So many new patients, and they seem so young, Dr. Humberto Gonzalez kept thinking as he made his rounds at Henry Ford Health System in Metro Detroit.
It was the summer of 2020, just a few months into the COVID-19 lockdown. And Gonzalez, a transplant hepatologist, was struck by the onslaught of incoming patients who were suddenly being hospitalized, not for COVID, but with alcohol-related liver diseases.
These weren’t the typical, late-stage alcoholic cirrhosis cases either, like the 50 and 60-somethings who’d become familiar faces in the hospital over months and even years of treatment.
Instead, many of these new patients had, until now, seemed to be “healthy and active, (and) productive in the community,” Gonzalez said. “And then they just so happened to become ill real fast.”
Now they had acute alcoholic hepatitis — a serious, potentially fatal inflammation of the liver that can be brought on by even relatively short periods of heavy drinking. This was a young group, too, with an average age of just 47.
“There's people who are younger than that, probably in their thirties, which is quite young to have this type of problem,” Gonzalez said. That’s typically “when people have young kids, when they're going to work, trying to pay for their house, travel, enjoy life,” he said. “...And [now] they require treatment, they require hospital visits, they require clinic visits, they require blood work, x-rays, medical care in general. Things that can put them out from being productive in society.”
“An alarming increase”
Lots of research has already linked the pandemic to an increase in heavy drinking and a rise in alcohol-related liver disease (ARLD), with a disproportionate impact on women. Total deaths involving alcohol rose 25% in 2020, with a 22% increase in alcohol-associated liver disease deaths.
Still, when Gonzalez and his team at Henry Ford crunched the numbers in a recently published paper, even they were staggered by just how sharp the increase was: in September 2020, the number of admissions for alcohol-related hepatitis was up 66%, compared to the same period in 2016-2019. Overall, the number of ARLD admissions (as a proportion of all hospitalizations) climbed 50% in 2020.
Meanwhile, at the University of Michigan health system, Dr. Jessica Mellinger (also a transplant hepatologist) said she was seeing “similar increases in alcoholic hepatitis.” Nationally, the number of alcoholic hepatitis patients registering for the transplant waiting list soared by more than 50%, compared to pre-COVID trends. The number of deceased donor liver transplants associated with alcoholic hepatitis shot up, too.
That, the University of Michigan researchers concluded, was “evidence for an alarming increase in (alcoholic hepatitis) associated with increasing alcohol misuse during COVID-19 and highlights the need for public health interventions around excessive alcohol consumption.”
Women were already drinking more, even before the pandemic
One reason a 50% jump in hospitalizations is a big deal, is that rates of alcohol-related liver disease had already been climbing for years before COVID — especially for women and younger adults.
“It was a pretty steady rise over the past 15, 20 years, (and) mortality (was) kind of rising as well,” said Mellinger. “This cohort of younger people in their 30s and sometimes even in their 20s, showing up with cirrhosis, advanced scarred-liver disease from years of drinking, are going up.”
By 2018, young women were reporting drinking as much, and even slightly more than, their male counterparts, for the first time in decades. Experts call this the “pinking of drinking,” Mellinger said.
“Drinking is being described more in sort of women- friendly terms. You see advertisements that are very keyed towards girls hanging out with other girls, hanging out with your friends…You see it described as ‘mommy juice.’ There's this whole, ‘I'm a stressed out mom and I need my alcohol to to to cope,’ type of thing. And those types of messages are everywhere. A lot of that marketing is really trying to appeal to women, and link it to emotional needs that women have…for connection and closeness.”
Even before the pandemic, there was evidence women were drinking for different reasons than men: in short, they were using it to cope. Women “are generally more likely to drink to regulate negative affect and stress reactivity,” researchers found. Stress, anxiety, and depression are “critical parts” of what made women more likely to drink, especially if they experienced childhood trauma. “Specifically, sexual abuse, emotional neglect, and emotional abuse were associated with increased rates of AUDS (alcohol use disorders) in women compared to men,” a 2019 scientific review concluded.
Women are also more susceptible to alcohol-related health risks like liver disease and acute hepatitis, even with less alcohol consumption than men. Among “people who had cirrhosis and then abstained from alcohol, women had lower 5-year survival rates than men,” researchers found.
COVID hits, and everything closes…except the liquor store
Then, the pandemic hit. And alcohol sales experienced “the largest annual increase in over 50 years,” according to the National Institute on Alcohol Abuse and Alcoholism.
“There were some folks who drank because they became more isolated, because they became more depressed, more anxious,” Mellinger said. “I certainly saw many people, especially those who were kind of early in recovery and just kind of building their recovery base, (who) relapsed. Because suddenly, their therapist wasn't taking appointments, and their AA meetings were shut down. And all of the supports that they had were completely pulled away from them. But the liquor store stayed open. And everybody started delivering liquor. So it became easier to get it in many respects.”
Since that 2020 spike, alcohol-related liver disease admissions have fallen slightly, Gonzalez and Mellinger said, though they’re still not back to baseline. But the types of treatment options have grown in recent years, beyond traditional inpatient rehab or Alcoholics Anonymous. Now there are “apps on your phone you can use,” Melligner said, and “medications we can give to help with cravings and urges…to make it easier to stay off alcohol.”
And that’s the key, she said.
“The thing that keeps these patients alive, particularly if they have cirrhosis or more advanced liver disease, is really alcohol cessation,” Mellinger said. “...And in the past few years, we've seen a bigger push towards integrating care, getting psychiatry, psychology, social work into the clinic with the liver doctors to really give these patients high quality, evidence-based alcohol use treatment, which works.”
In 2019, the University of Michigan opened a multi-disciplinary liver disease clinic called the Michigan Alcohol Improvement Network (MAIN). Designed to be a “one stop shop” for patients with alcohol-related liver disease, it combines addiction care and liver treatment in one place. Early results show promise, too, with patients experiencing fewer trips to the emergency department and fewer hospitalizations.
The goal is to offer care that’s “honest and compassionate and kind, with people who often don't get a lot of compassion and kindness when they have these issues,” Mellinger said. “There's a lot of judgment and a lot of misunderstanding about addiction, and alcohol use disorders in particular. And so I think it's refreshing when they come to a clinic where they're not judged, or where people just want to help them.”
If you or someone you know is struggling with alcohol use disorder, help is available. You can reach the SAMHSA National Helpline for free, confidential, 24/7, 365-day-a-year treatment here, or by calling 1-800-662-HELP (4357.) You can also find Michigan-based resources here.
