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. Author manuscript; available in PMC: 2024 Jan 1.
Published in final edited form as: J Psychopathol Clin Sci. 2022 Dec 8;132(1):101–109. doi: 10.1037/abn0000792

Pain as a Causal Motivator of Alcohol Consumption: Associations with Gender and Race

Joseph W Ditre 1, Lisa R LaRowe 2, Jessica M Powers 1, Kyle M White 1, Michael B Paladino 1, Michael J Zvolensky 3,4,5, Stephen Glatt 6, Stephen A Maisto 1
PMCID: PMC9870930  NIHMSID: NIHMS1851620  PMID: 36480413

Abstract

Despite accumulating evidence indicating reciprocal interrelations between pain and alcohol consumption, no prior work has examined pain as a proximal antecedent of drinking. The goal of the current study was to test effects of experimental pain induction on ad lib alcohol consumption among moderate-to-heavy drinkers without chronic pain (N = 237; 42% female; 37% Black; M = 3.26 daily drinks). Participants were randomized to either pain-induction (capsaicin + thermal heat paradigm) or no-pain-control conditions. Experimental pain induction lasted for 15 minutes, during which ad lib alcohol consumption was assessed using an established taste test paradigm. As hypothesized, results indicated that participants randomized to the pain-induction condition poured and consumed more alcohol and reached a higher peak blood alcohol concentration than those randomized to the no-pain condition (ps < .05; ηp2 range = .018 - .021). Exploratory analyses revealed the effects of pain on alcohol consumption to be most pronounced among participants who self-identified as male or Black (relative to female or White, respectively). These findings indicate that the experience of pain serves as a causal, situational motivator for alcohol consumption, and suggest that current drinkers may be susceptible to escalating their consumption of alcohol in the context of pain. Future research is needed to explicate observed differences in the effects of pain on drinking as a function of gender and race, and to extend this work to individuals with chronic pain and varying levels of alcohol use. Collectively, these findings may help inform development of integrated treatments to address co-occurring pain and alcohol use.

Keywords: alcohol, pain, gender, race

General Scientific Summary

Pain and alcohol use are posited to interact in the manner of a positive feedback loop, and emerging evidence suggests that pain may be a potent motivator of alcohol consumption. Healthy drinkers without chronic pain who were randomized to experimental pain induction (vs. no pain control), poured and consumed more alcohol and reached a higher peak blood alcohol concentration. Subgroup analyses revealed these effects were most pronounced among participants who self-identified as male and Black, respectively. These findings are the first to demonstrate that the experience of pain can serve as a causal, proximal antecedent of alcohol consumption.

Introduction

Alcohol use is the third leading preventable cause of death in the United States (Esser et al., 2020), accounting for more than $249 billion each year in healthcare, lost productivity, and criminal justice expenses (Sacks et al., 2015). More than half of all U.S. adults report drinking alcohol in the past month (Substance Abuse and Mental Health Services Administration, 2020). Adults who live with clinically significant pain are up to 60% more likely to endorse heavy drinking and/or meet diagnostic criteria for alcohol use disorder (AUD; Demyttenaere et al., 2007; Strine & Hootman, 2007; Von Korff et al., 2005).

Pain and alcohol use are posited to interrelate in reciprocal fashion, engendering greater pain and increased drinking over time (Ditre et al., 2019; Zale et al., 2015). Central to this perspective is the notion that pain can serve as a causal motivator of alcohol use (Zale et al., 2015). Individuals with chronic pain endorse pain-related drinking motives and use of alcohol to cope with pain (Boissoneault et al., 2019; Brennan et al., 2011; LaRowe et al., 2021; Riley III & King, 2009), which is consistent with evidence of alcohol analgesia derived from both human and rodent experimental models of acute/chronic pain (Neddenriep et al., 2019; Thompson et al., 2017). Although there is also initial evidence that laboratory-induced pain can increase self-reported urge and intention to drink alcohol (Moskal et al., 2018), we are not aware of any prior work that evaluated a causal relation between the experience of pain and alcohol consumption.

