The Hepatological Toll of NPIs Surfaces

In the early days of the pandemic, numerous detrimental side effects of nonpharmaceutical interventions (NPIs) were predicted. The potential for profound, long-term consequences were laid out, and pandemic policy makers either ignored them or didn’t understand them. Among those were the likelihood of excess alcohol consumption and the health consequences associated with it.  

It’s not as if alcohol-related maladies haven’t been on policymakers’ radar. A 2009-2015 study drawing data from over 100 US insurers of various types reveals that alcoholic liver disease had risen during that time period – possibly in part due to Great Recession stressors. While the amount of cirrhosis increased overall during the 6-year time period, the overall increase in alcohol-related liver disease increased 30 percent for men and greater than 50 percent for women. And despite the fact that alcohol-related liver disease represented some 36 percent of the total cirrhosis population monitored in that study, costs associated with their care amounted to 51 percent of the total $9.5B. Per-person costs of alcohol-related liver damage are nearly twice, in fact, what they are for non-alcohol related liver disease. 

And there are additional costs as well. Another study, also published in 2018, reported that

health care expenditures for alcohol-related diagnoses are increasing. Costs associated with alcohol disorders are reported to account for more than 1 percent of the gross national product in high- and middle-income countries…Prevalence of alcohol abuse/dependence is not completely known but is estimated to effect [sic] around 8 percent of adult Americans…Acute alcohol hepatitis (AH), a result of heavy, prolonged alcohol use, is one of these causes of hospitalizations and emergency department visits. One study reported that approximately 1 percent of hospital admissions in the US in 2010 were due to AH, which represented a 30 percent increase over 8 years.

And that the costs are not restricted to medical expenditures alone. 

AH most often occurs in persons aged 40-60 years – individuals who are in the prime of their working lives. The productivity loss to the economy and to employers is likely very high…[It] exacts a high toll from a societal perspective. Patients with the condition tend to be people of middle age in their prime working years (our mean age was 54), and the condition negatively affects their productivity in the workplace. This affects both their families and their employers. It also incurs a high cost to insurers due to the high consumption of health care resources by these patients. In this study, the average cost of these patients in the year of hospitalization is just under $50,000 including the truncated costs of the estimated 44 percent who die in the first year. In the years following, the costs are in the $10,000 to $15,000 range. 

A conservative estimate, according to the authors, is that in 2018 alcohol hepatitis cost US taxpayers $1.5B. With social costs the total is much higher. 

Crafters of lockdown policies dismissed or ignored the potential for alcohol abuse that mass house arrest, with its attendant worries about income, family, and a host of other issues created. That anxiety and depression often lead to substance abuse–particularly with alcohol, given its legal status, cultural significance, and widespread availability–doesn’t seem surprising, let alone controversial. Research points directly at heavy drinking among 9/11 survivors and first responders and more broadly during/after the Great Recession (even among individuals who didn’t suffer unemployment, and with sometimes complicated findings). 

A December 2020 Frontiers in Psychiatry article illustrates the sheer volume of peer-reviewed research relating crises and alcohol abuse that was available before the Covid pandemic. 

The World Health Organization (Europe), on the other hand, not only recognized the dangers associated with stay-at-home orders and alcohol, but suggested restrictions on alcohol availability

Alcohol consumption is associated with a range of communicable and noncommunicable diseases and mental health disorders, which can make a person more vulnerable to COVID-19. In particular, alcohol compromises the body’s immune system and increases the risk of adverse health outcomes. Therefore, people should minimize their alcohol consumption at any time, and particularly during the COVID-19 pandemic… Existing rules and regulations to protect health and reduce harm caused by alcohol, such as restricting access, should be upheld and even reinforced during the COVID-19 pandemic and emergency situation; while any relaxation of regulations or their enforcement should be avoided. 

Botswana actually did this. Whether in the US limitations or an outright ban on alcohol would have resulted in fewer alcohol abuse injuries, or instead have sent individuals to further extremes (hard drugs, improvised intoxicants, self-harm, etc.) is a grotesque counterfactual that distracts from the core issue. 

