The last time lawyer Erika Byrd talked her way out of an alcohol rehab center, her father took her to lunch.
"Dad, I know what alcohol has done to me," she told him that day in January 2011. "I know what it has made me do to you and mom. But that wasn’t me."
By the time she died three months later, Byrd had blocked her parents' calls because they kept having her involuntarily committed. They once had a magistrate judge hold a hearing at her hospital bed. He ordered herto undergo a month of in-patient treatment.
Byrd, who died in April 2011 at the age of 42, is among the rising number of people in the United States who have been killed by alcohol in the last decade.
It's an increase that has been obscured by the opioid epidemic. But alcohol kills more people each year than overdoses – through cancer, liver cirrhosis, pancreatitis and suicide, among other ways.
From 2007 to 2017, the number of deaths attributable to alcohol increased 35 percent, according to a new analysis by the Institute for Health Metrics and Evaluation at the University of Washington. The death rate rose 24 percent.
One alarming statistic: Deaths among women rose 67 percent. Women once drank far less than men, and their more moderate drinking helped prevent heart disease, offsetting some of the harm.
Deaths among men rose 29 percent.
While teen deaths from drinking were down about 16 percent during the same period, deaths among people aged 45 to 64 rose by about a quarter.
People's risk of dying, of course, increases as they age. What's new is that alcohol is increasingly the cause.
"The story is that no one has noticed this," says Max Griswold, who helped develop the alcohol estimates for the institute. "It hasn't really been researched before."
The District of Columbia, less than 10 miles away from the Venable law office where Byrd was a partner, had the highest rate of death from alcohol in the country, according to the institute's analysis. Georgia and Alabama came in second and third.
Alabama, in fact, ranked third among states with the strongest alcohol control policies, as rated by medical researchers in a 2014 report published in the American Journal of Preventive Medicine.
States can influence drinking – especially dangerous binge drinking – with policies such as taxes on alcohol and restrictions on where and when it can be sold.
Psychologist Benjamin Miller, chief strategy officer at the nonprofit Well Being Trust, says the larger health challenges in the South are to blame for high alcohol death rates. Southern states typically rank near the bottom in national rankings in cancer, cardiovascular disease and overall health.
Oklahoma, Utah, Kansas and Tennessee rounded out the five states with the strongest alcohol control policies, the researchers reported. States with more stringent alcohol control policies had lower rates of binge drinking, they found.
Nevada, South Dakota, Iowa, Wyoming and Wisconsin had the weakest alcohol control policies.
David Jernigan, a professor at Boston University's school of public health who has specialized in alcohol research for 30 years, notes that the beer industry holds considerable sway in Wisconsin.
Binge drinking is sending far more people to the emergency room, a separate team of researchers reported in the February 2018 issue of the journal Alcoholism: Clinical and Experimental Research.
The researchers, who looked at ER visits from 2006 to 2014,found the largest increases were among the middle aged – especially women. The number of teenage binge drinkers landing in the ER during that time actually declined.
Older, often lifelong drinkers don't need only to have their stomachs pumped. They frequently have multiple complications from their drinking.
Their often bulbous bellies need to be drained of fluid, which builds up from liver cirrhosis, and their lungs cleared of aspirated vomit, says Dr. Anthony Marchetti, an emergency room doctor at Upson Regional Medical Center in Thomaston, Georgia.
They might also have brain hemorrhages or internal bleeding, because booze prevents their blood from clotting properly.
By middle age, Marchetti says, long-term drinking can also lead to heart failure, infections due to immune suppression, a type of dementia from alcohol-induced brain damage, stomach ulcers and a much higher risk of cancer.
As opioid overdoses, which kill about 72,000 people a year, grabbed America's attention, the slower moving epidemic of alcohol accelerated, especially in Southern states and the nation's capital. About 88,000 people die each year from alcohol.
Making matters worse, alcoholism is trickier to treat – and criticize – than opioid addiction.
"Culturally, we’ve made it acceptable to drink but not to go out and shoot up heroin," Miller says. "A lot of people will read this and say 'What's the problem?' "
It might be a more socially acceptable addiction, but alcoholism is at least three times costlier to treat than opioid addiction, according to the Centers for Disease Control and Prevention. And it's a far more complicated midlife crisis to address.
The proven approaches – taxes on alcohol and limits on where and when alcohol is sold – are often rejected because the liquor industry has considerable clout with policymakers.
Ron Byrd says his daughter Erika was "beautiful inside and out."
To him, there's no question about what caused her death.
That's despite the fact there was no alcohol in her system when she was found dead at home. She was so sick, Byrd says, she hadn't been able to eat or drink for days.
"The death certificate never says alcoholism," he says. "It said heart arrhythmia and heart valve disease. But nobody in our family had heart problems."