The aim of the current study was to test the effects of experimental pain induction on ad lib alcohol consumption among a sample of moderate-to-heavy drinkers with no chronic pain. It was hypothesized that capsaicin + thermal heat pain induction (vs. no pain induction) would elicit greater volume of alcohol poured, greater volume of alcohol consumed, and higher peak blood alcohol concentration (BAC). Given past research showing that men tend to hold stronger expectations for greater alcohol-induced analgesia than women (LaRowe et al., 2021), and that Black/African American participants tend to demonstrate greater reactivity to experimental pain induction than non-Hispanic White participants (Campbell & Edwards, 2012; Campbell et al., 2005), exploratory analyses were also conducted to examine differences in the effect of pain on alcohol consumption as a function of gender and race.

Method

Participant Recruitment

Participants were recruited from the local community via newspaper and online advertisements for a two-session experimental study examining bidirectional pain-alcohol effects. One session tested the effects of pain on alcohol consumption and the other session tested the effects of drinking on pain reactivity (session order was counterbalanced so as to minimize potential impact of ordering effects). The current analyses pertain to the session testing the effects of pain on alcohol consumption. Prospective participants were screened by telephone for the following inclusion criteria: (1) 21 – 65 years of age; and (2) classification as a moderate or heavy drinker as assessed by the Quantity-Frequency-Variability measure (QFV; described below; Cahalan et al., 1969). Exclusion criteria included: (1) current acute or chronic pain; (2) current use of prescription pain medications; (3) current pregnancy; (4) medical conditions/medications contraindicated for alcohol use; (5) past 3-year treatment for alcohol use; (6) recent (past 3-month) treatment for psychiatric/substance-related problems and/or current acute psychiatric distress; or (7) allergy to chili peppers. Eligible respondents were scheduled for a study visit and were asked to refrain from using alcohol, cannabis, over the counter pain medication, and non-prescription drugs for at least 24 hours prior to their appointment.

Procedure

Study procedures were approved by the University Institutional Review Board. All sessions were conducted between 11:00 am and 6:30 pm. All participants were instructed to eat a light meal four hours prior to their session and to avoid use of nicotine/tobacco products within one hour of their session. After providing informed consent, participants underwent P80 assessment (i.e., temperature that elicits a numerical pain rating of 8 out of 10) using a test-of-limits protocol with a maximum allowable stimulus intensity of 44°C (Medoc Ltd., Ramat Yishai, Israel; Kilminster, 1974), completed baseline questionnaires, and were then randomly assigned to either pain-induction or no-pain-induction conditions. Total compensation ranged from $53 to $132 (commensurate with number of hours spent participating in the study, including time needed for BAC to reach .04% or lower).

Experimental Pain Induction

Pain was induced using an established capsaicin + thermal heat paradigm (Dirks & Petersen, 2003; Moskal et al., 2018; Petersen & Rowbotham, 1999). Capsaicin acts on transient receptor potential vanilloid (TRPV1) receptors on Aδ and C fiber nociceptors, inducing a burning sensation that resembles neuropathic and inflammatory clinical pain (Arendt-Nielsen & Andersen, 2005; Lötsch et al., 2015). Capsaicin-induced sensitization permits induction of prolonged pain with lower intensity contact-heat, thus reducing the risk of irritation (Schmelz, 2009). Pain models combining capsaicin and heat are regularly used in healthy participants to mimic features of pathological pain such as hyperalgesia and allodynia (e.g., Cavallone et al., 2013; Dirks et al., 2003).

Among participants randomized to pain-induction, capsaicin was administered topically to the non-dominant volar forearm using 1.5 × 1.5 cm bandages (to avoid interference with use of the dominant hand during the alcohol consumption paradigm). A 15-minute waiting period followed application of the capsaicin solution, as it takes approximately 15–20 minutes for capsaicin pain to peak (Geber et al., 2007; Petersen et al., 2001). A Medoc Q-Sense CPM System (Medoc Ltd., Ramat Yishai, Israel) thermode was then placed over the capsaicin application and temperature was increased to an individually predetermined P80 level at a rate of 1°C per second. Contact-heat pain was delivered continuously for 15 minutes. For participants randomized to the no-pain-induction condition, water was used in place of capsaicin, the same 15-minute waiting period followed application of the water, and thermode destination temperatures were set to 32°C.

