Article Thumbnail

Why Are Liquor Stores Essential Businesses? They Keep Alcoholics Out of ERs

Without them, experts — and alcoholics — worry that we’ll have another public-health crisis on our hands in addition to the coronavirus pandemic

The St. Anthony Residence provides housing for chronically alcoholic and homeless men in St. Paul, Minnesota, with little expectation that they will get sober, tacitly accepting that its 60 residents will likely drink themselves to death. These “unfortunates,” as the Big Book of Alcoholics Anonymous calls such individuals, aren’t at fault — “they seem to have been born this way.” And so, sponsored by Catholic Charities of St. Paul and Minneapolis, for $53 per day, the St. Anthony wet house allows its inhabitants to continue drinking while offering them three hot meals a day, clean sheets and a designated area on the back patio to safely consume alcohol. 

“It’s a tastefully designed recreational area with a bus-stop-type enclosure so folks can stay out of the elements if needed,” explains Tracy Berglund, senior director of housing stability at Catholic Charities, who adds that chairs, tables and checkerboards are provided for comfort. 

But when word reached Berglund that Minnesota Governor Tim Walz would be requiring Minnesotans to stay at home in order to slow the spread of coronavirus, she and her staff made a large advanced purchase of whiskey, vodka, gin and beer in the event that liquor stores would be closed as well. The threat of alcohol suddenly being inaccessible to St. Anthony residents was “extremely concerning” to Berglund and her staff, who feared withdrawal would befall them with limited medical resources available. (Fortunately for them, Minnesota liquor stores were eventually deemed to be essential.)  

Sudden prohibition could be catastrophic for the estimated 15 million people in the U.S. with alcohol use disorder, a chronic relapsing brain disease characterized by compulsive alcohol use, loss of control over alcohol intake and a negative emotional state when not using. George F. Koob, the director of the National Institute on Alcohol Abuse and Alcoholism, tells me there are more than 250,000 ER visits each year for alcohol withdrawal in the U.S., with an average of 800 people dying from it. “Untreated, alcohol withdrawal will kill one out of eight people,” he says. “For comparison, we only lose 20 people a year to opioid withdrawal. With opioid withdrawal, everybody thinks they’re dying, but they don’t really. With alcohol withdrawal, they really do.”

At the peak of Abigail’s drinking days last May, the 33-year-old from Tacoma was polishing off a handle of Jack Daniel’s every four days. That’s when she decided to “take a break” to focus on weight loss, which her doctor said was a priority given her diabetes. After 24 hours of not drinking, though, Abigail experienced unbearable migraines and abdominal cramping. Day Two was worse, with incessant vomiting and diarrhea leading to severe dehydration. 

Next, the hallucinations kicked in. “I told my husband I was going insane,” she tells me, adding that whenever she tried to read something, her vision was blurred and the words ran together. Abigail assumed her chest pains on Day Four were a heart attack, so she called 911 and was sent to the emergency room. There, doctors ran a bunch of tests as her blood pressure spiked. After stabilizing Abigail with a sedative, doctors explained to her husband that she was experiencing acute alcohol withdrawal, which could have been fatal had they not come to the hospital. After two days, Abigail was prescribed Librium, a benzodiazepine to manage anxiety, which she tapered off while detoxing at home.

Similarly, for Reggie, a 50-year-old engineer in Denver, alcohol withdrawal was “hell on earth” after quitting a 20-beers-a-day habit cold turkey last year, resulting in uncontrollable tremors in his hands, speech tics, poor balance, shortness of breath, night sweats, unbearable itchy skin and confusion. “I never stopped feeling sad and worthless,” he tells me. “Which is the whole reason I drank in the first place.” (He eventually relapsed and continues to drink today.)

Not surprisingly, since the start of the coronavirus pandemic, booze sales are booming nationwide. “We got a large bump when it seemed like the end of the world was coming,” says Greg Eccles, owner of Tops Liquors in Arizona who has seen an “unprecedented” 40 percent increase in his business.

Pennsylvania is the only state to completely close down all liquor stores in response to the pandemic, according to the Distilled Spirits Council of the United States, because if they become inaccessible, more people will die. Alabama closed state-owned shops but is allowing curbside pickup; liquor stores in Nevada are officially deemed “nonessential,” but grocery stores are still allowed to sell alcohol; and Denver Mayor Michael Hancock announced on the morning of March 23rd that liquor stores were among the non-essential businesses that would be closed in his city before an abrupt 180 at 5 p.m., tweeting that “liquor stores with extreme physical distancing in place will be exempt.”

Reggie admits he panicked when he initially heard Hancock’s announcement, racing out to buy three cases of beer, enough for a week’s taper. Now, he says it “feels a bit strange” that liquor stores are open, calling it “government acknowledgement that the public has an addiction that they quietly support.”

