Fatal drug overdoses had been slowly rising for a decade, but when the number of Coloradans killed by fentanyl soared during the first two years of the pandemic, state leaders, law enforcement officials, public health managers — even ordinary people — called for drastic action.
Hoping to stem the loss of life, lawmakers took the controversial step in 2022 of making it a felony to possess even a small amount of fentanyl, the synthetic opioid responsible for most of the state’s fatal overdoses.
Schools and colleges began stocking the overdose-reversal medication naloxone. Families and friends of people killed by fentanyl rallied for more treatment resources. Nonprofits conducted educational campaigns about the dangers of counterfeit medications, advising “one pill can kill.”
Colorado’s quiet killer
Alcohol-related deaths in Colorado spiked during the pandemic, and the state ranks as one of the worst for deaths due to drinking. In this four-part series, The Denver Post examines why so many Coloradans are dying, and ways to save lives that the state hasn’t pursued.
Yet at the same time, another drug quietly fueled its own surge in fatalities in Colorado.
Deaths from alcohol in Colorado shot up more than 60% between 2018 and 2021, falling slightly in 2022 — as did fatal overdoses. But alcohol fatalities are still 50% above pre-COVID levels, and experts fear Coloradans’ heavier drinking since 2020 will continue to exact a deadly cost in the years to come.
Alcohol killed 1,547 people statewide in 2022 — fewer than the 1,799 who died of overdoses — but that narrowly defined figure only includes certain types of organ damage and complications of withdrawal. Factor in deaths from long-term complications of drinking, and estimates put alcohol’s annual toll in this state at roughly twice that number.
Coloradans die from the effects of alcohol at one of the highest rates in the country, but, in comparison to fentanyl, the state’s reaction has been a shrug. Legislators haven’t seriously considered measures to discourage drinking, and voters expanded access to alcohol in grocery stores. Gov. Jared Polis said he considers drinking a matter of personal responsibility.
The Denver Post is publishing a four-part series this week examining why Colorado consistently ranks among the worst for alcohol-related deaths. The state hasn’t raised alcohol taxes or done anything to restrict access — steps that can reduce deaths. And while treatment is available in Colorado, information about how to access it hasn’t always reached families searching for help.
Rep. Marc Snyder, a Colorado Springs Democrat and chair of the House committee that oversees the state’s alcohol regulation said he found it “pretty shocking” to learn alcohol-related deaths are comparable to drug overdoses in Colorado.
“We kind of forget about alcohol,” he said.
Of course, alcohol and harder drugs like fentanyl also have important differences.
The fact that more people die from alcohol overall reflects that far more people use it. A single, more potent-than-expected dose of fentanyl can kill a user, while heavy drinking can take decades to claim a life. And the two drugs’ secondary effects are difficult to compare: illicit fentanyl brings violent crime from drug trafficking, while alcohol can increase the odds that personal disputes end in assault or murder.
Representatives for the alcohol industry said government intervention isn’t an answer to the growing problem of excessive drinking in Colorado. The state would do better to focus on screening and referring people who need help to treatment as needed, said Amanda Berger, vice president of science and health at the Distilled Spirits Council. Raising taxes will just push drinkers to use cheaper products, she said.
“Tax hikes will unfairly raise the cost on responsible consumers and harm hospitality businesses still trying to rebound from the pandemic amid a host of new challenges, including inflation and staff shortages,” Berger said in a statement.
Only about half of Americans drink on a regular basis, but surveys have shown those who do are more educated and affluent — the kind of people who make the laws, said David Jernigan, a Boston University professor of health law, policy and management who has studied alcohol marketing. They’re less willing to regulate a socially acceptable drug that’s popular in their circles than they are to take a stand against tobacco or opioids, he said.
Lawmakers in charge of regulating alcohol said they were surprised to hear that the number of people dying from drinking was even comparable to deaths from other drugs. They, and the governor’s office, pointed to Colorado’s efforts to stop underaged people from drinking and to reduce impaired driving.
The Centers for Disease Control and Prevention attributed only about 8% of Colorado’s alcohol deaths to car crashes, however — fewer than liver disease, cardiovascular problems or suicide. Reducing underage drinking could help stem the tide of deaths, but any effects would be decades in the future. While people who start drinking as teens are at a higher risk for alcohol-related problems, most die in their 50s or later.
For a long time, moderate drinking was considered healthy, or at least not something to worry about. That’s contributed to confusion, because, unlike smokers, regular drinkers don’t know what they’re consuming could hurt them, said Dr. Bill Burman, former director of the Public Health Institute at Denver Health.
Someone who drinks a six-pack of beer on a Saturday night doesn’t necessarily see that as unsafe, even though studies show it increases their risk of premature death, he said.
“I think almost everyone recognizes that severe alcoholism is a problem, that person who’s falling down on the street,” but most people who drink aren’t aware they could be at risk, he said.
The alcohol industry has been quite successful in keeping the focus on the most extreme drinkers, Jernigan said. When someone picks up a pack of cigarettes, they see a warning label that clearly outlines specific diseases they’re risking, but the alcohol label only states that drinking may cause birth defects or interfere with driving, and “may cause health problems.”
