Improving Hepatitis C Care

HCRC Teaching Guide

for Health Care Providers

Reducing Alcohol Use 

With Brief Intervention
HCRC Teaching Guide for Health Care Providers

The Intervention:

A patient-centered approach to reduce alcohol use among 

patients with hepatitis C.

The Rationale:

• Abstaining from alcohol use is one of the most important factors 

in preserving liver health in individuals with hepatitis C.

• 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. Present the Motivational Counseling Card to the patient and ask 

them which one of the topics they would like to discuss.

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” 

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.
IMPROVING HEPATITIS C CARE: Reducing Alcohol Use With Brief Intervention 

Purpose of this Guide:

This Teaching Guide can help you learn ways to discuss alcohol use 

with patients who have hepatitis C. The enclosed motivational counseling 

card is one of many tools you can use to help patients with hepatitis C 

reduce or eliminate alcohol consumption. Because hepatitis C infection is 

associated with worse liver disease outcomes among drinkers, diagnosis 

of hepatitis C infection and monitoring of liver function provide “teachable moments” for brief, effective interventions to motivate patients to 

cut back or eliminate alcohol use.

The HCRC Brief Intervention for Alcohol Use Reduction and Hepatitis C 

Toolkit includes the following resources:

• Motivational Counseling Card with provider scripts

• HCRC Teaching Guide for Health Care Providers

• Patient Education Brochure “Hepatitis C and Alcohol”

• Drinking Diary Card and Change Plan Template (wallet card)

• “Motivation” DVD: Behavior Change Counseling in Chronic Care from 

University of Washington GHC “Take Care to Learn” (2003)

Who can use these tools effectively?

Anyone who provides direct care to patients with the hepatitis C virus 

(HCV). 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. 

Addressing patient issues such as alcohol or substance use may be 

routine for you or may make you feel 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.

Improving Hepatitis C Care: 

Reducing Alcohol Use With Brief Intervention
 HCRC TEACHING GUIDE FOR HEALTH CARE PROFESSIONALS

Why target alcohol use?

It is not known whether any level of alcohol consumption is safe for 

people infected with HCV. Continuing to use alcohol in any quantity may be 

risky, and moderate-heavy drinkers are clearly at higher risk for cirrhosis and 

advanced liver disease (Peters & Terrault, 2002; Loguercio et al., 2000). Active 

drinkers are less likely to complete antiretroviral treatment for hepatitis C and 

thus have poorer outcomes from available therapies (Anand et al., 2006). 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 really in the hands of the patient, not the provider.

Helping patients reduce or abstain from drinking alcohol requires a 

different set of skills from managing patients with more acute problems. 

Although rates of substance abuse screening in primary care have improved 

in recent years, advice to reduce or abstain from drinking occurs infrequently 

(Burman et al., 2004). 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 5–15 minute session of 

patient-centered behavior change 

counseling, with at least one followup, as summarized by the U.S. 

Preventive Services Task Force on 

behavioral counseling interventions 

(USPSTF, 2004). The specific content 

of counseling sessions reported 

in the literature varies, but generally brief intervention counseling 

5A’s 

of Behavioral Counseling

Assess Evaluate alcohol 

consumption 

patterns

Advise Help patients to 

reduce or abstain 

from alcohol with 

personally relevant 

recommendations

Agree Set specific, 

feasible goals 

collaboratively

Assist Anticipate barriers, 

problem-solve 

solutions

Arrange Schedule followup contacts, use 

resources
IMPROVING HEPATITIS C CARE: Reducing Alcohol Use With Brief Intervention 

sessions contain: patient-centered assessment, concerned feedback and 

advice, collaborative goal-setting, plus further assistance and follow-up, 

often by telephone. (See the sample scripts on the back of your motivational counseling card.)

The “5A’s” (ASSESS, ADVISE, AGREE, ASSIST, and ARRANGE) is a useful 

organizational construct for clinical counseling on behavioral and preventive health care issues. This is a patient-centered approach recommended 

by USPSTF and has already been used to train physicians and other health 

care staff for a variety of problems. It was first applied to smoking cessation and has been incorporated into the Agency for Healthcare Research 

and Quality (AHRQ) tobacco use cessation guidelines as well as the USPSTF Behavioral Counseling Guidelines (Whitlock et al., 2004).

