Alcohol Related Liver Disease

Alcohol is the most widely consumed mood-altering substance in the United States. It is a causal factor in more than 200 disease and injury conditions.[1] Heavy drinking has many potential health consequences including liver disease. In the United States, it is the leading cause of liver disease.[2] Alcohol related liver disease [ARLD] is a result of heavy, prolonged drinking that results in liver swelling and inflammation. Over time this can lead to cirrhosis, the final stage of liver disease. The symptoms of ARLD depend on the stage of the disease.

There are three stages^[3]:

1. Fatty liver disease: This is the first stage of ARLD, where fat starts to accumulate around the liver. It can be cured by not drinking alcohol anymore.
2. Alcoholic hepatitis: Alcohol abuse causes inflammation (swelling) of the liver in this stage. The outcome depends on the severity of damage. In some cases, treatment can reverse the damage, while more severe cases of alcoholic hepatitis can lead to liver failure.
3. Alcoholic cirrhosis: This is the most severe form of ARLD. At this point, the liver is scarred from alcohol abuse, and the damage cannot be undone. Cirrhosis may eventually lead to liver failure.

The signs of liver disease can vary.  In the first stage of liver disease termed alcoholic fatty liver disease there are no physical symptoms. The findings on examination of an enlarged liver and unexplained elevation of liver function tests can be a clue. Occasionally a fatty liver is discovered incidentally during an ultrasound of the abdomen or with a CT/MRI scan for another medical issue. Remember. At this stage the patient has no symptoms related to alcoholic fatty liver disease.

Acute alcoholic hepatitis, the second stage of ARLD, can present with nausea, loss of appetite, weight loss, swelling of the abdomen or legs, confusion, vomiting, fever, malaise, and jaundice [yellowing of the skin]. Patients at risk for more severe ARLD include persons that do not eat well, binge drinkers, and persons with a family history of liver disease.

Alcoholic cirrhosis is the most severe stage of alcohol related liver disease. Cirrhosis occurs in 30% of individuals with long-standing consumption of more than 3 drinks a day.[4]  Cirrhosis implies that scar tissue has replaced the normal liver cells after the liver cells die. Cirrhosis is marked by degeneration of cells, inflammation, and fibrous thickening of tissue.  Once cirrhosis has developed, the liver damage is irreversible. The prognosis is improved with abstinence, but complications (e.g., gastrointestinal bleeding) often occur. Medications are available to assist in the management of more advanced liver disease including cirrhosis. Liver transplantation may be considered in patients with severe complications.[5]

Making the diagnosis of alcoholic liver disease requires a detailed patient history with supportive laboratory and imaging studies. A liver biopsy may be useful to confirm the diagnosis, and to rule out other diseases. [6] By far the most important recommendation to the patient diagnosed with alcohol related liver abnormalities is to openly discuss their drinking habits. Lying to your doctor may result in numerous extraneous and unnecessary tests and can ultimately delay the diagnosis.

Treatment and management of alcohol liver disease depend on the extent of the disease. In general recommendations include:

• Alcohol abstinence, enrollment to detoxification programs and treatment to support long term recovery
• Nutritional support
• Screening for hepatocellular carcinoma with ultrasonography every six months and screening for esophageal varices in those with cirrhosis
• Chronic alcoholics are more prone to develop hepatotoxicity from acetaminophen, so dosing should not exceed more than 2000 mg per day. An average person can tolerate up to 4000 mg of acetaminophen per day.
• Treatment of co-existing liver diseases such as Hepatitis B and C viral infections[7]

In summary the diagnosis of alcohol related liver disease at any stage can be treated once the diagnosis is established. The first step is to discuss openly your drinking behaviors with your physician. The second step is to be willing to address the drinking that got you there.

Marc Whitsett MD

DABIM, ABAM, FASAM

[1] https://www.who.int/news-room/fact-sheets/detail/alcohol

[2] https://www.ncbi.nlm.nih.gov/books/NBK546632/

[3] https://www.healthline.com/health/alcoholism/liver-disease#types-and-symptoms

[4] https://www.ncbi.nlm.nih.gov/books/NBK546632/

[5] https://pubmed.ncbi.nlm.nih.gov/9553600/

[6] http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/alcoholic-liver-disease/#:~:text=The%20diagnosis%20of%20alcoholic%20liver,for%20enrollment%20in%20clinical%20trials

[7] https://www.ncbi.nlm.nih.gov/books/NBK546632/

Dr. Whitsett is Board Certified in Internal Medicine and Addiction Medicine. He is the Medical Director for The Ridge Treatment Center. You can read his full bio here.

I Drink A Lot. Can I Just Quit Drinking Safely?

