At the start of the pandemic, stay-at-home orders were in place across the country to curb the spread of COVID-19. Disrupted routines combined with the uncertainty of the pandemic led many people to feeling isolated at home while experiencing greater stress. As a result, some people became their own bartenders and progressed into heavier drinking patterns to cope with pandemic anger, stress and anxiety.
According to an American Psychological Association report (PDF), nearly one in four adults reported drinking more alcohol to cope with the stress of the COVID-19 pandemic. And for those who are parents with early elementary schoolchildren, that proportion jumps to 52%.
The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines, especially throughout the COVID-19 pandemic.
For this installment, with many Americans going back to work in person, two AMA members took the time to discuss what patients need to know about unhealthy alcohol use and how to break the cycle of comfort or binge drinking. They are:
- Alёna A. Balasanova, MD, director of addiction psychiatry education and co-director of the addiction psychiatry consultation-liaison service at the University of Nebraska Medical Center in Omaha.
- Avani K. Patel, MD, MHA, a psychiatry resident at the University of Mississippi Medical Center in Jackson.
“It can range from risky drinking to an actual disorder. But even with risky alcohol use, that can lead to health consequences,” Dr. Patel explained, noting that “you would think that you don't really have health consequences until it becomes a disorder, but that's not necessarily true.”
“The thing to remember is that one in three adults in the United States actually engage in risky use, so this is super common,” said Dr. Balasanova. “That’s just something for people to be aware of—it’s not an isolated issue. It’s not unique to you. This is a super common thing that we need to be addressing because it is ubiquitous.”
“A narrative at the beginning of the pandemic was social distancing—and that term alone basically means isolation like you're distanced from others,” said Dr. Balasanova. “There was a grassroots effort to change that to physical distancing because realistically we need to be more socially connected than ever, particularly when we're physically distanced.
“When you can't sit next to somebody, a loved one, you need to engage socially with them in other ways—through the telephone, through other modalities using technology as a platform,” she added. “But that narrative contributed to this idea of isolation because it's like we were being instructed to isolate. We were being instructed to distance ourselves and that takes a toll.”
“JAMA Network Open actually published a recent study that found that as the COVID pandemic surged, alcohol consumption in adults increased by 14% from 2019 to 2020,” said Dr. Patel, adding that “the reasons for this included increased stress, increased alcohol availability—because with pandemic places were stocking up—and boredom.
“Other issues also included unemployment, working on the front lines—because that’s very stressful— working from home and having to manage children at home with their schooling and keeping them entertained all day,” she added. Increased drinking was also associated with “losing people who you love and even just losing some of your support, whether that’s financial or social.”
“The U.S. Preventative Task Force recommends one drink per day for a woman or two drinks per day for a man, although recent evidence suggests it should be one drink per day for everybody, even for men,” said Dr. Balasanova. “If you drink outside of those limits, you are engaging in risky drinking or hazardous drinking.”
“Binge drinking is defined as more than four drinks in one sitting for a woman or more than five drinks in one sitting for a man,” she explained. “And so that is also considered risky drinking.”
But it is also important to keep in mind the definition of a standard drink, which is “a 12-ounce beer, eight to nine ounces of malt liquor and five ounces of wine—which isn't a whole lot when you think about it—or 1.5 ounces of anything distilled,” Dr. Patel explained.
Learn more from the JAMA Patient Page “Unhealthy Alcohol Use,” co-written by Drs. Balasanova and Patel.
“We have seen a significant growth in the number of people needing evaluation for liver transplants—at least here in our facility because our team does those evaluations,” said Dr. Balasanova. “You can absolutely develop liver disease and eventually end stage liver disease such that you need a transplant.
“Alcohol-related liver disease is a leading cause of a need for transplant,” she added, noting that drinking large amounts can “also impact your heart. You can get cardiomyopathy and increased blood pressure, which then, of course, can increase your risk for having strokes.”
There is also “the mental health impact” which “can lead to anxiety, depression, and sometimes even suicide,” Dr. Balasanova said, noting that “about half of people die by suicide while they’re actively intoxicated.”
