During pandemic lockdowns, virtually every state considered alcohol retailers “essential businesses” that remained open while bars and restaurants closed.
Although the World Health Organization had recommended banning all alcohol sales during lockdowns, concerns arose that such a move would increase the number of people experiencing potentially life-threatening withdrawal symptoms, further taxing hospitals dealing with COVID-19.
But, as the authors of an article early in the pandemic observed, keeping alcohol retailers open during lockdowns could have unintentionally sent the message that alcohol is essential for life, encouraging consumption. A widely circulated myth that drinking alcohol protected against COVID-19 didn’t help matters.
More than a dozen studies have found that 20% to 40% of individuals surveyed reported consuming more alcohol than usual during the pandemic, George Koob, PhD, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), told JAMA.
For example, he noted, a Harris poll conducted in February for the American Psychological Association found that 23% of adults reported drinking more during the pandemic than previously (the proportion jumped to 52% of those with children aged 5 to 7 years at home).
In many cases, they’re drinking to cope with the stress of the pandemic, which “links up with the previous traumas to society,” such as Hurricane Katrina and 9/11, Koob said.
“What we have with COVID-19 is even more profound in some sense,” said Koob, who coauthored an article in November 2020 about addiction as a coping response to losses experienced as a result of the pandemic.
“You had not only the trauma of worrying about whether you were going to get the virus…but there was the physical isolation,” he said. “Now I think we’re starting to see some of the aftereffects.”
As he and his coauthors wrote, “increases in pandemic-related stress combined with elevated substance use could fuel an increase in mortality from overdose, suicide, and alcohol-related liver disease.”
Indeed, a recent review article concluded that the immediate effects of changing alcohol use patterns during the pandemic have been increases in alcohol-related emergencies such as alcohol withdrawal, withdrawal-related suicides, methanol toxicity, and alcohol-related motor vehicle crashes.
Complicating the situation is that people with alcohol use disorder (AUD) might have an increased risk of developing severe COVID-19, because alcohol impairs lung immune responses. In fact, heavy alcohol use was recognized as a risk factor for poor outcomes during the 1918 influenza pandemic. In addition, many people with AUD have comorbidities that further increase their risk of severe COVID-19, noted an article published in September 2020.
Alcohol Use Wrapped in a Pandemic
Even before the pandemic, half of US cases of liver disease stemmed from alcohol use, Koob noted, and research suggests the proportion could be increasing.
At New York City’s Mount Sinai Hospital, interhospital patient transfers for alcohol-associated liver disease (ALD) increased 62% between the prepandemic period, defined as January 1, 2020, to March 21, 2020, to what researchers described somewhat optimistically as the “declining COVID period,” April 23, 2020, to August 25, 2020. The hospital’s inpatient liver patient census also increased between the 2 periods, according to a recently published study.
Their findings not only confirmed predictions of rising AUD and ALD as a consequence of the pandemic, the authors wrote, but they also highlighted another contributing factor to racial and ethnic disparities in COVID-19 morbidity and mortality. “This aftershock particularly affected ethnically diverse patients with ALD with high inpatient mortality, reflecting the disproportionate impact of COVID-19 on underserved and minority populations,” Gene Im, MD, and his coauthors noted.
Mount Sinai’s experience has been the rule, not the exception, Im, a hepatologist at the Icahn School of Medicine and the Recanati/Miller Transplantation Institute at Mount Sinai, said in an interview. “All liver disease doctors throughout the country have seen a rise in alcohol-related problems in their patients.”
Nearly 10 months after the end of the “declining COVID period” in Im’s study, “we’re seeing a leveling off [of interhospital patient transfers for ALD] but still a significant increase from previous years,” he said.
“We are continuing to see a lot of young people with a severe form of alcohol-related liver disease,” including life-threatening hepatitis, Im noted. More than half the patients discussed at his center’s weekly transplant meetings have failing livers due to alcohol use, he added.
“I think that it’s not necessarily [because of] ongoing stressors from the pandemic per se,” Im said. Instead, he suggested that the sustained increase in cases could reflect patients’ growing comfort in leaving their homes and seeking medical care that they had postponed during lockdowns.
The one silver lining in his study, Im noted, was that none of the 25 patients in the analysis who’d had an early liver transplant—performed before they’d been sober for 6 months—had relapsed and resumed drinking. “This was the ultimate stress test for them,” he said. “They did very well. We know transplant doesn’t fix their addiction to alcohol. They were still able to show resilience during the pandemic.”
Soon after the pandemic began, Brown University gastroenterology research fellow Waihong Chung, MD, PhD, and his colleagues began noticing that an increasing proportion of inpatient consults for digestive tract and liver problems were related to alcohol use.
