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Alcohol-use disorder: Unmasked or exacerbated by the pandemic?

Alcohol-use disorder: Unmasked or exacerbated by the pandemic?

Healio
By Nancy S. Reau, MD, FAASLD, AGAF
May 31, 2022

The COVID-19 pandemic stripped away layers of sugarcoating in our society — it exposed weak points across aspects of American life, stretched resources in public health and highlighted a deficit in recognition and access to mental health care and addiction medicine.

Alcohol use is part of American culture. Alcohol is prominent in celebration as well as commiseration. Alcohol is introduced to children by their parents as an essential part of special occasions: girls’ nights, barbecues, outings with the guys, even book club. Alcohol is also seen as a just reward for a bad day or stressful experience. As children progress toward adulthood, alcohol plays a prominent role as a litmus test for entry into coveted societies: sororities and fraternities, college mixers, work socials. Alcohol continues to consecrate important interactions and becomes almost sacrosanct in business relationships. This unhealthy relationship is then fantasized in television and on social media. Ultimately, Americans look to alcohol in both good and bad times.

Policy vs. The Art of Medicine

It is no surprise that the pandemic was associated with an increase in alcohol-related hospitalizations and deaths. Not only was this time unprecedently stressful, but it also disrupted social networks, predictable routines and access to health care. It was not just that access to your physician was limited: Access to most preventative health care was put on the back burner while hospitals and communities struggled with understanding COVID-19. Feeling stressed and anxious? Unfortunately, your doctor can’t help you, the ER isn’t safe and the mental health lines are woefully understaffed. There were not many places to turn for assistance.

Alcohol-use disorder (AUD) does not affect everyone equally. The demographics of binge drinking are also important. Although we assign this behavior to high school and college-aged students, CDC data demonstrates that 76% of alcohol poisoning deaths occur among adults aged 35 to 64 years. Individuals aged 35 years and older typically account for the more than 140,000 deaths per year from excessive alcohol use in the U.S. This age demographic is more likely to have other medical conditions such as diabetes, obesity and fatty liver, all of which may increase the risk for liver damage from alcohol use.

Hospitalization for alcohol-related liver disease skyrocketed during the pandemic, and this naturally translates into various options for those with liver failure. Many of these individuals are considered for liver transplantation when their disease is so severe that they have little chance for survival, or they do not improve after a period of abstinence. When the paradigm is challenged, clinicians, institutions and payers are all forced to consider the current standard of care, otherwise known as the “6-month rule.” A 6-month period of abstinence does not accurately predict recidivism and penalizes those who will not survive this arbitrary period but would otherwise have excellent outcomes.

However, this does not mean that we should ignore traditional metrics for success. The period of sobriety may be in question, but that does not negate the other factors such as insight into the disease, social support and willingness to engage in preventative services. Addiction is a condition that can be managed. We need to recognize the need, link to appropriate services and ensure that funding is supportive of these necessities. But if an individual is unable or unwilling to recognize the role that alcohol has contributed to their liver failure, liver transplantation may not provide the best long-term outcome.

This challenges policy to match the art of medicine. Restrictive rules may exclude individuals that would have excellent long-term outcomes, yet permissive rules could allocate a resource to a group of individuals at high risk for relapse.

‘We Must Invest in Public Health’

Ultimately, this is a public health crisis. Individuals with AUD are under-recognized. Even when recognized, resources for AUD are limited and often nonexistent. When trying to help an individual with AUD, the impact of comorbidities such as obesity and metabolic syndrome may be missed.

So, where do we go from here? As with any public health crisis, awareness is essential. The CDC published recommendations for “healthy” drinking, but most American have no idea what this entails. To prevent alcohol-associated liver disease, we must invest in public health. Identifying those at risk, before a life-threatening event, is imperative.
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