Surveys show that the last 2 A’s (ASSIST and ARRANGE) are done less 

frequently than the first 3. This toolkit will show you ways to accomplish 

all of these within your practice setting.

Does Brief Intervention Work?

Systematic reviews of studies on the efficacy of brief interventions to 

reduce risky or harmful alcohol use (misuse) have shown good efficacy 

(Whitlock et al., 2004; Moyer et al., 2002). Evidence of the benefits of 

screening and brief intervention for alcohol misuse indicates that they 

are a cost-effective way of reducing alcohol consumption and related 

problems (Wutzke et al., 2002).

• A recent meta-analysis of brief alcohol intervention in primary care 

settings found that groups receiving the intervention reduced their 

alcohol consumption at 6 and 12 month follow-up, demonstrating a 

mean pooled difference of –38g of ethanol (approximately 4 drinks) 

per week (Bertholet et al., 2005).

• The World Health Organization (WHO) Brief Intervention Study Group 

found that 5 minutes of brief counseling were as effective as 20 minutes of counseling (WHO Brief Intervention Study Group, 1996).

• A review of good-quality controlled clinical trials found that patients 

who received brief multi-contact behavioral counseling (initial session 

up to 15 minutes and at least 1 follow-up) reduced alcohol intake 

13–34% more than controls (WHO, 1996).

• After one year, hazardous drinkers receiving brief intervention (BI) 

significantly decreased alcohol use and had fewer bed days of care 
 HCRC TEACHING GUIDE FOR HEALTH CARE PROFESSIONALS

relative to controls. Further, after 4 years, for every $1 spent on BI, the 

health care system saved $4.30 (Fleming et al., 2002).

Alcohol-dependent heavy drinkers have been shown to be most successful in reducing alcohol use when followed over time with multiple contacts, 

through an integrated outpatient treatment model (Willenbring & Olson, 

1999), including hepatology clinics using team treatment models (Lieber et 

al., 2003). Brief intervention can enhance and support specialized addiction 

services by enhancing motivation to change or to sustain change.

The AUDIT-C is an alcohol screen 

that can help identify patients who 

are hazardous drinkers or have active 

alcohol use disorders (including 

alcohol abuse or dependence). The 

AUDIT-C questions are:

Q1: How often did you have a 

drink containing alcohol in the 

past year?

Answer Points

Never 0

Monthly or less 1

Two to four 

times a month 2

Two to three 

times a week 3

Four or more 

times a week 4

Q2: How many drinks did you have 

on a typical day when you were 

drinking in the past year?

Answer Points

None, I do not drink 0

1 or 2 0

3 or 4 1

5 or 6 2

7 to 9 3

10 or more 4

Q3: How often did you have six or 

more drinks on one occasion in 

the past year?

Answer Points

Never 0

Less than monthly 1

Monthly 2

Weekly 3

Daily or almost daily 4

The AUDIT-C is scored on a scale 

of 0–12 (scores of 0 reflect no alcohol 

use). In men, a score of 4 or more 

is considered positive; in women, a 

score of 3 or more is considered positive. Generally, the higher the AUDITC score, the more likely it is that the 

patient’s drinking is affecting his/her 

health and safety.

http://www.oqp.med.va.gov/cpg/SUD/SUD_

Base.htm

What is the AUDIT-C?
IMPROVING HEPATITIS C CARE: Reducing Alcohol Use With Brief Intervention

What about screening for alcohol use?

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. VA clinics now use the “AUDIT-C” for 

screening. The AUDIT-C is a more sensitive indicator of alcohol misuse or 

hazardous drinking than the CAGE because it is sensitive to both alcohol 

abuse and risky alcohol use, and it consists of just 3 questions (see page 4 

for AUDIT-C).

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.

How does this approach fit in with other 

behavioral counseling guidelines?