Alcohol Consumption Paradigm

Ad lib alcohol consumption was assessed using an established taste test paradigm (Marlatt et al., 1973) that has demonstrated excellent sensitivity to experimental manipulations (Bidwell et al., 2013). Each participant was presented with the same beverage choices in three different pitchers, two containing 710 ml of U.S. domestic beer (two different brands were used, each 5% alcohol by volume) and one containing 710 ml of seltzer water (included to control for potential differences in thirst and effects of thirst on beer consumption; Sharbanee et al., 2014). Three empty glasses corresponding to each pitcher were also provided. Participants were informed that they had 15 minutes to rate each beverage on four characteristics (i.e., pleasantness, taste, flavor, and carbonation) and to drink as much of each beverage as needed to be precise in their ratings.

Alcohol Outcome Measures

Alcohol Poured and Consumed.

Amount of alcohol poured was assessed by measuring the volume of beer remaining in the two pitchers at conclusion of the alcohol consumption paradigm (subtracted from the starting volume of 1420 ml). Amount of alcohol consumed was assessed by measuring volume of beer remaining in pitchers and glasses at conclusion of the alcohol consumption paradigm (subtracted from the starting volume of 1420 ml). It has been suggested that volume of alcohol poured vs. consumed reflect distinct processes, with alcohol poured serving as a proxy for behavioral intention and alcohol consumed serving as a measure of drinking behavior (Albery & Spada, 2021; Frings et al., 2016).

Blood Alcohol Concentration (BAC).

BAC was assessed using an Alco-Sensor FST (Intoximeters, Inc., St. Louis, MO). BAC readings were taken at 15-minute intervals following alcohol consumption until two consecutive readings were at or below .04%. The highest reading during this period was recorded as the peak BAC.

Other Measures

Pain Manipulation Check.

During the pain induction manipulation, participants provided verbal pain intensity rating at 0, 7.5, and 15 minutes using a numerical rating scale ranging from 0 (no pain) to 10 (pain as bad as you can imagine).

Seltzer Poured/Consumed.

The amount of seltzer poured/consumed was determined using procedures identical to those described earlier for alcohol poured/consumed.

Beverage Pleasantness.

Participants were asked to rate the pleasantness of each beverage using a 10-point Likert scale ranging from 0 (unpleasant) to 10 (pleasant). Average beer pleasantness rating was calculated for each participant and this value was selected as an a priori covariate to account for preferences that may influence consumption (Jones et al., 2016).

Heaviness of Drinking.

The Quantity-Frequency Variability Index (QFV; Cahalan et al., 1969) was used to assess drinking pattern over the previous three months (i.e., types of alcoholic beverages consumed, frequency of consumption, and how much typically consumed per occasion). The QFV yields categorical classifications of drinking behavior (e.g., light, moderate, heavy).

Average Daily Drinks.

The Modified Daily Drinking Questionnaire (DDQ-M; Dimeff, 1999) assessed number of standard alcoholic drinks typically consumed on each day of the week over the past 90 days. Consistent with previous research (e.g., Naranjo et al., 1995), total weekly drinks were divided by seven to yield an average daily drinks value.

Body Mass Index (BMI).

Participant weight was measured using an Etekcity digital scale (Model: EB9380H, Anaheim, USA), and height was measured in inches. BMI was calculated by dividing weight (pounds) by height (inches) squared and multiplying by a conversion factor of 703 (Company, 1959).

Sociodemographic Variables.

Participants reported on a variety of sociodemographic characteristics, including age, gender, ethnicity, race, education, employment status, and annual income. Gender was assessed using a binary item (male/female). We have used the term “gender” throughout because this reflects the phrasing used in the baseline survey. For subgroup analyses, race was limited to those who identified as White or Black given the low number of participants who endorsed other racial categories (n = 7).

Data Analysis

Analyses were conducted using IBM SPSS statistics for Windows, V27 (IBM Corp., Armonk, NY USA.). Distributions for all variables were assessed for normality, and skewness/kurtosis values fell within acceptable ranges (George & Mallery, 2003). Data quality checks resulted in 12 participants being excluded due to equipment malfunction or lack of compliance with study procedures. Pain intensity manipulation checks were conducted using Analysis of Variance (ANOVA). Effects of pain on alcohol outcomes were tested using ANOVA (unadjusted) and ANCOVA (controlling for gender, race, BMI, QFV scores, and alcohol pleasantness ratings). ANCOVA (controlling for BMI, QFV scores, and alcohol pleasantness ratings) was also employed in interaction analyses to explore the role of gender and race in the effects of pain on alcohol consumption. Subgroup means were then compared in a manner commensurate with recent NIH guidelines (U.S. Department of Health and Human Services (HHS), 2022) and increasing emphasis on the importance of characterizing main effects as a function of gender and race (Liu et al., 2020; Wallach et al., 2016). This study’s design was preregistered; see https://clinicaltrials.gov/ct2/show/NCT03311594. Materials and analysis code for this study are available by emailing the corresponding author.

