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Barriers to abstinence in alcohol related liver disease
For correspondence: Dr Shiv Kumar Sarin, Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi 110 070, India e-mail: shivsarin@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Varshney M, Bhardwaj A, Dua G, Parel JT, SM S, Sarin SK. Barriers to abstinence in alcohol related liver disease. Indian J Med Res. 2026;164:522-7. doi: 10.25259/IJMR_501_2026
Abstract
Background and objectives
Alcohol-related liver disease is a major public health concern, and continued alcohol use despite medical advice remains common. This study examined factors associated with ongoing alcohol use among patients with alcohol-related liver disease attending a tertiary care centre in north India.
Methods
A comparative cross-sectional study was conducted among 3759 adult male patients (mean age 43.8 ± 19.4 y) with alcohol-related liver disease. Patients were categorised as those with recent alcohol use (within the past 60 d) and those abstinent for more than 60 d. Data on alcohol use patterns, dependence severity, motivation to change, and perception of alcohol-related harm were obtained using structured assessments like the severity of dependence scale, readiness to change questionnaire, and a structured questionnaire developed for clinical use.
Results
A majority of patients reported recent alcohol use. Most were long-term (n=2932, 78% >5 y) and frequently drinking alcohol (n=2905, 77.3%) drinking alcohol three or more times per week), and 57.4% (n=2158) had attempted quitting previously. Individuals with ongoing alcohol consumption had higher dependence severity compared to abstinent patients. Despite this, many current drinkers reported awareness of alcohol-related harms and the need for treatment. Motivation to reduce or stop alcohol use was reported in both groups.
Interpretation and conclusions
Continued alcohol use among patients with alcohol-related liver disease appears strongly associated with dependence severity rather than lack of awareness or motivation. These findings highlight the need for integrated hepatology- addiction care approaches addressing both behavioural and biological aspects of alcohol dependence.
Keywords
Abstinence
Alcohol dependence
Alcohol-related liver disease
Awareness
Motivation
Relapse
Alcohol consumption is a major global health risk and contributes substantially to morbidity and mortality worldwide. It is estimated that nearly 400 million individuals live with alcohol use disorders globally.1,2 In India, alcohol use is common, particularly among men, and its burden continues to rise.
Alcohol-related liver disease is one of the most serious consequences of chronic alcohol use and contributes significantly to liver-related morbidity and mortality in India.3 Continued alcohol consumption in individuals with liver disease accelerates disease progression, increases complications, and worsens survival outcomes.4 Alcohol use disorder is increasingly understood as a chronic relapsing condition characterised by neurobiological changes affecting reward, motivation, and executive control. These changes often lead to continued alcohol use despite awareness of harm and medical advice to abstain.5
Although several studies have examined relapse and treatment outcomes in alcohol use disorder, relatively less is known about factors influencing continued alcohol use among patients with alcohol-related liver disease. The relationship between dependence severity, motivation to change, and awareness of alcohol-related harm in this population remains unclear. We conducted this study to compare alcohol use patterns, dependence severity, motivation to change, and harm perception between patients with alcohol-related liver disease who continue to consume alcohol and those who are abstinent.
Methods
Study design and setting
A hospital-based comparative cross-sectional study was conducted by the departments of Psychiatry, and Hepatology, Institute of Liver and Biliary Sciences, New Delhi, a tertiary care centre specialising in liver disorders. The study included adult patients with a diagnosis of alcohol-related liver disease and co-existing alcohol use disorder who attended outpatient or inpatient services between 1st January 2023 and 1st December 2025. Ethical approval was obtained from the Institutional Ethics Committee of the Institute. Alcohol use disorder diagnoses were based on clinical assessments documented in patient records using standard diagnostic criteria, as part of routine clinical care.
