therefore recommend abstinence from alcohol to prevent fibrosis progression and to improve treatment response (8
). Cure rates for genotype 1 infection have been approximately 40% (31
), but may increase to 69-75% with the addition of two protease inhibitors that have recently received FDA approval (32
). However, these medications are given in combination with peginterferon-α and ribavirin, and alcohol use negatively impacts HCV treatment response with this regimen (6
). Therefore, alcohol use will remain contraindicated for antiviral therapy according to treatment guidelines (8
It is interesting that 20.8% of patients reported alcohol abstinence to the interviewer during their baseline interview, even though they reported hazardous to dependence alcohol use to their HCV medical provider at the time of study enrollment. It is possible that patients achieved abstinence because of 1) the brief alcohol intervention that occurred with the medical provider; 2) the initial meeting with the addictions specialist; and 3) the act of making a commitment to participate in alcohol treatment. Studies have found 5- to 15-minute brief alcohol interventions delivered by medical providers to result in significant decreases in alcohol use (34
). Although our brief intervention may have led to alcohol abstinence in nearly one-fifth of patients, we do not know if abstinence would have been achieved without making a psychological commitment to an alcohol treatment program, or whether abstinence would have been sustained without further treatment. Future studies should test our 6-month alcohol-HCV treatment model against brief alcohol counseling among HCV-infected patients.
In addition to decreases in ASI alcohol composite scores, we also found decreases in ASI drug composite scores. However, drug composite scores were low at baseline (mean = 0.048), increasing risk of type II error, and the only statistically significant decrease was found for the full sample between baseline and 3 months. Future replications of this integrated intervention may consider augmenting the substance use treatment components for patients affected by substance use in addition to HCV and alcohol use.
Our study had several limitations, including the lack of randomization, the small sample size, the use of a single hepatology clinic, and the lack of an objective measure of alcohol use at initial or outcome timepoints. The study is also limited by the lack of long-term follow-up for treatment outcomes. Patients with HCV may be particularly motivated to quit alcohol use, but it is unknown how long they are able to maintain abstinence based on this treatment. Future research will need to study these interventions in larger numbers among multiple settings and randomize patients to a treatment model or standard care. However, our study was effective in demonstrating the feasibility of incorporating the integrated care model into a hepatology clinic. Integrated behavioral-medical models have demonstrated positive impacts on alcohol use in primary care settings, but have rarely been tested in HCV specialty care settings (11
In 2004, the National Institute on Drug Abuse convened a panel of experts to review the state of treatment for persons with HCV and co-occurring substance use and psychiatric illness (35
). They concluded that early interventions for substance use and psychiatric illness need to be integrated by clinicians into their treatment algorithms and into a variety of health care settings, yet few studies have examined approaches to address alcohol use in HCV-infected patients. Review of the literature found only two integrated treatment studies from a team at the Minneapolis VA (36
). In their hepatitis clinic, HCV-infected patients received multi-disciplinary provider consultations and services from a co-located psychiatric clinical nurse specialist (PCNS) who provided cognitive behavioral and motivational therapy. Retrospective chart review indicated that patients seeing the PCNS were more likely to complete an evaluation for and initiate HCV antiviral therapy. Also, of the 47 patients who additionally received one to two brief alcohol counseling sessions by the clinic's medical providers, 36% became alcohol abstinent and 62% decreased their drinking by 50% or more (37
Like the Minneapolis VA studies, the HCV-alcohol intervention we tested co-located an addictions specialist in the clinic who engaged in multi-disciplinary consults. In contrast, our intervention relied heavily on group therapy, which has been shown to be an effective alcohol treatment format and is less resource-intensive. Our participants received on average more sessions (12.4 versus 4.5). We additionally made explicit efforts to provide education on the relation between liver health and alcohol use, based on the Health Beliefs Model (38
), which postulates that treatment participation and adherence are at least partly a function of a person's beliefs about susceptibility to illness, perceived severity of illness, perceived benefits and barriers to treatment, and cues to action. These factors readily apply to persons with HCV who drink alcohol. Relevant content was incorporated into psychoeducation in group and individual therapy sessions.
The integrated HCV-alcohol treatment reported here offers a feasible option to address alcohol use in HCV-infected patients, in a field where there are few rigorously examined options. In future testing in a randomized design, we will know with greater certainty the treatment model's effect size on alcohol use. Nevertheless, this integrated model was associated with substantial reductions in alcohol use for many patients, regardless of gender, age, race, income, and HIV status, thereby offering both providers and patients the opportunity to impact the course of HCV infection.