Results

Participant Characteristics

The final sample consisted of 237 participants (60.3% White, 37% Black, 2.9% Other race) who passed data-quality checks and completed the pain induction manipulation. The majority of the sample was male, including 58% (n = 83) of White participants, 62.1% (n = 54) of Black participants, and 14.3% (n = 1) of participants who identified with another race. Mean age for the sample was approximately 35 years, over 60% were classified as heavy alcohol users, and participants reported consuming an average of more than 3 drinks each day. No differences in sociodemographic or drinking characteristics as a function of experimental condition assignment were observed (see Table 1). Correlations among drinking outcomes (i.e., alcohol poured, alcohol consumed, and BAC) ranged from r = .812-.933 (ps < .01).

Table 1.

Sociodemographic and Alcohol Use Characteristics

Total Sample Condition Assignment
Pain Induction No Pain Induction
n (%) n (%) n (%)
Gender
 Male 138 (58.2%) 67 (57.3%) 71 (59.2%)
 Female 99 (41.8%) 50 (42.7%) 49 (40.8%)
Ethnicity
 Non-Hispanic 218 (92.0%) 106 (90.6%) 112 (93.3%)
Race
 White 143 (60.3%) 74 (63.2%) 69 (57.5%)
 Black 87 (36.7%) 40 (34.2%) 47 (39.2%)
 Other 7 (3.0%) 3 (2.6%) 4 (3.3%)
Marital Status
 Single 173 (73.0%) 90 (76.9%) 83 (69.2%)
 Married 30 (12.7%) 15 (12.8%) 15 (12.5%)
 Separated/Divorced/Widowed 34 (14.3%) 12 (10.3%) 22 (18.3%)
Education
 Did Not Graduate High School 13 (5.5%) 4 (3.4%) 9 (7.5%)
 High School Graduate 77 (32.5%) 39 (33.3%) 38 (31.7%)
 Some College 57 (24.1%) 29 (24.8%) 28 (23.2%)
 Technical/Associates Degree 25 (10.5%) 10 (8.5%) 15 (12.5%)
 4-year College Degree 43 (18.1%) 20 (17.1%) 23 (19.2%)
 Professional Degree (e.g., MD, PhD) 7 (3%) 5 (4.3%) 2 (4.2%)
Annual Household Income
 Less Than $10,000 62 (26.2%) 28 (23.9%) 34 (28.3%)
 $10,000 – $19,999 44 (18.6%) 23 (19.7%) 21 (17.5%)
 $20,000 – $29,999 41 (17.3%) 22 (18.8%) 19 (15.8%)
 $30,000 – $39,999 24 (10.1%) 16 13.7%) 8 (6.7%)
 Greater Than $40,000 66 (27.8%) 28 (23.9%) 38 (31.7%)
QFV Classification a
 Moderate 85 (35.9%) 45 (38.5%) 40 (33.3%)
 Heavy 152 (64.1%) 72 (61.5%) 80 (66.7%)
M (SD) M (SD) M (SD)
Age 34.70 (12.80) 34.11 (12.53) 35.27 (13.09)
BMI b 28.91 (7.38) 28.80 (7.46) 29.02 (7.33)
Average Daily Drinks 3.26 (2.92) 3.21 (3.13) 3.31 (2.72)
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Notes.

a

Quantity-Frequency-Variability Index,

b

Body Mass Index. No variables differed as a function of pain induction condition assignment (ps > .05)

Manipulation Check

As expected, participants randomized to the pain-induction condition reported greater pain intensity at all three time points, relative to those in the no-pain condition [0 Minutes: M = 6.20 (SD = 2.24) vs. 0.12 (0.45); 7.5 Minutes: 5.13 (2.58) vs. 0.24 (0.68); 15 Minutes: 5.31 (2.84) vs. 0.42 (1.09); all ps < .001; range ηp2 = .57-.78].