Eligibility criteria
Participants were categorised based on their self-reported alcohol use status at the time of assessment into patients with recent alcohol use (alcohol consumption within the past 60 d) and patients abstinent from alcohol for more than 60 d. This classification was used as a grouping variable for comparison rather than as a formal case-control design. The 60-d cutoff was chosen because indirect biomarkers of alcohol use and liver injury, such as carbohydrate-deficient transferrin (CDT) and transaminases typically normalise within 2–3 wk after abstinence and gamma-glutamyl transferase (GGT) declines over 2–6 wk, indicating that a 60-d interval provides a conservative period for washout and reduces misclassification of recent drinking;6 however, the possibility of relapse within this period cannot be excluded.
The diagnosis of alcohol related liver disease was based on standard clinical evaluation, liver function tests, imaging findings and other relevant laboratory parameters as per institutional protocols. Alcohol use disorder was diagnosed according to the DSM-5 criteria7 as recorded in the patient’s clinical file. Patients were excluded if they had incomplete records, were unable to provide information at the time of initial assessment (e.g., due to hepatic encephalopathy) or had major comorbid psychiatric or neurological conditions that could impair assessment.
Data were obtained from structured clinical assessments and included sociodemographic characteristics, alcohol use patterns (duration, frequency, and quantity) and history of quit attempts. Severity of dependence was assessed using the severity of dependence scale, a brief measure of psychological dependence.8 Motivation to change alcohol use was assessed using the readiness to change questionnaire, which categorises individuals into stages of change.9 Given the clinical setting, responses may reflect perceived intent to change rather than sustained behavioural change. Perception of alcohol-related harm was assessed using a structured questionnaire developed for clinical use, which included items related to awareness of harmful effects, addictive potential, need for treatment and importance of quitting. As this instrument has not been formally validated, findings based on this measure should be interpreted with caution.
Statistical analysis
All data were analysed using R version 4.3.2. Data were summarised using appropriate descriptive measures. Group comparisons were performed for key variables of interest. Given the exploratory nature of the study and limitations in available individual-level data, multivariable analysis was not performed. Findings should therefore be interpreted as associations rather than causal relationships.
Results
A total of 3759 male patients with alcohol-related liver disease were included in the study. Of these, 2932 (78.0%) reported alcohol use within the past 60 d, while 827 (22.0%) remained abstinent for more than 60 d. The mean age of participants was 43.8±19.4 y.
Alcohol use patterns
Most participants, 2932 (78.0%), reported alcohol use for more than 5 y. A higher proportion of individuals with recent alcohol use reported longer duration, including more than 15 y, compared to those who were abstinent. Alcohol consumption was frequent across both groups, with 2905 (77.3%) participants reporting alcohol use 3 or more times per week.
For quantity, participants were categorised into low (<180 mL), moderate (180–300 mL), and high (>300 mL) intake per drinking day. Most participants were in the moderate consumption group. A higher proportion of abstinent individuals reported prior high-quantity alcohol use, whereas those with recent alcohol use were more commonly represented in lower quantity but frequent consumption patterns.
Quit attempts
Overall, 2158 (57.4%) participants reported at least one prior attempt to quit alcohol use. Among those abstinent, a higher proportion reported multiple prior quit attempts compared to those with recent alcohol use. In contrast, 1246 (42.6%) participants reported no prior quit attempts, with similar proportions across both groups.
Severity of dependence
Patients with recent alcohol use had higher levels of dependence compared to those who were abstinent, as indicated by SDS scores (median and interquartile range among currently drinking patients: 9; 7.5-10.5) and (median and interquartile range among currently abstinent: 7; 5.4-8.8); (P<0.001; Fig. 1) Median dependence scores were higher in the recent use group, indicating greater psychological dependence among individuals who continued to consume alcohol.
Motivation to change
A statistically significant difference in the distribution of motivational stages was observed between cases and controls (P<0.001). The control group had a relatively higher proportion of patients in the precontemplation stage. The proportion of patients in the action stage was comparable between groups, with 55.3% of patients currently drinking and 54.3% of those abstinent reporting active readiness to change their drinking behaviour ( Fig. 2). This suggests that stage-of-change categorisation alone may not reliably predict abstinence in patients with alcohol related liver disease.
