Dry January: Scientific Evidence and New Pathways

End-of-year celebrations are traditionally times of excess. In addition to high alcohol consumption, overeating fatty and sugary foods is common, leading many people to start the year feeling they are not at their best. In this context, the Dry January campaign, launched in the United Kingdom in 2013, has become a global phenomenon.¹ The challenge is simple: go the 31 days of January without drinking alcohol. The campaign is aimed at people who drink above low-risk guidelines and wish to reassess their relationship with alcohol. It is not recommended for cases of severe alcohol dependence, which require clinical supervision to avoid withdrawal syndromes.

Main Benefits: What Does the Evidence Say?

Taking a break from alcohol consumption can bring numerous physical and mental benefits. New evidence reinforces the importance of this pause. A review published in 2025 indicates that for those who complete a month of abstinence, the benefits go far beyond increased physical energy, including:

• Metabolic and Liver Health: Significant improvements in insulin resistance, blood pressure, and liver function, including a reduction in liver fat.
• Cellular Markers: A decrease in the concentration of cancer-related growth factors after one month of abstinence.
• Psychological Well-being: Greater ability to concentrate, improved sleep quality, and an increase in drink refusal self-efficacy—that is, participants feel more confident saying “no” to alcohol in social situations.

The Myth of the “Rebound Effect” and Long-Term Maintenance

A common concern is that abstaining for a month might lead to a “rebound effect,” in which individuals drink excessively in February to compensate, thereby reversing the benefits. However, current literature challenges this view.²˒³ Studies show that the rebound effect is rare and occurs in a small minority, usually among those who did not complete the challenge. For most successful participants, Dry January functions as a “reset”: six months after the campaign, these individuals showed lower drinking frequency and fewer episodes of intoxication than before the challenge.

Damp January: Harm Reduction

For those who find total abstinence too difficult, the concept of Damp January (Janeiro Úmido) has gained traction.⁴˒⁵ Perfection is not the enemy of good: participants who did not remain completely sober but reduced their consumption still reported important benefits, such as improved mental well-being and greater control over their choices. Harm reduction is a valid and effective pathway to long-term health.

Tips and Guidance

Changing habits is not easy. CISA has updated its guidance based on predictors of success identified in recent research:

• Register officially: Data indicate that officially signing up for the campaign and publicly committing to it with family and friends increases the chances of success.
• Eliminate triggers: Distance yourself from reminders of alcohol. Avoid keeping alcoholic beverages at home and plan social activities away from bars.
• Find alternative activities: Fill free time with enjoyable activities that replace the habit of drinking, in addition to exercising, staying hydrated, and eating well.
• Seek support: If you experience severe difficulties, seek help from a healthcare professional.

References:

1.  de Ternay, J., Leblanc, P., Michel, P., Benyamina, A., Naassila, M., & Rolland, B. (2022). One-month alcohol abstinence national campaigns: a scoping review of the harm reduction benefits. Harm reduction journal, 19(1), 24. https://doi.org/10.1186/s12954-022-00603-x
2. Strowger, M., Meisel, M. K., Uriarte, S., & Colby, S. M. (2025). A scoping review of Dry January: evidence and future directions. Alcohol and alcoholism (Oxford, Oxfordshire), 60(5), agaf057. https://doi.org/10.1093/alcalc/agaf057
3. de Visser, R. O., Robinson, E., & Bond, R. (2016). Voluntary temporary abstinence from alcohol during "Dry January" and subsequent alcohol use. Health psychology : official journal of the Division of Health Psychology, American Psychological Association, 35(3), 281–289. https://doi.org/10.1037/hea0000297
4. Blum D. (2024) To Cut Back on Drinking, Try Damp January. https://www.nytimes.com/2024/01/08/well/dry-january-alcohol.html.
5. Dara J. (2023) How does Damp January compare to Dry January? https://www.forbes.com/sites/jilliandara/2023/01/11/how-does-damp-january-compare-to-dry-january/.

How Alcohol Alters the Brain Cells That Command Our Mind

For decades, it was believed that the brain was composed almost exclusively of neurons, while other cells (glial cells) were seen merely as support. However, recent studies reveal that astrocytes—star-shaped cells—are in fact the active conductors of brain communication, controlling plasticity and the development of the mind.¹ These cells play a decisive role in mental health and are severely harmed by alcohol consumption at all stages of life.

The vulnerability of astrocytes begins very early, since during pregnancy exposure to alcohol interferes with the maturation of these cells.² This process compromises the proper formation of synapses and the blood–brain barrier, directly contributing to the cognitive deficits observed in Fetal Alcohol Syndrome (FAS). During adolescence,³ the impact continues, with alcohol reducing the physical proximity between the processes of these cells and neurons, which impairs the efficiency of connections in the hippocampus—a region vital for the formation of new memories and learning—and in the prefrontal cortex, which acts as the command center for decision-making and impulse control.

In adults with alcohol dependence, astrocytes undergo a profound change known as reactivity, altering their molecular structure and beginning to produce inflammatory substances.² One of the most striking effects of this alteration occurs in the extracellular matrix, where these cells create networks that surround neurons.⁴ Excessive alcohol consumption can make these networks too rigid, trapping neural circuits and promoting behavioral inflexibility and compulsive drinking.

Despite this damage, science is beginning to see new hope for future treatments in these cells. Research in animals indicates that manipulating specific genes within astrocytes—such as through the use of PPAR-γ receptors⁵—can protect memory and learning against the toxic effects of ethanol. Understanding how these cells communicate with the rest of the brain may therefore represent a new frontier for restoring functions lost to alcoholism.

The consequences of this cellular dysregulation extend beyond microscopic biology, manifesting as profound damage to overall health and the integrity of human behavior. Gestational exposure to alcohol is the most common and preventable cause of intellectual disability worldwide, resulting in permanent structural abnormalities and lifelong impairments in cognition and social adaptability. In adulthood, the reduction in the number and density of these cells helps explain the cognitive decline and loss of brain volume observed in individuals with alcohol use disorders. Understanding this relationship is essential, as it suggests that the future of alcoholism treatment may lie in the restoration of these cells.

