SANTA ANA PUEBLO, N.M. — A hepatitis C virus clinic in Minnesota helped alcoholic patients become eligible for antiviral therapy by integrating alcohol screening and a behavioral intervention into medical care.
Nearly half (47%) of 47 new patients who were flagged for “severe alcohol use” reduced their drinking after physicians warned that it could make them ineligible for antiviral treatment, according to a poster presented by Dr. Eric W. Dieperink at the annual meeting of the Academy of Psychosomatic Medicine.
Some of the patients relapsed after this initial brief intervention. But nearly two-thirds (62%) subsequently reduced their alcohol use by participating in an on-site program with a psychiatric clinical nurse-specialist. And 17 patients (36%) achieved long-term abstinence and were offered antiviral therapy.
“There was a big effect of just having the [clinic staff] address alcohol use at the initial visit,” Dr. Dieperink, a psychiatrist at the University of Minnesota, said in an interview at the meeting.
“It's a cost-effective way to help people start treatment,” he added.
Standard practice is to refer patients to a substance abuse program and tell them to “come back in 6 months when you're sober,” Dr. Dieperink said. He and his colleagues reasoned that people who are facing medical consequences would be more likely to respond to an alcohol intervention than would a general population. They decided, therefore, to engage patients medically and psychiatrically at the clinic.
Gastroenterologists at the Veterans Affairs Medical Center in Minneapolis invited psychiatrists into the clinic about 6 years ago, Dr. Dieperink said, citing concerns about depression as a side effect of interferon treatment.
Over time, the collaboration between the two groups took on other psychiatric disorders in an ongoing attempt to address barriers to treatment.
“Alcohol is considered a barrier to treatment for hepatitis C and also hastens the fibrosis related to liver disease. So there were two reasons to address it,” Dr. Dieperink said.
The intervention began with all patients being screened for psychiatric problems at their initial clinic visit.
Instruments used for screening included the Alcohol Use Disorders Identification Test-C (AUDIT-C), which the psychiatric clinical nurse-specialist reviewed. The nurse-specialist subsequently met with patients who scored above 4 on the AUDIT-C or were referred by staff members for alcohol problems.
A cornerstone of the program was having gastroenterologists discuss alcohol each time they saw the patients. “At every visit, the hepatology folks continued to address alcohol,” said Dr. Dieperink.
“That was the synergistic—constantly attending to the alcohol use at every visit—which we think made a big difference,” he explained.
He described the approach as matter of fact. Physicians would compare the patients' drinking with standards and norms for their age groups, recommend that they cut back, and offer to arrange follow-up visits with the nurse.
The nurse intervention also was brief, he said, lasting 4–10 sessions, during which the nurse would “flexibly engage” the patients. Most patients had received some alcohol treatment in the past, according to Dr. Dieperink, and many did not want to be referred to another treatment program.
The poster described the 47 veterans as 51 years old on average. Of the 47 patients, 32 were diagnosed with alcohol dependence and 15 with alcohol abuse. Most (82%) were hepatitis C genotype 1. Nearly two-thirds had stage II or higher liver fibrosis. The mean AUDIT-C score was 6.5. In addition, 24 patients (51%) self-reported use of cannabis, cocaine, or methamphetamine during the previous 6 months.
The patients had consumed alcohol for an average of 17.3 days during the 30-day period before they came to the clinic, consuming a mean of 9.5 drinks per day.
After the initial brief intervention, the average number of drinking days per month fell to 10.6 and the average number of drinks consumed per day declined to 5.5.
Ten patients refused referral to the nurse-specialist. Among those who participated in the follow-up program, the average number of drinking days fell to 8.8 after 3–18 months and the number of drinks per day to 3.8 after 5–22 months.
Of 37 patients who participated in the follow-up program with the clinical nurse-specialist and/or a mental health practitioner, only 3 were excluded from antiviral therapy because of continued alcohol use. Seventeen were offered retroviral therapy, and 13 started treatment.
The investigators said the treatment rate, 28% of patients with serious alcohol use, compared favorably with the 21% treatment rate reported for consecutive hepatitis C patients in Veterans Affairs clinics nationwide.