It is crucial to help with alcohol cessation to improve the prognosis after diagnosis of alcohol-related liver disease (ALD) (1). To succeed with alcohol cessation, patients must be motivated to change drinking behavior (2,3). Some studies have investigated motivation to change in individuals with alcohol use disorder (4–6), but results from these studies may not apply to patients with ALD because illness increases motivation to change drinking behavior (5,7). Chang et al. (8) investigated motivation to change drinking behavior in 87 patients with ALD and found that severe alcohol problems, high self-stigma, and depression predicted a strong motivation to change. Chang et al. (8) did not find an association of liver disease severity with motivation to change, but the impact of hospitalization was not investigated. Another important factor in succeeding with alcohol cessation is engagement in alcohol misuse treatment, which improves survival in patients with ALD (9). Alcohol misuse treatment is underused in patients with ALD, and a recent study found that lack of motivation was an important barrier (10).
Knowledge about factors associated with motivation to reduce alcohol consumption in patients with ALD may help with the proper timing of brief interventions and offering of alcohol misuse treatment. Therefore, this study had 2 aims; first, to perform an exploratory analysis of multiple potential associations between clinical characteristics and the motivation to reduce alcohol consumption in patients with ALD and second, to assess whether such motivation predicted subsequent engagement in alcohol misuse treatment.
PATIENTS AND METHODS
This historical cohort study included patients with ALD who participated in 1 of 3 Danish National Health Surveys (DNHS) conducted in 2010, 2013, and 2017 (11). We included answers from DNHS regarding alcohol habits, CAGE questionnaire (12), health-related quality of life (a 12-item short-form questionnaire) (13), and motivation to reduce alcohol consumption. We obtained data on ALD, recent hospital care, alcohol misuse treatment, and socioeconomic status from national registries. Patients who reported active alcohol consumption were followed up for 2 years for engagement in alcohol misuse treatment after DNHS participation. The engagement, identified through registries, was defined as attending specialized alcohol misuse treatment and/or redeeming a drug prescription to treat alcohol use disorder.
First, in alcohol-consuming patients with ALD, we used a generalized linear model to calculate prevalence ratios (PR) for being motivated to reduce alcohol consumption according to multiple clinical characteristics. We performed a univariable and a multivariable analysis for each characteristic. All clinical characteristics were included in the model simultaneously in the multivariable analysis. Second, we used the competing risk method to compute the cumulative incidence of engagement in alcohol misuse treatment until 2 years after DNHS participation. In addition, we investigated whether the study cohort was representative of all patients with ALD in Denmark (see Table, Supplemental Digital Content 3, https://links.lww.com/AJG/C406). For details about methods, see Methods, Supplemental Digital Content 1, https://links.lww.com/AJG/C404. For all applied diagnostic codes, see Supplemental Digital Content 4 (https://links.lww.com/AJG/C407). For illustration of the cohort creation, see Supplemental Digital Content 5 (https://links.lww.com/AJG/C408).
We included 674 patients with ALD who participated in the DNHS. Of them, 388 (58%) had cirrhosis, and 436 (65%) reported weekly alcohol consumption (Figure 1). Only 30% of the 436 alcohol consumers reported motivation to reduce alcohol consumption (see Table, Supplemental Digital Content 2, https://links.lww.com/AJG/C405). Among abstainers, 67% had cirrhosis, and 60% had a recent outpatient visit. Among alcohol consumers, those proportions were lower: 52% and 45%, respectively. The included patients from DNHS were representative of all patients with ALD in Denmark according to age, sex, socio- demographics, and ALD stage (see Table, Supplementary Digital Content 3, https://links.lww.com/AJG/C406).
In the group of active alcohol consumers, a hospital admission 3 months before participation in the DNHS was associated with the motivation to reduce alcohol consumption with a PR of 1.8 (95% confidence interval [CI] 1.3–2.6) compared with patients admitted more than 12 months before participation (Table 1). A weekly alcohol consumption above 14 units and a CAGE score ≥2 was associated with motivation to reduce alcohol consumption when compared with a lower weekly alcohol consumption and a lower CAGE score, respectively. Poor mental quality of life was associated with motivation to change with a PR of 1.7 (95% CI 1.3–2.3) compared with better mental quality of life.
Within 2 years after DNHS participation, 65 of the 436 (15%) patients with ALD engaged in alcohol misuse treatment. This 2-year probability was higher among patients expressing motivation to reduce alcohol consumption than for patients without such motivation. (29% [95% CI, 23–39] vs 6.5% [95% CI, 3.9–11]) (Figure 2).
In the total cohort, 436 (65%) patients with ALD had active alcohol consumption and 30% of them were motivated to cut down. In the alcohol-consuming patients, a recent hospital admission, high weekly alcohol consumption, a CAGE score indicating alcohol use disorder, and poor mental quality of life were associated with increased motivation, whereas severity of liver disease was not. The motivated patients were more likely to engage in alcohol misuse treatment during the 2 years of follow-up.