Compared with the same period in 2019, the total number of inpatient gastroenterology consults in Rhode Island’s Lifespan Health System fell by 27.7% during the lockdown phase, defined as the period between March 23, 2020, and May 10, 2020, according to a hospital system-wide audit Chung presented in May during the Digestive Disease Week meeting. However, the proportion of those consults that were due to alcohol-related conditions—alcoholic hepatitis, alcoholic cirrhosis, alcoholic pancreatitis, and alcoholic gastritis—rose by 59.6%, the audit found.
In the reopening phase, defined as June 1, 2020, to July 19, 2020, the number of consults rose to the same volume seen during that period in 2019, but the proportion for alcohol-related gastrointestinal and liver diseases, in particular alcoholic hepatitis, was 78.7% higher.
“The overall picture points to the fact that people were drinking more,” Chung told JAMA.
Increases in Alcohol Withdrawal
While many people began to drink more when the pandemic began, some reported drinking less. For example, an online survey in May 2020 of a convenience sample of 832 US adults aged 22 years or older found that 60% of respondents said they were drinking more than they had pre–COVID-19, but 13% said they were drinking less.
Koob, who was not involved in that study, speculated that some people drank less at the beginning of the pandemic than before it because bars and restaurants closed. “They’re at home. They don’t feel like going to the trouble of getting booze delivered,” he said. “They only enjoy a drink when they’re with their buddies.”
But for people used to drinking heavily, abruptly stopping can lead to painful and even life-threatening withdrawal. A few studies have found that the number of people seeking care for alcohol withdrawal during the early months of the pandemic increased, even in jurisdictions that had deemed alcohol sales essential.
For example, compared with the same period in 2019, the proportion of emergency department (ED) visits for alcohol withdrawal and withdrawal with complications increased between March 1 and May 31, 2020, according to a study involving 5 New York City hospitals, all part of the Mount Sinai Health System.
New York City never banned alcohol sales, so the authors speculated that increased withdrawal visits might be related to people trying to stop hazardous drinking as part of an effort to adopt a healthier lifestyle, fear of leaving home to purchase alcohol, or transportation issues. The authors observed a decrease in ED visits related to alcohol use, but they speculated that could reflect a shift toward drinking in private homes instead of in bars or on the street, settings associated with ambulance calls.
The rate of alcohol withdrawal in hospitalized patients in Delaware’s ChristianaCare health system was consistently higher in 2020 than in 2019, according to a recent research letter in JAMA Network Open. Stress, anxiety, disrupted treatment plans, and increased alcohol use during the pandemic might explain the rise in alcohol withdrawal, the authors wrote.
The increase in alcohol-related digestive and liver diseases highlights the importance of screening patients for AUD.
“We have to double down on questioning patients on alcohol use,” Chung said. “If you don’t ask, you don’t know.” Rather than simply asking whether patients drink alcohol, Chung said, “I actually ask: How much did you drink in the past week? It helps some people who might think that they have an alcohol problem to really open up.”
AUD is underrecognized by primary care clinicians, who don’t screen patients for it as rigorously as they do for tobacco use, Im said. “Frontline providers are already overwhelmed by screening,” he said. Plus, he added, alcohol is more complicated than tobacco, because some evidence suggests a moderate amount of drinking might be cardioprotective, which, of course, is not the case for smoking.
Even specialists who treat conditions arising from AUD could do a better job of identifying and treating it, Im and his coauthors found in a survey conducted in March 2020, the first month of the pandemic. “The amount of addiction training in medical school and throughout medical training is really abysmal,” he said.
Im’s team surveyed a nationally representative sample of hepatologists and gastroenterologists as well as some outside the US. Virtually all respondents said they ask patients about alcohol use, but less than a quarter of them said they “usually” or “always” administer a screening tool to evaluate for hazardous drinking.
“This is a critical issue that we’ve identified as a really high priority going forward,” Koob said of the need to screen patients for AUD.
The pandemic has not only exacerbated symptoms of addiction and mental illness, but it has also forced changes in how AUD and alcohol withdrawal are treated, according to recommendations from the American Society of Addiction Medicine’s COVID-19 Task Force.
“Each patient should be reassured that quality treatment programs will remain open and that every effort will be made to continue their medication, peer support, case management, and counseling throughout this crisis, even if not in the traditional manner,” stated the recommendations, which were issued in November 2020.
For example, the recommendations advise clinicians to manage some patients with AUD via telemedicine and encourage them all to use online and smartphone recovery support resources, such as CheckUp & Choices, a digital program developed with NIAAA funding.
Like many aspects of life, sobriety support groups have gone virtual during the pandemic. Koob, who spoke in December at the virtual annual meeting of Secular AA, said members of that organization were enthusiastic about the ability to connect with people across states and countries online.
So far, most of the evidence about increased rates of hazardous drinking and alcohol-related diseases during the pandemic has come from studies of hospitalized patients, which likely don’t provide a complete picture of the problem, Chung said. “Our real concern is that people who drink and have any of these diseases might not come to the hospital because they might not feel sick enough. We are working on getting the outpatient data.”