Nora began drinking heavily in her late 30s, turning to alcohol after the demons of early childhood trauma resurfaced. A self-described emotional drinker, the fortysomething Denverite, who asked that her real name be withheld to protect her privacy, says her consumption only increased during the COVID-19 crisis. “You’d be seeing all these memes on social media at 2 p.m. that people were having wine parties together,” Nora says, “so you’d feel comfortable doing it as well.”

But after a two-week bender in early 2021, Nora woke up feeling more broken than usual. Finally listening to her overtaxed body, she quit cold-turkey and, through counseling, her mental health improved. The physical damage, however, was done. Less than a year after she got sober, physicians at UCHealth University of Colorado Hospital diagnosed Nora with liver cancer caused by alcohol abuse. “I own my actions,” she says. “I hold no fault toward anyone. The first thing my doctor told me was, ‘You gave yourself cancer.’  ”

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Nora wasn’t the only person to drink themselves sick during the pandemic. According to the Centers for Disease Control and Prevention (CDC), the number of Coloradans who died from alcohol-associated liver disease (ALD) increased by more than 32 percent from 2019 to 2021. That’s reflective of the trend across the United States, where such deaths rose by more than 17 percent a year between 2019 and 2021, dwarfing the 3.5 percent annual increase over the previous decade. Still, Colorado stands out: Researchers at Cedars-Sinai Medical Center in Los Angeles ranked Colorado among the top six states for the number of ALD-related deaths during the pandemic.

Not only are Coloradans—and Americans in general—developing ALD more frequently, but they are also doing so much earlier. People between the ages of 25 and 44 represented the sharpest upswing in the United States between 2019 and 2021, a statistic Dr. Elizabeth Pomfret, chief of the transplant surgery division at UCHealth, has witnessed firsthand. In the past, most of Pomfret’s patients were in their late 50s and 60s and feeling the effects of a lifetime of steady drinking. Today, her patients are often parents of school-age kids and younger professionals who upped their intakes during the pandemic to cope with employment uncertainties, health fears, homeschooling, and quarantine challenges. Says Pomfret, “It’s really been staggering and eye-opening for all of us in the transplant community to see just how unbelievably the incidence of really strong, strong alcohol use has changed things.”

It’s no secret that Coloradans love their booze. The Centennial State boasts some of the nation’s lowest taxes on liquor, beer, and wine, meaning imbibing is more affordable here than in most places. And though it’s only the 21st largest state by population, Colorado is home to the country’s fifth-highest number of craft breweries. Locals were feeling the negative effects of outsize consumption even before COVID-19: Colorado’s alcohol-related deaths have significantly outpaced the national rates for the past decade. “It’s been bad for a long time,” says Dr. Bill Burman, former director of the Public Health Institute at Denver Health. “We have just failed to recognize it. We’re so used to it that we don’t see it.”

Nevertheless, local governments went to great lengths during the pandemic to keep Coloradans’ glasses full. After the infamous Denver Prohibition of March 2020, when the city announced liquor stores would not be included among the list of essential businesses and, thus, would have to close temporarily, then Mayor Michael Hancock reversed that decision. (The mayor wasn’t only bowing to constituent pressure. Health experts warned that alcoholics could die from withdrawal if forced to go cold-turkey.) The state then issued an emergency executive order that, among other things, allowed restaurants to serve takeout alcohol. In June 2021, Governor Jared Polis signed legislation that extended the order. Now, adults can grab a pitcher of margaritas or an old-fashioned to-go between 7 a.m. and midnight daily.

Also during the pandemic, viral drinking jokes began filling social media feeds. Posts about “mommy juice” and recipes for “quaran-tinis” seemed to especially target women, who were often left to balance their full-time jobs with their children’s educations and well-being. “There was a meme going around that [said], ‘When I wear a face mask, nobody can smell that I’ve been drinking,’  ” Nora says. “It might’ve been tongue-in-cheek, but it was very real.”

While booze continued to flow freely, those who suffered from alcohol misuse suddenly found themselves without the social structures they depended on to stay sober. A crucial treatment strategy, says Dr. Jonathan Ritvo, senior medical director at UCHealth’s Center for Dependency, Addiction and Rehabilitation, is helping people discover common ground with others who have similar experiences. But for up to two months after COVID-19 hit, some Alcoholics Anonymous (AA) meetings were only available virtually. “The loss of their regular in-person meetings, loss of community and connections…was maybe the most important factor in relapse,” Ritvo says. “The loss of structure in not going to work, which made it possible to drink during the workday, played a role, too. Human connections are the most important antidote to an addiction.”

There are three stages to ALD: fatty liver disease, which rarely results in symptoms and is reversible; hepatitis that can lead to nausea, jaundice, and belly pain, but is also often reversible; and cirrhosis, where the scarring of the organ becomes so severe that a transplant is sometimes the only remedy. Other complications of ALD include, as in Nora’s case, cancer, which is usually treatable. But livers don’t typically fail from ALD overnight, Burman says, which suggests that Centennial Staters have been drinking to an unhealthy extent for a long time. COVID-19 just accelerated their reckonings.

With a growing contingent of heavy drinkers showing signs of liver disease, it’s not surprising to learn that ALD patients made up about 32 percent of those on the U.S. liver transplant list in 2020, compared with 22.2 percent a decade before, according to the U.S. Department of Health and Human Services. Although state numbers are not available, Pomfret says the number of Coloradans who need a transplant because of ALD has increased dramatically since early in the pandemic. (Currently, 170 people in Colorado are waiting for new livers.) The upshot: There’s an organ supply shortage throughout the country, one that UCHealth hopes to help mitigate in Colorado through the adoption of new technology.

