Introduction
Methods
Participants
Procedure
Alcohol use assessment | 1. How often do you assess alcohol use in routine care? |
2. What questions do you ask? | |
Addressing alcohol use issues | 3. In your opinion, how should we address alcohol use issues in the primary care setting? |
4. Who would be the key agents in addressing alcohol use issues? | |
Alcohol use and HIV-related outcomes | 5. What have you observed regarding HIV outcomes among patients that use alcohol? |
6. What recommendations do you give to your patients regarding alcohol consumption? | |
7. What kind of information are your recommendations based on? | |
8. Would knowing how much your patients used alcohol affect your course of treatment for HIV management? | |
Alcohol use resources and treatment options | 9. What resources or treatment options do you have in order to address heavy alcohol use? |
10. What resources or treatment options do you need in order to address heavy alcohol use? | |
11. How often do (or would) you use such resources? |
Data analysis
Results
Participant demographics
Years of work experience as an HIV care provider
| |
Mean | 12.2 |
Median | 14 |
Distribution | 1–28 |
Percentage of patients that experience a mental health issue
| |
Mean | 51.3% |
Median | 45% |
Distribution | 15–99% |
Percentage of patients that experience a substance use issue
| |
Mean | 42.8% |
Median | 37.5% |
Distribution | 10–95% |
How confident do you feel helping patients with alcohol use problems?
| |
Mean | 60% |
Median | 50% |
Distribution | 10–100% |
Emergent themes
Outside of the first visit, providers reported asking about alcohol consumption if the provider suspected an alcohol use problem:Provider 1: “So – if it’s a new patient or even a patient I’m inheriting, there are a few things I always touch on. One of them is if they are abusing any type of drug, whether it is IV [intravenous] or alcohol related. Always ask about that in terms of the past.”
One provider reported an existing protocol that wasn’t always followed:Provider 1: [Ask about alcohol consumption] “if we suspect something… if it seems like they’re having a hard time.”Provider 2: “Certainly we don’t [ask] at every each visit. I think we only do them if it’s a real problem. If someone comes in and says, ‘Hey, I have a problem’.
Other providers reported that limited time prevented them from conducting an alcohol use assessment:Provider 2: “We’re supposed to be doing that every year. I don’t think we’ve actually done it every year for the alcohol.”
Few providers reported assessing alcohol use at each visit (n = 3; PA, NP, MD).Provider 3: “Sometimes I just don’t have time for it [to ask about alcohol consumption].”
Of the providers that reported assessing alcohol use (n = 9), most reported asking questions to ascertain the frequency of alcohol use and the quantity (n = 6):Provider 4: “Well we are always aware of it. It’s one of our – you know, topics that we include in every regular visit with the patient.”
The other providers reported asking similar questions, in addition to assessing the type of alcohol that is consumed.Provider 3: “I ask ‘em, ‘Do you drink any alcoholic beverages? That includes beer, wine, wine coolers or other actual liquors.’ I ask them on average, how many a week. If it seems like they’re having a hard time, I say, ‘Do you drink every day, do you drink every other day?’ I try to get a good quantification. I ask ‘em about how many beverages and how many ounces those are.”
(2) There were inconsistent perceptions of self-report accuracy which may be affected by patient–provider rapport and trust When asked about alcohol assessment, several providers (n = 7; PA, NP, MD) indicated that an important barrier to assessment and use of information gained was accuracy of self-report. One provider expressed concerns of under-reporting:Provider 1: “I’ll ask how much do they drink on a daily basis – you know, are they drinking beer and wine versus hard liquor. Do they binge?”Provider 5: “We ask the amount, for how long they have been drinking, for how many years, if they are trying to quit, what happened – what made them restart [drinking alcohol]?”
Other providers recognized that self-report may not be accurate, but choose to trust in what patients are reporting:Provider 6: “The alcohol use itself is under reported. I think for alcohol [self-report] is very – I think patients – they downplay a lot when they give you history of alcohol use.”
One provider expressed that understanding the patients’ jargon was valuable in establishing this trust:Provider 7: “– and one of the things I do with my patients when I ask them…they tell me ‘Okay, I’m not going to lie to you.’ And I said ‘Listen – no, no, no, you can lie to me. You lie to me, I won’t be able to help you but I have to trust you. I have to believe whatever you tell me. I believe you.’ – Because I think we have to trust each other, and that’s why they come to see me because they trust me, and I will reciprocate that”
Other providers felt that their patients were open and honest about their drug and alcohol use:Provider 8: “– it helps in knowing what’s the latest drug, drink – you know – because if you speak the lingo then they meet you halfway and they don’t see that you’re judging them – you know, you’re just having a conversation.”
(3) Providers acknowledge potential negative impacts of alcohol use on health outcomes and how HIV-infection is treated Providers were asked to describe what they had observed regarding HIV outcomes among patients that used alcohol. Providers were also asked how knowing their patient’s used alcohol would affect treatment and HIV management. Many providers (n = 9; CA, PA, NP, MD) reported that alcohol consumption among their patient population influenced medical compliance, mainly through accidentally or intentionally missing their ART dose or missing appointments:Provider 9: “All [of] my patients are upright, they will say ‘I used yesterday, or I used last night.’ They also know I ask and I expect them to tell me the truth and they do. They are so honest with me, and… I tell them ‘Be honest with me, I don’t care that you use, it doesn’t faze me’.”