Some people drink a lot. They often ask can I quit drinking safely? Some people decide they should quit drinking, as they understand that excessive drinking is not healthy. For people who drink to excess, one of the most difficult things to do is to make that decision to quit.

However, before someone decides to just quit drinking, it is important for them to understand that for some people, this can be dangerous, even life threatening.

So how do you know if it is safe to just quit?

Well, it depends.

Most people that drink too much are not physically dependent upon alcohol. Alcohol-dependent individuals must drink every day. When they stop drinking for even 1 day, they suffer symptoms of alcohol withdrawal.

Symptoms of alcohol withdrawal include, but are not limited to:

• hand tremors
• a lot of anxiety
• sweating
• nervousness
• a racing heart
• body twitches
• seizures

Rarely symptoms of alcohol withdrawal escalate, leading to “DTs”, or delirium tremens, a life-threatening syndrome that can cause cardiovascular and respiratory failure. Other symptoms of DTs might include confusion, fever, and hallucinations.

In addition, someone who stops drinking abruptly can also suffer seizures, with or without DTs.

If a person is able to stop drinking for 24 hours and they have no withdrawal symptoms such as hand tremors, feeling a lot of anxiety, sweating, nervousness, a racing heart, and body twitches, generally there is no danger of continuing not to drink and medical care with medication is not required.

However, if a person experiences the above mentioned withdrawal symptoms:

1. While they are actively cutting down on their drinking, or
2. Within 24 hours of quitting drinking

then it is important to seek medical attention.

In general, people at high risk of medical complications coming off alcohol are:

1. Those that have a history of DTs.
2. Those with a history of seizures.
3. Those people with a history of chronic, heavy, daily drinking (usually for weeks or months without a day off).
4. Those that have to drink to start the day because of hand tremors or feeling ill.

It is difficult to quantify if there is a specific amount of alcohol consumed that places someone at risk for alcohol withdrawal syndrome and/ or DTs. 

While some people can drink large amounts (say a case of beer a day), not everyone that drinks this much has alcohol withdrawal since the ability to withstand alcohol’s physical effects can vary from person to person.

As a general rule (no medical studies to confirm), if a person drinks 13 standard drinks a day for a month, then they have about a 50% chance of having major life-threatening withdrawals.[1] 

In instances where a person develops alcohol withdrawal, it is recommended that the person seeks medical attention to assess and advise treatment. Alcohol withdrawal can be lethal. When alcohol withdrawal is medically managed, however, the fatality rate is extremely low.

When we assess a patient with alcohol withdrawal, we check vital signs, a breathalyzer, obtain a brief history and physical and do an assessment called a “CIWA-Ar”, or Clinical Assessment for Alcohol Withdrawal, Revised.[2] This 5-10 step assessment is simple, and can predict if someone is at risk for a mild, moderate or severe alcohol withdrawal syndrome.

When we identify a patient with alcohol withdrawal symptoms, we determine the severity of the withdrawal risk and then place the patient in a level of care appropriate for that particular patient. Most of the time, a patient can be treated with medication as an outpatient; rarely, the patient requires hospitalization.

So, my advice is that if a person is experiencing symptoms that suggest alcohol withdrawal, they should consult with a health care professional and obtain a medical evaluation to determine if they are at risk.

If the person is not at risk, no harm, no foul. But I guarantee that if they are at risk, they will be glad they sought medical attention to manage their withdrawal from alcohol in the safest manner possible.

[1] http://hams.cc/odds/; a standard drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of liquor

[2] https://www.mdcalc.com/ciwa-ar-alcohol-withdrawal

When people talk about the dangers of certain substances, they often are referring to how addictive these substances are. This is not necessarily the same thing, because a substance can be extremely dangerous and have a high potential for overdose without causing much dependence. Other substances are more addicting, yet their risk for sudden overdose is low. However, these substances are dangerous in their own way because they cause serious health risks if used over a long period of time.

Researcher David Nutt and his colleagues studied the most harmful drugs in the world and came up with a list of the top five. Nutt and his team developed a “matrix of harm” that helped them assess and classify substances based on the risk of each drug.

Nutt explains in the study, which was published in The Lancet, “Drug misuse and abuse are major health problems. Harmful drugs are regulated according to classification systems that purport to relate to the harms and risks of each drug. However, the methodology and processes underlying classification systems are generally neither specified nor transparent, which reduces confidence in their accuracy and undermines health education messages. We developed and explored the feasibility of the use of a nine-category matrix of harm…to assess the harms of a range of illicit drugs in an evidence-based fashion. Our methodology offers a systematic framework and process that could be used by national and international regulatory bodies to assess the harm of current and future drugs of abuse.”

The following are the five most addictive substances, according to researchers.