References

1. Chung, W. S., Baldwin, K. T., & Allen, N. J. (2024). Astrocyte Regulation of Synapse Formation, Maturation, and Elimination. Cold Spring Harbor perspectives in biology, 16(8), a041352. https://doi.org/10.1101/cshperspect.a041352
2. Guizzetti, M., Mangieri, R. A., Ezerskiy, L. A., Hashimoto, J. G., Bajo, M., Farris, S. P., Homanics, G. E., Lasek, A. W., Mayfield, R. D., Messing, R. O., & Roberto, M. (2026). Astrocytes and Alcohol Throughout the Lifespan. Biological psychiatry, 99(1), 9–20. https://doi.org/10.1016/j.biopsych.2025.04.013
3. Healey, K. L., Bell, A., Scofield, M. D., & Swartzwelder, H. S. (2022). Adolescent intermittent ethanol exposure reduces astrocyte-synaptic proximity in the adult medial prefrontal cortex in rats: Reversal by gabapentin. Addiction neuroscience, 4, 100047. https://doi.org/10.1016/j.addicn.2022.100047
4. Soles, A., Selimovic, A., Sbrocco, K., Ghannoum, F., Hamel, K., Moncada, E. L., Gilliat, S., & Cvetanovic, M. (2023). Extracellular Matrix Regulation in Physiology and in Brain Disease. International journal of molecular sciences, 24(8), 7049. https://doi.org/10.3390/ijms24087049
5. Garcia-Baos, A., Pastor, A., Gallego-Landin, I. et al. The role of PPAR-γ in memory deficits induced by prenatal and lactation alcohol exposure in mice. Mol Psychiatry28, 3373–3383 (2023). https://doi.org/10.1038/s41380-023-02191-z

Arthur Guerra’s Journey at the Helm of CISA: 21 Years of Leadership and Commitment

As he concludes his term after 21 years of leadership, Dr. Arthur Guerra leaves a remarkable legacy at CISA. Founder and president since 2004, he guided the institution in building a national benchmark in alcohol and health. His trajectory was decisive in strengthening the institution’s mission and expanding the reach of scientific information across the country.

Psychiatrist Arthur Guerra led the Center for Information on Health and Alcohol (CISA) from its founding in 2004 until 2025. Over these 21 years, he played a decisive role in consolidating the institution as the country’s foremost national reference in the production and dissemination of scientific knowledge on alcohol and health.

Under his leadership, CISA was created with a clear mission: to provide high-quality, evidence-based, and freely accessible information to support Brazilian society in understanding the impacts of alcohol consumption. Arthur Guerra directly contributed to transforming this mission into continuous, consistent, and widely recognized work.

During his tenure, CISA published studies, technical reports, educational materials, and pioneering initiatives that helped fill information gaps and promote essential debates on alcohol and health. Among the highlights is the annual publication series “Alcohol and the Health of Brazilians,” which since 2019 has become a reference document for public managers, health professionals, researchers, educators, the press, and society at large.

In addition to his institutional role, Arthur Guerra brought to CISA his extensive clinical and academic experience in the field of substance dependence. His multidisciplinary vision helped broaden the center’s focus to include themes such as prevention, social vulnerabilities, mental health, and determinants of alcohol consumption, contributing to the institution’s recognition for technical excellence and scientific rigor.

Over these 21 years, his management was characterized by a commitment to credibility, a defense of transparency, and a constant pursuit of improvement in CISA’s content and methodologies. His dedication enabled the center to become a respected space for information and dialogue, with a direct impact on public awareness and the training of professionals throughout the country.

Acknowledgments

CISA expresses its deep gratitude to Dr. Arthur Guerra for more than two decades of leadership, dedication, and strategic vision. His work was essential for the institution to achieve the recognition it enjoys today and for the topic of alcohol and health to gain greater visibility and depth in the Brazilian public debate.

His legacy endures in the principles he established, in the quality of the content produced, and in the culture of scientific responsibility he helped build. CISA moves forward grounded in the trajectory he initiated—a path marked by commitment to public health, science, and high-quality information.

Succeeding him as the institution’s new Executive President is Natalia Haddad, a psychiatrist with a medical degree from the ABC School of Medicine and a PhD from the Institute of Psychiatry at the Hospital das Clínicas of São Paulo (IPq-HCFMUSP, 2024). Natalia also serves as a psychiatrist at Hospital Sírio-Libanês (São Paulo) and is the coordinator of that service’s Psychoses Unit.

Her appointment to the Executive Presidency of CISA represents a new chapter in the institution’s history, marked by renewal, broader perspectives, and strengthened dialogue with contemporary public health challenges. With a solid academic background, clinical experience, and work at centers of excellence, Natalia brings the promise of a management focused on modernization, scientific innovation, and the development of new projects, while maintaining the technical rigor that has always characterized CISA.

Under her leadership, CISA reaffirms its commitment to producing and disseminating high-quality knowledge, continuously updating the debate on alcohol and health, and building strategies increasingly aligned with the country’s social, cultural, and epidemiological transformations.

Thank you, Dr. Arthur Guerra, for your invaluable contribution to CISA and to Brazil.

Low Demand for Treatment Is One of the Obstacles in Combating Alcohol Dependence, Study Finds

Despite the wide availability of evidence-based treatments for mental and substance use disorders, most affected individuals still do not receive adequate care. The situation is particularly critical in the case of Alcohol Use Disorder (AUD), a highly prevalent condition marked by low treatment-seeking behavior, poor-quality care, and significant stigma.

Low Coverage of Effective Treatment for Alcohol Dependence

Recent data from the World Mental Health Survey, published in JAMA Psychiatry, reveal that only 1.4% of people with Alcohol Use Disorder received effective treatment in accordance with clinical guidelines.¹ The study analyzed information from more than 56,000 adults in 21 countries, using representative population samples and standardized household interviews based on the Composite International Diagnostic Interview (CIDI).