In line with our results, previous studies, mainly in individuals with alcohol use disorder without ALD, have shown that higher levels of alcohol consumption and alcohol dependence symptoms affect the motivation to change (4,6,8). One study also found that hospitalization strengthened motivation to change in individuals with alcohol use disorder (5).
We found that our study cohort was representative. Even so, the included patients may drink less than the general Danish ALD population because a study found higher alcohol-related mortality in nonrespondents when compared with respondents in DNHS (14). Consequently, because heavy drinking is associated with increased motivation to reduce alcohol consumption (4,6,8), we may have underestimated the true proportion of motivated patients with ALD. We note, however, that the proportion of patients with ALD consuming more than 28 units of alcohol per week was similar to that reported by Lucey et al. (1) Furthermore, self-reported alcohol consumption has some limitations, and to improve this in future studies, we could apply an objective alcohol biomarker. Moreover, we excluded patients who had lived for more than 10 years with ALD before survey participation, and our results may not apply to them.
Our study highlights the high proportion of patients with ALD who continue to drink alcohol and the low proportion of these who engage in alcohol misuse treatment. Moreover, it showed that recent hospital admission was associated with motivation to reduce drinking. These findings underline the importance of motivational interviews and appropriate interventions as part of daily clinical care—and particularly, shortly after discharge from the hospital.
CONFLICT OF INTEREST
Guarantors of the article: Anna Emilie Kann, MD, and Gro Askgaard, MD, PhD.
Specific author contributions: A.E.K., P.J., L.M., C.C., K.F., A.I.C., C.J.L., J.W., and G.A.: design of the study. A.E.K. and G.A.: conception of the study. G.A.: data analysis. A.E.K.: first draft of the manuscript. A.E.K., P.J., L.M., C.C., K.F., A.I.C., C.J.L., J.W., and G.A.: critical revision of the article.
Financial support: A.E.K., P.J., and G.A. were supported by a grant from the Novo Nordisk Foundation (NNF18OC0054612). The fund had no role in study design, data collection and analysis, preparation of the manuscript, or decision to publish.
Potential competing interests: None to report.
1. Lucey MR, Connor JT, Boyer TD, et al. Alcohol consumption by cirrhotic subjects: Patterns of use and effects on liver function. Am J Gastroenterol 2008;103(7):1698–706.
2. Cook S, Heather N, McCambridge J. Posttreatment motivation and alcohol treatment outcome 9 months later: Findings from structural equation modeling. J Consult Clin Psychol 2015;83(1):232–7.
3. Bertholet N, Cheng DM, Palfai TP, et al. Does readiness to change predict subsequent alcohol consumption in medical inpatients with unhealthy alcohol use? Addict Behav 2009;34(8):636–40.
4. Williams EC, Kivlahan DR, Saitz R, et al. Readiness to change in primary care patients who screened positive for alcohol misuse. Ann Fam Med 2006;4(3):213–20.
5. Rumpf HJ, Hapke U, Meyer C, et al. Motivation to change drinking behavior: Comparison of alcohol-dependent individuals in a general hospital and a general population sample. Gen Hosp Psychiatry 1999;21(5):348–53.
6. Krenek M, Maisto SA, Funderburk JS, et al. Severity of alcohol problems and readiness to change alcohol use in primary care. Addict Behav 2011;36(5):512–5.
7. Sarich P, Canfell K, Banks E, et al. A Prospective study of health conditions related to alcohol consumption cessation among 97,852 drinkers aged 45 and over in Australia. Alcohol Clin Exp Res 2019;43(4):710–21.
8. Chang C, Wang TJ, Chen MJ, et al. Factors influencing readiness to change in patients with alcoholic liver disease: A cross-sectional study. J Psychiatr Ment Health Nurs 2021;28:344–55.
9. Rogal S, Youk A, Zhang H, et al. Impact of alcohol use disorder treatment on clinical outcomes among patients with cirrhosis. Hepatology 2020;71(6):2080–92.
10. Mellinger JL, Scott Winder G, DeJonckheere M, et al. Misconceptions, preferences and barriers to alcohol use disorder treatment in alcohol-related cirrhosis. J Subst Abuse Treat 2018;91:20–7.
11. Christensen AI, Lau CJ, Kristensen PL, et al. The Danish National Health Survey: Study design, response rate and respondent characteristics in 2010, 2013 and 2017. Scand J Public Health 2020.
12. Dhalla S, Kopec JA. The CAGE questionnaire for alcohol misuse: A review of reliability and validity studies. Clin Investig Med 2007;30(1):33–41.
13. Ware J, Kosinski M, Keller S. A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Med Care 1996;34(3):220–33.
14. Christensen AI, Ekholm O, Gray L, et al. What is wrong with non-respondents? Alcohol- , drug- and smoking-related mortality and morbidity in a 12-year follow-up study of respondents and non-respondents in the Danish Health and Morbidity Survey. Addiction 2015;110:1505–12.