1. Heroin and Opiates. The number one addictive substance on Nutt’s list is heroin an opioid street drug. Included in this category would be other opioids, including prescription painkillers, which work on the brain in the same manner as heroin. This group of drugs received a score of 3 out of 3, putting it at the top of the addictive substance list.

Heroin increases the levels of dopamine in the brain, causing a feeling of euphoria and making the user instantly crave more. Opioids, in general, have caused a huge disruption in America in the last decade, as more and more people are becoming hooked on prescription painkillers or their more dangerous replacement, heroin.  It is estimated that nearly 25% of all people who try heroin at least one time will become addicted.

According to the National Survey on Drug Use and Health (NSDUH), in 2016 about 948,000 Americans reported using heroin in the past year, a number that has been on the rise since 2007. This trend appears to be driven largely by young adults aged 18–25 among whom there have been the greatest increases. The number of people using heroin for the first time is high, with 170,000 people starting heroin use in 2016, nearly double the number of people in 2006 (90,000). In contrast, heroin use has been declining among teens aged 12–17. Past-year heroin use among the nation’s 8th, 10th, and 12th graders is at its lowest levels since 1991, at less than 1 percent in each grade level.

According to the National Institute on Drug Abuse, those who are addicted to heroin and stop using the drug abruptly may have severe withdrawal. Withdrawal symptoms—which can begin as early as a few hours after the drug was last taken—include:

• restlessness
• severe muscle and bone pain
• sleep problems
• diarrhea and vomiting
• cold flashes with goose bumps (“cold turkey”)
• uncontrollable leg movements (“kicking the habit”)
• severe heroin cravings

2. Cocaine. Second on Nutt and his team’s list of most addictive substances is another common illicit drug, cocaine. This drug is a stimulant that interferes with the dopamine receptors in the brain, causing dopamine levels to increase and cause a feeling of euphoria. Cocaine also causes increased energy, rapid heart rate, and increased blood pressure. It has an extremely fast impact on the brain and a short half-life, which causes the user to seek more as soon as the high wears off.

It is estimated that 21% of people who try cocaine will become dependent on it at some time in their life. According to the National Survey on Drug Use and Health (NSDUH), cocaine use has remained relatively stable since 2009. In 2014, there were an estimated 1.5 million current (past-month) cocaine users aged 12 or older (0.6 percent of the population). Adults aged 18 to 25 years have a higher rate of current cocaine use than any other age group, with 1.4 percent of young adults reporting past-month cocaine use.

According to the National Institute on Drug Abuse withdrawal from cocaine causes:

• depression
• fatigue
• increased appetite
• unpleasant dreams
• slowed thinking
• insomnia
• agitation
• extreme cravings for the drug

3. Nicotine. It might come as a surprise to some, but nicotine was the number three addictive substance on Nutt’s list. As nicotine is smoked, it is delivered to the brain rapidly, mimicking receptors in the brain and causing an increase in dopamine similar to cocaine.

According to the National Survey on Drug Use and Health (NSDUH), fewer Americans are smoking today. In 2013, an estimated 55.8 million Americans aged 12 or older, or 21.3 percent of the population, were current cigarette smokers. This reflects a continual but slow downward trend from 2002 when the rate was 26 percent.

However, those who are addicted to nicotine find it extremely difficult to quit, even when faced with serious health concerns. In fact, tobacco use is the leading preventable cause of disease, disability, and death in the United States, with 16 million people suffering from a serious illness that is caused by smoking. More than two-thirds of Americans who tried smoking reported becoming dependent during their life.

According to the World Health Organization:

• Tobacco kills up to half of its users.
• Tobacco kills more than 7 million people each year. More than 6 million of those deaths are the result of direct tobacco use while around 890 000 are the result of non-smokers being exposed to second-hand smoke.
• Around 80% of the world’s 1.1 billion smokers live in low- and middle-income countries.

It is difficult to quit using nicotine. According to smokefree.gov, symptoms of quitting smoking include:

• cravings for cigarettes
• feeling down or sad
• insomnia
• irritability
• trouble thinking clearly and concentrating
• feeling restless and jumpy
• slower heart rate
• weight gain

4. Barbiturates (“downers”). Next, on Nutt’s most addictive substance list are barbiturates or downers. These are medications that work on the individual by shutting down signals in certain regions of the brain. These medications are used to treat anxiety disorders and insomnia and can lead to addiction very easily.

Today in America, barbiturates have largely been replaced by benzodiazepines, which act in much the same way, and are also addicting. According to National Survey on Drug Use and Health (NSDUH), 12.5% of adults in the U.S. used benzodiazepines, which extrapolates to about 30.5 million persons. However, only 2.1% of U.S. adults misused them (at least once), and only 0.2% met the criteria for benzodiazepine use disorders. Among benzodiazepine users, 17.1% misused them, and fewer than 2% had benzodiazepine use disorders.