The methodology considered three levels of assessment in the so-called “coverage cascade”: (1) perceived need for treatment, (2) contact with health services, and (3) receipt of effective treatment, defined according to criteria of frequency, duration, and adherence for both psychotherapy and pharmacotherapy. In the case of AUD, the data indicated that only about one-third of affected individuals perceived a need for help, and an even smaller fraction actually sought or received treatment of a quality consistent with international guidelines.¹

Inequality of Access and Underutilization of Services

Low perception of the need for treatment, combined with social stigma and insufficient training among many health professionals, contributes to the undertreatment of AUD. A review published in The Lancet Psychiatry in 2022 reinforces this scenario, noting that fewer than 10% of patients with AUD in Europe receive any type of specialized intervention, even when they have a prior history of contact with health services.²

Impact of Simple and Timely Interventions

Studies also suggest that even brief interventions carried out during hospitalizations for other causes can reduce mortality and readmissions among people with alcohol and other substance dependence. One study showed that this type of approach can generate clinically relevant benefits, even when the patient does not subsequently gain access to specialized services.³

Conclusion and Implications for Public Policy

Given the large treatment gap for alcohol and other substance dependence, an urgent response is needed that goes beyond simply expanding service availability. Primary care must be trained to identify and initiate treatment, ensure continuity of care, and address the stigma that still keeps many patients away from health services.

In many Brazilian cities, basic medications for the treatment of alcohol dependence are still lacking, which directly compromises the effectiveness of interventions. Public policies should focus not only on access, but also on treatment quality, ensuring professional training, regular availability of medications, and integration between mental health care and primary care.

References:

1. Vigo, D.V., Stein, D.J., Harris, M.G., et al. (2025). Effective Treatment for Mental and Substance Use Disorders in 21 Countries. JAMA Psychiatry, 82(4), 347–357. https://doi.org/10.1001/jamapsychiatry.2024.4378
2. Rehm, J., Manthey, J., Shield, K.D., Ferreira-Borges, C. (2022). Barriers to treatment for alcohol use disorders in Europe: a literature review. Lancet Psychiatry, 9(2), 89–100. https://doi.org/10.1016/S2215-0366(21)00485-6
   
3. Lee, M.T., Gordon, A.J., Williams, J.T., et al. (2023). Association of Brief Inpatient Alcohol Interventions With Mortality and Readmission Among Adults With Alcohol Use Disorder. JAMA Network Open, 6(5):e2311507. https://doi.org/10.1001/jamanetworkopen.2023.11507

A New Potential Therapeutic Approach for Alcoholism: MCH11

A study evaluated the new selective MAGL inhibitor (monoacylglycerol lipase inhibitor) MCH11 in mice, showing that the compound reduces ethanol consumption and motivation to drink, in addition to exhibiting anxiolytic effects similar to those of antidepressants. The results highlight a crucial point for treatment development: the efficacy of MCH11 revealed marked sex-dependent differences, indicating that sex is a fundamental biological variable in therapeutic response.

Alcohol Use Disorder (AUD) is a condition that affects approximately 2.6 million people worldwide each year and has relapse rates of around 70% within the first year, even with pharmacological treatment.¹ ² In this context of limited effectiveness of current treatment options, the endocannabinoid system (ECS) has been explored as a target for new interventions.³

The study in focus evaluated MCH11 in mice—a novel MAGL inhibitor, the main enzyme responsible for degrading the endocannabinoid 2-arachidonoylglycerol (2-AG).⁴ Regarding alcohol use, MCH11 reduced both voluntary ethanol consumption and motivation to drink, but with pronounced differences between males and females. In males, all doses tested (10, 20, and 40 mg/kg) dose-dependently reduced ethanol intake and preference over 29 days, with a faster effect at the 40 mg/kg dose. In females, the initial doses were insufficient, and only after increasing the dose to 60 mg/kg (from day 20 onward) was a significant reduction in consumption observed—possibly in part due to higher baseline ethanol intake (8–9 g/kg in females versus 5–6 g/kg in males).

From a behavioral perspective, MCH11 showed an antidepressant-like profile in males. Importantly, acute treatment did not impair locomotion or performance in cognitive tasks, suggesting the absence of relevant sedation or cognitive impairment.

The study also explored the combination of MCH11 with topiramate (MCH11 + TOP), a drug already used in AUD. In males, the combined therapy reduced ethanol consumption more robustly than either drug alone. In females, topiramate alone and the combination were more effective than MCH11 alone, with the additional benefit of the combination being more modest than in males.

At the molecular level, the study showed that chronic ethanol consumption induced sex-dependent changes in the expression of genes related to the dopaminergic, opioid, and endocannabinoid systems (Th, Oprm1, Cnr1, Cnr2) in the ventral tegmental area (VTA) and the nucleus accumbens (NAc). MCH11 reversed most of these changes in males at lower doses, whereas in females only the highest dose (60 mg/kg) was partially effective and did not fully normalize genes such as Oprm1 and Cnr2. In contrast, the MCH11 + TOP combination increased Cnr2 gene expression in the NAc in both sexes, with an approximately twofold greater effect in females, suggesting this gene as a possible key mediator of the combined action.

Taken together, these preclinical findings support MAGL inhibition via MCH11 as a promising strategy to reduce alcohol consumption and motivation to drink, with additional effects on mood and impulsivity. At the same time, they demonstrate that treatment sensitivity, effective doses, and molecular mechanisms differ significantly between males and females. The study reinforces the need to systematically incorporate sex as a fundamental biological variable in the development of future therapies for alcoholism, especially in approaches targeting the endocannabinoid system.

