Early in the COVID-19 pandemic, it became clear that COVID-19, by disrupting health care and wider social structures, disproportionately impacted individuals with unhealthy substance use.1 Individuals with unhealthy substance use were at greater risk for COVID-19 infection and poorer outcomes for biologic reasons, including poorer respiratory health, immune changes, and clustering of comorbid illnesses among individuals with substance use disorders. Socio-structural drivers were also at play: individuals with unhealthy substance use may have encountered greater impediments to accessing COVID-19 prevention and care, physical distancing may have been more challenging, and the stressors of lockdown regulations, job loss, remote education for children, family loss, and isolation may themselves have driven more substance use, in a vicious cycle.

Among specific substance use disorders, the intersection of opioid use disorder (and opioid-related overdoses) with the COVID-19 pandemic has received much-needed attention and scholarship. Yet attention should also be drawn to alcohol-related disorders. The consumption of alcohol, which had already been increasing for years, accelerated during the pandemic. Measured in gallons of ethanol sold per capita, apparent consumption of alcohol increased by 6.6% between 2018 and 2021 across the USA—reaching approximately 597 drinks per capita per year—for Americans over 21, the highest consumption level since 1988.2 Between 2019 and 2020, the number and rate of alcohol-related deaths increased by 25%, far outpacing the rate increase of all-cause mortality during the same time.3 Studies suggest several causal pathways for COVID-19’s impact on alcohol use: childcare and school challenges, social isolation, income loss, worsening mood symptoms, and less treatment access all appear to have played roles in driving more individuals to drink larger quantities of alcohol.

Wang et al.’s useful study focuses on acute care hospitalizations as a metric of the burden of alcohol-related liver disease (ALD). The authors describe hospitalizations for alcohol-related liver diseases in the lead up to the COVID-19 pandemic and into its first year.4 In a retrospective trend analysis of adult hospitalizations for ALD at acute care hospitals across the USA from 2016 through 2020, the authors sought to quantify the ALD hospitalization surge and characterize its geographic and demographic contours. Their key finding is that, despite a decline in overall hospitalizations in 2020, there was a marked increase over that year in hospitalizations for which ALD was the primary diagnosis, reaching 10,247 hospitalizations per month compared to 8490 per month in pre-pandemic years (representing a 20.7% increase). Interestingly, there was an observed decline in hospitalizations for non-liver-disease-related alcohol use disorder-related diagnoses (including alcohol withdrawal), although the authors did not provide details on the diagnostic codes used to capture these disorders.

Additionally, their models highlight three important disparities in the burden of ALD. First, excess hospitalizations for ALD occurred disproportionately among younger (< 60 years) adults, which is concerning as younger patients with ALD are more likely to have greater losses of healthy years of life and may experience greater negative family and employment consequences from alcohol use. Second, regional analyses demonstrated higher increases in hospitalizations in the South and West USA, suggesting the need for unique regional approaches to prevention and care policies. Finally, the investigators report an over-representation of hospitalizations for ALD among White and Native American individuals.

Several limitations warrant mention. First, given that the study period concluded at the end of 2020, Wang et al.’s findings give insight into the early COVID-19 pandemic but not later stages in the pandemic when infectivity, severity, and options for care and prevention evolved considerably and better resemble the present day. Second, their unit of analysis was hospitalizations—not unique patients—and their administrative data did not allow them to identify repeat encounters for the same patient. This may obscure the burden of disease on a per-patient basis. Third, their finding that non-liver-disease-related alcohol use disorder-related hospitalizations decreased is interesting, but difficult to interpret without the specific diagnostic codes used to capture this group of disorders. Fourth, focusing on ALD as the principal diagnosis may miss cases of ALD for which the principal diagnosis was another disorder, including COVID-19, which surged during the study period. Finally, limiting analysis to hospitalizations misses other important, evidence-based care pathways for patients with ALD, including outpatient addiction treatment, hepatology care, and primary preventive care.5

Despite these limitations, Wang et al.’s findings imply an urgent need for interventions across multiple touchpoints to address unhealthy alcohol use in the current COVID-19 landscape and, even more so, should another infectious disease pandemic arise. Indeed, medications for alcohol use disorder (MAUD) have been found to be associated with improved survival and lower rates of liver-related complications such as hepatic decompensation among patients with cirrhosis.6 Acute medical hospitalization is one important touchpoint for engaging patients in evidence-based alcohol treatment, yet optimal approaches for engaging hospitalized patients with alcohol-related disorders in treatment post-discharge are unknown. Qualitative exploration of stakeholders in hospital settings suggests a need for education about MAUD among prescribing and non-prescribing clinical staff, as well as stigma reduction across stakeholders.7 One ongoing study randomizes patients with untreated alcohol use disorder to a brief negotiation interview (BNI) with referral versus BNI plus facilitated initiation of MAUD versus BNI plus MAUD plus initiation of a computer-based training for cognitive behavioral therapy (CBT4CBT).8

Acute medical hospitalization is not the only touchpoint wherein lie opportunities for alcohol-related care. Engaging patients with unhealthy alcohol use across the continuum of care settings, from outpatient primary care and liver clinics to emergency departments and hospital wards, is necessary to improve access to and continuity between different forms of alcohol-related care. A recent formative evaluation of four liver clinics in the Veteran’s Health Administration (VHA) sought to identify barriers and facilitators of integrating alcohol-related care using an implementation science framework.9 Interviews of nearly 100 clinical stakeholders and patient participants suggested that integrating alcohol-related care into liver clinics was possible, but that provider beliefs and clinic resources vary considerably so implementation strategies should be tailored to individual settings. Other settings with trusted professionals, including primary care offices and, for certain populations, pre-exposure prophylaxis (PrEP) for HIV prevention care settings, can be well suited to addressing alcohol-related care among patients with and without liver disease.10

Unhealthy alcohol use and access to evidence-based treatment vary across historically minoritized racial and ethnic groups, age groups, and geographic regions. These disparities are likely driven by systemic racism and other social hierarchies and their impact on health and health care access. Strategies in relevant touchpoints—including liver clinics, acute hospitalization, primary care, and specialty settings—are needed that overcome barriers imposed by structural racism and social determinants of health to address ALD across populations, particularly minoritized racial and ethnic populations.

In summary, in their retrospective analysis of hospitalizations for alcohol-related liver disease across the USA, Wang et al. noted marked increases in the year following the advent of the COVID-19 pandemic, with concerning disparities by age, race/ethnicity, and geographic region. Implementation strategies for evidence-based alcohol related care, including medications and behavioral approaches, need to be refined at multiple care touchpoints within the USA health system to turn the tide on these concerning trends and prepare our health system for future pandemics.