Alcohol use disorder contributes significantly to disease and premature death worldwide. This is alarming since there is no safe level of alcohol consumption for people with chronic liver disease (CLD), yet, many patients with this condition ignore this fact, putting their health at risk.

In addition to liver damage, adverse effects of drinking include depression, anxiety, impaired cognition and lower quality of life.

Researchers at University of California at San Francisco set out to improve treatment for with chronic liver disease patients by assessing the efficacy and feasibility of delivering Stepped Alcohol Treatment (SAT)—using telemedicine to deliver an integrated approach that provides individualized care for people with unhealthy alcohol use.

This could be a game-changer because practice guidelines recommending integrated, multidisciplinary alcohol use treatment such as routine screening, behavioral interventions, pharmacotherapy, and referral to specialized addiction treatment, are not often implemented in hepatology settings where patients receive liver care.

This may be because patients often have misconceptions about treatment and lack understanding about the serious consequences of continuing alcohol use. Additionally, hepatology clinics may not have access to intervention models adapted to patient needs and without links to addiction specialists.

“Integrated alcohol interventions remain rarely implemented in liver clinics,” said study senior author Mandana Khalili, MD, UCSF professor of medicine, chief of clinical hepatology, and director of clinical and transitional research in hepatology at the Zuckerberg San Francisco General Hospital (ZSFG). “This treatment gap is particularly serious given that current guidelines advise offering these interventions to all patients with CLD. The stigma around alcohol use in our patients with liver disease can also influence their engagement in treatment.” 

The study found that the telehealth-delivered SAT approach was effective in helping patients with CLD reduce their level of alcohol consumption over a six-month period. 

The researchers conducted a multicenter randomized controlled trial of SAT across three hepatology clinics based in publicly funded health care systems. They evaluated whether participants with CLD receiving SAT would demonstrate greater reductions in alcohol use and improved liver-related clinical outcomes than those receiving usual care treatment. Usual care was defined as routine alcohol screening and counseling to reduce alcohol use by hepatology clinic providers.

Participants in the SAT cohort received three sessions of motivational interviewing (an evidence-based counseling intervention designed to enhance motivation to reduce drinking) via telemedicine and were stepped up to more intensive addiction specialty treatment services (including pharmacotherapy and psychotherapy), when predetermined treatment goals were not met.

Study outcomes included measures of alcohol use quantity and frequency. SAT demonstrated greater efficacy than usual care in reducing the mean number of drinks per week at six months. The researchers also found that the 30-day abstinence rates at this point were 29% for SAT and 18% for usual care. Effects of SAT on alcohol use reduction were even stronger among female participants, those with Latino ethnicity, and those with greater motivation to reduce alcohol use at the time of study enrollment. 

“This patient population can be very challenging to engage and treat effectively” said study first author, Derek Satre, PhD, a clinical psychologist and UCSF professor, and an expert in use of motivational interviewing for alcohol treatment in various healthcare settings. “SAT via telemedicine may be a very valuable tool for clinicians to reduce alcohol consumption and improve psychological well-being and quality of life for these patients.”

Future research into the effectiveness and implementation of stepped care models should include greater attention to psychiatric comorbidities, socioeconomic challenges that influence alcohol treatment access, the researchers said. It should also include strategies for training hepatologists to deliver motivational interviewing and alcohol use treatment in hepatology settings.