Attorney Lisa Smith has been in recovery from alcohol and cocaine addiction for a decade. The New York City woman wrote the memoir "Girl Walks Out of a Bar" and co-hosts the podcast Recovery Rocks.
Smithspeaks at legal conferences and law firms such as Byrd's about the hazards of lawyers' high-stress days and booze-fueled dinners with clients. But she's fighting forces far larger than her profession.
"It is poison, and we’re treating it like it's something other than that because there‘s big corporate money behind it," she says. "A lot of people are getting really rich on something that is toxic to us."
Deaths of despair
In its Pain in the Nation report this year, the Well Being Trust called losses from drugs, alcohol and suicide "despair deaths."
The three are closely related. Suicide is the third leading cause of death from alcohol, after cancers anddigestive diseases. One in five individuals who die from opioid overdoses have alcohol in their system at the time of their death.
Drinking can lead to cancers all along the digestive tract, from the mouth to the colon. About 15 percent of U.S. breast cancer cases are considered to be caused by alcohol. A third of those cases affected women who drank 1.5 drinks or less a week, according to a 2013 report in the American Journal of Public Health.
The "direct toxicity" of alcohol damages the nervous system from the brain down to the spinal cord and to peripheral nerves, says Marchetti, the Georgia emergency physician. It's common for people in the late stages of alcoholism to have numbness in their feet and legs, which makes walking difficult even when they aren't impaired.
Emergency rooms are the most expensive place to treat problems. Between 2008 and 2014, the rate of ER visits involving acute alcohol consumption rose nearly 40 percent, according to the study in the journal Alcoholism: Clinical and Experimental Research. For chronic alcohol use, the rate rose nearly 60 percent.
The increases for acute and chronic alcohol use were larger for women.
People who drink throughout their lifetime develop a tolerance for alcohol. But as they age, they lose muscle and gain fat and become less tolerant.
That leads to increased injuries and illnesses, says Rick Grucza, an associate professor of psychiatry at Washington University in St. Louis and lead author of the Alcoholism study.
But why are so many people drowning so many sorrows?
Brenda Padgett believes it was postpartum depression that led her daughter to take up the heavy drinking that ultimately killed her last year.
Ashley Hartshorn, who lived in Hendersonville, North Carolina, had already suffered the trauma of hearing her stepfather kill his girlfriend while she was on the phone.
Then Hartshorn testified against him in court, which helped send him to prison for life.
The depression came after the birth of her third child in February 2012.
"She wanted so badly to quit drinking, but the shame and the fear kept her from being able to allow herself to reach out for help," Padgett says. "Like many, we were ignorant to the effects that alcohol has on the body. I thought she had time, time to hit rock bottom and time to seek help.
"I never knew that only five years of alcohol abuse could take the life of someone so young."
Neither did Nancy Juracka. Her son Lance died in 2006 after just three years of heavy drinking. He was 36.
Lance Juracka, who grew up in Hermosa Beach, California, was intimately familiar with the scourge of alcoholism: He knew an uncle and aunt had drunk themselves to death before he was born. He even produced a short documentary about alcohol abuse while at New York University's Tisch School of the Arts.
He started drinking when he got a job in Las Vegas reviewing shows – and was continually offered free drinks.
"Once he got a taste for alcohol, it really did him in fast," his mother says. "I don’t understand how Lance’s liver went so quick."
He headed back to California and ultimately moved back in with his mother.
He started a painting business. But his workers told Juracka he would just drink vodka or sleep.
"I thought I was going to lose my mind, I was so frantic," she says. "I would sit up all night with him so he wouldn’t choke on this vomit."
Joseph Garbely, an internal and addiction medicine physician at Caron Treatment Centers in Wernersville, Pennsylvania, says research shows that 10 percent of parents think having two or more alcoholic drinks a day is reasonable to reduce their stress.
But why? It's not as if liquor is becoming more accepted.
Consider, however, the lack of public service announcements about the effect excessive alcohol has on health or families.
Ali Mokdad is a professor at the Institute for Health Metrics and Evaluation. He notes that alcohol-related education focuses on drunk driving.
Miller and others point to the high level of workplace stress that began accelerating during the recession, loneliness linked to social media and increasing pressures on working mothers.
In fact, social isolation can be both a cause and the result of excessive drinking. Parents whose children drank themselves to death in their 20s and 30s often describe the drinking in isolation seen in elderly alcoholics.
Few who drink excessively while young will become alcoholics, much less drink themselves to death. Those who are in recovery for alcoholism say people who turn high school or college binge drinking into a nightly coping ritual are at the most risk.
Amy Durham came close to dying from alcohol six years ago, when she was 40. And she barely drank until she was in her 30s.
The child of an alcoholic father, Durham never thought she could or would lose control.
"I didn't even know what was happening to me," she says.
She attributes her plunge into alcoholism to unresolved trauma from growing up in an alcoholic home, the stress of her work as a school principal, a "toxic" romantic relationship and grief over an inability to get pregnant.
