Liver Disease and Alcohol: Is Binge Drinking To Blame?
For a young person who likes a busy social life, the COVID-19 pandemic has changed many things. But one thing that doesn’t seem to have changed much is the allure of alcohol, which—if anything—seems to have intensified. Bars and parties may no longer be an option, but there are Zoom happy hours, socially distanced gatherings, couple-time cocktails, or even drinking alone, all of which can lead to serious consequences—including liver disease, which doctors say is rising in younger people.
Albert Do, MD, clinical director of the Yale Medicine Fatty Liver Disease Program, reports that he regularly sees young patients with cirrhosis, which is the medical diagnosis for late-stage liver scarring caused by excessive use of alcohol. “The scary thing is that they're only in their 30s and 40s,” he says, noting that the chances of developing liver disease go up the longer a person has been drinking and is most common between the ages of 40 and 50. Other Yale Medicine doctors have diagnosed people with liver disease when they are still in their 20s.
It’s not only a worrisome development, but also perhaps a surprising one, given that the latest information shows that millennials (born 1981 to 1996) and Gen Zers (born 1997 to present) are drinking less than the generations before them—in fact, surveys show alcohol use has dropped steeply in these groups since the 1990s. But other studies show that deaths from alcohol-driven liver disease are highest among millennials: A study published in 2018 showed liver-related deaths rose 10% a year among those ages 25 to 35, while deaths from liver cancer doubled in this group.
“The overall decrease in drinking is a big plus, but it doesn’t tell the whole story because drinking in young people can still be quite problematic,” says Federico Vaca, MD, MPH, a Yale New Haven Hospital emergency medicine physician and researcher.
Often, Dr. Vaca sees young people arrive in the emergency department (ED) seriously intoxicated—some who are so drunk they can barely walk or talk, he says. These young patients may or may not have a chronic alcohol use disorder [commonly known as alcoholism], he says.
What concerns him is that they are often seeking acute treatment in the ED after an episode of “binge drinking,” or even worse, “extreme binge drinking,” which carries a considerable risk for life-threatening alcohol poisoning. Binge drinking is most common among younger adults aged 18–34 years, according to the Centers for Disease Control and Prevention (CDC), and most people younger than 21 who drink have reported binge drinking as well.
How liver disease develops
Drinking too much alcohol is not the only way to develop liver disease—in fact, many people who are diagnosed with liver disease don’t drink at all. But, in the United States, alcohol is the second most common cause of liver cirrhosis (late-stage liver scarring) after hepatitis C.
Alcohol causes fat to accumulate in the liver, and this eventually can cause the liver to scar, which can lead to inflammation, as well as cirrhosis, fatty liver disease, and liver cancer.
How much is too much?
Many newly diagnosed patients are shocked to learn that their drinking has been severe enough to cause liver damage. One reason for their surprise may be that, as with serving sizes for food, people underestimate how much alcohol is in a so-called single drink. Here in the U.S., the standard for a single serving of alcohol is 14 grams or 0.6 fluid ounces of pure alcohol, which is about 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounces of distilled spirits—but if you are using larger glasses or enjoying a “generous pour,” your serving sizes are larger.
Also (especially in these pandemic times where the weeks and weekends seem to run together), people might lose track of how many drinks they’ve had in a given week. “There is good evidence to suggest that patients often underreport in the doctor’s office, be it by memory or just difficulty quantifying how much alcohol is in certain drinks,” Dr. Do says.
People also are often inclined to drink at the same pace as peers. One person is having a third round and doesn’t appear to be intoxicated, but you may be a person who starts to feel buzzed after just one drink. Genetics, anatomy, physiology, and gender are all factors in how alcohol affects you, according to Dr. Do. Women have been found to develop alcohol-related problems sooner and at lower drinking levels than men, so one drink per day is considered moderate for women compared to two drinks for men.
Drinking to the extreme
Experts point out that the rise in alcohol-related deaths among millennials overlaps with a rise in the rates of binge drinking from 2002 to 2012 across much of the U.S. Binge drinking is when a woman has four or more drinks or a man has five or more —generally consumed within a couple of hours and bringing the blood alcohol concentration up to and beyond the legal driving limit.
Extreme binge drinking, which has become an area of research for Dr. Vaca, is drinking at levels far beyond the binge threshold. Definitions vary, but some studies define extreme binge drinking as two or more times the gender-specific binge drinking thresholds. “Blacking out is a key sign that someone has been extreme binge drinking,” Dr. Vaca says.
