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It was during the early months of the COVID-19 pandemic when Dr. Abdel Aziz Shaheen, MD, an associate professor in the Cumming School of Medicine, noticed the lineups to get into the liquor store were longer than the lines to get into the grocery store.

“It came to my mind that because everyone was staying at home, alcohol consumption was increasing,” says Shaheen. “I told my colleagues that we have to figure out the impact that the pandemic is having on alcohol consumption and liver damage.”

What he found was alarming. In the two years before the start of the pandemic, the hospitalization rate for patients with alcoholic hepatitis (AH) was 65 per 100,000 admissions. From April 2020 to March 2021, that rate more than doubled to 133 per 100,000 admissions. In the second year of the pandemic, April 2021 to March 2022, the rate was 102 per 100,000 admissions.

The numbers for the second year of the pandemic were especially concerning for Shaheen, as vaccines became widely available and life started to return to normal.

“The problem with alcohol use is if you build a habit or a trend, it is very hard for you to change it,” he says. “In the first year of the pandemic I thought people were drinking significantly because of the restrictions and no or limited access to social activities, but that doesn’t justify to me why after 18 months the rates are still doubled compared to pre-pandemic.”

Median age drops

On top of an increase in the hospitalization rate, the median age of the patients admitted showed a concerning drop. Before the pandemic, the average age of the patients was 48, but in the two years of the pandemic it was 44.

Shaheen says we are now seeing a social norm where drinking isn’t attached to a certain age. In the past, studies showed there was a spike during a person’s university-aged years, then a dip, and another spike in the late 40’s or early 50’s. Now, Shaheen says there is more a bell-shaped curve where the spike is at 44.

“This is for people who have a severe reaction or damage from alcohol use,” say Elizabeth Baguley, a research associate in the Division of Gastroenterology and Hepatology in the Cumming School of Medicine and a member of Shaheen’s team. “Forty-four is too young.”

With the problem identified, Shaheen and his team have now turned their attention to solutions, one of which has been making headlines in recent weeks.

New alcohol guidelines show gradient of risk

Shaheen is a fan of the Canadian Centre on Substance Use and Addiction’s new alcohol guidelines for two main reasons.

He says the previous guidelines, which advised 10 drinks a week for women and 15 for men, were too black and white.

“We basically were giving the wrong message that you were safe below 10 or 15 drinks and that you were in danger if you went above,” Shaheen says.

The new guidelines show a gradient of risk, allowing people to know what the consequences they could face for consuming a certain level of alcohol are.

“I’m sharing the tables they created with my patients,” says Shaheen. “I tell them ‘Hey, it’s up to you. For liver cirrhosis, if you drink two to three drinks per week, your risk is around 10 to 20 per cent, but if you drink 14 or more your risk 110 per cent.’”

The risk is also significantly higher for women. For two to three drinks a week, the risk of liver cirrhosis is 124 per cent higher, and 10-20 drinks per week increases the risk to around 500 per cent.

Primary care pathway for at-risk patients

The second reason Shaheen likes the guidelines is they are based off an aggregation of data, instead of one or two studies alone.

“The data is there, and now we can formulate it and tell people we have evidence this is the harm associated with each drink more you have,” he says.

Shaheen has also received funding from the Canadian Institutes for Health Research (CIHR) to develop a primary care pathway to identify and manage patients at risk of alcohol-related liver disease in Calgary.

In Calgary, primary care physicians are well-connected with specialists, and have networks to help patients manage things like diabetes and fatty liver. However, Shaheen says the elephant in the room was primary care providers were not aware of the burden of alcohol use disorders on the liver.

Shaheen and his team were able to provide the primary care physicians with the evidence from the first six months of the pandemic.

“I sat down with them and said we need to tackle this problem, and even if we start with the tip of the iceberg, at least we’re doing something,” says Shaheen.

In early 2022, they started to design a clinical care pathway for primary care physicians in Calgary to talk with their patients about how much they drink, and, if their consumption levels are high, to do some investigation to see whether they should be referred to a liver specialist. Shaheen says this allows the specialists to see the patients before they have end-stage liver disease.

2023 pilot for other alcohol-related health concerns

Primary care physicians approached Shaheen about creating another approach that focused on other alcohol-related health concerns such as addiction.

Shaheen and his team are in the process of developing that now and are hoping to launch a pilot for it in 2023. He says they will refine it as they go, as it is based upon individual patient’s needs.

Shaheen says the primary care physicians are the cornerstone for everything they’re doing.

“This pathway will fix the broken chain between identifying those that need help at an early stage and providing them with help,” says Shaheen.

“The beauty of it is we are not waiting in our clinics for patients, we are trying to reach out to patients in the community and tell them we are here to help if you need it.”