Alcohol Abuse Agitated by COVID-19 Stirring Liver Concerns

Ingrid Hein

May 06, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Clinicians at UCLA Medical Center in Los Angeles are concerned about an uptick in alcohol-associated hospital admissions.

"We believe we're seeing a significant increase in alcohol-related problems," explained Sammy Saab, MD.

In a poll of 1004 Americans conducted on March 18 and 19, 8% of respondents reported that they are consuming more alcohol or other drugs and substances during this period of social isolation.

"People who are isolated are drinking more," Saab said. "We see them coming to the hospital with significant liver damage from alcohol, all related to the isolation that's required to combat the coronavirus."

Saab said his team at UCLA and other centers are collecting evidence to help verify their early observation. "There are more people than usual showing a decrease in liver function," he reported.

In some cases, people already have a chronic underlying drinking problem. "They've been drinking for years, but more reasonably, and now the pandemic has tipped them over the edge," Saab explained.

We believe we're seeing a significant increase in alcohol-related problems.

Others have been binging on a regular basis for a long time and now the binging is getting out of control. "We see the yellow eyes, swelling bellies, and vomiting blood; convulsion and confusion; signs of inflammation in the blood. It's not necessarily at the point of cirrhosis, but they have acute liver injury."

The binging population is of particular concern. "This is a huge problem, driven by people in their 30s and 40s," Saab told Medscape Medical News. "It's fascinating; with each subsequent generation, risk behavior increases. Nobody seems to know why that is. Different parenting, different life stressors, social media? Things have changed."

In the 25- to 34-year age group, death from liver cirrhosis increased 10.5% from 2009 to 2016, according to data from the ACCELERATE-AH consortium, which is looking at alcohol use by patients before and after liver transplantation, as reported by Medscape Medical News.

Social isolation, stress, and anxiety are likely confounding the problem. "Boredom and a lack of purpose don't help," Saab said. And with unemployment in Los Angeles County expected to hit 32% later this month, stress is escalating.

"I'm a liver specialist," Saab pointed out. "By the time they come to me, they've already been screened for liver failure," yet "about 15% to 20% continue to drink." But if they continue drinking, it's a death sentence.

Alcohol Access Policies Different Around the World

The World Health Organization (WHO) has issued a warning about alcohol use during the pandemic.

"During the COVID-19 pandemic, we should really ask ourselves what risks we are taking in leaving people under lockdown in their homes with a substance that is harmful both in terms of their health and the effects of their behavior on others, including violence," Carina Ferreira-Borges, PhD, program manager for alcohol and illicit drugs at WHO, Europe, said in a recent news release.

In South Africa, police are enforcing a ban on alcohol sales, but in North America and Europe, alcohol is considered an essential service, even available for delivery.

In Canada, Quebec Health Minister Francois Legault assured citizens that alcohol and cannabis stores would remain open as essential services, saying that limiting or removing access to alcohol could cause health problems and complications, potentially requiring hospitalization, if people are forced to withdraw from alcohol use quickly.

Quitting drinking, even after the diagnosis of an alcohol-related liver disease, can be challenging. Community services like Alcoholics Anonymous (AA) are designed to help, but it's not clear how effective the online support groups that have replaced social gatherings are.

"We're definitely encouraging people to go to online support groups, but I do think face-to-face time is likely more effective," Saab said.

The Path to Recovery

Social isolation has made it difficult for people struggling to stop drinking to connect with others who can help them change their addictive behavior.

People in recovery for alcohol abuse often derive support from social groups that act as a substitute family — providing care, support, and a model of how to live life one day at a time — and reminding them, "you can do this," said Richard Hofman, chief executive officer of the Chatsworth Pavilion, a residential treatment center in Montreal.

"When those are removed and replaced with video conferencing and Zoom meetings" — as has been the case during the COVID-19 pandemic — "it's not quite the same," he told Medscape Medical News.