Barbiturates and benzodiazepines are dangerous to withdraw from, and the individual should be monitored when quitting these medications. Withdrawal symptoms include:

• irritability
• sleeplessness
• seizures
• tremors
• hallucinations
• fever
• sweating
• delirium
• cardiovascular collapse
• severe anxiety
• hypotension
• mood disorders
• death

5. Alcohol. Finally, one of the most commonly used legal addictive substances in America is on Nutt’s list. Alcohol is consumed by millions of people throughout the world, some even citing health benefits to moderate drinking. Not all agree, however. Alcohol depresses the central nervous system, causing the brain to release dopamine and endorphins. Those who consume alcohol on a regular basis develop a tolerance to it, which requires them to drink more and more in order to feel the same effects. During this time, dependence settles in for many and can lead to a lifetime of addiction.

According to the 2015 National Survey on Drug Use and Health (NSDUH):

• 86.4 percent of people ages 18 or older reported that they drank alcohol at some point in their lifetime; 70.1 percent reported that they drank in the past year; 56.0 percent reported that they drank in the past month.
• In 2015, 26.9 percent of people ages 18 or older reported that they engaged in binge drinking in the past month; 7.0 percent reported that they engaged in heavy alcohol use in the past month.
• 15.1 million adults ages 18 and older had and alcohol use disorder (AUD). This includes 9.8 million men and 5.3 million.
• About 6.7 percent of adults who had AUD in the past year received treatment. This includes 7.4 percent of males and 5.4 percent of females with AUD in this age group.
• An estimated 88,000 people die from alcohol-related causes annually, making alcohol the third leading preventable cause of death in the United States.
• In 2014, alcohol-impaired driving fatalities accounted for 9,967 deaths (31 percent of overall driving fatalities).

Alcohol withdrawal is dangerous and should not be attempted alone. Symptoms include:

• agitation
• anxiety
• headaches
• shaking
• nausea and vomiting
• disorientation
• seizures
• insomnia
• high blood pressure
• hallucinations
• delirium tremens
• death

All of these substances are dangerous if overused or abused. Some, such as prescription medications, can provide benefits if used with caution. However, it is important that we work to educate our communities about the dangers of these very addictive substances so that we can work to prevent abuse and dependence and provide treatment to those who are struggling with addiction.

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60464-4/fulltext

When choosing the best treatment option for someone struggling with addiction, there are lots of variables to consider: residential or outpatient? Location? Treatment philosophy? Recovery rate? Price? There’s another often-overlooked facet, though: size. Different drug and alcohol rehab facilities have different capacities, from less than a dozen to over one hundred patients at once. How can you tell which size of rehab facility best suits your needs?

Larger facilities have the capacity to hold up to (and sometimes more than) a hundred patients simultaneously. These centers often look very similar to hospitals or even college dormitories or campuses. They can have deeper medical staffs with entire detox wings. Size can be an asset. Group therapy is easy to organize with the massive client base. There is less chance of having to be on a waiting list, since there are more beds to fill. Food is generally served in cafeterias with buffet lines. Large facilities often have amenities on-site like a gym or lecture hall. This opens up a wide variety of possible activities for a patient in a center like this, and allows the center to schedule inspirational or motivational speakers to give speeches to the patients. Also, these centers can be more economical than facilities with fewer beds, although of course there are exceptions.

However, because of the sheer volume of patients at a large residential facility, it’s difficult to provide very focused treatment nor have a high staff to patient ratio. The setting might also seem uncomfortable to patients unused to small, dorm- or hospital-like rooms or an institutional way of living. Smaller facilities like The Ridge offer very few beds—only 14 in The Ridge’s case.

Addiction patients should not feel like they’re passing through an assembly line during treatment. Each patient at The Ridge receives focused attention. For more about us and our program click here.

Because the staff-to-patient ratio is much higher than in a larger center, patients receive intensely focused care and have special needs addressed. Often the facility is comfortably furnished like a lavish home. This level of familiarity and comfort with the setting helps patients not feel tense or afraid about treatment. Because the client base is so small and so concentrated, the patients often feel as if they’re living as a family. They form bonds of support and trust between each other that can be very helpful in recovery. Essentially, a patient at a smaller facility feels more like they personally matter and are receiving care for them as opposed to being a cog in a treatment machine.

Smaller drug and alcohol abuse rehab facilities may represent a higher investment, but The Ridge feels the quality of care makes that investment well worthwhile. The low census allows us to not only closely focus treatment, but also to provide recreation, exercise and chef-plated meals to restore nutrition.  We feel this premium care approach helps to boost our recovery rates.  Along with our Joint Commission accreditation, we are now certified by various licensing board assistance groups to treat licensed professionals, including doctors, dentists, nurses and lawyers.