As addiction medicine becomes more effective at treating opioid dependence, greater efforts will need to be placed on addressing long-term medical comorbidities common in populations of intravenous drug users (IDUs). We commend Gibson et al.  for bringing to our attention the importance of liver disease in contributing to the mortality of this ageing population. The authors highlight the need for the health-care community to place greater efforts on screening and treatment of hepatitis C virus (HCV) infection and concurrent heavy alcohol consumption to help reduce their long-term impact. This commentary summarizes some of the resources that are currently available for addressing these issues.
The authors point to chronic HCV infection as a major contributor to mortality caused by liver disease in individuals with a history of IDU. This suggests that programs that focus on screening and identifying HCV in this population are needed, particularly in medical settings where these individuals may present, such as emergency rooms, community out-patient and primary care clinics. Screening programs for HCV have been implemented in health-care settings, but with mixed success . Although HCV screening is likely to improve early detection, screening alone does not necessarily result in greater numbers of individuals receiving antiviral therapy . A variety of factors may serve as barriers to receiving treatment for HCV, including not showing up for appointments and being lost to follow-up, and psychosocial issues such as alcohol use disorders, that are contraindications to treatment [2–4]. Furthermore, those who do receive antiviral therapy may discontinue prematurely for various reasons, including an inability to tolerate possible treatment side effects . This suggests that screening alone is unlikely to improve rates of treatment initiation and adherence unless appropriate services are also provided to help address such barriers.
Heavy alcohol use may not only contribute to HCV disease progression but is perhaps the single most important modifiable barrier to initiation of antiviral therapy. Thus, clinics focusing on the detection and/or treatment of HCV should consider implementing standard screening for heavy alcohol use along with providing appropriate treatment options for these individuals. Brief alcohol interventions (BAIs) are one promising approach for treating heavy alcohol use in HCV clinics. The term BAI refers to a range of interventions, from a single 10-minute session to multiple sessions that take place over several weeks. BAIs typically include an initial assessment of alcohol use and related problems, personalized feedback comparing a respondent's reported alcohol use with that of age- and gender-matched peers and information about alcohol-related consequences and risk factors [6,7]. Research suggests that such BAIs can result in significant reductions in alcohol consumption among civilian adults , college students [9–11] and active duty military populations . BAIs have also been used to good effect in a variety of medical settings, including primary care  and HCV clinics , and can be delivered in various forms, including face-to-face and self-administered via computer, with no reduction in efficacy [9,11].
BAIs should be considered as an effective first-line approach in addressing heavy alcohol use in patients with HCV. Some individuals will undoubtedly require more intensive interventions [e.g. referral to specialty substance use disorders (SUD) treatment] beyond BAIs to help support them in reducing their alcohol consumption. The relatively low cost and low provider involvement needed to administer these interventions, particularly those that are technology-based, may make them especially attractive to busy clinics with limited resources and limited options for addressing concurrent heavy alcohol use.
In sum, we agree with Gibson et al.'s conclusion that as the life-span of individuals with a history of IDU increases, so too will the need for health-care systems to address slowly developing medical comorbidities such as liver disease. To do this successfully, we will need to allocate resources and implement feasible, evidence-based strategies to treat concurrent heavy alcohol use in ageing IDUs with HCV. BAIs are one promising first-line strategy for doing so. Such first-line interventions may also increase rates of HCV treatment eligibility and ultimately improve long-term health outcomes in this population.