Effects of Pain on Alcohol Poured/Consumed and BAC

ANCOVA indicated a main effect of pain on alcohol poured, with participants randomized to experimental pain induction pouring a greater volume (ml) of beer (M = 573.93, SE = 28.91), relative to those in the no-pain condition (M = 477.89, SE = 29.06; (F[1, 216] = 5.86, p = .016, ηp2 = .03, 95% CI =17.45:171.85). We also observed a main effect of pain induction on total volume of alcohol consumed (F[1, 227] = 4.90, p = .028, ηp2 = .02, 95% CI = 8.27:142.91), with participants in the pain condition consuming approximately 447 ml (SE = 25.04) compared to approximately 370 ml (SE = 25.22) among those in the no-pain condition (see Figure 1). Finally, we observed a main effect of pain on BAC (F[1, 227] = 4.90, p = .028, ηp2 = .02, 95% CI = 0.001:0.010), with those randomized to the pain condition reaching a higher peak BAC (M = .027, SE = .002) compared to those in the no-pain condition (M = .021, SE = .002; see Figure 2). This pattern of results was similar in unadjusted ANOVA models (see Table 2).

Figure 1.

Figure 1

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Volume of Alcohol Poured and Consumed as a Function of Pain Induction

Note: Error bars indicate standard error; Models covaried for gender, race, BMI, QFV, and alcohol pleasantness ratings;* p < .05.

Figure 2.

Figure 2

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Peak Blood Alcohol Concentration (BAC) as a Function of Pain Manipulation

Note: Error bars denote standard error; models covaried for gender, BMI, QFV, and alcohol pleasantness ratings; * p < .05.

Table 2.

Unadjusted Effects of Pain on Alcohol Outcomes

df F p ηp2
Pain vs. No Pain Total Alcohol Poured (mL)
225 4.48 .035* .020
Pain vs. No Pain Total Alcohol Consumed (mL)
236 4.30 .039* .018
Pain vs. No Pain Peak BAC a
236 4.97 .027* .021
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Notes.

a

Blood Alcohol Concentration (BAC);

*

p < .05.

Effect of Pain on Seltzer Poured/Consumed

As expected, ANCOVA indicated no effect of pain induction on amount of seltzer poured F[1, 216] = 0.01, p = .964, 95% CI = −36.12:37.83 (pain M = 207.51, SE = 13.67; no pain M = 206.66, SE = 13.75) or consumed F[1, 227] = 0.13, p = .724, 95% CI = −40.12:27.87 (pain M = 131.93, SE = 12.46; no pain M = 138.03, SE = 12.55).

Role of Gender and Race in Effects of Pain on Drinking

Exploratory ANCOVA revealed a significant pain induction × gender interaction for amount of alcohol poured (F[1, 217] = 3.96, p = .048, observed power = .508); however, there was no significant interaction for amount of alcohol consumed (p = .159, observed power = .291) or peak BAC (p = .422, observed power = .126). Subgroup analyses revealed a main effect of pain induction for amount of alcohol poured/consumed and peak BAC only among participants who self-identified as male (ps < .034; see Table 3).

Table 3.

Exploratory Analyses of the Effects of Pain on Alcohol Outcomes among Separate Subsamples of Male versus Female Participants

Male (n = 138) Female (n = 99)
Total Alcohol Poured (mL)
df F p ηp2 95% CI a df F p ηp2 95% CI a
Pain vs. No Pain 127 8.06 .005 ** .061 48.10:269.67 88 0.00 .962 .000 −103.49:108.63
Mean SE 95% CI Mean SE 95% CI
Pain 725.29 41.56 643.03:807.55 Pain 404.55 37.59 329.79:479.30
No Pain 566.41 40.73 485.79:647.03 No Pain 401.98 38.74 324.95:479.02
Total Alcohol Consumed (mL)
df F p ηp2 95% CI a df F p ηp2 95% CI a
Pain vs. No Pain 133 5.36 .022 * .040 16.73:213.34 93 0.10 .756 .001 −77.52:106.43
Mean SE 95% CI Mean SE 95% CI
Pain 574.06 36.81 501.23:646.88 Pain 302.13 32.30 237.95:366.30
No Pain 459.02 35.92 387.96:530.09 No Pain 287.67 33.48 221.14:354.20
Peak BAC b
df F p ηp2 95% CI a df F p ηp2 95% CI a
Pain vs. No Pain 133 4.49 .036 * .034 −0.013:−0.0005 93 0.51 .475 .006 −0.005:0.010
Mean SE 95% CI Mean SE 95% CI
Pain .032 .002 0.03:0.04 Pain .020 .003 0.02:0.03
No Pain .025 .002 0.02:0.03 No Pain .017 .003 0.01:0.02
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Notes:

a

95% confidence interval for the mean difference;

b

Blood Alcohol Concentration (BAC); Models covaried for BMI, QFV, and alcohol pleasantness ratings;