The technology is extraordinary, but "it's not the same as getting off your ass, making a commitment to go to a meeting, interacting with people, getting out of your head, going for coffee, and spending eyeball time with your sponsor," he explained.

With the social aspect of care missing, "I suspect we will see a higher rate of relapse, especially for those in early recovery — 6 months to a year — which is a very challenging time."

Online AA meeting rooms have become a lifeline for many struggling with addiction.

"The AA rooms help me stay connected to my recovery community," explained one AA member, who prefers to remain anonymous. "I need to be reminded that I'm an addict alcoholic, I'm self-centered, and my thinking takes me to dark places. And that my problem is never going to go away. It's 24 hours at a time."

The members of his AA home group, where he is most active, initially resisted Zoom meetings. "But after a couple of weeks of no meetings, we were starting to feel the disease. We realized we had to get organized. Now we're doing weekly meetings and I do think it makes a difference," the AA member reported. "But it's not the same as an AA meeting in person."

AA fellowship — socializing over coffee after the meeting — and one-on-one time with a sponsor is more difficult with Zoom. It's also easier to just leave a meeting. "For the first few meetings, attendance was high, but it's dropped off. I know of at least one member who has fallen off the wagon," he said.

People at the beginning of their recovery don't have the 12 steps under their belt yet and haven't practiced the principals of the program. Early recovery can be a fragile time.

A Tenuous Time

"When you come across someone who has relapsed, you ask what happened," Hofman said. "Usually they tell you, 'I stopped doing meetings, stopped the steps.' They might say, 'I lost a sponsor to cancer and never replaced them.' There's always some component that was removed or missing that led to a relapse."

Anyone who does five meetings a week, talks to their sponsor, works with others, does service in a group, meditates, stays spiritual, deals with their obsessions promptly, and practices the tenth step every night — reviewing their day to see where they played a part in doing harm, causing resentment against a person, place, or thing — never relapses. "I've never met the person who thoroughly followed the path and relapsed. Not in 40 years," he pointed out.

But the pandemic makes that path more difficult.

In fact, many inpatient recovery programs are shutting down because they can't respect social distancing. It's not only clients; caregivers and specialists aren't necessarily prepared to take the risk of contracting COVID-19, said Hofman.

In some areas, the risk is low. "But in New York, do you really want to go into an enclosed building, bunking four to a room, where people are coming and going every day?"

And you can't run a recovery center at 25% volume. "Recovery centers are starting to teeter on the verge of bankruptcy," he said.

The program Hofman runs, which only takes six people at a time, is unique. Each person has a private room. And each session begins at step one; some other programs start halfway through the steps.

It's not COVID-19 causing the increase in alcohol use, he said, reflecting on 40 years of observing and helping alcoholics and addicts. "I am a firm believer that you cannot create an alcoholic or an addict."

Physiologic dependencies can be created, just as one might become addicted to caffeine by drinking coffee every day, he explained.

"People say they became an alcoholic because of this or that," he said, but the fact is, they were likely always one. "There's a difference between causing and exacerbating, or revealing."

For example, when a 38-year-old man with a wife and three kids "ties one on, nobody cares as long as he keeps the lawn and the car maintained, he plays with the kids, he coaches little league," Hofman pointed out. The man is able to manage his stress — possibly resulting from trauma and insecurity he experienced during childhood — while controlling his drinking.

But then, his business goes bankrupt, leading to more stress, and he ends up moving out of his house and getting a divorce. "And then the guy hits the bottle even more, because life has supplied the level of stress that surpasses his ability to cope," Hofman said. "He feels he needs an external stress-management system, which he finds in substance abuse behavior."

The question is: "What kind of natural coping mechanisms do you have to begin with?" he said. "That's when the alcoholic is revealed."

When you look at the pandemic, you have to examine "the components needed to support ongoing abstinence and recovery. Then we realize how many of these components must now be missing," he said. From that, "we can guestimate that quite a lot of people are going to have a really hard time."

International Liver Congress (ILC) 2020.

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