Longitudinal Patterns of Substance Use Outcomes in Patients Contemplating HCV Treatment

Introduction.   Recent estimates indicate that 65%-73% of people living with hepatitis C virus (HCV) consume alcohol, 57%-67% smoke cigarettes and 57%-65% use illicit drugs. Alcohol use and smoking independently accelerate progression to HCV-related liver disease and cancer. On average, patients with HCV have lower levels of functioning, coping, and quality of life compared to the rest of the population. Although research has extensively described negative medical outcomes associated with use of specific substances in the presence of HCV, little is known about the associated functioning, coping, and quality of life outcomes in association with use of substances in general, and even less with specific substances.  This would be useful information for the hepatology clinical care team and especially for behavioral health care providers, such as social workers.  Therefore, the purpose of this study is to prospectively examine the independent courses of alcohol, drug, and smoking over 18 months in patients contemplating HCV treatment in relation to functioning, negative coping, and satisfaction with quality of life.  Specifically, outcomes are compared among patients with HCV who were consistently abstinent, consistently used, or achieved abstinence after study entry.

Method.  309 patients considering treatment for HCV were recruited from outpatient clinics at two major university medical centers and a Veterans Affairs medical center as part of a randomized controlled trial of a psychoeducation intervention.  Baseline, 6-month, and 18-month assessments included structured diagnostic interviews; questionnaires covering personal, social and risk behaviors; medical record review; and urine testing for presence of substances of abuse.  Three specific patterns of substance use (consistent abstinence, consistent use, and achievement of abstinence after study entry) were examined for functioning, coping, and satisfaction with quality of life both for changes over time and compared across substances within each time period.

Results.  For alcohol use, approximately 40% of the sample was abstinent across the study, 40% consistently used and 20% became abstinent over the course of the study.  For drug use, 21% were abstinent, 34% used consistently and 44% became abstinent.  For smoking, approximately 45% were abstinent, with the same percentage consistently using, and 10% becoming abstinent. The three specific patterns of substance use diverged in association with outcomes related to functioning, negative coping, and satisfaction with quality of life, not only across trajectories over time within substance types but also between types of substances.

Conclusion.  This study’s finding that different substances were associated with distinct clinical outcomes suggests the need to conceptually unbundle different types of substances in managing HCV.  Although long-term general health is a worthy goal of HCV treatment, of more immediate clinical importance is the cessation of alcohol use.  Social work practitioners working with persons with HCV need to focus specifically on alcohol cessation (the clinical recommendation for this population), rather than taking a broader focus on managing substance use. Future research is needed to examine the clinical utility of further unbundling of these substances and also to further investigate effects of various amounts of use of these substances.