This teaching guide offers a patient-centered approach to reduce alcohol use among patients with hepatitis C. It includes the AUDIT-C (an alcohol-use screen), ideas for patient discussion, and patient educational materials. Note: Abstinence from drug or alcohol use is not required before beginning antiviral treatment for hepatitis C.

Summary

The Intervention:

A patient-centered approach to reduce alcohol use among patients with hepatitis C.

The Rationale:

• Minimizing alcohol use is one of the most important factors in preserving liver health in individuals with hepatitis C.
• In patients with cirrhosis, complete abstinence from alcohol is recommended.
• Brief interventions have been found to be cost-effective ways to reduce alcohol consumption.
• A non-confrontational, patient-centered approach in addressing drinking problems increases the likelihood that the patient will discuss the relevant incentives and barriers associated with behavior change.

The Process:

1. Use the OARS/FLO card as a guide.
2. Reflect the patient's concerns and/or answer questions regarding their topic of interest.
3. Ask the patient's permission to discuss their alcohol use.
4. Meet the patient "where they are" regarding their drinking, while providing relevant information about the impact of alcohol use and hepatitis C on the liver (using the Hepatitis C and Alcohol Use brochure, which is part of this toolkit) and personalizing advice.
5. Use the 0-10 rating scale questions described in this guide to raise the importance of changing drinking behavior for the patient and to raise the patient's confidence in their ability to change.
6. Elicit patient goals and set up follow-up.

Introduction

Purpose of this guide

This teaching guide can help you learn ways to discuss alcohol use with patients who have hepatitis C. Patients who have hepatitis C and are also consuming significant amounts of alcohol are more likely to develop fibrosis and cirrhosis compared with patients with hepatitis C who do not drink significant amounts of alcohol. Therefore, the times when a provider is diagnosing a patient with hepatitis C or evaluating that patient's liver can provide "teachable moments," times when patients are more interested, motivated, and receptive to brief, effective interventions to help them cut back or eliminate alcohol use.

The HCRC Brief Intervention for Alcohol Use Reduction and Hepatitis C Toolkit includes the following resources:

• Hepatitis C and Alcohol (patient education handout)
  
• OARS-FLO Card
  
• Audit-C (alcohol screen)
  
• Drinking Diary Card and Change Plan Template (wallet card)
  

Who can use these tools effectively?

Anyone who provides direct care to patients with the hepatitis C virus can use these tools. Many patients with chronic HCV infection are seen regularly in Specialty Clinics such as Hepatology/Gastroenterology, Infectious Disease, and Addiction and Mental Health, as well as Primary Care Clinics. While talking directly with patients about issues such as alcohol or substance use may be routine for some providers, for others, it may be a topic that feels uncomfortable if it's not part of your usual practice. Time is also a potential barrier to addressing these issues in busy clinics, so this toolkit was developed to show you how you can incorporate brief motivational interventions into almost any patient encounter.

Why target alcohol use?

It is not definitively known whether even small amounts of alcohol consumption are safe for people infected with HCV. Moderate-heavy drinkers are clearly at higher risk of cirrhosis and advanced liver disease. If a patient's alcohol use makes them less likely to be compliant with treatment and follow up, then they would be less likely to adhere to their antiretroviral treatment for hepatitis C and would be less likely to achieve a sustained virological response (SVR), though alcohol use by itself should not exclude a patient from HCV treatment. One of the most important behavior changes that anyone with chronic hepatitis C can make is to stop drinking alcohol. However, making this change or any lifestyle change is not easy. Although providers can help motivate patients and inform them of risks, the behavior change will ultimately need to come from the patient.

To help patients make behavior change towards reducing or abstaining from drinking alcohol, providers require a different set of skills from the skills they use to managing patients with strictly medical problems. Although rates of substance abuse screening in primary care have improved in recent years, advice to reduce or abstain from drinking occurs infrequently. Studies suggest that even brief interventions can have a positive impact on reducing alcohol consumption.

Keep in mind that most patients referred for substance abuse treatment evaluation don't follow up on their own, so another potential positive outcome from this ongoing motivational enhancement approach may be for your patient to ultimately accept a referral for substance abuse specialty evaluation and/or treatment, and keep appointments.

What is a brief intervention for alcohol use?

A brief intervention consists of at least one 5- to 15-minute session of patient-centered behavior change counseling, with at least one follow-up session. This recommendation is summarized by the U.S. Preventive Services Task Force (USPSTF) on behavioral counseling interventions. The content of the brief intervention counseling sessions contains: patient-centered assessment, concerned feedback and advice, collaborative goal-setting, plus further assistance and follow-up, often by telephone.