This approach fits in with the VA/DOD clinical practice guidelines 

(CPG) for Treatment of Substance Use Disorders (SUDS CPG). See 

http://www.oqp.med.va.gov/cpg/SUD/SUD_Base.htm for a decisional 

tree from the SUDS CPG. According to these guidelines, the medically 

stable patient who screens positive for alcohol abuse should have 

results summarized and presented to him/her by the provider with 

information to “educate the patient about the problem.” If SUD specialty clinic referral is indicated, the patient is referred; if not, a brief 

intervention is recommended with ongoing support and follow-up. 

Unfortunately, often the post-­screening interventions stop with advice 

(or less), and SUD specialty referrals are often refused. This guide pro-
 HCRC TEACHING GUIDE FOR HEALTH CARE PROFESSIONALS

vides 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 (see page 8) 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.
IMPROVING HEPATITIS C CARE: Reducing Alcohol Use With Brief Intervention 

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). Use of the motivational counseling 

card included in this toolkit has been found to be helpful in beginning 

discussion about important lifestyle issues, and was well-received by 

both patients and providers for other chronic diseases such as diabetes 

and asthma (Stott et al., 1995). The card looks like a checklist of various 

behaviors that may impact their liver disease in a positive or negative way. 

The patient is asked which of the topics they want to discuss, so there is 

an opportunity for the patient to indicate what they think is important.

Recently, the motivational counseling card was revised to help teach 

primary care providers to use this patient-centered behavioral approach 

as part of the University of Washington’s “Take Care to Learn” project, 

supported by the Robert Wood Johnson Foundation. This program was 

effective and was rated highly by providers (Debbie Ward, 2005, personal 

communication).

Sample Script:

PROVIDER: Here is a card with some topics that are important to your 

health. No one does all these things perfectly. Which one of these do 

you want to discuss?

PATIENT: Well, I haven’t used drugs in years, but I still have a lot of 

stress in my life...
 HCRC TEACHING GUIDE FOR HEALTH CARE PROFESSIONALS

N ALCOHOLN OTHER DRUG USEN STRESSN SMOKING

N LABS & FOLLOW-UPN ACTIVITY & FOODN SUPPORTN HEPATITIS C TREATMENT

Ways to Manage

Figure adapted, with permission, from Stott, Rollnick, & Pill (1995).Family Practice 12(4):413.

your

Hepatitis C

These topics are very important to your healthAlcohol is the single biggest threat to your liver healthNo patients do these perfectlyIt’s best to work on one at a timeYou won’t be pushed into changing

Which one do YOU want to discuss?
IMPROVING HEPATITIS C CARE: Reducing Alcohol Use With Brief Intervention 

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 counseling card

Since most of the topics can be related to alcohol use, the provider 

can use the patient responses to the card to link with alcohol use assessment and tailored feedback. [continued from above discussion]

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 to a nondrinker, and drinkers are less likely to benefit from antiviral treatment.

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 liver biopsy results, complaints of fatigue or nausea, lab values 

or whatever helps 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.
10 HCRC TEACHING GUIDE FOR HEALTH CARE PROFESSIONALS

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 
IMPROVING HEPATITIS C CARE: Reducing Alcohol Use With Brief Intervention 11

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.

Raise Importance

On a scale of 0–10, how important is it to you to (change)?

Why did you give it (number) and not (lower number)?

What would it take to give it a (higher number)?

	 0	 1	 2	 3	 4	 5	 6	 7	 8	 9	 10

Raise Confidence

On a scale of 0–10, how confident are you that you can change successfully?

Why did you give it (number) and not (lower number)?

What would it take to give it a (higher number)?

	 0	 1	 2	 3	 4	 5	 6	 7	 8	 9	 10
12 HCRC TEACHING GUIDE FOR HEALTH CARE PROFESSIONALS

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 the liver clinic won’t even talk to me about 

treatment for hepatitis C until 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.
IMPROVING HEPATITIS C CARE: Reducing Alcohol Use With Brief Intervention 13

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.
14 HCRC TEACHING GUIDE FOR HEALTH CARE PROFESSIONALS

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 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.
IMPROVING HEPATITIS C CARE: Reducing Alcohol Use With Brief Intervention 15

In addition to the Counseling Card, this toolkit contains two items 

meant to facilitate frank discussions about alcohol and hepatitis C: One 

is a tri-fold patient brochure entitled, “Hepatitis C and Alcohol,” and the 

other is a wallet card that serves as both a “Drinking Diary Card” and a 

convenient template for patients to make a “Change Plan.” These items 

are meant to be given to patients who are interested in taking them. 