*

p < .05;

**

p < .01

A separate exploratory ANCOVA revealed no significant pain induction × race interactions (ps = .250 - .779, observed power = .059-.209); however, subgroup analyses revealed a main effect of pain induction for volume of alcohol consumed only among participants who self-identified as Black (F[1, 83] = 4.57, p = .036). See Table 4 for subgroup mean comparisons.

Table 4.

Exploratory Analyses of the Effects of Pain on Alcohol Outcomes among Separate Subsamples of Male versus Female Participants

Male (n = 138) Female (n = 99)
Total Alcohol Poured (mL)
df F p ηp2 95% CI a df F p ηp2 95% CI a
Pain vs. No Pain 128 2.30 .132 .018 −27.14:204.59 81 2.84 .096 .036 −20.53:247.71
Mean SE 95% CI Mean SE 95% CI
Pain 583.53 41.15 502.08:664.98 Pain 606.11 48.98 508.56:703.66
No Pain 494.81 41.96 411.76:577.86 No Pain 492.52 51.84 389.30:595.75
Total Alcohol Consumed (mL)
df F p ηp2 95% CI df F p ηp2 95% CI
Pain vs. No Pain 137 0.80 .374 .006 −53.02:140.11 83 4.57 .036 * .055 9.29:260.06
Mean SE 95% CI Mean SE 95% CI
Pain 442.50 34.15 374.95:510.05 Pain 489.95 45.16 399.72:579.51
No Pain 398.95 34.91 329.91:468.00 No Pain 354.95 48.18 259.04:450.86
Peak BAC b
df F p ηp2 95% CI df F p ηp2 95% CI
Pain vs. No Pain 137 2.67 .105 .020 −0.001:0.011 83 2.23 .139 .028 −0.002:0.016
Mean SE 95% CI Mean SE 95% CI
Pain .027 .002 0.02:0.03 Pain .028 .003 0.02:0.04
No Pain .021 .002 0.02:0.03 No Pain .021 .003 0.02:0.03
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Notes:

a

95% confidence interval for the mean difference,

b

Blood Alcohol Concentration (BAC); Models covaried for BMI, QFV, and alcohol pleasantness ratings;

*

p < .05;

**

p < .01

Discussion

The goal of this study was to conduct the first test of pain as a proximal antecedent of alcohol consumption among current moderate to heavy drinkers. Consistent with expectation, participants randomized to capsaicin + thermal heat pain induction poured and consumed a greater volume of alcohol and reached a higher post-manipulation peak BAC than participants randomized to no pain induction. Also as expected, we observed no effect of pain induction on volume of seltzer poured or consumed. This evidence builds upon initial work showing that experimental pain induction can increase self-reported urge and intention to drink alcohol (Moskal et al., 2018). Collectively, these results are consistent with accumulating evidence that the experience of pain can serve as a situational motivator of substance use in general and alcohol use in particular (Ditre et al., 2019; Edwards et al., 2020; Moskal et al., 2018; Zale et al., 2015). Alcohol has been shown to confer acute analgesic effects (Thompson et al., 2017), and current drinkers have been shown to hold expectations that alcohol can help them cope with and reduce pain (LaRowe et al., 2021). When considered in the context of an established reciprocal model of pain and substance use (Ditre et al., 2019), the current findings suggest that individuals who are motivated to use alcohol in response to pain may be at risk for engendering a vicious cycle that leads to heavier drinking and greater pain over time.