Perception of alcohol-related harm
Across all perception-related items, cases demonstrated significantly greater awareness of the harmful effects of alcohol, its addictive potential, and the necessity for professional help to quit. A higher percentage of cases acknowledged the importance of quitting alcohol following a liver disease diagnosis and were aware of available treatment options. These differences were statistically significant across all items ( Table).
| Perception item (Question) | Continuing to drink N=2932 (78%); n (%) | Abstinent N=827 (22%); n (%) |
|---|---|---|
| Do you consider alcohol use harmful? | 2636 (89.9) | 527 (63.7) |
| Are you aware of health harms of alcohol? | 2243 (76.5) | 483 (58.4) |
| Is alcohol addictive in nature? | 2322 (79.2) | 461 (55.7) |
| Can alcohol cause any major illness? | 2208 (75.3) | 435 (52.6) |
| Important to quit after liver disease diagnosis? | 2258 (77.0) | 465 (56.3) |
| Can people quit by willpower alone? (Yes = allow quitting) | 2146 (73.2) | 428 (51.8) |
| Is it important to see a doctor to quit? | 2120 (72.3) | 401 (48.5) |
| Aware of medicine/counselling/treatment availability? | 2372 (80.9) | 500 (60.5) |
P<0.001 was considered as significant
These findings reveal a paradox wherein current drinkers exhibit both greater awareness and higher motivational readiness to quit, yet continue alcohol use. This suggests that dependence severity, rather than knowledge or intent, is the principal barrier to cessation.
Model for end-stage liver disease (MELD) scores
Patients who were abstinent had more severe liver disease at presentation compared to those who continued to consume alcohol. The mean Model for End-Stage Liver Disease (MELD) score among abstinent patients was 21.7±12.6, compared to 20.0±18.0 among those who continued drinking (P<0.001).
Discussion
In this study on patients with alcohol-related liver disease, individuals who continued drinking alcohol demonstrated greater dependence severity and longer history of alcohol use, while motivation to change was high in both groups. Patients with ongoing alcohol use also reported greater awareness of alcohol-related harms. These findings suggest that knowledge and motivation alone may not translate into abstinence in the presence of significant dependence, highlighting the complex behavioural and biological factors that sustain alcohol use.
The finding that individuals who continued alcohol use reported higher awareness and motivation appears paradoxical. Self-reported measures of awareness and motivation may be influenced by reporting bias or social desirability, particularly in clinical settings, and repeated healthcare encounters among ongoing drinkers may increase exposure to counselling and health information. Previous studies have similarly noted that patients may acknowledge alcohol-related risks yet fail to achieve abstinence.10,11 Cognitive dissonance may also contribute, whereby individuals reconcile ongoing behaviour by endorsing intentions to change. Conversely, abstinent individuals may represent a different pathway to behaviour change driven by external pressures such as worsening illness or medical and family advice. Together, these findings suggest that awareness and motivation alone may be insufficient to translate into sustained behavioural change in the presence of dependence.
Patients who were abstinent had more severe liver disease at presentation, suggesting that disease severity may act as a driver of behaviour change. This supports a crisis-driven model of abstinence, where individuals are more likely to stop alcohol use in the context of advanced illness. However, survival bias may influence this observation, as individuals with severe disease who continue to drink may be underrepresented.10,11
In terms of motivational readiness, most of the current users were in the ‘action’ stage whereas higher proportion of those currently abstinent were in the precontemplation stage. This indicates that motivation alone is insufficient for sustained behaviour change, especially when powerful biological and psychological mechanisms are at play. It is possible that patients interpret ‘action’ as intention rather than sustained behavioural change. Misclassification of motivational stages may occur, particularly among individuals with severe dependence, where insight and behavioural control are impaired. These findings raise questions regarding the applicability of stage-based models in patients with alcohol-related liver disease and suggest the need for cautious interpretation of motivation measures.
