Addressing a Quiet Crisis

FOLLOWING THE COVID-19 OUTBREAK, another emergency has been developing — one that isn’t garnering attention but is taking thousands of lives. Alcohol-related hepatic disease has discreetly escalated to become the primary cause of alcohol-related fatalities, surpassing even car accidents. At Keck Medicine of USC, practitioners such as hepatologist Brian P. Lee witness the results directly.

“The liver acts as the primary filter of the body. It detoxifies the blood, medications, and bile that pass through it,” explains Lee, a liver transplant expert and an associate professor of clinical medicine at the Keck School of Medicine of USC. “Other organs rely on your liver, and if it fails, your kidneys and other organs are likely to fail as well.”

“Daily in my clinic, I encounter multiple patients whose livers have been irreparably damaged due to alcohol use. Our hospital ward is filled with individuals suffering from liver disease and liver failure requiring transplants.”

During the COVID-19 pandemic of 2020, Lee and his team observed a notable spike in patients with liver disease. “Admissions to Keck surged over 30% due to alcohol-related issues, with liver disease being one of the most prevalent conditions,” he states. That same year, there was also a significant rise in alcohol sales — increasing by 34% from 2019 to 2020. The surge in hospitalizations prompted Lee and his colleagues to explore the reasons in a study.

“Initially, we believed that individuals were consuming more alcohol during lockdown due to increased stress, and that once things returned to ‘normal,’ drinking rates would decline,” Lee mentions. “However, that’s not what we have been observing in the hospital.”

A LASTING PANDEMIC IMPACT

In 2024, Lee spearheaded a Keck Medicine follow-up investigation specifically analyzing alcohol consumption rates. He and fellow researchers discovered that the increases noted in 2020 persisted, if not escalated, in 2022. They examined data from the National Health Interview Survey, one of the largest and most thorough health surveys in the nation, which gathered alcohol usage information along with demographic and socioeconomic data for over 24,000 adults aged 18 and older. While the U.S. Department of Health and Human Services declared the official end of the pandemic in May 2023, the National Health Interview Survey categorized the year 2022 as post-pandemic, as normal routines began to resume.

The researchers compared alcohol consumption figures from 2018 to 2020, and then from 2018 to 2022.

They discovered that from the pre-pandemic year of 2018 to the height of the pandemic in 2020, heavy alcohol consumption among Americans surged by 20%, and any alcohol use increased by 4%. By 2022, these increases were maintained, and the rise in drinking was evident across all age brackets, genders, races, ethnicities, and regions of the nation, with the exception of Native and Asian Americans. Adults aged 40 to 49 experienced the most significant rise in alcohol consumption.

The Keck Medicine research did not delve into the reasons behind the increase in alcohol usage between 2018 and 2022, but Lee suggests some general theories. “We know that individuals often use alcohol as a form of coping,” he notes. He cites the widespread destruction from Hurricane Katrina in 2005 and the events of 9/11 in 2001, which saw increases in alcohol and smoking rates.

“However, those were temporary spikes,” Lee remarks. “The belief is that the pandemic has led to more enduring changes.”
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Prolonged exposure to triggers for heightened alcohol consumption indicates that even if you eliminate these triggers, it doesn’t necessarily eradicate the substance use disorder. This suggests that the behavior may transform from merely a routine into a lifestyle—an addiction.

THE JOURNEY TO LIVER FAILURE

Last December, a 63-year-old individual at Keck Medicine of USC underwent a liver transplant. He had fatty liver disease and alcohol-related liver health issues, ultimately developing cancer in the liver, according to his surgeon, Navpreet Kaur. He was released from the hospital within five days. Approximately two months later, he was eager to return to golfing and work.

“For patients like him, recovery can be remarkably swift, allowing them to engage in activities they loved before falling ill,” she states.

Although liver transplantation is fairly common, it is described as a “challenging and intricate procedure,” as expressed by Kaur, an assistant professor of clinical surgery at Keck School of Medicine, who performs over 40 liver transplants each year. Every transplant candidate undergoes a thorough pre- and post-surgery assessment for physical health, mental wellness, and evaluation of their out-of-the-hospital support network. However, the challenge posed by alcohol dependence can be daunting, and post-transplant success hinges on a transformation in health behaviors, particularly alcohol intake.

“Years back, I treated a patient with acute alcohol-related liver disease. She had a successful surgery,” Kaur recounts. Unfortunately, a year later, the patient resumed drinking. After her primary care provider assisted her in achieving sobriety through psychiatric treatment and counseling, Kaur remarks, “she managed to overcome and maintain sobriety, without any adverse effects on the liver transplant itself.”

As alcohol consumption is the leading cause of liver disease, it represents over 50% of liver-related fatalities. The second predominant cause is fatty liver, which is linked to obesity.

Liver disease progresses through four stages, with each phase monitoring liver scarring known as cirrhosis. This scarring occurs as the liver repairs and regenerates after being damaged by alcohol or other factors. In the fourth stage, the liver is typically too scarred to heal itself.

