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For years there's been a disturbing trend of young adults experiencing severe and often fatal liver disease and the problem continues. According to a BMJ 2018 study, "Mortality due to cirrhosis has been increasing in the US since 2009. Driven by deaths due to alcoholic cirrhosis, people aged 25-34 have experienced the greatest relative increase in mortality." Data shows that widespread alarming events such as the 2008 recession, Hurricane Katrina and 9/11 can trigger excessive alcohol use. George F. Koob, director of the National Institute on Alcohol Abuse and Alcoholism tells CNN, "What we've been picking up with numerous small studies is that about 25% of the population increased their drinking and these individuals were people who were drinking to cope with stress. And many people who drink to cope with stress inevitably go on to have an alcohol use disorder."

BMJ researchers noted certain areas and communities are affected greater than others and state,"White Americans, Native Americans, and Hispanic Americans experienced the greatest increase in deaths from cirrhosis. Mortality due to cirrhosis is improving in Maryland but worse in Kentucky, New Mexico, and Arkansas. The rapid increase in death rates among young people due to alcohol highlight new challenges for optimal care of patients with preventable liver disease."

Although the startling issue has been happening for a few years, the pandemic made it worse. Alcohol related deaths surged during the first year of COVID. CNN reports, "The alcohol-induced death rate has been steadily increasing in recent decades, but it jumped 26% between 2019 and 2020 – making nearly the same climb in one year as over the decade before. In 2020, alcohol caused 13 deaths for every 100,000 people, up from 10.4 deaths for every 100,000 people in 2019." Read on to learn more about liver disease.

Dr. J. Wes Ulm, Harvard and MIT-trained MD, PhD with a background in bioinformatics, gene therapy, genetics, drug discovery, consulting and education explains, "The liver is essentially the "master biochemist" for the human body. It's a marvelously complex and versatile organ that synthesizes critical compounds for blood clotting, the immune system, blood volume regulation, and other core functions, while also aiding in detoxification, excretion, digestion, and many additional linchpins of functional human physiology. 

It's likewise quite resilient and can regenerate itself after serious injury, but even this marvel of evolution can be overwhelmed by the repeated traumas of chronic inflammation, giving rise to liver cirrhosis. This can occur in the context of varied causes, including viral hepatitis and inherited metabolic disorders, but by far the most common trigger for the cirrhotic pathway is sustained excessive alcohol consumption. And as the disease advances, the aforementioned range of critical liver functions begin to falter."

Dr. Ulm tells us, "The COVID-19 pandemic has had a marked and dramatic effect upon the incidence and mortality of alcohol-associated liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD) in the United States. Increases in the age-standardized adjusted mortality (ASMR) are often measured in terms of a statistic known as the annual percentage change (APC), which calculates a sort of average annual increase (or decline) in the mortality from a given condition when measured over several years. In the referenced study (one among many such investigations), an international team of American and Chinese researchers found that the ASMR APC from 2010 through 2019 had been 3.5% for ALD — in other words, a roughly 3.5 percent yearly escalation in deaths from a significant form of liver disease resulting from alcohol consumption for every year from 2010 through 2019, in itself a striking and deeply concerning finding. However, the 2020-2021 APC for alcohol-associated liver disease was 17.6%, a nearly 5-fold elevation and a warning sign of a social and public health crisis in the US.

Still more disquieting is that the most drastic elevations in ALD mortality were seen in younger age cohorts, most saliently for the 25-44 age group – no doubt a major contributor to declines in US life expectancy, now among the lowest for any industrialized country. It's indicative of a worsening trend of alcohol abuse and liver damage that's exacting a significant toll on the US workforce and young families, even before 2020 but severely aggravated by the pandemic. The reasons remain unclear, but it is likely that the pandemic exacerbated preexisting stressors in American society that have long contributed to alcohol and general substance abuse. This is particularly so with reference to the social and economic difficulties that have likewise fueled the opioid epidemic in the USA, and engendered an epidemic in "deaths of despair," to use the term coined by economists Angus Deaton and Anne Case, as will be further discussed below."

Dr. Ulm says, "Even prior to the pandemic, there was a near quadrupling in alcoholic cirrhosis deaths between 1999 and 2019, representing a greater than 3-fold elevation in mortality rates (accounting for population changes) in a standardized adult patient cohort. The reasons are multifaceted, but evidence from multiple studies indicates that the primary contributor is the so-called "deaths of despair" phenomenon alluded to above. Economists Deaton and Case ascertained that the social and economic dislocations and worsening inequalities of the past roughly 40 years have had devastating public health effects on both rural and urban communities, particularly in the Rust Belt and Appalachian regions but seen across the United States. 

Their work and numerous related studies have pointed to several underlying factors: wage stagnation amid increased housing expenses and overall cost of living, breakdown of community supports, lack of universal healthcare and access issues (for general care and for mental health assistance), outsourcing and widespread local job loss, mounting stress across the US (among the most severe of any developed country), worsening rates of family dissolution, and policy and institutional paralysis. The net effect has been an intensifying American societal malaise that has manifested most prominently in the opioid epidemic, but just as significantly in the steep rise in chronic alcoholism and binge drinking (in part as a kind of self-medication in the ravaged communities). This, in turn, manifests clinically in the sharp and distressing surge in liver disease observed over the first two decades of the 21st century."

The mortality rate for liver disease associated with alcohol consumption is a widespread problem for young adults, but some are at greater risk, according to research. Recent findings show, "By race and ethnicity, researchers observed the highest rise in ASMR among Alaska Indians/Native Americans (18%), non-Hispanic whites (11.7%) and Blacks (10.8%) for ALD, with the steepest increases among Hispanics (13.1%), non-Hispanic Asians (12.9%), non-Hispanic whites and non-Hispanic Blacks (both 11.9%), and American Indians/Alaska Natives (10.9%)."

Dr. Ulm adds, "As hinted at above, one of the most unsettling facets of the surge in liver disease throughout the US has been the devastation it has wrought among younger Americans in particular, across all demographics but particularly those in blighted rural communities and small towns. The working-age populations in some American regions have been hit so hard by alcohol-associated liver disease that their workforce has been decimated, sparking a vicious cycle of further anomie and social dislocation."

According to Dr. Ulm, "The specific signs of liver disease depend on the stage and severity of the diagnosis, but in general represent the observable manifestations of the loss of core functions as discussed above. These include, for example, jaundice (a yellowing of the skin and sclerae, the whites of the eyes), a darkening of the urine and pale stools, swelling in the abdomen and lower extremities, enlargement of the spleen, pruritus (itchiness of the skin), nausea and vomiting, severe fatigue, changes in appetite and consumption, and elevated propensity for bruising and bleeding. 

The good news is that, as noted above, the liver is a remarkably resilient organ that can repair itself even from widespread damage, but its capacity to do so depends on how chronic and sustained the injury is. Liver disease, in simplified terms, progresses along a spectrum from acute fatty changes through fibrosis and advanced cirrhosis; the further this advances, the more difficult the damage is to undo."

For help with alcoholism, treatment is available. Resources include SAMHSA's Substance Abuse Treatment Facility Locator, NIAAA's Alcohol Treatment Navigator and the National Treatment Referral Routing Service available at 1-800-662-HELP. These resources can help you find treatment programs in your community and someone to speak with about an alcohol problem.

Wes Ulm, MD, PhD, is a physician-researcher, musician (J. Wes Ulm and Kant's Konundrum) ,and novelist, and earned a dual MD/PhD degree from Harvard Medical School and MIT. He is part of the Heroes of the COVID Crisis series in relation to his ongoing efforts in the drug discovery and public health arena.

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