More policy putrescence is now materializing. Reporting from the UK in October 2020, Frontline Gastroenterology reported that “[i]n the initial wave of the COVID-19 pandemic, the Office of National Statistics reported a 10.3 percent increase in supermarket alcoholic sales and a 31.4 percent annual increase in alcohol store sales in March 2020.” Continuing,

[w]e report a large increase in the number of patients being referred with alcohol-related liver disease in our tertiary liver unit. Referrals from our network more than doubled in June 2020 compared with June 2019…with 82.1 percent being currently active drinkers. These admissions were sicker, with 23.9 percent requiring high dependency unit or intensive care unit organ support for severe acute alcoholic hepatitis or alcohol-related acute-on-chronic liver failure compared with 10.7 percent in June 2019. None of the admitted patients to our unit in June 2020 were positive for SARs-CoV-2. Of those in June 2019, there was only one death within 30 days of admission, while in June 2020 four patients died within 30 days of admission. 

A trend echoed in the Journal of Clinical Gastroenterology, in an article entitled “The Pandemic Within the Pandemic: Unprecedented Rise in Alcohol-related Hepatitis During the COVID-19 Pandemic” (also October 2020):

We hypothesized an increase in cases of alcohol-related hepatitis requiring inpatient management, mirroring the strain on economic and society norms imposed by the COVID-19 pandemic. We performed a retrospective chart review to study the incidence of alcohol-related hepatitis in patients presenting to three community hospitals in Fresno, California, before and during COVID-19…There was a 51 percent increase in the overall incidence of alcohol-related hepatitis requiring hospitalization between 2019 and 2020 and 69 percent increase after implementation of the stay-at-home orders. In addition, a 94 percent increase in rehospitalizations was noted in 2020, a 100 percent increase in patients under the age of 40, as well as a trend towards a 125 percent increase of female patients admitted with this diagnosis during the COVID-19 pandemic. 

In June 2021, the following findings were reported at the International Liver Congress regarding pandemic trends in Alberta, Canada. 

“Our results actually show that an increase in alcohol sales post-pandemic will impact significantly the natural history of alcohol liver disease in Canada and probably most of the Western world,” Abdel-Aziz Shaheen, MD…said during his presentation. Shaheen and his colleagues…compared post COVID-19 restrictions (April – Sept 2020) with prior study periods and assessed inflation points with joinpoint regression. Results showed no significant change between average monthly admission rate, demographic, ICU admissions, and hospital mortality among alcoholic and non-alcoholic cirrhosis cohorts. Investigators reported patients with alcohol hepatitis had an increase in average monthly admission. April 2020 was the inflection point…While alcoholic hepatitis patients admitted post COVID-19 restrictions were younger, significant differences were observed in admission outcomes pre- and post COVID-19 among the alcoholic hepatitis cohort. “We found a decrease in mortality among non-alcoholic cirrhosis patients post-pandemic,” Shaheen said. “It went down from 11.5 percent to 8.5 percent. The striking, alarming result we found was a 9 percent increase on the monthly average for alcohol hepatitis admission post-pandemic. 

In the US, as recently as two weeks ago, new findings of the pervasiveness of alcohol consumption-related liver injuries were revealed. In Liver International, pertaining to Detroit: “[T]he number of [alcohol-related liver disease] admissions as a proportion of all hospitalizations was 50 percent higher in 2020 than in 2016-2019 [and] by September 2020, the number of admissions was 66 percent higher than in recent years.”

These echo, and are echoed by research from Denmark, Slovenia, and elsewhere.

At this point, the die has been cast. Little more can be done beyond remembering that when the former administration (and, to be fair, a handful of their political adversaries) pushed for a reopening of the economy, they were disparaged as being ruthlessly focused on economic performance to the exclusion of any other consideration. That was, as many of us pointed out at the time, disaster via the excluded middle: a false dichotomy suggesting a need to choose between economic viability and disease control. In dribs and drabs, the hideous effects of treating human beings like insects in mason jars with holes poked in the lid are coming to light. We cannot repair the damage done, but we can highlight and expose those who were responsible for the remainder of their waking days. 

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