Highlight
- Telehealth stepped alcohol treatment (SAT) in chronic liver disease (CLD) reduced weekly alcohol consumption at 3 and 6 months compared to usual care.
- No significant difference was found in the primary endpoint—percentage achieving moderate-level drinking—between SAT and usual care.
- Baseline motivation to reduce alcohol consumption positively influenced treatment outcomes.
- SAT shows promise for hard-to-engage CLD patients and may enhance hepatology-based alcohol interventions.
Study Background
Unhealthy alcohol use remains a pervasive challenge among patients with chronic liver disease (CLD), contributing significantly to liver disease progression, morbidity, and mortality. Despite its known deleterious impact, effective, scalable alcohol reduction interventions tailored to patients with CLD are limited. Traditional face-to-face interventions, including motivational interviewing and addiction medicine referrals, face barriers in accessibility, patient engagement, and clinic resources, particularly in vulnerable populations such as those served in safety-net and Veterans Affairs (VA) health systems.
With rising adoption of telehealth, stepped care interventions — which escalate intensity based on patient response — may offer tailored, resource-efficient approaches for reducing unhealthy alcohol use. However, evidence for such telehealth-delivered stepped treatment (SAT) strategies specifically in CLD populations remains sparse. Addressing this gap, the study by Satre et al. conducted a randomized controlled trial to evaluate the efficacy of SAT compared to usual care (UC) in reducing unhealthy alcohol consumption among patients treated in hepatology clinics.
Study Design
This multi-center, randomized controlled trial enrolled 157 adult participants with CLD and unhealthy alcohol use—defined by exceeding recommended weekly or daily drinking limits or engaging in heavy episodic drinking—between March 1, 2022, and February 28, 2024. Participants were recruited from one safety-net hepatology clinic and two Veterans Affairs hepatology clinics.
Patients were randomized to either the telehealth stepped alcohol treatment (SAT) arm (n=81) or usual care (UC) (n=76). The SAT intervention consisted of an initial step of three motivational interviewing (MI) sessions delivered via telehealth, focusing on alcohol use reduction. At three months, patients who had not reduced alcohol consumption moved to step two, involving addiction medicine referral. UC comprised standard hepatology care without the structured SAT protocol.
The primary outcome was the percentage of patients achieving alcohol consumption below a moderate level at 3 and 6 months. Secondary endpoints included changes in drinks per week, abstinence rates, and the role of baseline motivation in treatment response.
Baseline characteristics included a median age of 61 years, predominantly male (86%), with nearly half (48%) diagnosed with cirrhosis and over one-third of those having decompensated disease. Alcohol use disorder (AUD) was prevalent in 78% of participants, underscoring the clinical complexity of this cohort.
Key Findings
Regarding the primary endpoint, no statistically significant difference was observed between the SAT and UC groups in the proportion of participants achieving alcohol use below moderate levels at month 3 or month 6.
However, SAT participants demonstrated a significantly greater reduction in drinks per week compared to UC at both 3 months (estimated difference −0.66 drinks/week; P=0.03) and 6 months (estimated difference −0.67 drinks/week; P=0.03). This treatment effect persisted after adjustment for confounding variables in multivariable modeling (P=0.02 at 6 months).
Abstinence rates at 30 days prior to the 6-month follow-up were numerically higher in the SAT group (29%) versus UC (18%), but this difference did not reach statistical significance (P=0.14).
Analysis revealed a positive association between baseline motivation to reduce alcohol use and subsequent treatment response, highlighting motivation as a potential moderating factor in intervention efficacy.
The study notably enrolled a difficult-to-engage population with high rates of AUD and cirrhosis, emphasizing the real-world applicability of findings.
Expert Commentary
This study presents important insights on the utility of telehealth-based, stepped alcohol reduction strategies tailored to patients with chronic liver disease. The significant reduction in alcohol consumption, despite no difference in the primary threshold outcome, may reflect challenges in shifting population-level drinking patterns within six months but highlights clinically meaningful decreases in drinking intensity that could translate to improved liver outcomes long term.
The telehealth modality enhances accessibility and may reduce barriers such as transportation and stigma, crucial in safety-net and VA populations. The stepped approach allows resource targeting by escalating intervention intensity only to those not responding initially, potentially optimizing clinical workflow.
Limitations include the predominantly male veteran-heavy sample, which may limit generalizability to broader CLD populations, and the relatively short follow-up period. Additionally, reliance on self-reported alcohol use could introduce bias despite validated assessment tools.
Further research should explore longer-term clinical endpoints such as liver disease progression and cirrhosis complications, integration with pharmacologic treatments, and adaptation for diverse patient populations.
Conclusion
In summary, the telehealth stepped alcohol treatment model reduced mean alcohol consumption versus usual care among patients with chronic liver disease, without demonstrating superiority in achieving moderate drinking thresholds at six months. Baseline motivation influences treatment success, underscoring the importance of patient engagement strategies. SAT represents a promising, scalable approach to address unhealthy alcohol use in complex CLD populations and may be integrated into hepatology practice to complement existing care.
These findings support further clinical adoption and research to refine telehealth intervention components, improve patient tailoring, and ultimately mitigate alcohol-related liver disease burden.
Funding and Registration
The study was conducted across multiple healthcare systems including safety-net and VA clinics. Funding sources were not specified in the abstract. Trial registration details were not provided but can be searched on clinicaltrials.gov or related registries for the corresponding PMID: 42340251.
References
- Satre DD, Taj L, Wong RJ, et al. A randomized controlled trial of stepped treatment to reduce unhealthy alcohol use in patients with chronic liver disease. Hepatology. 2026 Jun 24. PMID: 42340251.
- Barnett NP, et al. Motivational Interviewing in the Treatment of Alcohol Use Disorders. Curr Psychiatry Rep. 2017;19(7):38.
- Weinstein ZM, et al. Telehealth interventions for alcohol use disorders: A systematic review. J Subst Abuse Treat. 2021;125:108254.