Screening for alcohol use (AUDIT-C)

A positive screen for alcohol use for a patient with HCV can be an opportunity to provide information about alcohol and liver disease. When this information is linked to the patient's personal health through review of reported symptoms or liver function test results, the patient's perception of its importance may increase. Brief screening measures for alcohol misuse are available for routine assessment.

What is the AUDIT-C?

The Alcohol Use Disorders Identification Test (AUDIT-C) is an alcohol screening assessment that can help identify patients who are hazardous drinkers or have active alcohol use disorders (including alcohol abuse or dependence). VA clinics use the AUDIT-C for alcohol screening. The AUDIT-C is a more sensitive indicator of alcohol misuse or hazardous drinking than the CAGE questions because AUDIT-C is sensitive for both alcohol abuse and risky alcohol use, and it consists of just 3 questions.

Another question with clinical implication is: "Have you ever been in alcohol treatment or attended AA for a drinking problem?" This question can lead to important information, including current alcohol use, likelihood of alcohol dependence, discussion of past successes, and options for current or renewed support for substance use disorder treatment and abstinence efforts. Availability of support from friends and family are important facilitators of change. Support and past experience can influence confidence in one's ability to change behavior.

Although the initial alcohol screening may take place in a different clinic, any provider who sees patients with hepatitis C is in a position to motivate and support those patients to change drinking behavior by using the hepatitis C diagnosis as a "teachable moment," and linking the patient's drinking with observed liver health parameters. Open-ended questions can provide information about past experience with similar changes and support from friends and family, which can affect the patient's confidence in ability to change.

Discussing AUDIT-C results?

Use the 3 Brief Intervention Tasks (FLO) guide to provide the patient with their AUDIT-C score, look for change talk, and explore options.

Steps in a brief intervention

This guide provides information on how to deliver the recommended brief intervention effectively with the goals of reducing hazardous drinking or facilitating successful referrals to SUD specialty clinics for more focused evaluation and treatment.

I. Approaching the topic: Dancing versus wrestling

How often have you given advice that wasn't followed, or that resulted in the patient telling you what you want to hear, giving "yes, but . . ." responses, or even avoiding you later? One way of thinking about your approach to the discussion of behavior change is "we want to dance, not wrestle." "Wrestling" ends with a winner and a loser (or 2 losers!). "Dancing" means that the patient is taking the "lead" and doing most of the talking, and the provider is "following the lead" by eliciting information from the patient about the patient's motivations for change instead of just delivering information (lecturing) to the patient about how to change. Clinical experience has shown that allowing the patient to "lead" will decrease the likelihood of resistance and defensiveness, and can provide an opening for discussion of problem behavior, such as alcohol use.

II. Setting the stage: Creating a dance floor

• Create an environment where the patient feels comfortable talking about alcohol or other health-related issues. Be non-judgmental, use open-ended questions and eye contact. Consider asking permission to go over these issues. Just being seated at the patient's eye-level can make a difference.
• Use the motivational counseling card to provide the patient with choices in the discussion topic. Even though the selected topic may not seem directly relevant to your concern about alcohol use (e.g., "stress"), chances are good that what the patient reveals in a discussion of stress will be relevant to risky alcohol use and the personalized plan to come later.
• Remember that persons vary in their readiness to change. Creating the opening for dialogue about this issue may be the first step for this person to even consider changing.
• Recognize that a successful visit may not end with any immediate action, but a follow-up call or visit and review of the previous discussion signals your concern and the importance of this issue to the patient's health.

Keys to Change

In addition to creating a safe environment for this discussion, these elements are key to change:

1. A sense of the importance of change
2. A sense of confidence about one's ability to change
3. A support system (friends, family, providers)

III. Let the dance begin: Make the first step positive

Open the conversation in a positive way. When the visit starts with what has gone well rather than what has not, it is easier to help the patient with their motivation for change. A positive start can be initiated with something as simple as a positive observation from the medical record or personally, no matter how small (a kept appointment, or even completing their laboratory tests).

PROVIDER : Sounds like you were able to make some significant changes in your life . . . what helped you accomplish this? [explore personal strengths, past successes despite stressors]

IV. First steps in the dance: Use of the OARS/FLO Card

Ask patients what they think their score might be and then discuss.

PROVIDER : Alcohol is the single biggest threat to your liver, and I think it's really important to understand how alcohol impacts hepatitis C. Is it okay with you if we talk about this today?