“That doesn’t tell you anything,” he said. “You don’t think of alcohol as a factor in heart attacks, as a factor in cognitive decline.”
Lack of a legislative response
Colorado lawmakers haven’t hesitated to regulate some drug threats.
In addition to making possession of one gram of fentanyl a felony, the state legislature also recently raised the minimum age to buy tobacco to 21 and took steps to reduce youth access to marijuana. Legislators limited the amount of high-potency cannabis products an individual can purchase each day and required a more extensive relationship before a physician can sign off on a medical marijuana card.
Nothing similar has been proposed to reduce alcohol use, even as alcohol-related deaths spiked in Colorado.
In 2018, the State Epidemiological Outcomes Workgroup laid out four strategies to lessen the impact of excessive drinking: reducing the density of businesses selling alcohol, raising alcohol taxes, limiting the hours when alcohol can be sold and increasing liability for selling alcohol to someone who’s underage or already intoxicated.
The state hasn’t done any of those things. Instead, the density of outlets selling alcohol has increased, and the state may extend the hours during which restaurant and bar patrons can drink alcohol next year. In 2022, voters approved Proposition 125, which allowed grocery stores to sell wine, further expanding on a 2019 change that allowed grocers to sell full-strength beer.
That’s not unusual, Jernigan said: passing new alcohol taxes is difficult anywhere, and cities get significant pressure to offer more alcohol licenses as a way to recruit businesses and revitalize struggling areas. Of course, that argument doesn’t account for the costs of increased drinking, such as higher rates of police calls and emergency room visits, he said.
Health and safety is Polis’s “top priority,” and the state has been successful in decreasing underage drinking, said Conor Cahill, a spokesman for the governor. The Colorado Department of Public Safety also provides training to local law enforcement on impaired driving, he said.
“Gov. Polis believes in personal responsibility,” Cahill said. “The state continues to invest in substance-use disorder treatment and alcohol risk education resources, and, ultimately, legal adults have the right to safely and responsibly access alcohol as long as they don’t risk public safety.”
A number of groups representing the alcohol industry, including the Colorado Brewers Guild, Colorado Beer Distributors Association, the Colorado Cider Guild and Molson Coors either declined to comment or didn’t respond to The Post’s requests for an interview.
Micki Hackenberger, executive director of the Wine and Spirits Wholesalers of Colorado, said the Taxpayer’s Bill of Rights — which requires all tax increases to go before voters — and the ability of local governments to decide where alcohol should be sold limit the state’s ability to make sweeping changes. That said, Colorado has taken steps to reduce deaths through the Task Force on Drunk and Impaired Driving and with efforts to expand training for bartenders and wait staff, she said.
“They actually have done a lot,” Hackenberger said. “Safety is an issue that I think everybody is concerned about.”
The state might pay more attention to alcohol in the near future, since an interim legislative committee proposed a bill that would limit how wine and beer can be displayed in grocery stores, said Raquel Garcia, a member of the Colorado Behavioral Health Administration’s advisory committee.
Garcia said pushing for action on alcohol is difficult, though, because selling it is so profitable, and people who aren’t in addiction recovery haven’t considered it a priority. And, of course, the deaths caused by alcohol are quieter than when someone overdoses on opioids in public.
“We’ve allowed (alcohol) to creep into every segment of our society,” she said. “I think in Colorado, we’ve been irresponsible.”
Pandemic increase in deaths hasn’t ended
Colorado has recorded higher-than-average rates of alcohol-related deaths than the country as a whole since at least 2009, and had the sixth-highest rate in 2021, according to an analysis by KFF, the health policy research organization formerly known as the Kaiser Family Foundation.
The KFF data, like the state’s, only includes deaths caused by behavioral health symptoms related to alcohol, like psychosis or withdrawal; alcohol poisoning; and certain alcohol-induced conditions affecting the liver, pancreas, heart, nervous system and stomach.
The CDC estimates include a broader range of causes, and have generally been about double the state’s numbers, but aren’t calculated every year.
Colorado’s alcohol deaths started rising steadily around 2015, then jumped dramatically in 2020 and 2021. In 2022, they dropped from their pandemic high of 1,653, but still were up 50% compared to 2018. The trend persisted even after adjusting for population growth and aging.
“Everyone thought (the increase in alcohol-related deaths) was COVID and the pandemic, and we thought it would go back down,” said Joseph Schacht, a clinical psychologist who studies alcohol at the University of Colorado’s Anschutz Medical Campus.
So far, however, it appears many people have continued to drink at elevated levels, pushing those whose bodies had already sustained some damage into serious illness, he said.
Emily Marberry, of Denver, believes the pandemic contributed to her husband Rick Gildar’s death from liver failure, at just 36.
Gildar was a “super smart” software engineer who could take anything apart and put it back together, and taught himself how to play the guitar, his wife said. But he also had social anxieties and depression that he soothed with alcohol. He went to detox centers two or three times and avoided alcohol for a few months each time, but then would decide he could safely drink again and start the cycle over, she said.
