Alcohol use continues to skyrocket, prompting record-setting numbers of people to need liver transplants — especially young women.

More than half of liver transplants at UCHealth University of Colorado Hospital are now related to heavy alcohol use. In the past, most people who needed liver transplants had contracted hepatitis C or had other liver diseases that were unrelated to alcohol use.

Since alcohol use rose sharply during the pandemic, liver transplant expert Dr. James Burton, Jr. has seen a sharp spike in the number of young people in their 20s and 30s who need liver transplants. A handful were not even old enough to drink alcohol legally. Others were mothers of young children or young working professionals.

“Alcohol use was a problem before the pandemic, but the pandemic just lit it on fire. Alcohol sales shot up,” said Burton, a professor of medicine and gastroenterology at the University of Colorado School of Medicine and medical director of liver transplantation at University of Colorado Hospital on the Anschutz Medical Campus.

“It’s a huge problem. About 80% of the transplant evaluations that we’re doing on a weekly basis are in younger and younger people with alcohol-associated hepatitis and cirrhosis from alcohol,” Burton said. “A decade ago, we would see old men who had been drinking heavily for 20 to 30 years and had developed cirrhosis. Now we’re seeing patients in their early 20s with liver and kidney failure who need both liver and kidney transplants.”

While alcohol abuse has been deadly for decades in the U.S., alcohol use rose sharply during pandemic lockdowns, prompting dramatic spikes in the number of people who were drinking excessively and ultimately dying from alcohol-related illnesses, Burton said.

“Some people were staying home and having happy hour in their pajamas earlier and earlier during the day,” he said. “Alcohol deliveries started happening and that was huge too.”

While many impacts related to the COVID-19 pandemic have eased, alcohol purchases and consumption have continued at high levels, prompting a deadly hangover from the sharp pandemic spike in alcohol use.

Alcohol use has risen in every region of the U.S. and spurred health problems among people of all ages.

To understand more about alcohol use disorder, increased disease and deaths related to alcohol, impacts on liver transplantation, and how people can reduce their alcohol use, we consulted with Burton.

How do you define problem drinking or alcohol use disorder? Do doctors still use the term ‘alcoholic’?

No. Doctors no longer use the term “alcoholic.” Instead, substance use experts now use the term “alcohol use disorder.” The symptoms of alcohol use disorder can range from mild to moderate to extreme.

Addiction experts identify people as having alcohol use disorder or problem drinking when a person is experiencing two or more of the following symptoms:

• Consuming a larger amount of alcohol than intended over a longer period of time
• Persistent desire to reduce or control alcohol use
• Unsuccessful attempts to reduce alcohol use
• Cravings for alcohol
• Failure to fulfill major work, school or home obligations due to alcohol use
• Giving up important work or social activities due to alcohol use
• Recurrent alcohol use when it’s physically hazardous
• Physical symptoms of withdrawal after reducing alcohol use or quitting drinking

Alcohol use has been on the rise in recent years among all racial and ethnic groups and has increased especially sharply among women.

What are some of the health problems that people can experience if they have alcohol use disorder?

People who drink too much can experience many health problems, according to medical experts at the U.S. Centers for Disease Control and Prevention. These range from high blood pressure to increased risk of stroke, increased risk of cancer, severe liver disease, dangerous sexual encounters, miscarriage, stillbirth, fetal alcohol disorders and death.

What are the different types of alcohol-associated liver diseases?

They include fatty liver disease, alcohol-associated hepatitis and cirrhosis.

In alcohol-associated fatty liver disease, fat builds up inside a person’s liver cells and leads to a swollen liver.

People with alcohol use disorder can progress to getting alcohol-associated hepatitis, which is a sudden onset of hepatitis. It kills liver cells and is very dangerous.

Burton said 30-to-40% of patients with severe alcohol-associated hepatitis will die within months without transplant.

Finally, excessive alcohol use can lead to cirrhosis, which is permanent damage that destroys the liver.

