Module 8: Lifestyle and living with HCV - section 1

In this document:

Alcohol and other drugs

Activity: Exercise in pairs with large group discussion
Section Time: Approximately 20 minutes
Materials required: Handout

This activity enables people to evaluate the impact of alcohol and other drugs on the well-being of people with HCV and their decisions about whether they should aim to moderate or stop using one or more substances.

Show Slide 8.2 (Group work) and distribute Handout 8.1 – Impact of alcohol and other drugs when living with HCV:

To facilitate the discussion:

  • Allow about 10 minutes for the activity
  • Encourage people to detail their reasons, questions and comments as fully as possible
  • Take brief feedback in a large group
  • Use Slides 8.3 (Impact of alcohol on hepatitis C), 8.4 (Alcohol, hepatitis C and treatment) and 8.5 (Impact of other drugs on hepatitis C) to develop the discussion:

Points to emphasise

  • Overwhelmingly, when compared against other commonly-used illicit drugs, alcohol is the main threat for liver disease progression for people with chronic HCV.
  • If needed, discuss alcohol consumption with reference to other examples. As illustration, 8 grams of pure alcohol = 10ml of pure alcohol = one ‘unit’ in the UK. It is important to note that ‘standard drinks/units’ vary from country to country, as do the serving sizes that are commonly used for spirits, wine and beer.

Points to emphasise/discuss

  • Although there is no consensus on the impact of occasional, moderate drinking, this recommendation is based on the precautionary principle.
  • To what extent do PWID with alcohol problems have access to treatment and support for their alcohol use?

Points to emphasise/discuss

  • Besides their general risks, there is also evidence that each drug may have a specific, adverse effect on HCV; however, in general the evidence is not strong enough to give detailed guidance on how risk may vary with frequency, duration of use or dose.
  • The evidence is weakest for cannabis (a single study) and heroin (based on laboratory research not human studies).
  • A single study has also compared modest cannabis versus no cannabis use during HCV treatment and found improved retention and outcomes among cannabis users.
  • It may be relevant to interpret the morphine studies in the context of our extensive experience with another opioid – methadone – and guidance that this is not contra-indicated during HCV treatment.
  • People may want to consider ‘the precautionary principle’ and should understand that an absence of evidence cannot be interpreted as absence of impact.
  • In practice, people will make trade-offs between the risks and rewards of their preferred drug(s) and their quality of life. In some cases, they will judge that the cost of stopping/reducing (e.g. reductions in enjoyment/drug withdrawal) will exceed the benefits from possible reductions to risk and benefits to health.
Supporting content:

Overall, the conclusions concerning alcohol are generally more robust than those for other drugs, but the science regarding drugs other than alcohol is far from definitive. For this reason, the main references that have been used in this section are detailed below.


Alcohol study 1 - Ghany MG, Strader DB, Thomas DL, Seeff LB, American Association for the Study of Liver Diseases. Diagnosis, management, and treatment of hepatitis C: an update. Hepatology 2009 Apr;49(4) :1335-74.

“Controversy exists…about the level of alcohol intake that is clearly harmful to the HCV-infected person. It is widely believed that the daily consumption of more than 50 grams of alcohol has a high likelihood of worsening the fibrosis, but there are reports of levels of alcohol intake of less than that amount having a deleterious effect on the liver disease. Clearly, for heavy alcohol users, efforts should be undertaken to treat the alcohol abuse and dependence before starting treatment, but treatment is not contraindicated for persons who have an occasional drink of alcohol or who have a past history of alcoholism. Although no consensus opinion exists, it seems reasonable to recommend either the complete suspension of alcohol intake while on treatment or restricting its use to an occasional drink during the course of the treatment.”

Alcohol study 2 - Hutchinson SJ, Bird SM, Goldberg DJ. Influence of alcohol on the progression of hepatitis C virus infection: a meta-analysis. Clin Gastroenterol Hepatol. 2005 Nov;3(11) :1150-9.

The evidence overwhelmingly shows a worsened outcome for those with chronic HCV and concurrent alcohol use. Studies varied widely in their definition of significant alcohol intake, and so the true threshold above which alcohol accelerates HCV disease progression remains uncertain. Alcohol consumption should be minimized as much as possible in those who have chronic HCV until a safe threshold is more definitively determined.

Alcohol study 3 - Siu L, Foont J, Wands JR. Hepatitis C virus and alcohol. Semin Liver Dis. 2009 May;29(2) :188-99. Epub 2009 Apr 22.

“There is a relationship between increased alcohol intake and decreased response to interferon (IFN) therapy, which may be reversed by abstinence. Clinical studies are needed to optimize treatment responses in alcoholic patients with chronic HCV infection.”


Highleyman L (2010) How Does Smoking Affect Hepatitis C Progression?

Several studies cited in this review highlight ways that smoking may worsen HCV progression.


Ishida J et al (2008) Influence of Cannabis Use on Severity of Hepatitis C Disease. Clinical Gastroenterology and Hepatology. 6 (1) :69-75.

Daily cannabis use was found to be strongly associated with moderate to severe fibrosis. The researchers recommend that HCV-infected individuals should be counselled to reduce or abstain from cannabis use.

Sylvestre DLClements BJMalibu Y (2006) Cannabis use improves retention and virological outcomes in patients treated for hepatitis C. Eur J Gastroenterol Hepatol.  18 (10) :1057-63.

In a sample of 71 ‘recovering substance users’, cannabis users were significantly more likely than non-users to complete treatment and achieve a SVR.


Li Y et al (2003) Morphine enhances hepatitis C virus (HCV) replicon expression. The American Journal of Pathology;163(3) :1167-75.

Morphine (the immediate breakdown product of heroin) use may have adverse effects on HCV. “Our in vitro data indicate that morphine may play an important role as a positive regulator of HCV replication in human hepatic cells and may compromise IFN-alpha therapy”

Ilić G et al (2005) Chronic intravenous heroin abuse: impact on the liver. Medicine and Biology. 12 (3) :150 – 153.

“Direct hepatoxic effects of heroin are vesicular changes in hepatocytes, fat changes are the result of chronic influence of alcohol, whereas the rest of the morphological lesions to the liver are the result of the interaction of heroin, viral infection and alcohol.”


Various animal studies have shown experimentally that cocaine/amphetamines can cause immune suppression. These suggest that stimulant use may increase HCV progression. Furthermore, the metabolite cocaethylene (produced when cocaine is used with alcohol) is associated with liver damage and increased risk of death.

Colombo LL et al (1999) Effect of short term cocaine administration on the immune system of young and old C57BL/6 female mice. Immunopharmacology and immunotoxicology. 21 (4) :755-769.

Freire-Garabal M et al (1991) Effects of amphetamine on T-cell immune response in mice. Life Sciences.  49 (16) : 107-112.

Andrews P (1997) Cocaethylene toxicity. Journal of  Addictive Diseases. 16(3) :75-84. 

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