References

1. P. Bach, J. Franck, J. Hallgren, H. Widing, M. Gissler, J. Westman, Pharmacological treatments in alcohol use disorder and risk of Alcohol-Related hospitalizations: a register study, Acta Psychiatr. Scand. (2025), https://doi.org/10.1111/ acps.13802.
2. P. Le, J.J. Rich, E.Y. Bernstein, J. Glass, H. Gasoyan, S.E. Back, et al., Disparities in treatment for alcohol use disorder among all of us participants, Am. J. Psychiatry 181 (11) (2024) 973–987, https://doi.org/10.1176/appi.ajp.20230730.
3. M.S. Garcia-Gutierrez, F. Navarrete, A. Gasparyan, D. Navarro, A. Morcuende,T. Femenia, et al., Role of cannabinoid CB2 receptor in alcohol use disorders: from animal to human studies, Int J. Mol. Sci. 23 (11) (2022), https://doi.org/10.3390/ ijms23115908.
4. Torregrosa, A. B., García-Gutiérrez, M. S., Navarro, D., Navarrete, F., & Manzanares, J. (2025). MCH11, a new monoacylglycerol lipase inhibitor, reduces ethanol consumption and motivation to drink in mice, with sex-dependent differences. Biomedicine & pharmacotherapy, 192, 118662. https://doi.org/10.1016/j.biopha.2025.118662

How Alcohol Alters Sleep: Scientific Evidence on Its Effects on Sleep Architecture and Rest Quality

Consuming alcohol before bedtime is a common practice, often seen as a way to facilitate sleep. However, recent scientific evidence, including a systematic review and meta-analysis of 27 studies published in 2025, shows that alcohol can significantly alter sleep quality in healthy adults. Even if it appears to help with falling asleep, its effects throughout the night compromise essential restorative sleep cycles.

Alcohol acts as a central nervous system depressant, reducing the time it takes to fall asleep by promoting relaxation and drowsiness. However, its effects on sleep are not uniform across the night. Alcohol can significantly alter sleep architecture, mainly by reducing the duration of and delaying the onset of REM sleep—a sleep stage associated with memory consolidation, emotional regulation, and brain restoration.

A review study published in 2025¹ showed that even low to moderate doses of alcohol impair REM sleep and increase sleep fragmentation and awakenings during the second half of the night, when the body is metabolizing alcohol and its byproducts, such as acetaldehyde and acetate, which increase physiological activity and body temperature. High doses accelerate the onset of deep sleep (N3), but REM sleep disruption and persistent fragmentation remain, compromising overall sleep quality.

In addition, alcohol relaxes the muscles of the throat, increasing the risk of snoring and sleep apnea—disorders that further worsen sleep fragmentation and poor sleep quality. The subjective perception of a good night’s sleep, often reported after alcohol consumption, does not match objective polysomnography data, which show less restorative sleep and greater fatigue the following day.

It is important to note that the effects of alcohol vary among individuals, with women potentially being more sensitive due to metabolic and hormonal differences. Using alcohol as a sleep aid is therefore a counterproductive strategy that impairs cognitive and emotional functions as well as physical performance in daily life.

In conclusion, evidence from the systematic review reinforces that alcohol, although it may facilitate sleep onset, compromises overall sleep quality—especially by reducing REM sleep, which is crucial for cognitive and emotional processes. Other complementary studies confirm these findings²,³, showing that regular alcohol consumption is associated with greater sleep fragmentation and poorer daytime performance, including fatigue, impaired attention, and mood disturbances. Furthermore, research indicates that the negative impact of alcohol on sleep may be even more pronounced in vulnerable populations, such as older adults and individuals with pre-existing sleep disorders. Therefore, the recommendation is to avoid using alcohol as a sleep aid and to focus on practices that promote natural and restorative sleep, thereby ensuring better health and quality of life.

References

1. Gardiner C, Weakley J, Burke LM, Roach GD, Sargent C, Maniar N, Huynh M, Miller DJ, Townshend A, Halson SL. The effect of alcohol on subsequent sleep in healthy adults: A systematic review and meta-analysis. Sleep Med Rev. 2025;80:10203.
2. Kim HJ, Lee SY, Park JH, Kim SH, Choi J, Lee HW. Enhanced alcohol metabolism and sleep quality with continuous positive airway pressure in patients with obstructive sleep apnea. Sci Rep. 2025;15(1):17345.​
3. Pabon E, Caldwell JA, Swamy RN, Bailey SJ, Wilkinson M. Effects of alcohol on sleep and nocturnal heart rate: behavioral and physiological outcomes. Alcohol Clin Exp Res. 2022;46(3):408-416.

Alcohol-Related Liver Disease: What Do We Know Today?
By Roberto de Carvalho Filho

Alcohol has been part of human history for millennia. From early prehistoric fermentations to modern social rituals, its consumption has become an almost universal habit. But the same substance that symbolizes celebration and social interaction is also one of the leading causes of preventable illness and death worldwide.

Among the various consequences of abusive use, alcohol-related liver disease (ALD) is the most emblematic. It represents a spectrum of injuries that begins with simple fat accumulation in the liver but can progress to inflammation, fibrosis, cirrhosis, and liver cancer. It is the most frequent cause of liver cirrhosis in Western countries and in Brazil.

The global impact of alcohol

Worldwide, the average consumption of pure alcohol is 5.5 liters per person per year, but among those who drink alcoholic beverages, this average rises to 12.4 liters. In Brazil, the average consumption is 7.7 liters per person per year, and 13.3 liters among non-abstainers. According to the World Health Organization’s Global Status Report on Alcohol and Health¹, about 2.6 million people die every year from alcohol-related causes, equivalent to 4.7% of all deaths worldwide.

The COVID-19 pandemic worsened the problem. Studies have shown an increase of more than 30% in hospitalizations for alcoholic liver disease in several medical centers. Isolation, anxiety, and declining social well-being were triggering factors for excessive consumption in many populations.

Despite the growing consumption of alcoholic beverages, data on the prevalence of ALD remain limited. Rates above 10% have been reported in Uganda, Sweden, Italy, and India. There are no precise Brazilian data on the prevalence of the disease, but the Center for Information on Health and Alcohol (CISA) estimated that, in 2022, more than 11,000 annual deaths were directly attributable to alcoholic liver disease². This report confirmed that prevalence is higher among men, although an increase in deaths among women—particularly Black women—was observed. It is important to note that women are biologically more vulnerable to the toxic effects of alcohol than men, because they metabolize ethanol more slowly and have higher blood concentrations after consuming the same dose.

