Why Do Patients With Chronic Hepatitis C Drink Alcohol?

An Examination of Pain, Depression and Drinking Motives

Julius M. Wilder; Donna M. Evon; Rae Jean Proeschold-Bell; Jia Yao; Malik Muhammed Sohail; Donna Niedzwiecki; Christina Makarushka; Terra Hodge; Andrew J. Muir


J Viral Hepat. 2021;28(5):699-709. 

In This Article

Abstract and Introduction


Alcohol consumption in the setting of chronic HCV is associated with accelerated progression towards cirrhosis, increased risk of hepatocellular carcinoma and higher mortality. This analysis contextualizes how sociodemographic factors, chronic pain and depression relate to the motivations of individuals with chronic HCV to consume alcohol. We conducted a secondary analysis of baseline data from the Hep ART trial of behavioural interventions on alcohol use among patients with HCV. Alcohol consumption was measured using the Drinking Motives Questionnaire and a novel 6-item measure of pain-related drinking motives. Statistical analyses performed included ANOVA for bivariate analyses and multivariable ordinary least-squares linear regression. At study baseline, 181 participants had an average age of 55 years; the majority (66.7%) reported beyond-minor pain; and a third (37%) met criteria for depression; drinking motives were higher for individuals with beyond-minor pain (means 9.9 vs. 4.6, p < .001) and who met criteria for depression (means 10.9 vs. 6.4, p < .001) when using the pain-related drinking motives items. Average pain(coef = 1.0410067141 < .001) was significantly associated with increased motives to drink to relieve pain in the full baseline model specification controlling for all covariates using ordinary at least squares; depression (coef = 7.06; 95% CI 1.32, 12.81; p = .016) was significantly associated with increased non-pain-related motives to drink. From baseline to 3-month follow-up, compared to participants who had mean average pain scores among the sample, motives to drink to relieve pain decreased in participants who had higher average pain scores (coef = –0.30; 95% CI –0.59, −0.01; p = .40). Physical pain and depression are associated with increased motives to consume alcohol. Patients with chronic liver disease should be screened for chronic pain and depression and, if present, referred to pain specialists or co-managed in partnership with pain specialists in hepatology clinics.


The number of individuals with chronic liver disease in the United States in 2017 was 4.5 million, accounting for 1.8% of the United States population aged 18 years and older.[1] The end result of chronic liver disease is cirrhosis which results in death due to infection, haemorrhage, renal failure and liver cancer.[2] The major contributors to the development of cirrhosis in the United States are chronic hepatitis C infection (HCV) and alcoholic liver disease.[2–4] These two conditions have contributed significantly to the doubling of the burden of cirrhosis in the United States over the past decade.[4–6] The era of direct-acting antivirals (DAAs) revolutionized treatment for chronic hepatitis C. The Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) have implemented policies for the elimination of hepatitis C.[7] However, the burden of alcoholic liver disease, a preventable cause of chronic liver disease and cirrhosis, continues to increase.[8] Between 1999 and 2016, mortality in the United States from cirrhosis increased by 65%. This increase was driven by deaths due to alcoholic liver disease, particularly among individuals 25–34 years old.[8] The burden of deaths from chronic liver disease and cirrhosis is projected to triple by the year 2030.[9]

While alcohol consumption is a major contributor to chronic liver disease on its own, it works synergistically with chronic hepatitis C to worsen liver disease progression. The combination of alcohol consumption with HCV accelerates progression towards fibrosis, increases the likelihood of developing hepatocellular carcinoma (HCC) and increases overall risk of mortality.[3,10–12] Even after viral clearance of HCV, alcohol use can be damaging, especially if the liver is fibrotic or cirrhotic from prior HCV and/or alcohol use.[12]

Given the large negative effects of alcohol consumption on patients with chronic liver disease, there is a need to evaluate the motives of individuals who consume alcohol in the context of liver disease. In the current analysis, we draw upon data collected for the Hepatitis C-Alcohol Reduction Treatment (Hep ART) study of patients recruited from outpatient liver clinics who currently have or ever have had chronic HCV and consume alcohol. The objective of this study was to elucidate sociodemographic and health factors such as income, chronic pain and depression that are associated with increased motivation to drink alcohol among patients with hepatitis C. For these exploratory analyses, we did not have a priori hypotheses. Contextualizing the factors related to drinking motives, as well as characterizing the motives themselves among patients with chronic liver disease, will allow for the tailoring of interventions aimed at decreasing alcohol consumption in patients with chronic liver disease.