(Your supply can be replenished when close to depletion.)

Patient Education Brochure: “Hepatitis C and Alcohol”

A growing body of literature highlights the risk of heavy alcohol 

consumption on liver disease progression. This tri-fold patient brochure 

attempts to capture findings from the most relevant literature and 

present them in a way that is easily understandable for patients. When 

the opportunity presents itself in the discussion, use this brochure to 

explain scientific evidence that highlight the dangers of heavy alcohol 

use on liver disease and/or the rationale behind certain clinical recommendations (e.g., why a period of abstinence is often recommended 

before attempting antiviral therapy for hepatitis C). Here is a summary 

of the relevant empirical data illustrated in the brochure:

• Liver disease progression after infection with hepatitis C proceeds at 

a slow pace with highly variable outcomes, with only a minority of 

patients experiencing severe, life-threatening liver disease. However, 

complications such as cirrhosis and hepatocellular carcinoma appear 

aggravated by behavioral factors such as heavy alcohol use (Alter & 

Seeff, 2000).

• The amount of hepatitis C viremia in the bloodstream (as indi­cated 

by serum HCV RNA) has been correlated with alcohol intake (r = .26), 

and this relationship was independent of other factors such as age, 

sex, and route of viral contamination (­Pessione et al., 1998).

• While duration of hepatitis C infection was found to be strongly associated with rate of fibrosis progression, patients identified as heavy 

drinkers (50g of alcohol per day or more) showed significantly higher 

rates of fibrosis progression than light- or non-drinkers (p<.001; 

Poynard, Bedossa, & Opolon, 1997).

Brief Intervention Toolkit: Components for Patients
16 HCRC TEACHING GUIDE FOR HEALTH CARE PROFESSIONALS

• A recent meta-analysis (Hutchinson, Bird, & Goldberg, 2005) found that 

heavy drinkers consuming at least 210-560g of alcohol per week (about 

2 to 6 standard drinks per day) are 2.33 times more likely to develop cirrhosis than light- or non-drinkers (95% confidence interval, 1.67­–3.26). 

• Sustained viral response (SVR) to interferon therapy for hepatitis C has 

been shown to be inversely related to the degree of alcohol consumption 

and positively associated with duration of abstinence prior to initiating 

therapy. Only 3 out of 36 (or 1 in 12) patients defined as heavy drinkers 

prior to starting interferon treatment had successfully cleared hepatitis 

C virus 6 months after conclusion of antiviral therapy, and none of 17 

patients who drank heavily within one month of starting interferon 

demonstrated a 6 month SVR (Ohnishi et al., 1996).

• An analysis of 726 veterans undergoing antiviral treatment for hepatitis 

C found that recent alcohol use resulted in a greater proportion discontinuing treatment (40% vs. 26%) (Anand et al. 2006).

Drinking Diary Card and Change Plan Template (Wallet Card)

One intervention that can be effective for patients in early stages of 

changing their drinking habits is to have them self-monitor their alcohol 

consumption. The wallet cards included in the toolkit provide the patient 

a means to record their alcohol use over a 4-week period. Typically, this is 

done by converting whatever alcoholic beverages are consumed during the 

day to a certain number of “standard drinks.” A standard drink is defined as:

• 12 ounces of beer

• 4 ounces of wine

• 1.5 ounces of liquor

The act of measuring a behavior is in itself an intervention. Patients who 

use the Drinking Diary Card will have a more concrete understanding of how 

much alcohol they are consuming on either a regular or episodic basis. They 

may also use this information to understand some of the social contexts 

or special occasions in which they drink heavily. From a harm-reduction 

perspective, any decrease in alcohol consumption will likely lessen the risk of 

liver damage to some degree. This exercise in self-monitoring can serve as a 

valuable first step in making reductions in the amount of alcohol the patient 

consumes per occasion or over time.
IMPROVING HEPATITIS C CARE: Reducing Alcohol Use With Brief Intervention 17

On the back of the Drinking Diary Card is a template for making a 

Change Plan. Research on goal-setting has shown that goals are more 

likely to be pursued and accomplished when they are made explicit, 

achievable, and public (i.e., with a verbal commitment). The Change Plan 

provides a mechanism for patients to state their behavior change goals 

explicitly and problem-solve about how to realize them. The questions 

posed by the Change Plan Template are:

• “My specific goal is to . . .”