How does alcohol damage the liver?

The liver is the main organ responsible for metabolizing ethanol. When a person drinks, most of the alcohol is converted into acetaldehyde, a highly toxic substance. This process, driven by the enzymes alcohol dehydrogenase (ADH) and CYP2E1, generates free radicals and oxidative stress, profoundly altering hepatic metabolism. Excess NADH produced during ethanol oxidation inhibits the breakdown of fatty acids and promotes fat accumulation — this is how hepatic steatosis, the first stage of ALD, develops. If consumption persists, inflammatory cells are activated and cytokines (TNF-α, IL-6, IL-1β) are released, intensifying liver tissue damage.

In addition to its direct effects, alcohol alters the intestinal microbiota, increases gut permeability, and allows bacteria and endotoxins to reach the liver, worsening inflammation. Over time, repeated inflammatory processes lead to fibrosis, in which normal tissue is replaced by scar tissue that accumulates in the organ.

Some factors make certain individuals more prone to disease progression. One of the most studied is the PNPLA3 gene, whose mutation increases the risk of alcoholic cirrhosis by up to threefold. Other factors—such as female sex, obesity, high-fat diets, and binge drinking—also accelerate liver damage.

Disease stages

Not everyone who drinks heavily develops severe liver injury. Progression depends on the amount, frequency, and duration of consumption, as well as genetic and environmental factors. A family history of alcohol-related cirrhosis and the coexistence of conditions such as diabetes, obesity, hypertension, dyslipidemia, and smoking increase the risk of cirrhosis and its complications. Thus, even small regular amounts of alcohol, when combined with metabolic syndrome, can accelerate this process.

Overall, the clinical spectrum of ALD follows this progression:

How to identify alcohol-related liver disease?

Diagnosing ALD begins with a detailed clinical history, essential to identifying a pattern of abusive alcohol consumption, typically spanning more than 5 to 10 years. Most individuals with ALD (though not all) meet criteria for alcohol use disorder (AUD), such as tolerance and signs of withdrawal (current or past), among others. In some situations, screening tools such as AUDIT-C (Alcohol Use Disorders Identification Test) can be helpful. On physical examination, classic signs of advanced chronic liver disease may be present, such as palmar erythema, telangiectasias, hepatomegaly, jaundice, and ascites. Enlargement of the parotid glands, Dupuytren’s contracture, and certain neurological findings suggest alcoholic etiology.

In laboratory tests, a characteristic finding is an AST/ALT ratio > 1.5, with values generally below 400 U/L. Other alterations include elevated GGT and MCV (mean corpuscular volume). In advanced stages of the disease, coagulopathy (thrombocytopenia and elevated INR), high bilirubin levels, and hypoalbuminemia may occur. Other complementary methods may provide relevant information:

• Abdominal ultrasound: shows liver enlargement and steatosis.
• Liver elastography: measures liver stiffness to estimate fibrosis.
• Liver biopsy: indicated only when the diagnosis is uncertain or when overlap with other diseases is suspected.

Alcoholic hepatitis — one of the most severe forms of ALD — usually presents with recent jaundice, painful hepatomegaly, low-grade fever, leukocytosis, and an AST/ALT ratio > 2 or 3. Diagnosis is generally clinical and laboratory-based, but liver biopsy may be needed when confounding factors exist.

Treatment: abstinence is the foundation!

No medication replaces the benefits of complete abstinence. It is the main factor associated with clinical improvement and reduced mortality. In an Austrian study of 320 cirrhotic patients followed for three years, those who managed to stop drinking had significantly higher survival rates than those who continued³.

Abstinence, however, is rarely simple. It requires continuous support, psychotherapy, and often medications to reduce cravings and prevent relapse. Psychotherapeutic interventions are an essential part of treating AUD associated with ALD. The most commonly used approaches include motivational interviewing, cognitive-behavioral therapy, and dialectical behavior therapy, in addition to complementary strategies such as brief interventions, psychoanalysis, and group therapy, which can enhance adherence and self-awareness, especially when integrated into a structured social and family support network.

Pharmacological treatment of AUD associated with ALD acts as an ally to psychotherapy by reducing compulsive alcohol cravings. The most commonly used medications in Brazil are naltrexone and baclofen, whose efficacy and safety have been demonstrated in clinical studies involving individuals with ALD. Gabapentin and topiramate have shown promising results. Acamprosate, which stabilizes GABA and glutamate neurotransmission, would be another good option, but it is not currently available in Brazil. Disulfiram, although effective due to its aversive reaction to alcohol ingestion, should not be used in patients with suspected ALD because of the high risk of hepatotoxicity. Regardless of the drug used, therapeutic success always depends on continuous medical follow-up and integration with psychosocial interventions.

Liver transplantation: when there is no other option

Liver transplantation is the only curative option for advanced cirrhosis or severe alcoholic hepatitis unresponsive to clinical treatment. For many years, a minimum of six months of abstinence was required before the procedure. Today, this rule is more flexible: the focus is on assessing motivation, family support, and adherence. In a classic study⁴, early transplantation in selected cases of severe refractory alcoholic hepatitis resulted in 77% six-month survival, with relapse in only 15% of cases. More recent studies confirm these positive results, showing that, when well indicated, these patients achieve survival comparable to other transplant indications⁵ ⁶.

Conclusion and future perspectives

Alcohol-related liver disease is a clear example of how a culturally accepted substance can cause silent and profound health damage. The liver “suffers quietly” for a long time, without symptoms, until injuries become irreversible. But there is good news: the liver’s capacity for regeneration is remarkable. When alcohol use is stopped, the healing process begins almost immediately, and improvements can be seen within a few weeks.

ALD is a 100% preventable disease. Prevention begins with health education and early identification of abusive alcohol use. Simple tools such as AUDIT-C can be used in primary care units for risk screening. Public policies that restrict advertising and access, increase costs, and promote alcohol-free social environments have proven effective in many countries and should be adopted.