Exploratory gender subgroup analyses indicating that observed effects of pain on amount of alcohol poured/consumed and peak BAC were driven by participants who self-identified as male are consistent with evidence of heightened alcohol-induced analgesia derived from laboratory studies that included a greater proportion of male participants (Thompson et al., 2017), and recent data indicating that men with chronic pain hold stronger expectations for alcohol analgesia (LaRowe et al., 2021). Exploratory analyses also indicated that the effect of pain on volume (ml) of beer poured may be more pronounced among participants who self-identified as Black, which is broadly commensurate with evidence that Black/African American participants tend to demonstrate greater sensitivity (lower pain threshold) and lower pain tolerance than non-Hispanic White participants across a variety of quantitative sensory testing modalities (Campbell & Edwards, 2012). It is important to note that because our examination of race and gender in the effects of pain on drinking were exploratory, with observed power values below recommended levels (e.g., 0.8; Serdar, Cihan, Yucel, & Serdar, 2021), these findings warrant replication and should be interpreted with caution. Nonetheless, given evidence of racial bias in pain assessment and treatment, and known disparities regarding the management of chronic pain among Black/African American populations (Hoffman et al., 2016; Knoebel et al., 2021), additional investigation into the role of pain in patterns and trajectories of alcohol consumption among Black drinkers is warranted.

Strengths of the current study include use of established experimental pain and alcohol consumption paradigms, application of a rigorous randomized controlled trial design, and biochemical verification of alcohol consumption/intoxication. One important limitation is that these findings do not necessarily generalize to lighter drinkers, those seeking treatment for AUD, or individuals with chronic pain. For example, although experimental pain induction allows for standardization of stimulus delivery, there is a cost to external validity in that clinical pain tends to be less predictable with greater emotional significance and overall lifestyle impact (Edens & Gil, 1995; Ford, Halaki, Diong, & Ginn, 2020). Nonetheless, experimental pain induction studies are important for identifying areas for future study of clinical pain phenomena (Edens & Gil, 1995), and although we are not yet sure how these findings will extend to clinical pain, this is an important first step in a line of translational programmatic research. Future research examining the effects of pain on alcohol consumption should include individuals with chronic pain who endorse varied patterns of current/historical drinking. Future studies may also wish to examine the potential for a dose-response relationship between pain intensity and alcohol consumption. In addition, utilization of experience sampling methodologies (e.g., ecological momentary assessment) would allow for examination of real-time covariation between the experience of pain and alcohol consumption (Kuerbis et al., 2019). Finally, exploratory analyses showed differences in effects of pain induction on alcohol consumption as a function of self-reported gender and race, with effect sizes that may be characterized as small-to-medium in magnitude (Cohen, 1973). Although most of these models were not statistically-significant, these findings are presented given the stated importance of conducting/reporting analyses by gender and race (Althouse, 2016; Liu et al., 2020; HHS, 2022; Wallach et al., 2016). Nonetheless, future research is needed to replicate and extend observed effects of pain on drinking as a function of gender and race among larger, more gender- and race-balanced samples that include individuals from diverse racial and ethnic, socioeconomic, and geographic backgrounds (e.g., Latinx drinkers with pain; Mayorga et al., 2022; Paulus et al., 2018). Additional work is also needed to elucidate underlying disparities in pain and alcohol use as a function of gender and race, such as socioeconomic status, gender/cultural norms, healthcare access, and discrimination (Campbell & Edwards, 2012; Fillingim, 2017).

In summary, this is the first study to demonstrate a causal effect of pain on alcohol consumption in humans. These findings contribute to a growing literature indicating that pain can motivate drinking (Ditre et al., 2019; Moskal et al., 2018), and suggest that current drinkers, particularly those who self-identify as male or Black, may be susceptible to escalating their consumption of alcohol in the context of pain. This and future research may advance understanding of how painful experiences can contribute to the maintenance/escalation of drinking, and ultimately help inform the development of integrated treatments for individuals with co-occurring pain and alcohol use problems.

Acknowledgments

Research reported in this publication was supported by a National Institute on Alcoholism and Alcohol Abuse (NIAAA) of the National Institutes of Health (NIH) grant awarded to Joseph Ditre and Stephen Maisto (R01AA024844). This research was also supported by a National Institute on Minority Health and Health Disparities (NIMHD) of the National Institutes of Health (NIH) grant awarded to the University of Houston under Award Number U54MD015946. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This study’s design was preregistered; see https://clinicaltrials.gov/ct2/show/NCT03311594. Materials and analysis code for this study are available by emailing the corresponding author.

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