By Jody DiPerna
Pittsburgh Current Senior Contributor
Bars are closed up and the liquor stores are, too. The lack of access to craft cocktails during the COVID-19 crisis may be something to joke about as an uptown problem in the face of the most serious public health crisis of our lifetimes, but it is a serious matter for alcoholics.
For a person with significant alcohol dependence, what happens when the well runs dry and the tap is shut off?
The nature of alcohol itself makes the problems unique as the body starts to go into physiological withdrawal very quickly. According to Lawson Bernstein, MD, Medical Director for Behavioral Health at UPMC McKeesport “Alcohol is a very short half-life drug, so you stop drinking and within six to twelve hours you’re in trouble.”.
Going cold-turkey is a risky way to come off of alcohol dependence. Because it is metabolized so quickly, the body starts to crave it fast.
“You’ve got a substance which basically has turned down the volume on a variety of different physiological functions and you suddenly take that away? All those functions go wild. So your blood pressure goes up, your pulse goes up, you start shaking like a leaf. The lights are brighter, the sound is louder. At about the 24-hour mark, you may have a seizure,” Bernstein told the Current via telephone.
Pennsylvania is a unique state, given the state-run liquor business. People can still buy beer and wine at grocery stores and convenience stores which are licensed to sell them. Some wineries and craft breweries are open for take out orders or curbside delivery in an effort to limit or halt exposure to coronavirus, while still serving their customers.
“It’s not completely unavailable to everybody. It requires more effort and work. It’s not ideal,” Gary Swanson, MD, told the Current. Swanson is a psychiatrist with Allegheny Health Network working out of Allegheny General Hospital on the North Side.
Still, in this Commonwealth, state-run liquor stores and the bars they supply are the only game in town for hard liquor. Additionally, access to wineries and craft brewers means access to transportation and the ability to pay on-line, which is not a foregone conclusion for everybody. In short, middle-class and wealthier alcohol addicts may weather the COVID-19 storm better than those who already struggle economically.
According to the PLCB site, one liter (1,000 ml) of Vladimir Vodka [80 proof] retails for $7.79. One would have to drink a considerable amount of wine or beer to replicate that effect. [Vodka averages about 40% alcohol by volume; wine is typically anywhere from 6% to 20% abv; and most beers range between 4% and 12%.]
Obviously, with lines out the doors on Tuesday evening, people tried to stock up. But nobody knows how long this crisis will last before things start to return to normal. Stocking up for two weeks may be possible for many people. Stocking up for six weeks? Eight weeks? Even six months? That’s nearly impossible.
Given the risks associated with COVID-19 and in light of what we are seeing in Italy and Seattle, there are no perfect solutions, particularly for Dr. Rachel Levine, who is the Secretary of Health for the Commonwealth and who had to make the call.
“I know that [Rachel] Levine was aware that this might be an issue for this group of patients, but you have varying risks and balancing whether it’s safer to close down the state stores and deal with possible alcohol withdrawal. Or leave them open and allow the spread of coronavirus more rapidly. Those are tough decisions to make. It’s an unintended consequence, but something people are going to have to wrestle with,” Swanson said.
What actually happens when the body goes into severe or complicated alcohol withdrawal? What are the risks involved?
“When we talk about ‘complicated alcohol withdrawal,’ we mean seizures or delirium tremens. With delirium tremens and seizures — there’s a risk of both and both carry inherent risk. When this delirium is in combination with elevated blood pressure and heart rate, that is a very significantly dangerous and deadly situation. It is a very high mortality rate,” Gina Goszinski, DO, a psychiatrist with Jade Wellness, an outpatient substance abuse treatment center in Pittsburgh, told the Current.
According to Bernstein, the mortality rate can be higher than you think. “The prevalence of death in untreated serious alcohol withdrawal is 50%. That comes from the bad old days — that’s original research done at Boston City Hospital in the 1940s before there were really detox protocols. But if you did nothing and you were going into moderate to severe withdrawal? [There is a] risk of severe disability or [the risk of] death is one in two.”
Alcohol withdrawal can be treated safely in a medical setting. For some patients, their underlying health conditions in combination with severe dependence on alcohol land them in the Intensive Care Unit. But generally, the treatment is to administer some benzodiazepines (which are things like valium, Librium, Xanax and so on.) The drugs mimic what alcohol does in the body, thus they regulate the withdrawal and ameliorate adverse medical risk. It’s also simply easier to tolerate.
All three doctors stressed the need for medical care in the case of severe withdrawal. For those who have been dependent on alcohol for years, there are often underlying medical conditions such as decreased liver function, pulmonary issues or high blood pressure. It’s dangerous to navigate those conditions without professional care.
“As to the Emergency Department, if people are worried about coronavirus and worried about how busy we are, the fact of the matter is right now things are a little slow,” Swanson said.
“I think everybody is reluctant to go out and that includes coming to the hospital. Part of me would caution people, if they think they have a problem, they shouldn’t be too hesitant about coming to the hospital — we’re taking precautions and doing the best we can to make sure that people aren’t exposed to COVID. If you’re having a serious problem, I wouldn’t discourage you from coming in, even if it isn’t for COVID. There are plenty of other things that require treatment.”
People are understandably concerned about presenting to anywhere, but medical intervention at an emergency room or treatment center is called for despite the need for social distancing and the risks associated with coronavirus. As Bernstein said, “Everything now is a potentially personal and public health event.”