“You can be sure that repeated binge drinking and extreme binge drinking are not good for your liver,” Dr. Vaca adds. “In fact, a condition called acute alcoholic hepatitis can cause severe liver inflammation initially, without any scarring at all. This type of hepatitis can be caused by binging behavior over several days or so,” he says.
Excess weight compounds the liver damage caused by drinking too much. Obesity is usually a primary factor in nonalcoholic liver disease—and also a growing epidemic among children, teens, and young adults, according John Morton, MD, chief of bariatric surgery for Yale Medicine. “If you're drinking and you're obese, it's not only additive, it's probably synergistic. It makes it even worse when you have both things going on, for sure.”
In such a situation, it can be difficult to parse out how much of a person’s liver disease has been caused by alcohol and how much is due to obesity, says Dr. Do, who also has special training in obesity medicine. “Like soda, alcohol is high in carbohydrates—and then the alcohol itself causes fat to accumulate in the liver. We're finding a lot more information about how alcohol can make nonalcoholic fatty liver disease worse, and the other way around—how excess weight and obesity can make alcohol-associated liver disease worse,” Dr. Do says.
If you need to treat your drinking behavior
The good news is that the liver has a unique ability to heal itself and replace damaged tissue with new cells. If your liver disease is diagnosed early, doctors can treat it. Lifestyle changes and a CT scan every six months to monitor the disease will be important. But if liver disease is diagnosed in later stages, cirrhosis can develop into an irreversible condition, putting patients at higher risk for liver cancer. In advanced cases, the only treatment is a liver transplant.
In some cases, even if some scarring has accumulated, cutting back on alcohol consumption could help, as could losing weight, Dr. Do says. If you drink, your doctor will advise you to stop doing so, in order to allow your liver to start to heal. “I know that is a big ask for a lot of people. But we are talking about chronic inflammation and scarring of the liver, and we don’t want to do further damage.”
If drinking has become problematic to the point where it’s hard to stop on your own, there are numerous treatments available. Patrick O’Connor, MD, MPH, Dan Adams and Amanda Adams Professor and chief of Yale Medicine General Internal Medicine is a primary care physician, addiction medicine specialist, and past president of the American Board of Addiction Medicine.
He believes that the best treatment is individualized, based on each patient’s needs and lifestyle. There are a number of effective, evidence-based approaches that have been developed over the past several decades. These typically include both counseling (talk therapy) and/or the use of one of three FDA-approved medications designed to prevent ongoing alcohol use, he says. One of those is Naltrexone, which diminishes the craving for alcohol, making it easier to cut back or stop drinking altogether.
There are several highly promising new medications that are likely to be approved by the FDA in the future, he adds. Along with counseling and medication, many people find self-help groups, such as traditional 12-step programs, helpful.
It’s never too early to talk to your doctor
Meanwhile, Dr. O’Connor believes primary care doctors can play a key role by always asking their patients to provide thorough histories of past and present substance use, which would include how their alcohol use has affected their health and life. “That's my general approach, and I do it for every single patient, regardless of their background or why they came to see me,” Dr. O’Connor says. A professor at Yale School of Medicine, he teaches his medical students to do the same. The hope is that more drinking problems will be flagged earlier on, which could, in turn, prevent liver disease and other medical, psychiatric, and social complications of excessive alcohol use.
Christopher Cutter, PhD, an addiction expert at the Yale Child Study Center, would like to see doctors address drinking at even earlier ages. One known risk factor for binge drinking is growing up in a family that normalizes drinking—families where parents have favorable attitudes toward drinking and drinking in excess, and who drink in front of their children. Certain team sports can also put teenagers at risk when weekend party cultures develop around them, he says.
As kids grow up, “we have to help manage their desire to want to use alcohol,” Cutter says. If parents sense their teenager or young adult has a drinking problem, they could seek advice themselves from an addiction specialist on how to help their child—if the situation is already serious, they should steer their child to a specialist, he says. “There are a lot of interventions,” he adds, and getting help early can help avoid not only later liver damage but a multitude of other problems as well.
If you or someone you know is struggling with an alcohol or other substance abuse problem, call the National Drug and Alcohol Treatment Referral Routing Service (1-800-662-HELP).
Read a summary of our liver series.
Read part 2 of our liver series—on one patient's unexpected diagnosis of nonalcoholic steatohepatitis (NASH).
Read part 3 of our liver series—on new hepatitis C screening guidelines.