After Pennsylvania Governor Tom Wolf included liquor stores as nonessential businesses to be closed, the state’s Department of Drug and Alcohol Programs warned of alcohol-withdrawal health problems stemming from the shutdown. In response, the commonwealth’s online spirits shops reopened for business on April 1st. “This gets to be a health issue for those with a substance-use disorder,” Wolf explained. The Pennsylvania Liquor Control Board also established “specialized access” methods by which health-care providers can buy consumable alcohol while liquor stores remain closed, which Control Board Press Secretary Shawn M. Kelly tells me is part of a “comprehensive plan to support individuals with substance-use disorder” and proactively “deter individuals in need of drug and alcohol treatment” from clogging emergency rooms. 

As for the biology of it all, severe alcohol withdrawal is essentially a “huge exaggeration” of a hangover, Koob explains, and a rebound of everything that’s suppressed when highly intoxicated. To that latter point, neural activity is restrained when you drink, particularly activity involved in arousal and keeping us awake. In response, the brain and body work to keep you homeostatic, or at a normal level. For example, alcoholics often become hypothermic due to vasodilation as blood vessels relax to allow more blood to flow through the skin and tissues. Then, if you suddenly stop drinking, you get hyperthermia, the equivalent of a fever. “When alcohol is removed, all you have left is the overreaction,” he adds. “So you get hyperthermia, seizures and hallucinations in the most severe cases due to increased body temperature.”

Very heavy drinkers may experience delirium tremens, the worst kind of alcohol withdrawal, which Koob likens to a bad LSD trip. “There are creatures suddenly crawling out of the walls, and it’s very scary — not to mention dysphoria, irritability and gastrointestinal disturbances. Essentially, you feel god awful as opposed to relaxed.”

“Alcohol withdrawal was terrible for me,” explains Dan, a 40-year-old firefighter/paramedic in the Mid-Atlantic who felt like he was in a constant state of fight or flight, always on a hair trigger with severe agitation and anxiety. “I drank all day, every day when I wasn’t at work and battled withdrawal symptoms on days when I was on shift. I work 24-hour shifts, and we’d frequently be held over for mandatory OT, which became a 72-hour shift. By the end of that, I’d be a wreck and have to drink the second I walked through the door.” 

Still, Dan admits his knee-jerk reaction to liquor stores being deemed as “essential” was to think, Who the hell NEEDS alcohol? 

“Well, alcoholics do,” he answers. “So at best, you’d have additional EMS calls and hospitalizations from alcoholics drying out, taking away precious hospital resources. We’re very low on supplies, and emergency services are at a critical breaking point. The last thing we need clogging up hospital beds are alcoholics who really just need a strong drink.” 

Even executives at premier drug and alcohol recovery centers acknowledge the reality that making liquor available to addicts is sometimes the only option. William C. Moyers, vice president of public affairs and community relations for the Hazelden Betty Ford Foundation in Minnesota, says depriving alcoholics of alcohol isn’t a solution to their illness. “I often take people to detox and have to stop at the liquor store on the way to buy them a pint, not because I condone it, but to keep them from going into withdrawal during the car ride,” he tells me. “It’s not the alcoholic crying out for help. It’s the alcoholic’s body crying out for the substance that allows it to function. It’s why prohibition didn’t work: People who needed alcohol still got it. They may have had to drink it out of a medicine bottle or brew it in the bathtub, but they did so because the alternative was horrifying.” 

That said, Moyers doubts that anyone other than alcoholics will shed a tear for drunks unable to score since active alcoholics “can also be very, very cruel — not only to their family, but to the rest of society.”

Along those lines, some, like Peter Bach, a physician at Memorial Sloan Kettering Cancer Center in New York City, are calling for states to immediately order the closures of liquor stores as domestic violence rates appear to be soaring. Meanwhile, the Fresno Sheriff’s Department filed 77 percent more domestic violence reports two weeks ago than three weeks ago; the Seattle Police Department received 614 domestic-violence calls in the last two weeks, 22 percent more than average; and domestic-violence prevention organizations nationwide are warning of an increase in battery cases.

Nonetheless, people like Abigail continue to insist that liquor stores are, indeed, essential — even life-saving. “Without access for those who are in the pits of alcoholism, ERs and hospitals would become even more overwhelmed by people experiencing withdrawal,” she says, which could add to the risk of exposure to COVID-19 in waiting rooms and triage areas. “Social distancing in a liquor store is safer than a waiting room at a crowded hospital.”

Berglund agrees. In fact, she says that if liquor stores were again threatened with shut down, she’d make an even larger advanced purchase to shore up St. Anthony’s booze reserves. Or as she puts it, “It’s really about keeping people safe, meeting them where they’re at and not giving up on anyone.”