Alan Bonder, MD, and Juan Ramos, PsyD, on Alcohol Use Disorder in the Pandemic: Part 1

In this podcast, Alan Bonder,MD, and Juan Ramos, PsyD, begin a 2-part discussion on the dramatic increase in alcoholic liver disease seen since the onset of the COVID-19 pandemic, its impact on the demand for liver transplantation and how to best treat these patients for alcohol use disorder.

Listen to Part 2 here.

Alan Bonder, MD, is the medical director for liver transplantation at Beth Israel Deaconess Medical Center and an assistant professor of medicine at Harvard Medical School in Boston, Massachusetts. Juan Ramos, PsyD, is the transplant psychologist at Beth Israel Deaconess Medical Center and an instructor in psychology at Harvard Medical School.

TRANSCRIPT:

Welcome to this podcast from the Gastroenterology Learning Network. Today Drs Alan Bonder, medical director of liver transplantation at Beth Israel Deaconess Medical Center in Boston, and Juan Ramos, transplant psychologist at Beth Israel Deaconess, will begin a 2-part discussion on the dramatic increase in alcoholic liver disease seen since the onset of the COVID-19 pandemic, its impact on the demand for liver transplantation and how to best treat these patients for alcohol use disorder.

Dr. Bonder:   Good afternoon, everyone. It's a pleasure to be again with all of you for Gastroenterology Learning Network. I am Dr. Alan Bonder. I'm the medical director of liver transplant at Beth Israel in Boston.

I have the pleasure to have with me today, our transplant psychologist, Dr. Juan Ramos. Juan, welcome and thanks for giving us your time for today.

Dr. Juan Ramos:  Thank you so much.

Dr. Bonder:  I think in today's topic, we will discuss what's been going on in the last couple of years since COVID hit us. As Juan is aware, we have been having this massive inflow of patients with diagnosis of alcoholic liver disease. We would like to get Juan's input, how are we going to diagnose this problem? What are we seeing in the hospitals, and what are we doing for those patients?

First, Juan, I would like to ask you, how do we diagnose someone, or how do we consider someone with heavy alcohol use?

Dr. Ramos: There's different layers, different levels of alcohol use. We have the diagnostic manual for mental health, the DSM‑5, that include specific criteria for alcohol use disorder. Overall, whenever we're seeing a patient in clinic, we want to look at 2 specific factors.

One is the heavy alcohol use that means that for men is 4 or more drinks per day, or more than 14 drinks per week. For female patients, it's 3 drinks per day and 7 drinks per week. That is considered heavy alcohol use, although that's heavy alcohol use doesn't necessarily mean that the patient meet criteria for alcohol use disorder. The DSM‑5 describe very functionally‑oriented diagnostic criteria.

In addition to heavy alcohol use we have the binge drinking, which for males is 5 or more drinks, for female patients, 4 or more drinks in about 2‑hour periods. All those, that amount of standard drinks in 2 hours. Those 2 components are considered in the alcohol‑use disorder diagnosis.

The diagnosis is focused on 3different levels ‑‑ mild, moderate, and severe ‑‑ and it's based on the number of symptoms. These symptoms are usually based on functionality. How much impact does the alcohol use is having in this patient's life-- including socially, financially, family? It's basically based on a standard diagnosis of the DSM‑5 considering these factors.

Dr. Bonder:  This is very interesting. Based on what you just described to us of alcoholic‑use disorder, can you comment a little bit what was the impact of COVID to increase alcohol intake in what's been going on the last couple of years?

Dr. Ramos:  Before COVID, the prevalence of alcohol‑use disorder was about 8.5%. A little bit higher than that, 12.4% in males. With the pandemic, what we've seen is a significant increase. I would say exponential increase in alcohol use. If we divide the alcohol use in 3 factors ‑ harmful alcohol use, probable or possible alcohol dependence, and severe alcohol dependence ‑‑ we've seen a significant increase in all these categories.

To give an example, for instance, harmful alcohol use since the beginning of the pandemic in April to September 2020 went from 20% to 40.7%, almost duplicate the harmful alcohol use. What we're talking about here are patients that, before the pandemic, probably they were drinking heavily or close to heavily. These are patients that, because of the pandemic, they have to stay home. There's a significant difference between people that have to get out and work during the pandemic versus those staying home, which is most of us. We see that increase in harmful alcohol use.

Unfortunately, we'll see a very similar tendency with probable alcohol dependence. When I say alcohol dependence, this is a really problematic alcohol use, most likely alcohol‑use disorder. With the pandemic, those patients in lockdown, they went from 7.9% to 29%, and this is significant. We're talking about from April to September. A significant increase in alcohol use, and in severe alcohol dependence.