• “The steps I plan to take in changing are . . .”

• “Challenges that might interfere:”

• “How I will handle these challenges:”

• “I will know my plan is working if . . .”

Change Plans are meant for patients in later stages of change about 

their drinking, for they presume that the patient is willing to make some 

attempt at behavior change. If you hear your patient making positive 

statements about reducing or quitting drinking (i.e., “change talk”), it may 

be an appropriate time to introduce this wallet card to discuss the specific 

steps and possible barriers associated with making that change. 

Brief Intervention Toolkit components for patients:

• 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
18 HCRC TEACHING GUIDE FOR HEALTH CARE PROFESSIONALS

• Visit the VA HCRC website at http://www.hepatitis.va.gov/ 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 weblinks below)

• See the National Center for Health Promotion and Disease Prevention 

(NCP) website http://www.prevention.va.gov/Health_Promotion.asp 

for patient education materials on prevention topics of interest to your 

patients, including weight management and physical activity materials

References

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infection: a perspective on long-term outcome. Semin Liver Dis 20: 17-35.

Anand, B.S., Currie, S., Dieperink, E., Bini, E.J., Ho, S.B., Shen, H., Wright, T. for the VAHCV-001 Study Group 2004. Alcohol use and treatment of hepatitis C virus: Results 

of a National Multicenter Study. Gastroenterol 130, 1607–16.

Bertholet, N., Daeppen, J.B., Wietlisbach, V., Fleming, M., Burnand, B. (2005). Reduction 

of alcohol consumption by brief alcohol intervention in primary care: Systematic 

review and meta-analysis. Arch Intern Med 165, 986–95

Burman, M.L., Kivlahan, D., Buchbinder, M., Broglio, K., Zhou, X. H., Merrill, J.O., 

McDonnell, M.B., Fihn, S.D., Bradley, K.A. (2004). Alcohol-related advice for veterans 

affairs primary care patients: Who gets it? Who gives it? J Stud Alcohol, 65, 621-630.

Dunn, C. & Rollnick, S. (2003). Lifestyle Change. London: Mosby of Elsevier, Ltd.

Fleming, M.F., Barry, K.L., Manwell, L.B., Johnson, K., London, R. (1997). Brief physician 

advice for problem alcohol drinkers: a randomized controlled trial in community 

based primary care practices. JAMA, 36–43.

Fleming, M.F., Mundt, M.P. French, M.T., Manwell, L.B., Stauffacher, E.A., Barry, K.L. 

(2002). Brief physician advice for problem drinkers: long-term efficacy and benefitcost analysis. Alcohol Clin Exp Res, 26, 36–43.

Huntington, J., Ward, D., Lessler, D., Dunn, C., Rhoads, C. (2004). Teaching Guide for 

Motivation: Behavior Change Counseling in Chronic Care. Seattle: University of 

Washington.

Hutchinson, S.J., Bird, S.M., Goldbert, D.J. 2005. Influence of alcohol on the progression 

of hepatitis C virus infection: A meta-analysis. J Gastroenterol Hepatol 3, 1150–59.

Lieber, C.S., Weiss D.G., Groszmann, R., Paronetto, F., Schenker S.; For the Veterans 

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Loguercio, C., Di Pierro, M., Di Marino, M.P., Federico, A., Disalvo, D., Crafa, E., Tuccillo, 

C., Baldi, F., del Vecchio Blanco, C. (2000) Drinking habits of subjects with hepatitis C 
IMPROVING HEPATITIS C CARE: Reducing Alcohol Use With Brief Intervention 19

virus-related chronic liver disease: Prevalence and effect on clinical, virological and 

pathological aspects. Alcohol & Alcoholism, 35(3), 296-301.