Tell me more about the increased need for liver transplants related to alcohol-associated hepatitis since the pandemic

Before the pandemic, about 40% of people on liver transplant waiting lists had experienced liver damage related to alcohol use.

Now, that percentage has shot up, both because alcohol use disorder is on the rise and because there are now cures for hepatitis C, which used to cause liver damage that led to liver transplants.

Pre-pandemic, far fewer patients were suffering from alcohol-assisted hepatitis, Burton said.

Once alcohol use skyrocketed during the pandemic, there was a dramatic spike in the number of patients with alcohol-associated hepatitis, Burton said.

“We are currently evaluating up to 13 people per week for liver transplant. That number used to be closer to six to eight per week,” he said.

The same has been true across the country, Burton said.

Liver transplants nationally that are necessary due to alcohol-associated hepatitis have doubled.

“There was this clear association between alcohol use and the pandemic,” he said.

Tell me more about women and the risk of alcohol use disorder. Why are women so vulnerable to severe liver disease related to drinking too much?

Alcohol makers have aggressively marketed alcohol to women. Many younger women, from students to young professionals to stressed young mothers, have embraced lifestyles that promote dangerous binge drinking in college, boozy brunches with bottomless drinks for young professionals, and “rosé all day” mommy culture for stressed parents.

While women have adopted heavy alcohol use — just like many men — their bodies can’t process alcohol in the same way.

“Women can’t drink as much as men can,” Burton said. “Moderate drinking for a woman is one drink per day, whereas for a man, it could be considered two drinks a day.”

Even if women drink less than men, they can suffer severe health problems sooner, including alcohol-associated liver diseases.

“Women’s bodies contain proportionately less water and more fat than men’s bodies,” Burton said. “Water dilutes alcohol, and fat retains it. Women also have less alcohol dehydrogenase, an enzyme that breaks down alcohol.

“At any given dose, blood-alcohol levels in a woman will be higher than a man, even taking into account body weight,” he said.

Which alcohol-related illnesses have increased the most?

Burton and his colleagues have seen a large increase in the number of people who have alcohol-associated hepatitis.

“It’s an inflammation of the liver that is related to heavy alcohol use,” Burton said. “In severe cases, alcohol-associated hepatitis is related to cirrhosis. Half of people who have severe alcohol-associated hepatitis will also have cirrhosis.”

Describe a typical patient who needs to be evaluated for a liver transplant now

“The typical person I’m seeing now is not someone who has been drinking heavily for decades. Rather, it’s a young person who has been drinking heavily for many months to a couple of years. For a man, they might be drinking five drinks a day, and for a woman, four (drinks a day),” he said. “It’s not uncommon to see people drinking 10 drinks a day and doing this every day or multiple times a week.”

It’s especially poignant and heartbreaking for Burton to see young women who are drinking so much that they need a liver transplant.

“I see some young women who have children, and they’re taking care of their kids all day. Then, they get them to bed and say, ‘I need a drink.’ One woman was having four drinks after her kids went to bed. She’d stay up watching Netflix. And I said, ‘That’s a problem,’ and she didn’t really put it together because she didn’t think she was drunk and didn’t think it was impacting her life.”

The woman told Burton, “I’m not falling down drunk. I’m able to take care of my children.”

But he had to deliver a tough wake-up call: “You drink too much, and the alcohol you are drinking is causing problems with your liver.”

Spouses or partners often are not aware of how much a person is drinking.

“I had a patient who was a very successful lawyer, and his wife didn’t know how much he was drinking. He told me he took the recycling out to the garage a lot, and he made excuses to go into the backyard and had alcohol there,” Burton said. “It can happen to the best of people. Very successful people can cover up their drinking until they get caught for drunk driving or something like that.”

Burton said there’s a lot of stigma about alcohol use disorders. There are misperceptions, too.

“People think, ‘I’m not in an alley drinking a bottle of booze out of a brown paper bag,’” Burton said. “But many people are drinking too much and just don’t realize it.”