Like kidneys, livers can come from both deceased and live donors, which, in theory, expands the pool. However, barriers to live organ donation—which include large incisions, a lengthy recovery, and the inherent risks of surgery—are hefty. (The University of Colorado Hospital suspended its program for a short time in 2010 after the death of one of its live donors.) It’s not a sacrifice many are able or willing to make, especially if the donation is nondirected, meaning the liver goes to a stranger.

UCHealth already boasts one of the largest nondirected liver donor programs in the country, with 14 percent of its transplants coming from people the patient doesn’t know, compared with about one percent worldwide. Pomfret can’t point to a specific reason why that’s the case, so she chalks it up to Coloradans’ altruistic nature. In an attempt to grow UCHealth’s stock and make liver donations less daunting, in June, Pomfret’s team performed its first robotic hepatectomy, which involves less cutting and a shorter recovery time for donors.

The first person to go under the UCHealth robot’s knife, Danel Kuhlmann, 54, had previously given a kidney to her mother before bestowing a part of her liver to a stranger. “I believe in technology and advancements,” Kuhlmann says, “and I’m a big believer in jumping on board with change. I wasn’t scared of the robot, [which] can help them see 10 times what the naked eye can see.” After the operation, Kuhlmann returned to near full speed in weeks, about half the typical recovery time, without any significant scars. That’s part of the reason why Pomfret believes robotics will not only boost the number of live donors but also reduce economic inequities in the transplant system, as underserved folks often don’t have anyone within their circles who is both a match and can afford to take extended time off work.

Another way to address ALD, says Dr. Clark Kulig, a transplant hepatologist at HealthOne’s Presbyterian/St. Luke’s hospital, is through early detection. Because livers heal themselves so efficiently, a slow buildup of scar tissue wouldn’t necessarily be detectable until heavier drinking (say, stress binging during a global pandemic for two years) accelerated the damage. Kulig suggests that an elastography—a type of noninvasive test that sends vibrations into the liver to detect scarring—should be the norm. The procedure is covered by most insurers, Kulig says, but most patients don’t realize it’s an option. “It’s really hard to tell who’s scarring, short of a liver biopsy,” Kulig says. “People who drink a certain amount per week could get this test to understand if that’s hurting their liver. Maybe every couple of years.”

Meanwhile, the surge of ALD has forced an adjustment in the dynamic of care. Rehab, social support, and abstinence used to be required to even get on the transplant waitlist. Now, patients sometimes arrive too sick to delay treatment. “We had to change the entire structure of how we conduct the evaluation,” Pomfret says. “How do we build [these treatments] on the back end now and get these people the support they need? It’s really put an enormous burden on the health care system.”

Medical advances will only treat one end of the ALD crisis; social programs, public outreach, and policy interventions may be the best ways of curbing drinking before patients reach liver failure. But following Prohibition in the 1920s and early 1930s, “drink responsibly” has been the most widespread rallying cry about the adverse effects of alcohol—and it’s clearly not working. “I don’t know that the inaction is due to the power of the [alcohol] industry,” Burman says. “There hasn’t been a serious attempt that might trigger vigorous pushback. I suspect the libertarian background of the West is part of the answer.”

Burman points to the successful anti-smoking initiative as a possible roadmap for influencing drinking behavior. That effort largely began in the 1960s with the U.S. Surgeon General’s report linking tobacco to cancer and ramped up when federal and state governments increased taxes on cigarettes and sued the major tobacco companies.

Jenn Jones, whose liver succumbed to alcohol-induced hepatitis and cirrhosis in 2018, knows how damaging a lack of social support can be. The 52-year-old drank to excess to numb symptoms of complex PTSD, major depressive disorder, and general anxiety disorder, largely stemming from intimate partner violence. After nearly drinking herself to death, the shame overwhelmed her. Only the rekindling of a strong connection—in her case, caring for her beloved dog—helped her take steps toward recovery. “He needed me, I needed him,” she says. “Finding that short-term purpose really got me through that initial point in time.”

ALD carries a stigma, Jones says, that makes it difficult for people to advocate for themselves and determine the most effective course of treatment and healing. Often, she says, people won’t admit how much they drink to their doctors because they’re ashamed. So last year, Jones founded an Aurora-based organization that’s now known as Sober Livers to help people like herself navigate an ALD diagnosis. By recently restructuring as an official program of the nonprofit Fatty Liver Foundation, Sober Livers will be able to apply for grants to build out initiatives such as facilitated online group support and resource sharing networks. It will also provide access to an advisory group of medical providers who will offer the latest news and information about ALD. The overarching mission: to engender a sense of purpose, belonging, and connection.

But until more healthy livers become available, patients like Nora will either get lucky or they will die. In December 2022, after three potential donors fell through, Nora received a transplant and is today healthier than she’s ever been. Looking back, it’s clear that her mental health struggles were no match for COVID-19’s booze-as-survival culture. “It was normalized, and triggers were so easy,” she says. “Who wasn’t drinking during the pandemic?” She has, however, been able to forgive herself: “You are not your mistakes.” Nevertheless, you still sometimes have to pay for them.

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