Drinking alone: COVID-19, lockdown, and alcohol-related harm

Coronavirus disease 2019 (COVID-19) has, it is frequently said, changed everything. But to appreciate its effects fully, one must not only look at the ways in which clinical services have been reorganised to cope with the flood of patients with COVID-19, or even at the public health measures aimed at flattening the epidemic curve. Globally significant health issues that existed before COVID-19 have not gone away: in many instances, the pandemic may have exacerbated the problem.

Alcohol-related harm is one such case. In the UK, which went into lockdown on March 22, data from the Office for National Statistics show that sales in alcohol stores in March had increased in month-on-month volume by 31·4%. Alcohol consumption patterns have also altered, according to a survey by the charity Alcohol Change UK. Reassuringly, more than a third of the 1555 people surveyed who reported drinking alcohol before lockdown stated that they had stopped drinking or reduced how often they drank in the 2 weeks after lockdown commenced. However, around a fifth responded that they had been drinking more frequently in the same period. And while about half of drinkers said they were consuming about the same amount on a typical drinking day, 15% said they had been drinking more per session since lockdown began. Of particular concern was that almost one in five of those who drank alcohol on a daily basis had further increased the amount they drink since lockdown. While these preliminary data must be treated with caution, they hint at the emergence of a subgroup of drinkers at risk of establishing potentially dangerous patterns of alcohol consumption during lockdown.

While isolation at home and social distancing undoubtedly have an immediate and important role in controlling the COVID-19 pandemic, the effects of long-term isolation on the health of the general population are unclear. Specifically, the ways in which the stress, boredom, and isolation of physical distancing might affect drinking patterns in at-risk individuals is unknown. For individuals with alcohol use disorder, the lack of structure and familial and social support may lead to relapse—indeed, a recent story in the New York Times reported on individuals with alcohol use disorder who were struggling to remain sober due to the cancellation of in-person support meetings. The disruption of COVID-19 thus has a potential double effect: individuals are put under stresses that increase risk of relapse while also experiencing disruption of the social networks that might otherwise help maintain sobriety.

These issues cannot wait until the COVID-19 pandemic comes under control. Preliminary signs suggest that increased alcohol misuse during the COVID-19 pandemic is manifesting as alcohol-related liver disease. While firm data are scarce at present, anecdotal reports have emerged of an increased number of people admitted to hospital with alcohol-related liver injury. The situation is further complicated by the suggestion that, relative to the pre-COVID-19 period, hospitalisations for cirrhosis in patients with pre-existing chronic liver disease might be delayed: in a study of veterans with liver disease, cirrhosis-related hospitalisations decreased dramatically in the period after the first reported COVID-19 death in the USA, and those who were admitted had higher MELD scores at admission compared with those admitted before the outbreak. These delays may be due to services setting a higher threshold for access to urgent care as they attempt to shield vulnerable patients from the risk of COVID-19. It might also be the case that concerns about hospitals having insufficient capacity and posing a risk of infection might lead to patients delaying presentation. Whatever the reasons, these reports raise grave concerns about near-term clinical outcomes for such individuals.

As with many challenges faced by health care in the wake of COVID-19, there is unlikely to be a single, simple fix. Further data are urgently required to assess the scale of the problem. At the individual level, telemedicine—which has seen rapid adoption since the onset of the pandemic—offers one route by which alcohol counselling and addiction treatment could be accessed by those in need. Virtual offerings could also allow health-care providers to monitor patients with existing alcohol-related liver disease more closely, preventing late presentation of severe complications. Close integration of clinical and alcohol services will be necessary to help deal with the probable increase in new diagnoses of alcohol use disorder and alcohol-related liver disease. Finally, governments must incorporate warnings about the harms of excessive alcohol consumption into their public health messaging about COVID-19 if we are to lessen the collateral damage due to alcohol.