Also:Provider 1: “It’s the patients that have serious alcohol abuse issues; it begins to be a problem because they forget to take their medication or they’re just out of it and on a binder for a few days and they don’t take their medications.”
Providers (n = 4; PA, NP, MD) mentioned noticeable differences in viral load suppression among their patients that drink:Provider 10: “Sometimes patients feel like, [I’m going drinking today, so I maybe be pro-active and I’m not going to take my medication]. Cause they feel, [the medication can hurt my liver, drinking is going to hurt my liver, but I’m going to drink, so I just won’t take my medication today]. I think that even my moderate drinkers sometimes are irresponsible as far as their care. They may miss appointments.”Provider 11: “When they [patient] are in care and then all of a sudden they just drop out of care again, we know what’s going on [regarding alcohol use].”
Also:Provider 3: “I can think of one particular example. This guy drinks all of the time. He comes to clinic every time smelling like beer. Every – every time. He comes to clinic almost difficult to understand. I’m like, Oh my God! Did you drive yourself? His viral loads are detectable.”
Several providers (n = 6; PA, NP, MD) mentioned the need to consider altering their patients’ ART medication regimen due to heavy drinking or problems caused by alcohol use (i.e. ART resistance due to medical non-compliance):Provider 1: “They are the patients I worry about because they have detectable viral loads and develop resistance and it just becomes a really bad cycle.”
Also:Provider 8: “I mean, when you have non-compliance you start dealing with resistance and your options for treating them become less and less. But, you would want to try and simplify the regimen as much as possible to decrease their burden – you know – to try and again, meet them in the middle. At the end of the day that’s all you can do.”
Some providers (n = 3; NP, MD) reported concerns discontinuing ART altogether because of the contraindication with alcohol:Provider 1: “If I know a patient is drinking a lot and it’s a problem, it’s going to interfere with what medication their going to take. I’m not going to prescribe them medication that has very low barrier to resistance. So, I may choose a less wimpy regimen – something a bit stronger or stable because I would be worried about it if they keep missing doses they eventually build up resistance. I want something a bit more aggressive in terms of regimen.”
Some providers (n = 3, CA, NP, MD) also felt that, aside from HIV-related outcomes, alcohol consumption had a detrimental effect on behavioral/mental health that often affected the level of care that could be provided in the clinic setting:Provider 10: “As [your] healthcare provider, responsibly, I can’t continue to provide you with these medications until we evaluate you for liver failure. The client perks up to that and is like ‘So, I really have a problem?’ [Provider says], ‘Yeah, whether it’s drinking or not, you have a liver problem.’ It’s good to have something wrong because they can see it. It’s tangible.”
Also:Provider 12: “If the provider feels that it is not an appropriate time to see the patient because they may not understand the instructions they are getting [due to alcohol use], we’ll just reschedule the appointment. We don’t want to service a client that is under substance abuse, or not acknowledging services they are receiving”
Related, a clinical administrator expressed concern that the primary provider does not engage patients well enough to address the underlying issue. This provider also reported perceptions of stigmatization of patients with unhealthy alcohol use.Provider 9: “I’ll just say ‘Okay, this appointment is over. I will not discuss your healthcare with you while you are under the influence of drugs. If you want your information, come back sober”.
As mentioned above, most providers did perceive a link between alcohol consumption and poor health outcomes, related to medical non-adherence, viral load, and behavioral issues. However, there was a subset of providers (n = 4, PA, MD) that reported no such link among their patients who engage in light to moderate alcohol use:Provider 12: “I think sometimes, this is my opinion that maybe the provider gives up too fast. You know, we know alcohol abuse is a disease and I think that sometimes here maybe the provider feels, [well, if you’re not taking care of your HIV, how are you going to take care of your other stuff?]. – When I say give up, I mean maybe they are like [I’m not going to see the patient because they are drinking] – you know? Or they’ve missed too many appointments, because they are probably home drinking.”
(4) Providers reported inconsistent recommendations regarding alcohol use When asked to describe the recommendations given to their patients regarding level of alcohol use, some providers (n = 5; MA, MD) reported abstinence as their recommendation, citing ART adherence and organ failure to be the main reason for this recommendation:Provider 8: “Moderate use, I don’t really see any kind of correlation, because they take their meds and you know, they might have a beer at night and that’s it.”
More providers (n = 8; PA, NP, MD) felt that, if alcohol is to be consumed, light to moderate alcohol consumption was a reasonable recommendation to their patients. Providers with this recommendation seemed to provide patients with information regarding how much low to moderate drinking is and what level of drinking they recommend their patients not exceed, if they are to drink:Provider 3: “I never recommend a safe level of alcohol use. If they have hepatitis C or hepatitis B, I ride them hard to give up alcohol and to avoid Tylenol and stuff. Now one of the things you have to realize is alcohol is one of the number one causes of fatty liver disease… steatohepatitis. Most of my patients end up having that. They’re obese or they were on old-time HIV medications that also caused fat to deposit in the liver. I’m very clear – zero alcohol.”