Mellinger et al11 noted that even severe illness does not consistently translate into sustained abstinence. In contrast, many participants in the present study reported recognising the need for external support to maintain abstinence. This difference may reflect contextual and methodological factors. Cultural differences in healthcare engagement may influence how patients conceptualise help-seeking; in many settings in India, patients frequently interact with family members and physicians during hospitalisation, which may reinforce the perceived importance of support. Second, our study assessed self-reported perceived need for help, whereas previous studies have largely focused on actual utilisation of treatment services, which may remain low despite recognition of need. Finally, patients treated in a tertiary hepatology centre may represent a subgroup with greater illness severity and more frequent healthcare contact, which could increase both awareness of harm and perceived need for structured support. Together, these findings suggest that recognising the need for help does not necessarily translate into sustained engagement with addiction treatment.
In our study, while duration of alcohol use was more among individuals who continued to drink, conversely, those abstinent had more quit attempts. This suggests that sustained abstinence may emerge after several cycles of relapse and renewed efforts to quit. In contrast, a substantial proportion of individuals who continued drinking had never attempted to quit, suggesting lower readiness for behavioural change. This pattern is consistent with the relapsing course of alcohol use disorder, where repeated quit attempts are often part of eventual abstinence. With respect to quantity of alcohol consumption, a higher proportion of abstinent individuals reported prior high-quantity alcohol use. Several explanations may account for this. First, individuals with historically higher alcohol intake may experience more severe health consequences, which can act as a strong motivator for cessation. Second, this observation may partly reflect recall telescoping, whereby past heavy drinking is remembered as more recent or intense amongst those currently abstinent. Third, survivor bias: individuals with extremely high and persistent consumption may be underrepresented if they have already experienced severe morbidity or mortality before reaching treatment settings.
In the present study, individuals who continued drinking had greater dependence severity, even when awareness of harm and motivation to quit were present. This suggests that neurobiological adaptations associated with chronic alcohol use may undermine behavioural change. Alcohol use disorder is a chronic, relapsing condition involving dysregulation across brain reward, stress and executive circuits. Repeated alcohol exposure alters dopaminergic reward pathways in the basal ganglia, strengthens stress-related signalling and impairs inhibitory control. These neuroadaptations contribute to craving, compulsive alcohol seeking and diminished control.5
This study has several strengths, including a large sample size and the use of structured clinical assessments within a tertiary care setting. However, limitations should be acknowledged. The cross-sectional design precludes conclusions regarding causality or temporal relationships. Alcohol use disorder was diagnosed according to the DSM-5 criteria7 as recorded in the patient’s clinical file, no other structured instrument was used. Alcohol use status was based on self-report and was not uniformly validated using biochemical markers, which may result in misclassification. The 60-d abstinence cut-off may not capture intermittent relapse. Information on treatment received was not available and may confound both motivation and abstinence. The harm perception questionnaire was not formally validated. The study sample included only male patients from a single centre, limiting generalisability.
In conclusion, continued alcohol use among patients with alcohol related liver disease cannot be explained solely by poor insight or lack of motivation. Our findings suggest that dependence severity and underlying neurobiological mechanisms represent key barriers to sustained abstinence, even among individuals who recognise alcohol-related harm. These findings highlight the need for routine screening and structured assessment of alcohol dependence within hepatology services, along with strengthened referral pathways to addiction treatment.
Author contributions
MV: Conceived and designed the study, supervised data collection, guided the analytical framework, data analysis, interpretation; AB: Coordinated the study, data analysis, interpretation, manuscript writing; GD: clinical data compilation, data analysis, manuscript writing; JTP: Data collection, data management preliminary organisation of study variables; SSM: Provided hepatology expertise, clinical interpretation of findings, manuscript writing; SKS: Supervision, institutional oversight, manuscript writing. All authors have read and approved the final printed version of the manuscript.
Financial support and sponsorship
None.
Conflicts of Interest
None.
Use of Artificial Intelligence (AI)-Assisted Technology for manuscript preparation
The authors confirm that there was use of AI-assisted technology (ChatGPT web app) for language editing and improvement of grammar and clarity, which was reviewed by the authors. No AI tools were used for data analysis, data interpretation, figure generation of this study.
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