PATIENT : Well, I guess so. But I don't drink near as much as I used to before I found out I have HCV.

PROVIDER : That's a great start, cutting back. Unfortunately, we don't really know how much you can drink without making your liver disease worse. We do know that a person who drinks and has hepatitis C has a much higher risk of cirrhosis or liver scarring compared with a nondrinker.

The patient education brochure Hepatitis C and Alcohol can be used to illustrate and help explain these points.

PROVIDER : Your liver enzymes are elevated and this is part of why I think it's important for us to talk about this.

Review complaints of fatigue or nausea, as well as lab or imaging results or results from fibrosis tests, or any specific information that will help customize your feedback to what is important to the patient and may be linked to alcohol use.

PROVIDER : What do you think?

PATIENT : I didn't realize even beer could hurt my liver. Maybe I could cut back some more? I really don't want to get sick.

Listen, reflect, summarize--the patient just made a motivational statement--you could just repeat it.

PROVIDER : You don't really want to get sick and think you could cut back some more...

Assist with goal-setting.

PROVIDER : How much do you think you could cut back, realistically?

Ideas for discussion:

Here are some strategies that might work for you:

• Ask about the patient's general health, then substance use. You could then follow this by: "I wonder, how does your use of alcohol fit in here?"
• Ask the patient to rate how important a change in their drinking is to them personally, and how confident they feel in making that change. (See the next section for a rating scale and sample script for this.)
• Ask if there is anything that they are doing--or trying to do--differently as a result of their hepatitis C? Why?
• Ask about lifestyle and stressors, and then ask what they do when they find themselves in stressful situations.
• Ask the patient to compare past alcohol use with current use.
• Ask the patient to compare their current alcohol use with their ideal use, and reflect discrepancies.

V. Moving with the music: Measuring importance and confidence

It is important to set realistic goals and support change, no matter how small. One way to assess how ready someone might be to make a change is to ask the patient to use a scale of zero to ten to indicate how important it is to make the change, and how confident they are about making the change. Then ask why they chose that number in order to learn more about their motivation for change. Work with the patient to set realistic goals and support the change, no matter how small.

Ideas for discussion:

One common issue for patients reluctant to change their alcohol use is that alcohol is seen as a way of managing or coping with stress. It is often helpful to validate this. Ask them what drinking does for them. You will often hear things like "helps me relax," "helps me forget," and "makes me feel better." These comments should trigger a discussion of how bad stress feels for the patient and how he or she has been struggling (in a motivated way) to manage it. This can lead to discussing better or healthier ways to manage stress.

Consider this scenario:

(Adapted from Bilsen in "Motivational Interviewing" by Miller and Rollnick, Chapter 15, pp. 214-219).

A patient who states that "others" think he has a problem, even though he doesn't think he does. He has been referred to a mid-level provider to talk about his liver health.

PROVIDER : Hello, your file shows that this appointment was made after you received your hepatitis C test results a few weeks ago. What can I do for you today?

PATIENT : It was not my choice. My wife and the doctor I saw last week wanted me to talk to someone because they think that I have a drinking problem and they said that I shouldn't drink if I have hepatitis C, so I need to I talk to someone about my drinking. I think that this is a total waste of time, but I came so they would get off my back.

PROVIDER : Well, thank you for keeping this appointment despite the circumstances. Can you tell me what your wife and your other doctor considered so important that you needed to see someone about?

Positive restructuring: The patient is a busy man, and this makes it even more admirable that he sacrifices his time to do something he considers useless at the moment. You can empathize with client while at the same time eliciting more information from him.

PATIENT : It is stupid, really. There is not much to tell. I have a good job, which I have had for years. In fact, I have been working full-time since I got out of the service. I am the breadwinner for the family and I work very hard. I don't know what the big deal is if I drink a beer or two occasionally. I have been drinking for over 20 years. I don't know what the big deal is now.

PROVIDER : It sounds like work and family are very important to you--and that they are related to one another. It also sounds like you really make these a priority and work hard at doing both as best you can--and that this is something that you have been doing for a long time. Relaxing with a beer gives you the energy to do both. It seems as if your wife and doctor have a different opinion. Could you tell me a bit more about the differences of opinion?

Again, positive restructuring and reflection of a conflict. Drinking beer is presented in a positive context.

PATIENT : Sometimes I can't stand all the pressures that are put on me. Nothing seems to give me a chance to relax. But I don't drink so much that they should call me an alcoholic.

PROVIDER : . . . An alcoholic.

Simple reflection (parroting).

