The burden of chronic liver disease in the United States is substantial, affecting about 4.5 million American adults, according to recent data. The end result of chronic liver disease is cirrhosis, which can lead to deaths from infections, hemorrhage, renal failure, and liver cancer. Chronic hepatitis C infection (HCV) and alcoholic liver disease have contributed significantly to doubling the burden of cirrhosis in the US during the past 10 years. Despite the emergence of direct-acting antiviral therapies to treat chronic HCV, the burden of alcoholic liver disease continues to increase.

On its own, ethyl alcohol (ETOH) consumption is a major contributor to chronic liver disease, but it also works synergistically with chronic HCV to worsen liver disease progression. “Alcohol accelerates the development of advanced scarring in the liver among patients with HCV,” explains Julius M. Wilder, MD, PhD. “People with HCV who drink significant amounts of alcohol have an increased risk of cirrhosis, liver cancer, and death.” Considering the negative effects of consuming alcohol on patients with chronic liver disease, efforts are needed to evaluate the motives of those who drink in the context of liver disease.

Assessing Sociodemographic & Health Factors

For a study published in the Journal of Viral Hepatitis, Dr. Wilder and colleagues sought to learn more about sociodemographic and health factors that are associated with a higher motivation to drink alcohol among patients with hepatitis C. Specifically, the authors analyzed data on behavioral interventions regarding alcohol use among 181 patients with HCV. Alcohol consumption was measured using the Drinking Motives Questionnaire and a novel 6-item measure of pain-related drinking motives.

“We wanted to know more about why people were drinking ETOH and how to best stop them from drinking it,” says Dr. Wilder. “Our goal was to see if our intervention to reduce ETOH consumption was more effective than the usual care these patients receive from their liver clinic. This information is important because alcohol consumption has a significant impact on health that goes beyond liver disease. The mechanisms we identify may be relevant in other disease processes. Furthermore, we’ve seen a significant increase in unhealthy alcohol behaviors throughout the US since the COVID-19 pandemic emerged.”

Pain & Depression as Drinking Motives

According to the study, drinking motives were higher for people with beyond-minor pain and for those who met criteria for depression after assessing pain-related drinking motives items (Table). Average pain was significantly associated with increased motives to drink to relieve pain, and depression was significantly associated with increased non-pain-related motives to drink. The independent relationship between pain and motives to drink alcohol persisted even after controlling for sociodemographic factors and depression.

“Alcohol consumption among patients with HCV is at an all-time high, in large part because of COVID-19, but there are many other reasons why these individuals drink,” Dr. Wilder says. “Our study indicates that pain control is a major contributing factor to drinking alcohol, but this is a modifiable risk factor. Recognizing and addressing pain in our patients could have a positive and significant impact that goes beyond just controlling pain. It may influence other unhealthy behaviors that patients adopt to address their pain, such as ETOH consumption.”

Ensuring Sustained Alcohol Cessation

According to the study group, the findings have significant implications for the management of patients with chronic HCV. “Physicians need to regularly assess alcohol consumption when treating their patients with HCV,” says Dr. Wilder. “Efforts are also needed to assess for factors that may contribute to ETOH consumption, such as poor pain control, stress, and underlying psychological issues like depression. When these issues are present, physicians should engage healthcare partners in substance abuse counseling and pain control to co-manage these more complex patients in multidisciplinary clinics.”

An emphasis should be placed on understanding the origins of pain experienced by patients with HCV, according to the study authors. With greater understanding of how pain originates, clinicians can optimize pain management and refer appropriate patients to other multidisciplinary care team members. “Ultimately, we need to find better ways to ensure sustained alcohol cessation in patients with a history of alcohol abuse,” says Dr. Wilder. “We also need to create multidisciplinary clinics that can co-manage complicated patients with providers from medicine, psychiatry, and pain control.”