“It can also worsen your psychiatric disorders if you're experiencing anxiety or depression,” or even post-traumatic stress disorder (PTSD), said Dr. Patel. “It actually worsens PTSD and can be associated with other substance-use disorders, so you may pick up another substance to supplement what you're already doing.
“Then in pregnancy, you can get fetal alcohol spectrum disorder that affects your baby, particularly with birth defects, developmental disabilities and even intellectual disabilities,” she added.
“With my consult service, at the very beginning of the pandemic, it was really busy—a lot of people were getting hospitalized for alcohol-related problems,” said Dr. Balasanova. “Then it kind of died down as things were getting better.”
“Now it's picking back up again. And I don’t know if that’s because of the Delta variant or what, but it started to pick up before then,” she said, noting that “a part of that was actually the social reintegration and this idea of going back into society was really anxiety-provoking for people, so then they just drank more, which led to all sorts of negative health outcomes.”
“A really good thing to do is to take inventory of your alcohol use” such as keeping “a journal or a diary,” Dr. Balasanova recommended. “On a calendar, write down how much you're drinking every day just so you know where you're at,” as well as what is going on at the time.
“Once you have at least two weeks, you have an idea where you’re at and can start making incremental goals to reduce that use,” she said. For example, “if you are seeing that a bottle of wine is lasting you two days, you can always make a goal where you make it last three days and then see how well that goes for a week or two. If that seems to go well, see if you can make it last for days.”
Additionally, “take a look at what your family history of alcohol problems are because it’s very much genetic and linked,” said Dr. Patel. “And then check out any medications that are contraindicated with alcohol. It’ll help give you a clearer picture of what your life is like and where alcohol may or may not fit.”
“So many people do use alcohol as a crutch and what I would caution folks about is if they are using it as a maladaptive coping mechanism, we need to find some healthy coping mechanisms to replace it with,” said Dr. Balasanova. “If we eliminate it altogether, then you have no coping skills and that's not going to work either.
“If there’s something you like to do—scrapbooking, knitting or whatever—try to engage more in those activities,” she added. “Also making sure you’re getting enough sleep is crucial—so the basics of sleep, diet, making sure you're hydrated.”
“These are things everybody overlooks because they’re like, oh, that’s too simple. But it matters,” said Dr. Balasanova. “It matters if you’re hydrated, if you’re sleeping well, if you’re eating right and not just eating fast food all the time—eating nutritious foods and vegetables.”
By “keeping track of your urges and cravings, you can identify what your triggers are, which can be people, places, things, times of the day that offer drinking opportunities or remind you of drinking,” said Dr. Patel. “Other things can be internal triggers that just kind of pop up, so I recommend that you take the time to question the urge, think about why and challenge it.
“It’ll allow you to become more aware and use that healthier coping mechanism that you’ve developed instead,” she added. “Remember that urges and cravings come in waves. It’s like an ocean wave and it will pass.”
“We have three medications that are FDA-approved, including one that's not even a pill—it's an injection that you get once a month, so you really don’t even have to deal with taking pills every day,” Dr. Balasanova explained. “Then we have our psychosocial treatments. We also have community peer-support groups, so overall we have a variety of services.”
“It’s not a cookie cutter, one size fits all because in the past that’s what people would associate with,” she said, noting that the assumption was “you go to rehab and that’s what you have to do. That’s not the case anymore.”
“First and foremost, if you really feel like things are out of control, please seek help. Talk to your doctor and talk to your primary care provider,” said Dr. Balasanova. “Or if you have a psychiatrist or mental health specialist, talk to them.
“But honestly, this is something you can talk to your primary care about and just say, ‘I really have been drinking a lot more lately. I'm really struggling. What can be done on that end?'” she added.
“The most important thing is if you're struggling, tell somebody. Don’t go through that alone,” Dr. Patel echoed. “There are so many resources out there, particularly for substance use because it’s a big area of prevention and it’s just as much of an illness as anything else is.”