From a medical perspective, it is important to integrate hepatologists, psychiatrists, nutritionists, and social workers into a continuous care network. The approach should be empathetic and non-stigmatizing, valuing each step the patient takes toward abstinence.

The central message is simple and powerful: there is no level of alcohol consumption that is completely safe for the liver. The less, the better — and the sooner one stops, the greater the chances of liver recovery.

References:

1. World Health Organization. Global status report on alcohol and health and treatment of substance use disorders.Geneva: WHO; 2024. Available from: https://www.who.int/publications/i/item/978924009674
2. CISA – Centro de Informações sobre Saúde e Álcool. DATASUS 2022–2024.
3. Hofer, B. S., Simbrunner, B., Hartl, L., Jachs, M., Bauer, D. J. M., Balcar, L., Paternostro, R., Schwabl, P., Semmler, G., Scheiner, B., Staettermayer, A. F., Trauner, M., Mandorfer, M., & Reiberger, T. (2023). Alcohol Abstinence Improves Prognosis Across All Stages of Portal Hypertension in Alcohol-Related Cirrhosis. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 21(9), 2308–2317.e7. https://doi.org/10.1016/j.cgh.2022.11.033
4. Mathurin P, Moreno C, Samuel D, Dumortier J, Salleron J, Durand F, Castel H, et al. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med. 2011;365(19):1790-1800. doi:10.1056/NEJMoa1105703.
5. Louvet, A., Labreuche, J., Moreno, C., Vanlemmens, C., Moirand, R., Féray, C., Dumortier, J., Pageaux, G. P., Bureau, C., Chermak, F., Duvoux, C., Thabut, D., Leroy, V., Carbonell, N., Rolland, B., Salamé, E., Anty, R., Gournay, J., Delwaide, J., Silvain, C., … QuickTrans trial study group (2022). Early liver transplantation for severe alcohol-related hepatitis not responding to medical treatment: a prospective controlled study. The lancet. Gastroenterology & hepatology, 7(5), 416–425. https://doi.org/10.1016/S2468-1253(21)00430-1Louvet, A., & Mathurin, P. (2015). Alcoholic liver disease: mechanisms of injury and targeted treatment. Nature reviews. Gastroenterology & hepatology, 12(4), 231–242. https://doi.org/10.1038/nrgastro.2015.35
6. Parker, R., Aithal, G. P., Becker, U., Gleeson, D., Masson, S., Wyatt, J. I., Rowe, I. A., & WALDO study group (2019). Natural history of histologically proven alcohol-related liver disease: A systematic review. Journal of hepatology, 71(3), 586–593. https://doi.org/10.1016/j.jhep.2019.05.020

Other References:

- Crabb, D. W., Bataller, R., Chalasani, N. P., Kamath, P. S., Lucey, M., Mathurin, P., McClain, C., McCullough, A., Mitchell, M. C., Morgan, T. R., Nagy, L., Radaeva, S., Sanyal, A., Shah, V., Szabo, G., & NIAAA Alcoholic Hepatitis Consortia (2016). Standard Definitions and Common Data Elements for Clinical Trials in Patients With Alcoholic Hepatitis: Recommendation From the NIAAA Alcoholic Hepatitis Consortia. Gastroenterology, 150(4), 785–790. https://doi.org/10.1053/j.gastro.2016.02.042

- Altamirano, J., Miquel, R., Katoonizadeh, A., Abraldes, J. G., Duarte-Rojo, A., Louvet, A., Augustin, S., Mookerjee, R. P., Michelena, J., Smyrk, T. C., Buob, D., Leteurtre, E., Rincón, D., Ruiz, P., García-Pagán, J. C., Guerrero-Marquez, C., Jones, P. D., Barritt, A. S., 4th, Arroyo, V., Bruguera, M., … Bataller, R. (2014). A histologic scoring system for prognosis of patients with alcoholic hepatitis. Gastroenterology, 146(5), 1231–9.e96. https://doi.org/10.1053/j.gastro.2014.01.018

- Thompson, R., Taddei, T., Kaplan, D., & Rabiee, A. (2024). Safety of naltrexone in patients with cirrhosis. JHEP reports : innovation in hepatology, 6(7), 101095. https://doi.org/10.1016/j.jhepr.2024.101095

- Parker, R., Arab, J. P., Lazarus, J. V., Bataller, R., & Singal, A. K. (2025). Public health policies to prevent alcohol-related liver disease. Nature reviews. Gastroenterology & hepatology, 22(8), 587–594. https://doi.org/10.1038/s41575-025-01084-6

The Importance of Screening for Alcohol Use During Pregnancy

Screening for alcohol use during pregnancy is a crucial strategy to protect the health of both the baby and the mother. Despite clear international recommendations, studies show significant variation between countries in the implementation of protocols and in the training of health professionals.

Alcohol consumption during pregnancy can cause a range of problems for the child, grouped under the term Fetal Alcohol Spectrum Disorders (FASD). There is no safe amount, and any exposure can increase the risk of physical, cognitive, and behavioral alterations with lifelong impact.

In Australia, considered a global reference in screening policies, a study involving more than 45,000 pregnant women receiving public healthcare between 2010 and 2021 found that 99.3% were asked about alcohol use during their first prenatal appointment¹. Screening was conducted by trained professionals using validated tools and systematic follow-up. Among the analyzed cases, about 7% of pregnant women reported alcohol exposure, with 1.3% classified as high risk. Even so, only half of the women considered high risk were reassessed during follow-up, revealing that there are still points to improve, including documentation of information and coordination with multidisciplinary teams.

A different scenario is observed in the United States. According to a national study, only 35% of healthcare professionals reported asking screening questions about alcohol use during pregnancy². Additionally, 37% of professionals interviewed mistakenly believed that consuming alcohol at some point during pregnancy could be safe. This finding reveals a significant gap in training and in the consistency of practices, reinforcing that clear protocols, ongoing education, and validated tools are essential for screening to fulfill its preventive role.

