Transcript

Russell [00:00:02] Let's get stronger.

Gates [00:00:04] Healthier.

Prickett [00:00:05] Calmer.

Russell [00:00:05] Smarter.

Gates [00:00:06] Better.

Russell [00:00:07] Living a healthier life is a journey, not a destination.

Gates [00:00:10] You can always get better.

Prickett [00:00:12] Let's get better together.

Russell [00:00:21] Today, we're going to be talking to Hepatologist Dr. Amanda Cheung about alcohol use disorder and issues around alcohol in general. Well, I feel like this is an issue that hits home with everybody because, especially in the first year or two of the pandemic, I think a lot of people turn to alcohol for all the stress and other emotional issues that kind of came with living through a pandemic. And as we move forward, hopefully towards the other side of it, I think we have to deal with the consequences of those things we use to just help us get through the day. So, I'm excited to hear Dr. Cheung talk about what alcohol use disorder is and how you kind of differentiate that from appropriate alcohol consumption.

Gates [00:01:01] Absolutely. I think studies in the pandemic showed that many different things increased use to try to deal with the stressors of the pandemic, including alcohol use. Shopping. I'm probably guilty of that. Understanding, really, you know, anything in moderation, it's not a bad thing. And so, understanding what exactly moderation is when we're talking about alcohol use and then when we're moving past moderation and when things are concerned and then understanding the potential impact of overuse.

Prickett [00:01:33] I think this is a topic that hits just about every family, like, on some level. How do you intervene? What should we be looking for? So, I think this is a really timely topic. So, I'm happy to hear about the medical side and how we can approach this.

Gates [00:01:45] Absolutely. I remember during the pandemic, during my time in the ICU, obviously we were dealing with COVID. But one of the other things that I felt like I personally saw a lot more of is people having had years of sobriety, unfortunately, landing in the hospital in the ICU after breaking sobriety just to deal with the stressors. And so, it's definitely a topic that we need to explore and acknowledge and to take away the stigma and the shame.

Russell [00:02:09] Yeah, and we saw a lot of really young people, too, coming in with end-stage liver disease after just one or two years of very heavy drinking. I feel like we almost had a wave of that after one of the waves of COVID. So, let's go learn more about this so that we can all understand better how to use alcohol responsibly. Today, we're talking about alcohol and your liver with Northwestern Medicine Liver Doctor Amanda Cheung. Dr. Cheung is an expert in alcohol use disorders and alcohol-associated liver disease. Welcome.

Cheung [00:02:48] Thank you. Thanks for having me. So happy to be here.

Russell [00:02:50] So in the past, people have used the term alcoholism to refer to people who drink to excess. But instead, we've been using this term “alcohol use disorder.” So, what is the difference between the two and why? Was there a change?

Cheung [00:03:05] Yeah, so we're really trying to stop using the term alcoholism altogether, mainly because it — over time — started to carry a lot of stigma and sometimes would lead to delayed care because patients were either embarrassed or didn't want to be judged with this label. So, I think sometimes people also think of an alcoholic as someone who chooses to drink alcohol. In reality, this actually is a disease process. It's not a choice. You know, you don't choose to have diabetes. I mean, you can make it worse by eating cakes and brownies every night. Right. Same thing with alcohol use disorder. It's not necessarily a choice. You have it. And we need to help you find coping mechanisms to control it. So, we use a term, alcohol use disorder, to refer to any medical condition where someone is unable to control the amount or the frequency of alcohol use despite knowing that they have health consequences or if they've experienced any negative social or occupational effects from the alcohol use like loss of job or DUIs and things like that.

Russell [00:04:07] The three of us as ICU doctors, certainly during the pandemic, over the last few years, it was almost like a wave after a COVID wave where we would see this incredible influx of people in our ICUs with alcoholic hepatitis and then sometimes overt decompensated cirrhosis.

