It was no surprise to see that we maintain our competitive streak and rank 8th and 9th for the highest rate of monthly binge drinking and alcohol consumption per capita respectively compared to other OECD countries. 

I suppose it could be worse because the data tell us our alcohol consumption has not changed since 2016, but we are below the Government’s target for 2020 which is 9.1L per capita.

In 2019, those over 15 years of age in Ireland drank 10.8L of pure alcohol per capita, that equates to 40 bottles of spirits, 113 bottles of wine or 436 pints of beer. Given that one in four of us do not drink, the rest of us are left with the burden of drinking 53 bottles of spirits, 149 bottles of wine or 574 pints of beer each. Added to this over half of us are hazardous drinkers and binge drink.

Excess alcohol consumption causes fatty liver, which is fully reversible in the early stages. Ongoing consumption silently (and that’s the deadly part, there are often no telling or early signs) leads to scarring or fibrosis and eventually the worst form of liver disease, cirrhosis.  

This can be complicated by jaundice (going yellow), ascites (fluid build-up in the abdomen or stomach), bleeding from dilated veins, confusion and liver tumours. No surprise then that alcohol-related liver disease is associated with a high morbidity (getting sick) and mortality. 

We witness a lot of deaths in hepatology. However, for those who can, it is never too late to stop drinking; abstinence can result in stabilisation and improvement for some.

Unfortunately the consequences of this consumption are seen on a daily basis. Since I started my career in hepatology over two decades ago I have had the privilege of seeing many changes, but one thing is for sure, like viruses, alcoholic liver disease isn’t going away anytime soon. 

I have seen the typical inpatient with severe alcoholic liver disease change from mostly middle-age men to a higher percentage of females, patients presenting at younger ages, overall numbers increasing and many young patients dying during their first hospital admission.

Miriam's case

I sat at the edge of Miriam’s bed; she had been admitted five days earlier with severe jaundice and ascites (swollen abdomen due to excess fluid). I hoped she might ‘turn the corner’ although I knew the odds were against her. It was clear she was not going to get better and would die. 

I had to tell her this and asked if she would like me to speak to any member of her family. Having being separated a few years previously she did not want to share her health issues with any other family member but had two children aged six and 10.

The social worker waited patiently at the door and was outwardly distressed to hear of her poor prognosis. I did not envy her job when days later Miriam died leaving her children behind. 

The one comment that I will always remember is Miriam saying ‘if only she knew’. She was a mother like me and clearly had no idea that her drinking habits were a threat to her life and, unlike some, she was not going to get a second chance.

Liver disease and women

The risk of liver disease increases exponentially based on how much alcohol is consumed. Women by virtue of being smaller and having more body fat have higher alcohol levels after consuming similar amounts to males and are therefore more likely to get liver disease at a younger age. 

This is a huge concern as while the HRB have shown that hospital admission rates for alcohol are still higher in men than women, in those aged 17 years and younger, half are female. So in the future it is likely that we will see as many females and perhaps more than males with end-stage liver disease.

I looked to see if the HRB statistics reflect what is happening locally and I believe they do. Looking at patients with cirrhosis (the most severe form of liver disease due to alcohol) that have been under my care in CUH, 67% are male and 33% female. The median age is 62 years, ranging from 24 to 85 years. 

Since I started the database in 2010, 37% of them have sadly died. The death rate has continued to increase every year and most of those dying are in their 40s, 50s, 60s and 70s, showing yet again that alcohol is a premature killer.

While alcohol-related hospital discharges have increased 216% since 1995, discharges due to alcohol-related liver disease have increased 262% in the same time period. The length of stay for alcohol-related conditions has increased from six to 10.3 days since 1995. 

While males account for 71% of hospital discharges, in those aged 17 years or younger, females accounted for almost half. 

Patients with liver disease tend to spend a long time in hospital. Undoubtedly some of this is due to the severity of their liver disease that takes time to improve but they also commonly have other issues such as malnutrition, infections, confusion and bleeding, all of which take time to treat. 

Eventually when these medical conditions are treated and stable there are not uncommonly social issues that delay discharge. 

Long-term placement or a nursing home must be found for the now confused 55-year-old no longer capable of living alone. This can take weeks and it is not unusual for us to have patients like this on the ward waiting for a place to be discharged to; not infrequently as the weeks pass and they benefit from abstinence, they are fit to return home by the time an alternative is found. 

