Alcohol Use Disorder Admissions During the COVID-19 Pandemic: Findings From a Tertiary Community Hospital

Objectives: The first case of Coronavirus disease-19 (COVID-19) in the United States was confirmed by the Centers for Disease Control (CDC) in January 2020. The presence of COVID-19 and the subsequent spread of this disease led to stress, anxiety, grief, and worry. We aimed to study the rate of hospital admission for alcohol use disorder (AUD) before and during the COVID-19 pandemic in a tertiary community hospital in Michigan. Methods: Two subsets of hospital data were collected for comparison between hospitalized patients before and during the pandemic in a tertiary community hospital. Logistic regression was used to identify the odds ratio of AUD admission rates among all patients in 2020 compared with 2019 while controlling for covariates. Results: Our data showed a statistically significant increase in AUD patients in 2020 compared to 2019 (3.26% versus 2.50%, adjusted OR=1.44 with P=0.002). In addition, females had significantly lower chances of admission for AUD compared with males (OR=0.22 with P<0.001) and African Americans had significantly lower chances of admission for AUD compared to Whites (OR=0.44 with P <0.001). Divorced patients had a higher probability of admission for AUD compared to married patients (OR=2.62 with P<0.001). Conclusion: Our study found a significantly higher rate of AUD admissions in 2020 during the COVID-19 Pandemic compared to 2019. Gender, race, age, and marital status are significant risk factors related to AUD admissions.


Introduction
Pandemics are not just a medical phenomenon; they affect individuals and society on many levels, causing disruptions. Panic and stress have also been linked to outbreaks [1]. Several studies have identified an increase in mental health problems, alcohol, and substance abuse during the ongoing COVID-19 (Coronavirus disease-19) pandemic [2][3][4]. This increase was most likely secondary to stress due to a combination of working from home, temporary unemployment for others, home-schooling of children, lack of physical contact, and unpredictability associated with the pandemic. Stress is a prominent risk factor for the onset and maintenance of alcohol misuse. For example, chronic alcohol use results in neuroadaptations in stress and reward pathways, which lead to dysfunctional hypothalamic-pituitary-adrenocortical and sympathetic adrenomedullary axes, characterized by dysregulation of the cortisol response and deficits in emotional regulation [5]. According to the 2019 National Survey on Drug Use and Health conducted in the United States of America, nearly 15 million people ages 12 and older had an alcohol use disorder (AUD) [6]. An AUD is defined as a chronic brain disorder marked by compulsive drinking, loss of control over alcohol use, and negative emotions when not drinking. Of the 15 million people with AUD, 6.8% were men and 3.9% were women [7]. This prevalence of alcohol abuse and dependence translates into about 18.5% of emergency department visits on average [8]. One of the studies reported an increase in the frequency of alcohol consumption in 2020. On average, alcohol was consumed one day more per month by three out of four adults. For women, there was also a significant increase of 0.18 days of heavy drinking, from a 2019 baseline of 0.44 days, which represents an increase of 41% over the baseline [9]. In 2020, alcohol use will increase worldwide. During the first wave of COVID-19 in the USA, brick-and-mortar and online sales of alcohol skyrocketed [10]. We aimed to study whether there was a concomitant increase in inpatient admissions for alcohol use disorder in various subsets of the patient population during the pandemic.