Cheung [00:04:26] Well, we definitely saw the rates rise during COVID. And that at least in part, probably just due to the psychosocial stressors, a lot of job loss, a lot of social isolation that led to more time at home. Increase alcohol intake, whether it's alone or not. In the first year of the COVID pandemic, the studies have shown that alcohol-attributed deaths, not just liver disease, but overall alcohol-attributed deaths, rose by at least 25%. There have been further studies that look specifically at alcohol-associated liver disease and the mortality rates of alcohol-associated liver disease, and found that nearly all groups, across all age groups, across both genders, increased by at least 20%. It seemed to impact more the 25-to-45-year-old age range, and it definitely impacted women more than men. Not totally clear unless it's just there was more alcohol use in women for whatever reason. Part of that may be the social situation. Suddenly, if they're needing to homeschool kids on top of trying to keep their jobs, working from home. So maybe there are some more psychosocial stressors there compared to others. So, because of that, while we saw an acute rise during the COVID pandemic, we're really not out of that yet because some of the injury from alcohol use is not reversible. So now we have a whole cohort of patients who drank in excess and have, for instance, developed cirrhosis.

Prickett [00:05:48] It's really hard for us to understand what is acceptable amounts of drinking and what, kind of, puts us closer to the alcohol use disorder. Do you mind us kind of elaborating on what the definitions are and what might be leaning toward alcohol use disorder?

Cheung [00:06:00] It varies a lot, but for the most part, a standard glass of wine, which should be just five ounces, is considered a one drink. For distilled spirits like vodka, rum, gin, things like that, it's about 1.5 ounces. And then for just your regular standard beer is 12 ounces. Keep in mind that a lot of your kind of fancier beers tend to be more than 5% alcohol. So that's what we define as one drink. An individual is drinking too much alcohol from a medical standpoint, at least, if it's more than one drink a day for women or two drinks a day for men. And then we have separate definitions, for instance, for binge drinking, which is really defined as the amount of drinking that then becomes harmful to the body. And that's defined by four or five drinks in a sitting for women versus men, respectively.

Russell [00:06:48] So from now on, I have to bring my kitchen scale when I go out to a restaurant to accurately measure how much I'm drinking and make sure that I'm not overdoing it, correct?

Cheung [00:06:58] Well, yeah, you're probably honestly getting way too much. Even though people complain like, oh, this restaurant was stingy. But really it's probably actually more than a standard drink when you're ordering a drink at the restaurant.

Russell [00:07:11] So what does it mean to drink in moderation? And how can you sort of police yourself about whether you're doing right by your body in terms of how much alcohol you're taking in?

Cheung [00:07:21] The standard for moderate drinking is really, again, based on amount that will be safe, what we think at least is safe without developing health-related conditions. So, we stick to one a day for women, two a day for men, but also realizing that cumulative dosing doesn't matter when it comes to the body. So, for instance, you can't just not drink from Monday through Friday and then on Saturday have your seven drinks in one sitting because your body doesn't recognize that. That's considered binge drinking, and that is actually just as harmful, if not more harmful, then slow and steady throughout the week.

Gates [00:07:55] So we've heard the amount that we should be paying attention to. But can we talk about why are we talking about this? What is the concern? What are the health implications for alcohol use disorder?

Cheung [00:08:07] So alcohol does affect basically every organ system in your body. So, if we start at the top of your body, for instance, the brain; so long-term alcohol use can cause an increased risk of strokes. It can actually cause — in excessive amounts — a specific type of psychosis that can be irreversible or cause a dementia-like state. For the gut, it increases the risk of a lot of the cancers, including throat, esophagus, stomach, colon, pancreas, liver. So, it really increases all the different types of cancers. Of course, the liver, which is what I'm most interested in, but it can definitely cause all kinds of liver diseases. Right next to the liver is the pancreas. It can cause both acute and chronic pancreatitis, which can severely impact quality of life once that happens. For the heart, it can actually lead to increased risk of a specific type of heart failure related to the alcohol use and then also increases risk of heart disease. And then lastly, also, it can actually really affect your ability to absorb nutrients and can lead to malnutrition, which can also be associated with increased risk of osteoporosis, as well as muscle loss and frailty.