When we think about our liver transplant patients, we want to focus on those patients with severe alcohol use given the amount of alcohol, the frequency of alcohol use. With the group that are probably at more risk of having some hepatic problems secondary to alcohol, those groups increased during the pandemic from 3.9% to 17.4%. It's a significant increase.

These correlate with the alcohol sales across the nation where they also have 34% of increase from 7 billion to 9.5. This study that evaluates these different levels of alcohol use in some way is correlated with, overall, the nationwide increase in alcohol sales.

Here we are with people who were probably not drinking that much, drinking more than usual. People who were usually drinking heavily now probably been in criteria for severe alcohol dependence. Those are patients that are definitely at more risk of having some medical complications including liver decompensations.

Dr. Bonder:  This is very concerning about all those things you just explained to us. We are seeing this in the transplant centers. As everyone is aware, alcohol damage deliver and then we're seeing a spectrum of a different disease. Juan can talk to what we're seeing in our transplant center. We're seeing younger people with severe acute alcoholic hepatitis independence who need to be enrolled, who need to be listed for liver transplants.

Based on that, Juan, can you comment if there is any trend or any difference in the people who are listed with a new diagnosis of acute alcoholic hepatitis or alcoholic liver disease recently?

Dr. Ramos:  We saw that increase, and in some ways...we were in the middle of the pandemic then. Almost at the beginning of last year, we have a significant increase in cases. Most of those cases look very similar from their psychosocial profile. Usually, patients, they were working before the pandemic. They went to lockdown, or they lost their job. They were home. There were no significant risks to having a DUI or being drunk at work. The boredom and the isolation increased that level of alcohol use.

We started seeing that increase in patterns of new patients — relatively young patients, less than 50 — coming to the center with a new onset of acute alcoholic hepatitis. Most of these patients had a history of heavy alcohol use, but like I said, during the pandemic, it was worse. We saw that with both males and females, and with different psychosocial and socioeconomic status.

This is congruent with what some studies reported in terms of the increase in waitlist registrations and deceased donor liver transplant across the nation where there was an increase. There was an decrease of transplant right at the beginning of the pandemic, because some centers stopped or their services were disrupted. When things got back to normal — whatever that means during the pandemic — transplant centers started working with patients and doing this transplant. We saw a significant increase in this tendency of waitlist registrations and deceased donor liver transplant compared to the predictions that we had before transplant, up to almost 60% increase in waitlist registrations, and similar to deceased donor liver transplant.

It's not surprising to see an increase in alcohol use, increase in alcohol sales, and now, an increase in waitlist registrations and deceased donor liver transplant. That seems to, in the big picture, follow that kind of tendency.

Dr. Bonder:  This is also very interesting. You being with me on the floors, I think we can echo or describe what we've seen the last 2 years. There's a basically interesting article in the New York Times about the increased incidence of young females coming into the hospitals with acute alcoholic hepatitis. This is what you just described.

Also, it's important to send the message out there that alcoholic liver disease, specifically acute alcoholic hepatitis, is right now something that is kind of a hot topic in the transplant world. Right now, we do have a pretty life‑saving therapy, which includes transplantation.

Based on that, Juan, what we can do is how can we relay a message? What are those patients, or what are we doing for those patients when they fail therapy? Then, we think about transplant, who's those patients who we really, psychologically or psychiatrically, need to address? What arethe things that we looked into them so we can make them a good transplant candidate?

Dr. Ramos:   It's very hard to predict future behaviors as we all know, but there's certain elements. One of the main elements is that as a transplant center, we have to see the alcohol use as an illness, as a disease, as a psychiatric and medical disease, and treat it like that.

We have some risk factors, predictors that we can identify pretransplant, but one of the most important parts is to evaluate and to see what we do with this patient post‑transplant. We know that there's a risk of relapse like with any other addiction. However, what we've seen is that the risk of relapse compared to the mortality rate pretransplant is much lower. We're talking about 34% for early transplant patients, around 25% for a patient that had some type of sobriety before transplant. The key factor in this process is to help these patients engage in meaningful treatment for alcohol‑relapse prevention post‑transplant.

There are some risk factors that are standard or that are stable that we were not able to change pretransplant, especially if the patient is very acutely ill. But post-transplants focusing on the alcohol use as a medical disorder is essential, and providing treatment for that is key.

We see that patients reduce not only the frequency of relapses, but also the severity of these relapses post‑transplant whenever they engage in meaningful alcohol‑relapse prevention treatment post‑transplant. I think that that's the key factor in this process.

Join us for part 2 of this podcast as Drs Bonder and Ramos continue their discussion about how best to offer continuing care for patients with alcohol use disorder and how to help them avoid relapse and to remain healthy after liver transplantation.