Alcohol Brief Intervention for People with Chronic Viral Hepatitis: A Randomised Controlled Trial

Purpose: Viral hepatitis is among the top 10 infectious disease killers and the leading cause of liver cancer and cirrhosis with more than 500 million people living with this disease. A synergy has been found to exist between heavy alcohol consumption and chronic hepatitis virus infection in the aetiology of hepatocellular carcinoma. Heavy alcohol consumption and chronic viral hepatitis are both risk factors significantly associated with liver cirrhosis, accelerated development of fibrosis and subsequent increased mortality risk.  It is therefore suggested that these patients should abstain from consuming alcohol.  Little quality research has examined the effectiveness of alcohol reduction programs in this cohort. This study informs clinicians, health services and policy makers of the most effective approaches to alcohol reduction for those with chronic viral hepatitis (B and C) to reduce the risks of poorer patient health outcomes, mortality and the health burden.  The purpose of this study was to identify if an assessment and brief intervention (BI) using motivational interviewing (MI) and the 5As model, compared to routine care (no formalised intervention) for alcohol reduction was an effective intervention.

Methods: A randomized controlled trial was undertaken.  Participants were blinded to the randomisation process, and the intervention provided. They were also stratified according to viral type (B and C). Following consent, participants in the intervention group received an alcohol use assessment using the instruments, Alcohol Use Disorders Identification Test_Consumption (AUDIT C) and the Timeline Followback_Alcohol (TLFB_A). They were then randomised into the control or intervention groups. The intervention group received a BI using the 5As model and motivational interviewing from the Nurse Practitioner (Hepatology). The 10 minute intervention was a part of the routine appointment. The 5As model (Assess, Advise, Agree, Assist, Arrange) is a model of behaviour change for application in the primary care setting that can be used for alcohol counselling management and was used in this study. The control group received routine care only. The primary outcome of a 50% reduction of alcohol consumption measured by the Alcohol Timeline Follow back survey over a 30 day period was examined using chi-squared. TLFB_A was also examined to see if there was a mean difference between groups and was logarithmically transformed to reduce the effect of outliers. Geometric means and 95% confidence intervals were reported.  Audit C and TLFB_A were analysed using linear mixed models with an unstructured covariance structure to account for repeated measures.

 Results: A total of 66 people participated in the study.  After four weeks, 57% of those in the intervention group had a 50% or greater reduction in alcohol compared to 41% of those in the control group (x²=1.097, p=0.295).   This reduction was maintained by both groups at eight weeks with 53% of the intervention reporting a 50% reduction compared to 43% in the control (x²=0.382, p=0.536). TLFB_A results were also found to significantly reduce over time (p<0.001) participants reported on average consuming 51.2 (38.7, 67.7) standard drinks over the 30 day period. This reduced to 20.7 (12.8, 33.2; p<0.001) standard drinks after four weeks and 14.1 (7.7, 25.4; P<0.001) drinks after eight weeks. The intervention group reported 18.8 (10.9, 32.2) standard drinks and generally reported a lower mean TLFB_A compared to the control group 32.4 (18.7, 55.7; p=0.166). A clear trend emerged with the intervention group showing a much sharper sustained drop in TLFB_A results over time. This was found to be clinically important, however, not found to be statistically significant (p=0.073). The results of the AUDIT C were found to reduce over time (p=0.001).  Mean AUDIT C results were significantly lower at four weeks 5.7 (4.7, 6.7; p=0.003) and eight weeks 5.4 (4.5, 6.3; p=0.001) compared to baseline 6.9 (6.2, 7.6).  There was no difference between groups (P=0.776). Although there was no significant interaction between time and group (p=0.179), the intervention group tended to have a slightly higher reduction of alcohol consumption over time.

 Conclusion: Assessing for alcohol use using the AUDIT C, and providing a brief intervention using motivational interviewing and the 5As model by the Nurse Practitioner Hepatology compared to routine care was a useful intervention to reduce alcohol consumption in people with chronic viral hepatitis.  Additionally this study adds to the evidence that brief interventions for people with alcohol use disorders in the primary healthcare setting are clinically effective. This adds to the literature on interventions for the management of people with chronic viral hepatitis and alcohol consumption. This study showed that alcohol consumption in patients from this this high risk, chronic disease population  who may or may not have an alcohol disorder but may be drinking in ways that are harmful, can benefit from an assessment and brief intervention similar to that provided in general populations .