An international review compared the main screening tools currently used to identify alcohol use during pregnancy³. Questionnaires such as T-ACE, TWEAK, AUDIT-C, 4Ps Plus, and the Hoja Verde show good validity and can be applied quickly and easily. The success of screening, however, depends on the context: supportive environments, inclusion of partners in consultations, and systematic repetition of questions throughout pregnancy greatly improve the detection rate of at-risk cases. Barriers such as lack of professional knowledge, cultural issues, access to services, and alcohol use by partners still affect outcomes in different countries.

In summary, international experiences show that countries adopting universal screening policies integrated into prenatal care are more successful in identifying at-risk pregnant women, preventing complications, and promoting better health for both mother and baby. Family involvement, team training, effective documentation, and educational campaigns are essential pillars for advancing the prevention of the effects of alcohol during pregnancy.

In Brazil, there is currently no official policy or protocol for screening and intervention to identify and treat cases of alcohol use during pregnancy. Therefore, it is crucial to validate and implement such tools in the public healthcare system, provide training for health professionals to ensure early recognition of the problem, disseminate information to the population, and ensure specialized treatment availability for children affected by the syndrome⁴.

References:

1. QianS, Seddon Examining alcohol screening rates during pregnancy and documentation of prenatal alcohol exposure in a public health district in Australia. Journal of Advanced Nursing. 2025.
2. ChiodoLM, Cosmian C, Pereira K, et al. Prenatal alcohol screening during pregnancy by midwives and Alcoholism Clinical and Experimental Research. 2019;43(8):1747-1758.​
3. Azurmendi-Funes ML, Sánchez-SaucoMF, Campillo López F, et al. Revisão dos questionários utilizados para a detecção do consumo de álcool durante a gravidez e a Hoja Adicciones. 2023;35(4):493-502.​
4. FUNDAÇÃO OSWALDO CRUZ. Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira. Portal de Boas Práticas em Saúde da Mulher, da Criança e do Adolescente. Postagens: Principais Questões sobre Efeitos do Álcool na Gestante, Feto, Recém-nascido e Criança. Rio de Janeiro, 9 jan. 2025. Disponível em: <https://portaldeboaspraticas.iff.fiocruz.br/atencao-recem-nascido/principais-questoes-sobre-efeitos-do-alcool-na-gestante-feto-recem-nascido-e-crianca/>.

Harmful Alcohol Consumption Among People Aged 55 and Over in Brazil: What Do the Data Show?

Harmful alcohol use is yet another challenge arising from the aging of the Brazilian population. Analyses conducted by CISA – the Information Center on Health and Alcohol indicate growth in both alcohol-related deaths and abusive consumption among people aged 55 and over in Brazil.

Although this article is based on data from the publication Alcohol and the Health of Brazilians: Panorama 2024, it is worth noting that on November 12, CISA will release Panorama 2025, with updated datasets and an even more detailed look at the population aged 55 and older. The new edition, which will be available for download on CISA’s website, delves deeper into the very points discussed here: trends in alcohol-attributable deaths, consumption patterns, and care priorities in aging — providing a more current overview to guide prevention and health assistance strategies.

Data analyzed for Alcohol and the Health of Brazilians: Panorama 2024 show that alcohol-attributable deaths disproportionately affect people over 55 years old — and this trend is on the rise. The age group 55 and over was the only one to show an increase in alcohol-related deaths between 2010 and 2022, with a 29.4% rise over the period. Among women, the increase was even higher, reaching 33.6%, while among men, it was 27.6%. Despite this difference, men continue to be the most affected, accounting for 68% of these deaths.

In absolute numbers, alcohol-attributable deaths in the 55+ population rose from 30,471 in 2010 to 39,440 in 2022. Among men, the number went from 21,043 to 26,844, and among women, from 9,428 to 12,595. Notably, all other age groups showed declines in alcohol-related deaths, especially younger cohorts.

Regarding causes of death in this population, older adults tend to suffer more from the long-term effects of alcohol use. The elderly are more affected by chronic health conditions that are aggravated by continued alcohol consumption. There is also a marked difference between men and women regarding causes of death. While younger individuals are more affected by external causes — such as violence and traffic accidents linked to alcohol use — older adults are more likely to die from chronic diseases such as hypertension, cancer, and alcoholism itself.

The main causes of alcohol-related deaths among people aged 55 and over varied by sex:

• Men: Alcoholic liver disease (21%), Alcohol use disorders (15%), Liver fibrosis and cirrhosis (7%), and Colon cancer (4%).
• Women: Hypertension (7.9%), Liver fibrosis and cirrhosis (7.8%), Pneumonia (7.0%), and Colon cancer (5.8%).

Other causes mentioned include liver fibrosis and cirrhosis and esophageal cancer.

Another noteworthy finding is the increase in binge drinking among people aged 55 and over, characterized by consuming large quantities of alcohol within a short period. In 2010, 8.9% of Brazilians in this age group reported this pattern of consumption, rising to 10.6% in 2023. Binge drinking is more common among men (11.3%) than women (9.6%). It is also important to note that the peak prevalence in the time series was observed in 2021, reaching 13.4%, with spikes during the first two years of the COVID-19 pandemic (2020 and 2021).

Aging can reduce the body’s tolerance to alcohol due to various physiological and body composition changes. With age, total body water and lean body mass decrease, which reduces the volume of alcohol distribution and increases blood alcohol concentration for the same dose. Other factors include reduced first-pass metabolism, decreased blood flow and liver volume (resulting in slower alcohol clearance), and greater sensitivity of the central nervous system to alcohol’s effects. Impaired balance and vision, a tendency toward orthostatic hypotension, and more fragmented sleep further increase the risk of falls and confusion after drinking.

Additionally, there are psychosocial risk factors that are relatively common in this age group and may contribute to harmful alcohol use — such as widowhood, loneliness, loss of friends, retirement, and social isolation.