"I just needed to be numb," she says.
Ron Byrd says Erika, too, dreamed of having children. After two divorces and stage 3b breast cancer, however, the chance was slipping away.
"She wanted so desperately to have a baby," Byrd says.
Durham is now corporate director of alumni relations at Pennsylvania-based Caron Treatment Centers, where she was treated.
"I wasn’t able to see that my drinking was a problem until it was almost too late," she says. "I put limits on myself and would say that i'd only drink two glasses of wine in a social setting and then go home and drink a lot in isolation."
When her father died in July 2012 of esophageal cancer, Durham says, she began a "very bad downward spiral."
She remembers his funeral.
"i was trying to be nothing like my father, but I couldn’t wait to get out of that church and drink," she says. "The shame of what was happening to me was more than I could bear."
Like Hartshorn and Byrd, Durham started with white wine. But she ended up drinking copious amounts of vodka.
By the time her family got her to a hospital, Durham was in triple organ failure and wound up in a coma for 10 days.
That was followed by six weeks of dialysis.
When she arrived at in-patient rehab after the dialysis, Durham says, her body and eyes were still yellow and she was carrying 100 extra pounds of fluid – half of it in her legs.
She says fellow rehab residents – no strangers to the telltale signs of addiction – quickly looked away as she passed.
Men vs. women drinkers
When men crash and burn from alcohol, Mokdad says, the spectacle is often public. They get into bar fights, get cited by police for drunk driving or lose heir jobs.
A more typical trajectory for women starts with evening wine as a way to de-stress from the work day – either in a professional setting, or home with young children.
Author and podcast co-host Stefanie Wilder-Taylor, writer of "Sippy Cups Are Not for Chardonnay," believes this stems from stubborn gender roles and norms surrounding stress.
"Moms just aren't going to call home and say they're stopping for a couple drinks after work with friends or going to the gym to unwind," the Los Angeles woman says
Otherwise, they might feel like parenting failures as they compare themselves to other moms. So they drink wine while they make dinner, which can lead to a nightly pattern of excessive drinking.
That describes nurse practitioner Eileen O'Grady, who quit drinking 12 years ago.
O'Grady, who lives in McLean, Virginia, says her two sons, now in college, never really saw her drunk. But she couldn't bear the thought of continuing her destructive double life. She would drink continually from dinner until she went to sleep, she says, and then start again the next evening.
For O'Grady, the last straw came after a night of especially hard drinking with another mom in her neighborhood.
The other woman, a schoolteacher, vomited in O'Grady's car. She returned the next day to clean it up.
O'Grady hasn't taken another drink.
"I could see my life if I kept going," O'Grady says. She is now active in her local recovery community and working as a wellness coach.
Her schoolteacher friend taught classes until last fall. Within days of leaving the classroom, she was in a hospital with end-stage liver disease.
She died in hospice on Jan. 3.
At least 15 people at the woman's memorial service asked O'Grady how her friend had died. They were stunned to learn alcohol was the cause.
The woman was poisoning herself with a half-gallon of vodka a day, O'Grady says, yet no one knew beyond her immediate family, O'Grady and a mutual friend in the neighborhood.
"We're closeted," O'Grady says. "We're not in bars getting in fights."
As for Durham, she was on a liver transplant list for about five months in 2011 and 2012. Then she learned she no longer needed a new liver.
"Livers have a great capacity for recovery," says Dr. Michael Lucey, a professor and head of the division of gastroenterology and hepatology at the University of Wisconsin medical school.
Durham was once in a sorority at University of Mississippi, where beauty was competitive and a popular saying was "pretty is as pretty does."
"But there was nothing pretty about my drinking," she says.
If she had been diagnosed with breast cancer, Durham says, she wouldn't think twice about getting treatment and talking about it.
Durham stopped drinking six years ago Thursday. She says she surprises people with how openly she shares the gritty details of her near-death experience.
"I want to show the world what recovery looks like, especially for women where stigma is still the way it is," Durham says. "I want people to know there is hope."
Erika Byrd called her father in hysterics on April 9, 2011. She had been fired after failing to turn in paperwork to continue getting disability coverage through her law firm.
"I don’t want to want it, but I want it," Byrd recalls her saying, sobbing.
"I said, 'If you can stop drinking you can do anything,' " Byrd says. "I told her, 'We love you, Erika,' and she hung up."
Byrd and his wife were getting ready to go to church the next day when there was a knock on the door. A pastor stood with a police officer. Erika was dead.
A doctor from the National Institute for Mental Health called to ask if the Byrds would consider donating Erika's brain for research.
They said yes.
"She had done everything she knew how to to beat this terrible disease," Ron Byrd says. "I would think she would want it."
If you are interested in connecting with people online who have overcome or are currently struggling with health problems mentioned in this story, join USA TODAY’s "I Survived It" Facebook support group.