I thought that people who have alcohol use disorders are not eligible for liver transplants. Has that changed? Do doctors perform liver transplants for people who are using alcohol?

Yes, to some extent, the protocols have changed, Burton said. Under the right circumstances, doctors perform liver transplants on people who have struggled with alcohol use disorder. There’s a very simple reason.

“Research has shown that transplanting patients with alcohol-associated hepatitis saves lives,” Burton said.

Many people who have alcohol-associated hepatitis have such severe alcohol use problems by the time they seek help that they only have a few months left to live.

In the past, doctors required patients to get sober before receiving a transplant. Burton said experts now have learned that they can save lives in some cases by giving select patients a new liver, then sending them directly from liver transplant recovery to an inpatient or intensive outpatient addiction treatment program.

“Even before the pandemic, we came up with some criteria. People who had short-term alcohol use issues — related to certain life experiences, like the death of a family member or a divorce that drove them to drink heavily for a period of time — but didn’t have underlying psychiatric disorders and had strong social support networks, could recover well,” Burton said.

Back in 2019, Burton and his colleagues created protocols to determine which patients with alcohol-associated liver disease could benefit from the new protocol of providing the transplant first, followed by treatment for alcohol use disorder.

“We transplanted more than 30 people (with alcohol-use disorder). And no one relapsed with the alcohol use,” Burton said.

“This was surprising. We expected about 20 or 30% to relapse,” he said.

Through monthly testing, Burton and the team confirmed that patients who had received transplanted livers were maintaining their sobriety.

“We realized that we probably had been too restrictive in the past,” Burton said.

He and other transplant experts since have teamed up with addiction specialists at UCHealth CeDAR, which stands for the Center for Dependency, Addiction and Recovery, and is located adjacent to University of Colorado Hospital on the Anschutz Medical Campus.

“We have some people go directly from a liver transplant to inpatient rehab at CeDAR, and over the last year and a half, we’ve really been fine-tuning this, Burton said.

They’ve been pleased to see success stories.

“We’ve transplanted people who are never going back to drinking, and the transplant has a huge impact on their lives,” he said.

I understand there’s another big change in liver transplants. Do you now perform transplants with infected livers?

Yes. Burton said treatments for hepatitis C are now so good that doctors can perform transplants using livers from deceased donors who had been infected with hepatitis C. This new protocol increases the number of livers that are available for transplantation and boosts the chances that people who need donated livers can get them.

“We now use organs infected with hepatitis C — including hearts, lungs, livers and kidneys — and we put them in people who don’t have hepatitis C. Then we can cure the hepatitis C after the transplant,” Burton said.

Why did diseases related to alcohol use spike so dramatically during the pandemic?

“There were people who couldn’t even get into alcohol treatment because some programs closed down. You couldn’t go see your therapist. People with underlying mental health disorders like anxiety and depression were told they couldn’t leave their houses. And many, many people turned to alcohol to cope,” Burton said.

The pandemic accentuated behavioral and mental health problems.

“Often, there are no good ways of dealing with these problems. So people use alcohol, and it might make them feel good for a little while, but it’s probably going to make you more depressed,” Burton said. “But if you can’t get in with a psychiatrist, psychologist or other mental health provider, then you’re going to treat your issues yourself. It’s a multi-factorial issue.”

Have alcohol use problems eased?

No. Use of alcohol continues to surge as do evaluations for liver transplants, Burton said.

“Many people are getting acute viral hepatitis. They develop severe injury to their livers as a consequence of heavy daily use of alcohol. And even if people quit drinking, and the hepatitis gets better, many patients will have cirrhosis (which causes permanent liver damage),” Burton said.

What are the keys to dealing with these problems?

“We can’t just keep living and working the way we were ten years ago. We’ve got to change how we approach treatment. We have to treat liver disease and alcohol use disorder,” Burton said.

“Transplant programs need to transplant the sickest people. It’s our job to save lives. That’s what we do.”