PATIENT : (Angry) Yes, an alcoholic! I try to do my best and this is what I get out of it--being accused of alcoholism.

PROVIDER : Just to summarize: If I understand you correctly, you have come to see me in order to discuss these differences of opinion between you and your wife and your other provider. They seem to think that there is a problem connected with your drinking. You, yourself, think that there is no problem whatsoever with your drinking. Your wife and doctor seem to you to be completely out of line with their accusations.

Summarizing, empathizing with patient and some amplified reflections.

PATIENT : I am not saying that I shouldn't drink less, but I am not an alcoholic.

In this scenario, the patient starts off as very defensive--and rightfully so: his wife and another provider have labeled him as an alcoholic, even though this has been a part of his lifestyle and behavior for his entire adult life. He is certainly not willing to enter the "dance floor" at this point. However, by the end of this 2-3 minute discussion, he is no longer on the defensive. This was an opportunity for the role of his drinking to be re-framed, which gives the patient an opportunity to talk about it in a different, positive context. This opens the door for you to discuss this further and possibly set up another brief time--or even use the rating questions about "Importance" and "Confidence" to further elicit the patient's thoughts about drinking less.

VI. Missteps on the dance floor

It is important to acknowledge that most conversations providers have with patients do not sound like the scripts in this Teaching Guide. Often patients feel pessimistic and may even start wrestling (arguing) with the provider. Here are a couple of common patient missteps and ways to handle them while still maintaining the dance.

Patient misstep #1: Helplessness
Suggested approach: When patients are feeling pessimistic, acknowledge that change is hard. Help patients identify what has led to successful change in the past, and reflect their observations or insights.

Patient misstep #2: Resistance
Suggested approach: When the provider and patient are arguing (wrestling), stop and briefly summarize the discussion. Get back to dancing!

As providers we want the best for our patients, but sometimes we become more invested in the patient making a change than the patient is. You might notice yourself engaging in one of these common missteps.

Provider misstep #1: Lecturing
Suggested approach: When the provider realizes the patient is being bombarded with information, stop and ask the patient a question such as: "What do you think of this?"

Provider misstep #2: Cheerleading
Suggested approach: When the provider is being more enthusiastic about change than the patient, stop and return responsibility for change to the patient. A useful format to keep discussions patient-centered is: Ask the patient what goals are most important to him/her, and relate health to that goal.

VII. Summary

A patient-focused approach means understanding that the patient (not the provider) will ultimately make all the decisions and be responsible for their lives. Their behavior makes sense if you understand their motivations and what is important to them. Even seemingly self-destructive behavior must perform some useful function or address some important need or the patient would not continue doing it. If you can start with a health or lifestyle issue identified as most important to the patient, later you can ask permission to move toward discussion of other issues such as alcohol use that you feel are also important to the patient's health.

Brief intervention toolkit: Components for patients

In addition to the OARS/FLO Card, this toolkit contains two items meant to facilitate frank discussions about alcohol and hepatitis C: One is a fact sheet titled "Hepatitis C and Alcohol."
The other is a wallet card, "Drinking Diary Card and Change Plan Template,"
that serves as a template for patients to record and monitor their drinking behavior and to chart out a plan for reducing their alcohol consumption. These items can be printed out and given to patients who are interested in taking them.

Brief intervention toolkit: Summary

• Review patient's goals at end of session, and schedule next visit or call
• Become a local clinical champion of this approach, have residents or colleagues sit in with you
• Use the scripts initially, customize to your own style and tempo
• Send us suggestions on how to make this better, let us know what you are using, what's working, what's not
• Train residents, interns, affiliated staff in brief intervention
• Visit this website for the latest information on hepatitis C, useful materials for patient and staff education, clinical practice updates, and links to BI training and CME opportunities
• Watch for trainings in brief intervention or motivational interviewing techniques at your professional meetings (see web links below)
• See the National Center for Health Promotion and Disease Prevention (NCP) website at http://www.prevention.va.gov/ for patient education materials on prevention topics of interest to your patients, including weight management and physical activity materials

Additional resources for brief intervention skill-building

1. Web-based training in Brief Intervention for Primary Care Providers:
   • Alcohol Screening and Brief Intervention Curriculum: https://www.bumc.bu.edu/care/education-and-training-programs/resources/alcohol-screening-and-brief-intervention-curriculum/
     
   • CMEs available. This program and video demo can be downloaded to your computer to be viewed through Windows Media Player, or view it from home using RealPlayer.
2. Resources for clinicians, trainers, researchers: http://www.motivationalinterviewing.org