Miller, W.R. & Rollnick, S. (1991). Motivational Interviewing. New York: Guilford Press.

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20 HCRC TEACHING GUIDE FOR HEALTH CARE PROFESSIONALS

Additional resources for brief intervention skill-building

1. Web-based training in Brief Intervention for Primary Care Providers:

• The Alcohol Clinical Training Project (ACT) http://www.bu.edu/act/

• 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 clinicans, trainers, researchers: 

http://www.motivationalinterviewing.org/

Acknowledgments

Special thanks to Kristy Straits-Tröster, Ph.D., for being the principal editor and contributor for this Teaching Guide and to Connie Lewis of the National Center for Health 

Promotion and Disease Prevention for her help on an earlier version.

Content Contributors:

John Baer, Ph.D., Katherine Bradley, M.D., Jane Burgess, A.C.R.N., M.S., Sue Currie, M.A., 

John Davison, M.B.A., Ph.D., Eric Dieperink, M.D., Christopher Dunn, Ph.D., Peter Hauser, 

M.D., Dan Kivlahan, Ph.D., Julie Nelligan, Ph.D., Martha Shea, R.N., Yong Song, Ph.D., 

Kristy Straits-Tröster, Ph.D., Mary J. Wingert, M.S.

Design/Production Contributors:

Jeff Paulino, Connie Lewis, Meaghan Splan, M.P.H., Patricia Long, Mary Salome.

VA National Hepatitis C Program of the Public Health Strategic Health Care 

Group:

Jane Burgess, A.C.R.N., M.S., Acting Director, John Davison, M.B.A., Ph.D., James Morrill, 

MA.Ed.

VA Hepatitis C Resource Center (HCRC) Directors:

Jason Dominitz, M.D., M.H.S. (Northwest), Guadalupe Garcia-Tsao, M.D. (West Haven), 

Alexander Monto, M.D. (San Francisco), Eric Dieperink, M.D., and Janet Durfee, R.N., 

M.S.N., A.N.P. (Minneapolis)

Brief Intervention Development Group Leaders:

Dr. Davison, Dr. Straits-Tröster, and Ms. Burgess led the development of this resource.
NOTE: This HCRC initiative (“Improving Hepatitis C Care: Reducing Alcohol 

Use With Brief Intervention”) is based on the University of Washington’s 

“Take Care to Learn” training project and teaching guide (“Motivation: 

Behavioral Change Counseling in Chronic Care”). Adapted with permission, Drs. Debbie Ward and Daniel Lessler, Principal Investigators.

About VA Programs in Hepatitis C

The Department of Veterans Affairs (VA) leads the country in hepatitis C screening, testing, treatment, research and prevention. VA is 

the largest single provider of medical care to people with hepatitis 

C infection in the United States.

The National Hepatitis C Program works to ensure that veterans 

with or at risk for hepatitis C receive the highest quality health 

care services from the VA system. Led by the VA’s Public Health 

Strategic Healthcare Group (PHSHG) and carried out by VA medical 

facilities across the country, the hepatitis C program makes 

use of a comprehensive approach to hepatitis C prevention and 

treatment that includes screening, testing and counseling, patient 

and provider education, optimal clinical care, and management of 

data to continuously improve program quality. 

The Hepatitis C Resource Centers (HCRCs), a part of the National 

Hepatitis C Program, develop best practices in clinical care delivery, 

patient education, provider education, prevention, and program 

evaluation that can be used by the entire VA health care system 

and other medical care systems. They function as field-based 

clinical laboratories for the development, testing, evaluation, and 

dissemination of new and innovative products and services for 

improving the quality of hepatitis C clinical care and education in 

every VA medical facility.

VA provides extensive information on hepatitis C for health 

care providers, veterans and their families, and the public at 

http://www.hepatitis.va.gov.
http://www.hepatitis.va.gov

The VA Hepatitis C Resource 

Center Program and National

Hepatitis C Program Office 

Veterans Health Administration

U.S. Department of Veterans Affairs

September 2006