Unhappy Hour: The Emerging Burden of Alcoholic Liver Disease
Gastroenterology & Endoscopy News
By Brian C. Davis, MD & Jasmohan S. Bajaj, MD
May 23, 2019
Alcohol use is deeply ingrained in American culture. More adults in this country report drinking regularly than say they voted in the last election, own a pet, or attend religious services—in some cases, by significant margins. And the problem is worsening.
In the United States, more people are consuming alcohol, with the share of adults who reported drinking in the last year up from 65% in 2001-2002 to 73% in 2012-2013. The data also illustrate rising percentages of high-risk or binge drinking behavior, defined as more than four standard drinks for women, or more than five for men, on any day at least weekly. Roughly 13% of Americans met these criteria in the period 2012-2013, an increase of 30% over the previous decade. Rates of high-risk drinking rose faster in women, people over the age of 65 years, minorities and individuals of a lower socioeconomic status.1
The increasing use of alcohol correlates with other studies evaluating the public health costs of alcohol consumption. In 2010, the total annual costs of drinking were estimated at $249 billion, an increase from $223.5 billion in 2006.2 The majority of the costs were linked to binge drinking.
Deaths related to alcohol use also are on the rise. The CDC estimates that about 88,000 people per year die as a result of direct (alcoholic liver disease [ALD]) and indirect factors (cancers, motor vehicle crashes, falls, homicides, suicides) associated with drinking.3 The most recent estimates reported 34,865 deaths in 2016 from alcohol-induced causes.4 The age-adjusted death rate was 9.5 per 100,000 people in this country, an increase of 26% from 2000.
While the age-adjusted death rate was more than two times higher in men than women, the annual increases in mortality are rising faster in women, which corresponds with rising rates of binge drinking among women. In addition, a recent analysis of CDC data showed that mortality rates from cirrhosis are rising, particularly among people aged 25 to 34 years, which is driven by sepsis or peritonitis related to alcoholic cirrhosis.5 The number of deaths more than doubled in young Native Americans, Asian/Pacific Islanders and whites.
To stem the rise in ALD-related mortality, a concerted effort across multiple levels within the health care system is imperative. Policymakers should tighten the control of alcoholic beverages and taxation policies, and increase funding for mental health and substance abuse programs. Primary care providers should screen all patients for alcohol use disorder and offer early referrals to substance abuse counseling, addiction medicine or hepatology specialists, if evidence of liver disease is present. Ultimately, novel treatments for both alcohol abuse and ALD are urgently needed.
Advice to General Practitioners
Given these grim statistics for a preventable problem, what can be done to counter this public health epidemic at the clinical level? All providers should become comfortable in discussing alcohol use with patients. That starts with knowing what constitutes a standard drink. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines a standard drink as 14 g of pure alcohol, which is equivalent to a 12-ounce can of beer with 5% alcohol, a 5-ounce glass of wine containing 12% alcohol, or a 1.5-ounce shot of liquor at 40% alcohol.6
The NIAAA recommends avoiding alcohol for individuals who are going to drive or operate machinery; take medications that interact with alcohol; have a medical condition, such as liver disease, that may be exacerbated by alcohol; or pregnant or trying to become pregnant.7