Gates [00:09:16] Can you talk a little bit more in detail about what alcohol-related liver disease is exactly?

Cheung [00:09:22] Yeah. So, there's actually a whole spectrum of alcohol-associated liver disease. And we think of three main types, although you can certainly have all three at once. So, anybody who consumes alcohol on a regular basis is almost definitely going to develop what we call steatosis or fatty liver. So, we think anybody, even if it's just one drink a day, that regular consumption, about 90% of those people are actually going to develop fatty liver. Now, fatty liver alone isn't necessarily going to cause a problem; but over time, it leads to this chronic state of inflammation in the liver, and the liver will start making what we call fibrosis or scar tissue. And that leads to the second thing that can happen in the liver, which is cirrhosis. So, cirrhosis is a severe form of scarring in the liver. Usually by the time you develop cirrhosis, you may start developing some symptoms like jaundice, yellowing of the eyes or even liver failure. And I didn't mention, just to backtrack for a second, is that when you develop fatty liver, most people actually don't have any symptoms. So, you can have alcohol-associated liver disease and have literally no symptoms at all. And then there's a third type of alcohol-associated liver disease, which is specifically called alcohol-associated hepatitis. Now, sometimes people think of hepatitis as being infectious, but this actually just means inflammation of the liver. So, this is a specific type of damage where the alcohol actually leads to a very robust inflammatory process in the liver and can actually, even in the absence of cirrhosis or scarring, can actually lead to liver failure. So, it's a huge spectrum of what alcohol can present like in the liver itself.

Gates [00:10:57] What are some of the symptoms of alcohol-related liver disease? What do we need to be worried about?

Cheung [00:11:03] So in the beginning stages, nothing. Like you literally won't feel anything. And that's why it's so important to get screened for. But once you start developing symptoms from alcohol-associated liver disease, it's almost always actually just symptoms of cirrhosis. That's going to be things like yellowing of the eyes, dark urine. One of the things that can happen, not uncommonly, is patients come in and they say, "Well, I was this gaining weight for like the last six months and I started having a belly and now I look pregnant. So, I figure maybe it was time to get checked out." And it turns out that whole time they were actually developing what we call ascites, which is fluid in the belly, which comes from cirrhosis. So that's actually really not an uncommon way that patients present is just thinking they're gaining weight and descending. So, you know, if that's obviously happening to you and you're drinking excessively, then maybe you should think about getting checked out. Little things that you can see sometimes and the downstream effects of liver disease. Sometimes you can develop what are called spider angiomas, which are little red blood vessels that may start popping up on your chest or your back. That can be one of the first signs of liver disease as well. From the provider perspective, one of the first signs of developing more scarring or advanced liver disease is actually a platelet levels being low. So that's another not uncommon thing that happens is patients have a low platelet level and they go on this wild goose chase looking for causes of low platelet levels. And then it turns out it was cirrhosis the whole time.

Gates [00:12:30] So there's nothing in between. It's either normal or cirrhosis.

Cheung [00:12:35] As far as symptoms. Yeah. Mm-hmm. So, people always like to say abdominal pain. But the truth of the matter is, is that it really doesn't cause abdominal pain. So, your liver itself really doesn't have pain fibers. Now, what that is that the capsule surrounding the liver does have nerve endings in it. So, let's say you're one of these people that drinks kind of on a regular basis. You're starting to develop fatty liver disease. With that fat infiltration in the liver, sometimes the liver starts stretching and becomes bigger and bigger and that can stretch the capsule. Now it doesn't cause like sharp stabbing pain, like you think of like, "Oh, I have gallstones" or things like that. It's kind of annoying, aching feeling that you have on the right side sometimes more positional. So that can be like a subtle sign, but it's not actually very common.

Gates [00:13:19] So, Dr. Cheung, you just sent me to a panic because you said drinking and fatty liver disease. Please tell my patients if there are other ways to get fatty liver disease.