Materials And Methods
The study was approved by the Michigan State University Biomedical and Health Institutional Review Board. The study was reviewed by the Institutional Review Board (IRB) through the Non-Committee Review procedure. The IRB has found that this study protects the rights and welfare of human subjects and meets the requirements of MSU's Federal Wide Assurance (FWA00004556) and the federal regulations for the protection of human subjects in research (e.g., 2018 45 CFR 46, 21 CFR 50, 56, and other applicable regulations).
We obtained admission and demographic data for all adult hospitalized patients (age 18 or above at admission) at the local tertiary level hospital dating between March 1, 2019 to December 31, 2019, and March 1, 2020 to December 31, 2020. Two subsets of hospital data were collected for comparison between hospitalized patients before and during the pandemic. Patients with an F10 principal or admission diagnosis, i.e., an alcohol-related disorder from the International Classification of Diseases Tenth Revision (ICD-10), were included in the study cohorts. To incorporate the most recent discharge diagnoses, data were extrapolated from the discharge summaries. Data were stratified on subsets of age, gender, employment, race, and marital status. Statistical testing was done using Chi-square tests to compare gender distribution in the same months in 2019 and 2020. Significance was set at two-tailed p < .05. All calculations were done using SAS statistical software version 9.4 (SAS Institute Inc., Cary, NC). The probability of admission was calculated by logistic regression. Data analysis was performed from March to December. These specific monthly data were chosen to curb seasonal bias and were coincident with the first statewide lockdown of the COVID-19 pandemic.

Results
There were a total of 15 Table 3). There was no statistically significant difference in admissions of female patients for the duration of the measurement period (March-December).

Discussion
We found a statistically significant increase in the number of admissions for alcohol use disorder during the first wave of the pandemic (2020) in the USA, compared to the year prior. In 2019, 2.50% of patients were admitted for AUD, compared to 3.26% in 2020 ( Figure 1). The increase was statistically significant in the months of May, June, and October (p-values < 0.05; Figure 2).
Our study also found a statistically significant difference in the percentage of AUD females admitted to the hospital in the month of April compared to the year prior ( Table 3). Women have also been subject to increased abuse and loss of jobs, potentially worsening the existing gender disparity and further exacerbating mental health problems in this demographic [11]. Unemployment was another major contributor to alcohol-related admissions during the pandemic. The expected number of job losses due to COVID-19 was taken from the International Labor Organization's press release dated March 18, 2020, reporting a decline of 24.7 million jobs as a high scenario and 5.3 million jobs lost as a low scenario [12]. Our study showed the most significant effect in the month of October, when the impact of unemployment was high. According to the Current Population Survey in the Detroit Metro area, the unemployment rate was highest in March-April (around 45%) but improved to less than 20% in August. There was another upward trend in September-October and the unemployment rate started to go above 20%. [13] At the start of this pandemic, several state governments imposed stay-at-home orders, requiring schools, restaurants, and nonessential businesses to close to mitigate the spread of the disease. During this period, alcohol consumption increased considerably. There was a 54% surge in national alcohol sales during the first week of the pandemic, and subsequent reports indicated persistent increases in rates of alcohol consumption [14]. The rate of alcohol abuse increased more significantly in women compared to men secondary to job losses disproportionately impacting women [15] and with many women playing multiple, conflicting roles of athome worker, primary caregiver, and homeschooling teacher [16].
The pandemic has both short-and long-term implications for mental health and substance use, particularly for groups at risk of new or exacerbated mental health disorders and those facing barriers to accessing care. A common result of long-term alcohol use is the development or exacerbation of depression. Several studies have shown an increase in suicide rates secondary to increased anxiety, depression, alcohol, and other substance use disorders [17].

Limitations
There are limitations to our study. We had a small sample size and our sample frame was limited to one tertiary community hospital during the lockdown period, limiting the generalizability of our results. We did not follow up with patients to see how many had readmissions for relapses with alcohol abuse. However, our findings highlighted the impact of the COVID-19 pandemic on the mental health of the general population, using alcohol as a coping mechanism during times of stress.

Conclusions
Our results highlight the impact of a pandemic on alcohol abuse and subsequent hospital admissions for alcohol use disorder. Our study found a higher rate of AUD admissions in 2020 during the COVID-19 pandemic compared to 2019. Gender, race, age, and marital status are significant risk factors related to AUD admissions. Women have been subject to increased abuse and loss of jobs, potentially worsening the existing gender disparity and further exacerbating mental health problems in this demographic. Unemployment was another major contributor to alcohol-related admissions during the pandemic. This calls for attention from public health authorities and healthcare practitioners to anticipate and ensure support for subgroups of patients coping with the stressors of a pandemic. No verbal consent was required from patients. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.