The Concerning Rise in Alcohol-associated Liver Disease

An essay by Hanna Blaney, MD, MPH

Alcohol has been embedded in human history and culture since at least 6000 B.C., with archeologic evidence of wine production found in Syria. Evidence of the knowledge of dangers of alcohol use is apparent in Egyptian hieroglyphics from 3500 years ago. Alcohol has since been used throughout history in many cultures to varying extents.?

In the last century, alcohol was believed to be non-toxic to the liver based on early studies in rats. As a result, the health effects, including the liver damage seen in people who drank heavily, were attributed to malnutrition. It was not until the 1960s and 70s that alcohol was confirmed as a liver toxin in both human and animal studies.

Since then, alcohol has emerged as a hotly debated topic in human health. Studies popularized by the media suggested that moderate alcohol drinkers were actually healthier than non-drinkers. Red wine was especially touted for its possible health benefits. Anecdotally, many non-drinkers began having a daily glass of red wine to improve their health with a sharp increase in red wine sales in the US following the release of these studies.

Over the years, these studies have been called into question, with strong studies over the last several years have consistently shown that alcohol is associated with poor health outcomes, from increased mortality in young people to increases in multiple types of cancers and heart disease. In fact, 5.1% of the global burden of disease is attributable to alcohol.

Unfortunately, despite strong evidence that alcohol causes harm, rates of alcohol use are increasing worldwide. Diagnoses of alcohol-use disorder, defined by an impaired ability to stop or control alcohol use despite its negative effects, have also increased accordingly. In the US, 29.5 million people in 2022 carried this diagnosis.

While alcohol is associated with over 200 health conditions, the liver is especially vulnerable to alcohol. Alcohol-associated liver disease (ALD) results from excessive drinking. Excessive drinking is defined as more than 7 drinks a week for women or more than 14 drinks for men, or by binge drinking, which is defined by 5 or more drinks for male and 4 or more drinks for female in one sitting. ALD a leading cause of death from excessive drinking, with about 20% of people who drink excessively eventually going on to develop ALD including cirrhosis. Unfortunately, deaths from ALD are on the rise in the United States, particularly in young people and women. Rates of liver transplantation to treat ALD are also rising. In fact, in 2022, ALD was the leading reason for liver transplantation, with ALD responsible for 48% of liver transplants.

Women’s livers are especially susceptible to the toxic effects of alcohol. One of these reasons is that women have higher blood alcohol levels then men at the same rate of alcohol consumption. As such, women develop more severe liver damage and scaring at faster rates then men at the same level of alcohol use. With changes in culture worldwide, more women are now drinking more alcohol than they did previously. Even more concerning is the rate at which teenage girls are drinking, with teenage girls now drinking alcohol including binge drinking at higher rates compared to teenage boys.

One of the reasons that ALD is so deadly is that it is often silent and diagnosed at late stages, often when the only available treatment is a life-saving liver transplant. In the early stages, patients may have elevations in liver associated enzymes on routine blood tests.? However, liver associated enzymes may not be elevated and, if alcohol is not discussed in a clinic visit, the disease may go completely undetected. If the damage from alcohol is caught and managed at early stages, the liver can recover and repair itself.

Unfortunately, there are currently no approved medications for ALD. Treatment of ALD is centralized on abstaining from or drastically reducing alcohol use. If a patient has an alcohol use disorder, it is important that they receive treatment with either medication, behavior therapy, or both.

If ALD is diagnosed in the early stages, stopping alcohol use can reverse the damage done to the liver. Studies have shown that both medications and behavior therapies are effective in treating alcohol use disorder (AUD). In fact, large studies have shown that people with ALD and AUD who receive medications for AUD have lower rates of mortality. Even if diagnosed alcohol-associated cirrhosis or Alcohol associated Hepatitis, an acute and severe form of ALD associated with a high short-term mortality, stopping alcohol use can improve survival. Given the concerning rise in AUD and ALD cases, there is an urgent need for more preventative measures.

If ALD caught in the late stages when cirrhosis has developed or if someone develops alcohol associated hepatitis, the patient has a high risk of death without a lifesaving liver transplant. While patient who receive a transplant for ALD tend to do well, unfortunately, many patients with ALD either do not qualify for a transplant or become too sick to undergo a transplant. Transplantation is also hugely expensive, with a liver transplant costing over 1 million dollars in the United States.

Considering the rising trend in alcohol use and the escalating rates of ALD, especially with limited treatment options, urgent attention is needed on preventing alcohol-related liver disease. Recent studies looking at society wide measures to reduce the societal harms of alcohol have been performed. One study graded the strength of each country’s alcohol policies and compared the strength of these policies with various health outcomes. Stronger alcohol policies were associated with decreased mortality from ALD.

Another study looked at the effects of the introduction of minimum unit pricing (MUP) in Scotland, a policy passed in 2018 that required a price minimum of 50 pence per unit of alcohol. This resulted in a reduction of alcohol sales by 3%. It also resulted in a profound reduction in alcohol attributable deaths and hospitalizations. In the 32 months following the implementation of MUP legislation, the policy was associated with a significant 13.4% decrease in deaths wholly attributable to alcohol consumption compared with what would have been observed in the absence of MUP legislation.

In the United States, a 2021 study found that that states with stronger alcohol policies in place had lower rate of mortality from ALD, with more restrictive policies associated with decreased mortality from ALD. The evidence supporting stronger alcohol policies exists.

In conclusion, alcohol poses significant health risks, especially to our livers. We have determined that diagnosing liver disease related to alcohol can be challenging and that treatment options are extremely limited. We have also learned that preventative measures can be effective on a societal level to reduce health consequences from unhealthy alcohol use.

So, what actions can we take? On a personal level, we can normalize not drinking or can drink at levels that are less likely to cause damage to our livers. This is especially important in our teenagers and young adults, as this is when problem drinking usually starts. We can also work to destigmatize people who struggle with alcohol use disorder by retiring stigmatizing language like “alcoholic.” Destigmatizing alcohol use disorder will allow for patients and their doctors to have healthy and productive conversations around alcohol use, which will help people with alcohol-use disorder get the help that they need.

On a societal level, we can vote for politicians that support medical research so that we can make progress on diagnosing and treating this common and devastating disease. We can also support policies that involve evidence-based methods to reduce unhealthy alcohol use, such as implementation of alcohol.