Cheung [00:13:30] Yeah, that's a really good point to bring up because you definitely want to make sure to screen for all their causes. So, you're not accusing the patients of drinking when obviously there may be other causes. So actually, the top one and two causes of chronic liver disease in the world and in the United States specifically are going to be alcohol-associated liver disease and something that we call nonalcoholic fatty liver disease, and we call that NAFLD for short. So NAFLD is very different. NAFLD is associated with different conditions that are affiliated with what we call the metabolic syndrome. So that's going to be like diabetes, high blood pressure, high cholesterol levels and overweight or obesity. So nonalcoholic fatty liver disease actually can do the same thing that alcohol-associated liver disease can do, meaning that it can deposit fat and the liver, it can cause chronic inflammation to liver and it can cause scarring in the liver. It's good that you brought that up because this is actually something that we have to become more and more aware of because there's a lot of overlap these days. So, we have somebody who is at risk for liver disease already because they're overweight and have diabetes, but then they, on top of that, are drinking alcohol regularly. And then that just increases the likelihood of developing scarring in the liver.

Russell [00:14:45] Once you get fat in the liver, can that be reversed or is it permanent?

Cheung [00:14:50] Yeah. So, the awesome thing is, is that it actually is reversible. Now, if you have fat in the liver, whether it's from alcohol or from these metabolic conditions, if you take away whatever's causing that injury or causing the fat deposition, then you can have reversal. So, for instance, if you have NAFLD or nonalcoholic fatty liver disease and you are overweight and you have poorly controlled diabetes, if you control the diabetes and you successfully lose weight, you can actually have reverse of the fat in the liver. And similarly, if you have alcohol-induced fatty liver, and you cut out the alcohol use, then you can also reverse the fatty liver. The other very interesting thing is we used to think that scarring in the liver is permanent. But what we know now actually is that if we catch it early enough before you have cirrhosis and decompensation, you can actually have reversal of the scarring as well, under the same concept that you remove what's causing injury, the fat goes away, the inflammation goes away, and then whatever scarring has develop can potentially reverse over time.

Russell [00:15:53] That's fascinating. So as long as you don't have cirrhosis, it's not too late.

Cheung [00:15:57] That's right.

Russell [00:15:58] That's fantastic. So, we also mentioned that alcohol-related use and alcohol-associated liver disease is now much more common in younger women. Why is that the case? Why are we seeing that phenomena?

Cheung [00:16:10] Well, we've always known that women are more susceptible to alcohol injury compared to men. There's probably lots of reasons for it. But the main one that it comes down to is the fact that most women are going to be relatively smaller compared to men. And so, if you have the same exact drink that you consume, the actual percentage or concentration of alcohol is going to be higher in a person who is smaller. And so, from that perspective, then it equates to a relatively increased exposure to the alcohol and then you're more likely to develop alcohol-related, not only liver disease, but other conditions as well.

Prickett [00:16:49] If you're worried about your liver and you're not having symptoms, is there a test you could do? And when do we need to see a hepatologist?

Cheung [00:16:55] Yeah, that's a great question. And that's one that is not so easily answered because, you know, when I mention was that one of the things that can happen when you drink too much alcohol is you can develop fatty liver, but sometimes you can have fatty liver and have completely normal liver tests. So as a starting point, you can go to your primary care provider and say, "Hey, I realize I'm drinking too much alcohol. Can you order some tests for me?" And the first test probably will just be a liver panel bloodwork to check your liver tests. And if your liver tests are elevated, then it's certainly reasonable to consider further investigation. We have a special type of test nowadays, which is becoming more and more common and more and more prevalent. It's something called a FibroScan. And a FibroScan is a special type of ultrasound where it is measuring liver stiffness. So basically, what this is doing is that it's sending sound waves through the liver, measuring the speed of those sound waves. And the speed of the sound waves is telling us how stiff the liver is. And the stiffness is a surrogate marker essentially for fibrosis or scarring in the liver. So, if there is concern that you may be developing alcohol-associated liver disease, if you have a longstanding history of excess alcohol use, a FibroScan, in my opinion, would be the best screening tool to see if you've developed some scarring in the liver.