The scenario is worrisome considering that this segment of the population is more vulnerable to alcohol’s effects, requiring increased attention to health care. Combined with the rapid growth of Brazil’s elderly population, this calls for urgent implementation of programs promoting healthy aging, including campaigns to prevent harmful alcohol use.

References:

1.      GBD 2023 Disease and Injury and Risk Factor Collaborators (2025). Burden of 375 diseases and injuries, risk-attributable burden of 88 risk factors, and healthy life expectancy in 204 countries and territories, including 660 subnational locations, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023. Lancet (London, England), 406(10513), 1873–1922. https://doi.org/10.1016/S0140-6736(25)01637-X

2.      GBD 2023 Causes of Death Collaborators (2025). Global burden of 292 causes of death in 204 countries and territories and 660 subnational locations, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023. Lancet (London, England), 406(10513), 1811–1872. https://doi.org/10.1016/S0140-6736(25)01917-8

Global Burden of Disease (GBD) Overview on Alcohol-Related Disorders and Risks

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) is a well-established reference for measuring health, mortality, and disability in a comparable way across more than 200 countries and over time. The GBD integrates multiple data sources and applies standardized methods to estimate the burden of hundreds of diseases and injuries, as well as the impact of various risk factors — extending far beyond alcohol (such as tobacco use, diet and hypertension, obesity, air pollution, among others).

The GBD uses a set of complementary metrics to quantify health burdens in a comparable manner. For mortality, it reports the number of deaths (in thousands). For morbidity (non-fatal losses), it uses YLDs (Years Lived with Disability), which estimate how long the population lives with diseases and limitations, weighted by the severity of symptoms. It also uses YLLs (Years of Life Lost), which measure how many years of life are lost when someone dies before the expected age for their cohort. The summary measure is the DALY (Disability-Adjusted Life Year). This framework allows for the assessment, for example, of alcohol’s impact on both fatal outcomes (such as cirrhosis or accidents) and non-fatal outcomes (such as alcohol use disorders, depression, and injuries), comparing periods and regions using the same measurement standard.

Although the GBD includes data going back to 1990, the structure of the most relevant findings focused on long-term percentage changes in alcohol-related mortality and morbidity used 2000–2023 and 2010–2023, respectively, as reference periods.¹,²

Morbidity and Global Trends in Alcohol Use Disorder and Excessive Alcohol Consumption (2010–2023)

In 2023, Alcohol Use Disorder (AUD) accounted for 11.6 million Years Lived with Disability (YLDs) (95% UI: 8.08–16.5), corresponding to 1.2% of the global disability burden (UI: 0.9–1.4), ranking 26th among causes of morbidity. Between 2010 and 2023, the non-fatal burden from AUD increased 12.6% in absolute numbers (UI: 9.6–15.3), while the age-standardized rate of YLDs per 100,000 population decreased by 4.9% (UI: −6.7 to −3.1), suggesting a slight reduction in average individual risk despite population growth and aging.

For fatal outcomes, between 2000 and 2023, Years of Life Lost (YLLs) due to AUD decreased 8.9% in total count, from 7,088.2 thousand (UI: 6,447.9–7,992.7) to 6,460.2 thousand (UI: 5,727.4–7,529.1), and the age-standardized YLL rate dropped 39.7% (UI: −49.8 to −27.1).

Considering the total burden in Disability-Adjusted Life Years (DALYs), excessive alcohol consumption as a risk factor rose from 14th place in 2010 to 11th in 2023 in the global ranking — reflecting the combined effect of deaths and disabilities attributable to alcohol use.

Mortality Burden from Alcohol Use Disorders (2000–2023)

Between 2000 and 2023, mortality fully attributable to alcohol use disorder remained virtually stable in absolute numbers, while declining significantly when adjusted for age: total deaths changed by only +0.8% (UI: −14.9 to +19.9), whereas the age-standardized death rate dropped 36.7% (UI: −46.6 to −24.5). In other words, although population growth and aging kept the number of deaths at similar levels, the average risk of dying from AUD — per 100,000 inhabitants and age-adjusted — decreased over the period.

Mortality from Diseases Fully Attributable to Alcohol (2000–2023)

Specific and severe consequences of alcohol use, such as cirrhosis and cardiomyopathy, were also tracked:

• Alcohol-attributable cirrhosis showed opposite trends across the two metrics: between 2000 and 2023, total deaths increased 22.6% (UI: +6.3 to +41.5), while the age-standardized death rate decreased 29.9% (UI: −39.5 to −19.3). In simple terms, there are more deaths in absolute numbers — an effect of population growth and aging — but the average risk per person, adjusted for age, has decreased.
• For alcoholic cardiomyopathy, improvement was observed in both dimensions: total deaths fell 18.6% (UI: −28.8 to −7.4), and the age-standardized rate dropped even more sharply by 52.3% (UI: −58.3 to −45.7), suggesting a consistent reduction in risk over time.
• In contrast, alcohol-attributable liver cancer presents a more concerning picture: total deaths rose 86.1% (UI: +58.3 to +116.7), and the age-standardized rate remained virtually unchanged (+1.3%; UI: −13.8 to +17.7). In other words, the absolute burden increased substantially, and there was no clear decline in average risk — underscoring the need for prevention and early diagnosis.

In Summary

Despite decreases in age-adjusted rates, the absolute burden linked to alcohol continues to rise due to population growth and aging. The path forward is clear: reduce harmful alcohol use, expand screening and treatment, and monitor outcomes using robust metrics such as those employed by the GBD.

References:

1.       GBD 2023 Disease and Injury and Risk Factor Collaborators (2025). Burden of 375 diseases and injuries, risk-attributable burden of 88 risk factors, and healthy life expectancy in 204 countries and territories, including 660 subnational locations, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023. Lancet (London, England), 406(10513), 1873–1922. https://doi.org/10.1016/S0140-6736(25)01637-X

2.       GBD 2023 Causes of Death Collaborators (2025). Global burden of 292 causes of death in 204 countries and territories and 660 subnational locations, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023. Lancet (London, England), 406(10513), 1811–1872. https://doi.org/10.1016/S0140-6736(25)01917-8