“The liver possesses the ability to regenerate, but only to a certain extent,” Lee explains. “Even if you retain small portions of healthy liver, you might feel fine, yet when serious damage occurs, symptoms like fluid accumulation in the abdomen, swelling of legs, confusion, bleeding from large vessels, or jaundice may appear. Liver failure can develop rapidly.” Afterward, a transplant often becomes the sole option.

THE HIDDEN IMPACT ON YOUNGER ADULTS

What makes individuals under 50 particularly vulnerable to alcohol-related liver disease? During the study period, alcohol consumption surged across all age groups and demographics. “However, young adults, notably younger women, have emerged as the fastest contributors to the rise in liver-related fatalities, and the reasons behind this remain unclear,” Lee remarks. This situation appears to be connected to the experiences endured during the COVID-19 pandemic.

During the pandemic, this age demographic faced significant stressors. “For instance, many were on the cusp of flourishing in their careers, only to have that disrupted by the pandemic,” Lee notes. “Numerous women had young children or teenagers at home who transitioned to remote learning.”

In the research study, adults were identified as having engaged in any alcohol consumption or heavy alcohol use within a year of the survey, with researchers calculating the frequency of both types of alcohol use. Heavy drinking for men was defined as five or more drinks on any given day or 15 drinks weekly. For women, it was four or more drinks per day or eight per week.

SHIFTING THE FOCUS TO AVOIDANCE

On the frontlines of healthcare, Lee observes the shock and surprise among his patients. “Time and again, even individuals with liver failure are astonished to learn that their drinking habits have led to their condition,” he states. “For me, it’s about identifying solutions for our patients, of course, but also about preventing individuals from ever reaching that state.”

Given that many patients at Keck Medicine are middle-aged, Kaur emphasizes the need for preventive information to reach individuals earlier in life. “When a person begins drinking at 21, no one discusses the effects of alcohol on the body,” she explains. “We educate about the dangers of smoking, yet alcohol is widely accepted as a recreational substance in this country. We must enlighten young people about the long-term ramifications of alcohol.”

Other research indicates that drinkers tend to underreport their intake, yet health professionals are aware that over 70% of Americans consume alcohol. “Thus, it’s highly likely that a patient is drinking, and it’s essential for a doctor to understand their consumption levels to conduct proper tests,” Lee states. “The more transplants I witness, the more I recognize the impact of proactive prevention. Liver disease resulting from alcohol use is avoidable.”

Lee hopes the Keck Medicine research will educate both medical professionals and patients. “If your consumption exceeds the threshold, it’s crucial to converse with your doctor about it so you can be screened for potential health issues,” he asserts. “If recognized early, it may be possible to prevent and manage the advancement of liver disease.”

Both Kaur and Lee recognize that the term ‘alcoholic’ carries stigma. “There is a stereotype that individuals must consume two cases of liquor daily,” Lee states. “But that’s not the reality we observe in the clinic.”

Generally, Kaur adds that society is comfortable with “recreational substances, like alcohol, in social contexts. But, when a person overindulges, we tend to distance ourselves instead of inquiring if they are experiencing life stresses that require support.

“Consequently, the individual consuming alcohol loses more of their support network, which may drive them to drink more. Thus, it’s not solely a physician’s or healthcare worker’s responsibility to assist them; we must consider it from a societal perspective and support one another.”

AN INCREASING DEMAND FOR ORGAN TRANSPLANTS

Alongside the post-pandemic surge in alcohol consumption is the rising need for available livers for transplantation, which is the definitive remedy for end-stage liver disease. Keck Medicine conducts approximately 150 liver transplants annually.

However, there exists a deficit of donor livers. “We face an imbalance between organ supply and demand, with about 15,000 individuals awaiting liver transplants nationwide,” Lee reports. “About 20% to 30% of patients requiring a liver will not receive a transplant. We must continue spreading awareness to the public as every organ is essential.”

Public education on organ donation and innovative approaches to enhance the viability of donated livers for transplantation are gaining traction.

A NEW LEASE ON LIFE

Over the years, Lee has witnessed how lifestyle choices have consequences on his patients’ livers. “I’ve encountered individuals who drink more due to personal losses, such as the death of parents or job loss,” he observes, adding that many are taken aback by the seriousness of their condition. “They were unaware they had liver disease because previous to this, they exhibited no symptoms, then suddenly experience liver failure and require a transplant.”

The evaluation process for transplants is exceedingly thorough. “We have an entire team that collaborates with patients, inclusive of liver specialists, surgeons, social workers, psychologists, addiction experts, physical therapists, and nutritionists,” Lee states. “The psychosocial assessment ensures that each patient is both physically and mentally equipped to endure the transplant procedure and remain a responsible steward of the transplanted organ for years and decades ahead.”

He refers to it as the “miracle of transplant.”

“One week post-transplant, they often leave the hospital,” Lee comments. “Most individuals undergoing transplantation due to alcohol eliminate drinking altogether, undergoing significant changes in their lives because of their gratitude. That embodies the essence of transplantation—it’s about a second chance.”