Gates [00:18:13] How do we treat this? What are our treatment options if we've been diagnosed with alcohol-related liver disease on the spectrum? What are our treatment options?

Cheung [00:18:22] The most important treatment is really to treat to alcohol use disorder. And so, there's a variety of options available. The first one would be, of course, is medications. Now, it's not that the medications are treating the liver disease, but there are medications that can help decrease patient's desire to drink and decrease risk of relapse once they have successfully stopped drinking. And then, of course, despite the medications, or sometimes people don't want to take medications or they have side effects. Then it really comes down to is behavioral health treatment. And it really needs to be tailored to the person and what's going to work for them because counseling and things like that, they're not going to work if the person themselves doesn't feel like they need it or will benefit from it. So, thanks to COVID, there have been a lot of online modules available. Most people have heard of AA, Alcoholics Anonymous, so a lot of those have shifted to online modules. If people don't like 12-step programs, there's things like Smart Recovery and LifeRing, which are also online meetings that you can do throughout the day. So, lots of virtual meetings available. Then there's kind of more intense therapies. So if somebody has been drinking large amounts of alcohol every day for a very prolonged period of time, you can actually withdraw from the alcohol and it can be dangerous. So, if that is the case, then an inpatient rehab is usually necessary for monitoring during that kind of detox period. And then there are also things like what we call IOP, which means intensive outpatient program. Those are usually structured programs, usually 3 to 4 hours a day, 4 to 6 days a week that lasts about one or two months at a time. And it's this really intense therapy to get people over that initial kind of desire and need to drink. And then after that and doing kind of weekly counseling is usually a good idea. And then, very importantly also, is that hopefully for people who do have a strong network, friends, family, that they can do some sort of group therapy or family therapy, marriage counseling, things like that can be very helpful because sometimes these people with alcohol use disorder have kind of alienated some of the people in their life.

Gates [00:20:26] So you talked about some of the, like, cessation and medication treatment options. In alcohol-related liver disease, is liver transplant an option?

Cheung [00:20:35] It is. In fact, actually, alcohol-associated liver disease is the number one leading indication for liver transplant nowadays. It used to be hepatitis C was the leading indication for transplant. We have really great medications for hepatitis C now, which is why alcohol use suddenly risen to the top of the list as far as indications for transplant. So, it is a possibility now. That being said, not everybody who comes and sees us and has liver failure from alcohol use is going to be a transplant candidate. We just have to feel confident that the alcohol use disorder is well treated and is under control and that there is a backup plan as far as coping mechanisms, for instance, because stress is probably one of the leading reasons why people relapse with alcohol use disorder. And as you can probably imagine, a transplant is pretty stressful. So, the short answer is yes, it is an option, but it gets complicated.

Prickett [00:21:31] If any of our listeners recognize either themselves or their loved ones in this conversation around alcohol use disorder, how do they start? Where would you recommend it? If they came to you and said, I believe I have this problem or a loved one of mine has this problem.

Cheung [00:21:43] I think the most reasonable would be either to seek care from a primary care provider or a psychiatrist, because then those two providers can potentially talk you through, will medications be helpful for you? Is there another issue going on that's driving alcohol use? So, for instance, I hear quite often patients say, "Well, I was just using the alcohol because I can't sleep." So then if you fix a sleeping disorder, then maybe they don't need alcohol. Or another one we hear very commonly is: I just have a lot of pain. And so, if you can treat that, then maybe they won't use alcohol. So, I think a primary care provider is probably the best first step just because then you can dig into what is actually driving the alcohol use. And then also psychiatry can be very important as well, just because there's a lot of overlap with alcohol use disorder and particularly depression and anxiety, we see it quite a bit.

Russell [00:22:33] Thank you so much for talking with us. Today. Dr. Cheung, we've learned so much about the liver, implications of drinking, and it was really great talking with you.

Gates [00:22:42] Thanks for coming.

Cheung [00:22:43] Yeah, thanks for having me. This is so much fun.

Russell [00:22:49] Thanks for listening to Get Better.

Gates [00:22:51] We hope you'll leave this podcast better than when you started.