Receipt of alcohol-related care among patients with HCV and unhealthy alcohol use

Highlights

• Unhealthy alcohol use compounds the adverse effects of hepatitis C virus (HCV).

• Many with HCV and unhealthy alcohol use did not receive alcohol-related care.

• Future efforts should increase alcohol-related care in specialty medical settings.

Abstract

Background

Alcohol use—particularly unhealthy alcohol use—exacerbates risks associated with Hepatitis C virus (HCV). However, whether unhealthy alcohol use is appropriately addressed among HCV+ patients is understudied. We examined receipt of alcohol-related care among HCV+ patients and unhealthy alcohol use.

Methods

All positive alcohol screens (AUDIT-C score ≥5) documented 10/01/09-5/30/13 were identified from national electronic health records data from the Veterans Health Administration (VA). Regression models estimated unadjusted and adjusted proportions of HCV+ and HCV- patients receiving 1) brief intervention within 14 days of positive screening, 2) specialty addictions treatment, and 3) pharmacotherapy for alcohol use disorder (AUD) in the year following positive screening. Adjusted models included demographics, alcohol use severity, and mental health and substance use disorder comorbidities.

Results

Among 830,825 VA outpatients with positive alcohol screening, 31,841 were HCV+. Among HCV+, unadjusted and adjusted prevalences were 69.2% (CI, 68.7–69.6) and 71.9% (CI, 71.4–72.4) for brief intervention, 29.9% (CI, 29.4–30.4) and 12.7% (CI 12.5–12.9) for specialty addictions treatment, and 5.9% (CI, 5.7–6.1) and 3.3% (CI, 3.1–3.4) for pharmacotherapy, respectively. Among the 20,320 (64%) patients with HCV and documented AUD, unadjusted and adjusted prevalences were 40.0% (CI, 39.3–40.6) and 26.7% (CI, 26.3–27.1) for specialty addictions treatment and 8.1% (CI, 7.7–8.4) and 6.4% (CI, 6.1–6.6) for pharmacotherapy, respectively. Receipt of alcohol-related care was generally similar across HCV status.

Conclusions

Findings highlight under-receipt of recommended alcohol-related care, particularly pharmacotherapy, among patients with HCV and unhealthy alcohol use who are particularly vulnerable to adverse influences of alcohol use.

Introduction

In the United States, three to four million individuals are living with chronic hepatitis C virus (HCV; Centers for Disease Control and Prevention, 2016), making it four times more prevalent than HIV (Satterwhite et al., 2013). HCV is a leading cause of liver damage and advanced liver disease, such as cirrhosis and hepatocellular carcinoma (Lavanchy, 2011; Sulkowski, 2007), which can necessitate liver transplantation (Charlton et al., 2011; Ly et al., 2012). Alcohol use at all levels can compound the adverse effects of HCV and lead to heightened risks of mortality, particularly among those co-infected with HIV. Alcohol use lowers the risk of HCV spontaneous clearance, exacerbates inflammation, and hastens the progression of HCV-related fibrosis (e.g., Hutchinson et al., 2005; Peters and Terrault, 2002; Piasecki et al., 2004; Tsui et al., 2016a) and subsequent liver diseases (e.g., cirrhosis, liver cancer) (Morgan et al., 2003; Peters and Terrault, 2002; Sulkowski, 2007).

Despite the deleterious effects of alcohol use in this population, many patients with HCV consume alcohol (Tsui et al., 2016b). Further, in the U.S. population, persons with HCV are more likely than those without (Taylor et al., 2016) to drink at levels consistent with “unhealthy alcohol use”—a spectrum from drinking over national recommended limits to meeting diagnostic criteria for alcohol use disorders (Saitz, 2005). Thus, persons with HCV are a key target population for evidence-based alcohol-related interventions that may help facilitate cessation (Chung et al., 2015).

Multiple processes of care are efficacious and recommended for addressing the spectrum of unhealthy alcohol use (Bradley and Kivlahan, 2014; The Management of Substance Use Disorders Work Group et al., 2015; Jonas et al., 2012; Maciosek et al., 2006; National Health Service, 2010; Solberg et al., 2008). Brief intervention is recommended for primary care patients who screen positive for unhealthy alcohol use (Jonas et al., 2012). For individuals with more severe unhealthy alcohol use—those with alcohol use disorders (AUD)—both behavioral (e.g., cognitive behavioral therapy offered in a specialty addictions treatment setting) and pharmacological treatments are recommended (Department of Veterans Affairs et al., 2016; Jonas et al., 2012; National Health Service, 2010). Three pharmacotherapies are FDA-approved for treatment of AUD: acamprosate, disulfiram, and oral or injectable naltrexone (Jonas et al., 2014; Kranzler et al., 2014; National Institute on Alcohol Abuse and Alcoholism, 2007). Topiramate also has strong support based on a meta-analysis for the treatment of AUD (Jonas et al., 2014).

Despite availability, the extent to which patients with HCV receive evidence-based care for unhealthy alcohol use is unknown. The national Veterans Health Administration (VA) offers a unique opportunity to examine this question. The prevalence of HCV is higher among Veterans than within the general U.S. population, and the VA is the largest provider of HCV care in the world (Graham, 2016). Moreover, annual screening for unhealthy alcohol use is performed for the vast majority of outpatients in VA (thus enabling identification of the target population for alcohol interventions; Bradley et al., 2006). Evidence-based care for unhealthy alcohol use is recommended (Department of Veterans Affairs et al., 2016) and incentivized either by national performance measure (brief intervention) or by routine monitoring of care for quality purposes (specialty addictions treatment and AUD pharmacotherapy receipt). Therefore, we used national data from the VA to examine receipt of evidence-based alcohol-related care among patients with unhealthy alcohol use with and without HCV.