The forced isolation of the first months of the pandemic didn’t help his mental state, Marberry said, and he was discouraged when a rehab facility turned him away in May 2020, saying he was too sick to manage. He stopped drinking for a few months before his death later that year to try to get on the liver transplant list, but it was too late to undo the damage, she said.
“I think those things that happened would make him feel more defeated, and he would drink more,” she said.
Alcohol, suicide deaths related in the West
The states with alcohol-related death rates even higher than Colorado’s in 2021 were also in the West: New Mexico, South Dakota, Alaska, Wyoming and Montana.
Part of that simply reflects that people living in Western states tend to drink more. With the exception of the period from about 2009 to 2017, the West has had the highest per capita alcohol consumption of any region since the 1970s.
“Heavier-drinking states are going to have higher rates of alcohol-related deaths,” Schacht said.
Coloradans 14 and older drank an average of about three gallons of pure alcohol in 2021, spread out across beer, wine and liquor. That was the ninth-highest consumption rate in the country.
The state’s residents also reported binge-drinking — five or more drinks on one occasion for a man, or four or more for a woman — at higher rates than Americans overall. About 19% of Colorado adults reported binge drinking in 2022, and 8% reported consistently exceeding the guideline that men have only two drinks a day and women have only one, according to CDC data.
More people likely exceed the healthy drinking guidelines, though, because a cocktail that an average person would consider one drink might contain multiple shots, making it several drinks in the CDC’s eyes.
From the early 1980s to the mid-1990s, average alcohol consumption was trending down in Colorado, but that reversed for unclear reasons. By 2021, the average Coloradan was drinking about 25% more than in 1999. In the same period, consumption increased about 16% nationwide and 15% in the Western region.
Drinking heavily seems to be part of the culture in the West in a way that it isn’t in other parts of the country, Denver Health’s Burman said. While studies generally have described a consistent pattern of heavier drinking in the West, researchers haven’t established why that might be.
The combination is particularly bad, though, given the suicide rate in the Western states, Burman said. Gun ownership is also higher in the West, and using a firearm increases the odds that a suicide attempt will end in death.
A state report found that about 42% of people who died by suicide from 2011 to 2015 and had toxicology information had alcohol in their systems at the time of their deaths. About 28% were legally intoxicated. So far, the state’s suicide prevention programs haven’t mentioned alcohol as a risk factor or suggested that people at risk be discouraged from drinking.
“Alcohol lowers that threshold for doing something rash, and that can include suicide,” Burman said.
“A brutal disease”
While alcohol is directly toxic to cells at very high concentrations, most of its health effects seem to come from increasing inflammation in the body, CU Anschutz’s Schacht said.
Over time, that inflammation contributes to cancers or directly causes scarring on organs like the liver, he said. While red wine contains some antioxidant compounds, it doesn’t have high enough concentrations to outweigh the damage caused by the alcohol.
On average, mortality starts to rise significantly when men have about three drinks per day and when women have about two drinks per day, according to a study compiling the available data. People who drank less, or only had alcohol occasionally, didn’t see a significant rise or decline in overall mortality, though the risk of specific diseases rises at lower levels.
Calculating how many people died because of alcohol use is less straightforward when they had illnesses with multiple risk factors, such as breast or throat cancer, strokes, or improper heart rhythms, Schacht said. Researchers have to come up with estimates based on the number of people who died of relevant causes, and how much heavy drinking increases the risk of those conditions, he said.
“There’s certainly a percentage of breast cancer deaths that are attributable to alcohol, but you’ll never see alcohol as a cause on a death certificate” for someone who died of cancer, he said.
Using the CDC’s more expansive definition, about 18% of deaths in Colorado of adults 20 to 64 were related to excessive drinking between 2015 and 2019, behind only New Mexico, Alaska and Wyoming. The odds that a death involved alcohol were even higher for adults under 35, with drinking listed as a factor for more than 28% of Coloradans in that age group who died.
While many will still choose to drink, people need accurate information about risk so they can make decisions, as they do when considering whether to try a dangerous sport, Schacht said.
“Really, any level of alcohol use is not great for your health,” he said.
On average, people who die of alcohol-related causes lose about 30 years of potential life, according to a 2021 report from the state health department. That puts them in their prime years for earning income and raising families.
Andrea Carter, of Highlands Ranch, said that in some ways she felt like a single mother even before her husband Matt died of liver disease at 39.
Matt wasn’t a bad person, she said — he was a blast when they were students at Colorado State University and loved the two daughters they had together — but as his drinking escalated over time, he wasn’t emotionally able to be present as a father. Sometimes, she’d take their daughters to their grandparents’ house when he was drinking, because while he was never violent, he’d rapidly lose patience and snap at them.
He sought residential treatment in 2014 and 2015, but the longest stretch he went without alcohol was when he broke both shoulders and couldn’t drive, Carter said. At the time, she said she didn’t know the neurobiology underlying addiction and thought he just wasn’t willing to stop for his family.
It was only after he died in 2018 that Carter told their daughters, who were then 8 and 11, that he would have chosen something different if he could have.
“I don’t wish it on my worst enemy. It’s a brutal disease,” she said.
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