Other providers feel moderate drinking is acceptable, but only if HIV viral load and other related comorbidities are well managed:Provider 3: “I tell them, ‘I really don’t want to see you using more than 2 grams of alcohol. If you’re going to drink, I’d really prefer that you not drink every day, and if you do drink, I’d prefer you to limit it to two drinks, either a couple of ounces of liquor or the 12 oz beers. That 32 oz beer is more than one beer. I do encourage them to think about it. Sometimes it’s a slippery slope that can lead to more drinking. That’s what we talk about”.
Some providers (n = 5; PA, NP, MD) reported that, if their patients engage in unhealthy alcohol use, they try to plan for alcohol reduction as opposed to complete abstinence:Provider 10: “That one or two glasses of wine, or one or two beers, or one or two cocktails – I’m okay with that as long as your liver enzymes are normal and you’re doing well. But, if your numbers start to change, if I see a problem, I’m going to let you know… I’m not against [drinking]. I am not an anti-drinker, but I do encourage that they consider the amount… and don’t miss your medicine. Take your medicine anyway.”
A couple of providers (n = 2; NP, MD) focus on referrals for those patients that engage in unhealthy alcohol use, as opposed to making quit or reduction plans:Provider 8: “So, if they’re heavy users you never try to tell them to quit – right – you try to bargain. ‘Well alright – if you have six today, would you mind having maybe only four tomorrow, or four and a half? Like throw out the last half of that last can.’ Because, if you tell them anything about changing it doubles instead – so you work things out. You have to bargain with them”
Some providers (n = 4; MA, NP, MD) reported trying to educate the patient on the effects that alcohol use may have on their health and life, in lieu of an alcohol consumption recommendation:Provider 7: “Some of them, they will relapse very easily, and it is hard, that’s why I refer my patients to somebody else. Because, I try. All of the times I’ve tried to help somebody quit, I cannot do it. I think it’s more intense in-patient than for them to just be told once every three months that they should just stop, or they should decrease the amount of alcohol.”
(5) Providers have limited resources for patients with unhealthy alcohol use Providers were asked to describe what resources or treatment options they currently have in order to address unhealthy alcohol use. Some providers were able to identify one or two local alcohol programs (n = 5; CA, NP, MD; Alcoholics Anonymous [AA], Drug Abuse Comprehensive Coordinating Office [DACCO], South Florida AIDS Network) or mental health professions (n = 4; MA, NP, MD) that were available either as a referral or within the same healthcare unit to help patients with unhealthy alcohol use:Provider 3: “What I try to say [is], ‘Even if your alcohol use isn’t affecting your HIV care, it seems to be affecting your life. You have fights with your partners or you’ve gotten a DUI [driving under the influence]. These are some serious consequences from your drinking that to me, suggests that you might have a problem. Do you think you have a problem?’ We talk about what other things are going through the liver or we talk about the HIV medications – all of them require your liver to be healthy, for the most part. If you’re on any regimen, it’s going to need a healthy liver.”
Also:Provider 3: “I usually print out a list of local places that they can have access to, Alcoholics Anonymous meetings they need – AA. I give everybody the AA part because I figure it doesn’t matter what you’re doing, it might help.”
Several providers (n = 6; PA, MD) reported significant barriers to helping patients with unhealthy alcohol use, ranging from lack of resources to lack of patient motivation:Provider 13: “We have psychologists that come here in the afternoon. We have social workers that work with the patient. The patient can be seen the same day, or sometimes they just come and even when they don’t have an appointment – we try to get an appointment either with the social worker or the psychologist.”
Also:Provider 3: “I don’t have a lot of resources for referral. There really are limited resources in some of these rural areas for folks for even AA meetings when they don’t have transportation.”
(6) Providers have low confidence in their ability to help patients reduce alcohol use Several providers (n = 5; CA, NP, MD) mentioned low confidence in their training or little experience helping patients with unhealthy alcohol use. One provider mentioned lack of clinical training as a barrier to providing interventional support for their patients who engage in unhealthy alcohol use:Provider 2: “It is very difficult to get [patients] to go to a DACCO or another session. Most of the time, people don’t want it. They, I think, are treating their concomitant depression or mania – and say ‘No. I like alcohol as my drug. I’m not going to change.’”
One provider mentioned lack of personal experience as a barrier:Provider 3: “I probably am not very effective in alcohol counseling. The reality is that it is not something that I was trained in… an advocate and maybe somebody that actually knows how to empower [patients] better than I do… maybe I don’t know the right way to encourage people.”
Provider 9: “See, I’m not the expert in substance abuse. I’ve never used drugs, I’m not an alcohol drinker – a little bit of wine will do me – I never smoked and I don’t have the background of the people that use these. I don’t know what possessed them to start drinking. So, I’m totally clueless… I would find it better to have somebody that I can [send] them to and have them deal with it – somebody who really understands the whole dynamics. Because, they do a better job. I can tell them ‘don’t do it, stop your alcohol use,’ but what tools do I have to give them to do this? I know nothing.”