In the interim I cannot help but calculate how many patients could have benefited from that same bed.

The effects of Covid

Will we ever see the demand again for toilet roll and wine like we did last March? Off licences were declared an essential business and remained open, so thankfully we were not going to be overwhelmed with patients in the DTs at the frontline. 

We worried about the cost of PPE while €158m was spent on off-trade alcohol in four weeks. 

However, overall alcohol consumption fell by 6.5% in 2020 mainly as a result of pub closures. Beer consumption fell by 17% while wine consumption increased by 12%. Clearly, we were drinking at home.

While this may appear safer in some aspects, we were unlikely to get caught for drunk driving, it is likely that the vulnerable and children dealt with the harmful and unpleasant nature of excess drinking in the home. The HRB reported findings similar to my own experience; 22% reported drinking more since Covid, 17% were drinking less, often men as the pubs were closed. 

We saw many patients drinking more due to stress (both the stress of working from home or losing business), and out of boredom or habit. 

Since the start of the pandemic we have seen a steady flow of patients admitted with advanced liver disease, there has been no reduction in numbers, many of these are delaying presentation due to the pandemic and therefore are presenting at a much more advanced stage, with an associated higher death rate.

As I write 12 of my current 17 in-patients with severe liver disease have alcoholic liver disease. Statistics and experience tell me only some of them will make it out of hospital alive this time. Many will re-present if they don’t stop drinking and live to suffer from complications and perhaps several further hospital admissions.

Apart from the health consequences due to alcohol, there is a huge cost to society. The cost of alcohol-related harm in Ireland in 2013 was estimated at €2.35bn (figures from Alcohol Action Ireland). This was due to a combination of hospital discharges (€1.5bn), crime, accidents, absenteeism and premature mortality. 

Every night 1,500 beds are occupied as a result of alcohol problems. 10% of all general in-patient costs are spent on alcohol-related discharges with 30% of emergency department and 7% of GP costs related to alcohol.

Public awareness of alcohol-related harm

In the era of Dr Google what did surprise me in the report is the public’s lack of awareness about some aspects of alcohol. Only 21% were aware that alcohol is associated with many cancers, including breast cancer. 

When asked, 90.5% were however aware of a connection with alcohol and liver disease but less than half were aware of a connection between alcohol and other common illnesses such as pancreatitis, high blood pressure, and bowel cancer. I wonder too if they know that there are at least 30 conditions at least wholly attributable to alcohol and many more partially attributable to alcohol (heart disease and stroke, injuries, infection to mention a few).

I would like to take this opportunity to dispel the myth that all liver disease is due to alcohol. This incorrect assumption by many has resulted in an unnecessary stigma attached to liver disease. As a consequence liver disease is not a glamorous disease to admit to having and suffers from lack of funding and priority compared to many other illnesses.

A female patient of mine died from autoimmune liver disease a number of years ago on a cardiology ward and asked in her death notice for donations to go to the cardiology ward, sending out a message to her small community that she did not have liver disease and was not a drinker (which she wasn’t) but I guess it sat more easily with her family to pretend she died of a cardiac condition. 

While most of our sickest in-patients with liver disease have drunk too much, there are many other causes of liver disease. Inherited conditions such as haemochromatosis and cystic fibrosis can be associated with cirrhosis, as can chronic viral hepatitis B and C. 

Patients can develop autoimmune conditions of their liver and bile ducts such as autoimmune hepatitis, primary biliary cholangitis and sclerosing cholangitis. The other current epidemic we are dealing with is metabolic-associated fatty liver disease (MAFLD) where fatty liver often associated with obesity and diabetes can result in cirrhosis and end-stage liver disease. This has now become a global health burden equivalent to alcoholic liver disease.

I would recommend that everyone takes a look at this concise, easily readable and superbly laid out report from the HRB, there are many other aspects covered that are of interest such as alcohol in children, pregnancy and the elderly. The final chapter is dedicated to alcohol policy and the all-important Public Health (Alcohol) Act 2018; the three-year interval between the publication of the Bill and enactment of the Act was apparently the longest ever in Ireland. 

I remain optimistic (perhaps naïvely) that this is embraced by the Irish people with the same enthusiasm as the smoking ban and that I might see some of the improvements and reduced mortality from alcohol in my working lifetime.

• Dr Orla Crosbie MD, FRCPI, is a consultant hepatologist at CUH