Hospitalization Trends for Alcohol Withdrawal During the Pandemic

Introduction:
▪ Alcohol use disorder (AUD) is the third leading preventable cause of death in the United States.1 Additionally, AUD has a significant burden on healthcare systems, with approximately 8% of all patients admitted to the hospital being at risk of alcohol withdrawal.2 Preventative measures to mitigate transmission of novel corona virus have been speculated to have a negative impact on the substance use disorder population and increase hospitalization rates for alcohol and opioid withdrawal. Forced abstinence, economical stress, worsening anxiety, disrupted treatment strategies due to lockdown are factors that may contribute. We hypothesized that there will be an increase in alcohol withdrawal syndrome after our State announced lockdown to prevent the spread of COVID-19 on 24th March 2020.

Method:
▪ We analyzed patterns in number of hospital visits with the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score≥8 between 1st January 2019 and 30th July 2020 at a tertiary care hospital. We divided 2020 study period into three categories, pre lockdown period (1st Jan – 24th March), lockdown period (25th March – 31st May) and after lockdown ended (1st June – 1st July). Biweekly data were analyzed. Incidence rates (IR, per 1000 visits), and incidence rate ratio (IRR) of visits with CIWA ≥8 was computed for biweekly periods. The rate ratios were calculated using the same time periods in 2019 as reference. The confidence intervals (CI) and P values for IRR were computed assuming that the rates followed an independent Poisson distribution.

Results:
▪ The average age of patients with CIWA ≥8 was 53 years (SD ~14) and remained consistent before, during and after the lockdown period. Compared to the same time periods in 2019, the incidence rates of visit with CIWA ≥8 were significantly higher for the periods of 22nd April – 5th May (IRR: 1.47; CI: 1.04-2.08), 20th May – 1st June (IRR: 1.82; CI: 1.28-2.58), 30th June – 13th July (IRR: 1.50; CI: 1.03-2.18), and 14th July – 26th July (IRR: 1.60; CI: 1.11-2.30). To note, the incidence rate of visits with CIWA ≥8 was higher in 2020 than in 2019 even before the onset of pandemic. (Jan 1 -March 24: IRR=1.21; CI:1.05-1.40).

Conclusion:
• In this study we were able to conclusively demonstrate statistically significant increase in incidence rate ratio (IRR) for alcohol withdrawal hospitalizations during the pandemic (post lockdown). Seasonal variations were accounted for in the analysis as IRR was calculated using the same time period last year as baseline. Interestingly, IRR was also higher for 2020 before lockdown, however the magnitude of increase in IRR during these months was relatively smaller as compared to post lockdown time period. Further, we observed increasing trend of alcohol withdrawal hospitalizations in early phases of reopening, which has been anticipated in literature by experts.3 Our group is currently working to further characterize these findings and identify cohorts vulnerable to alcohol withdrawal during the pandemic.

References: 1. 2017 National Drug Threat Assessment. U.S. Department of Justice, Drug Enforcement Administration. October 2017
2. Gladden RM, Martinez P, Seth P. Fentanyl Law Enforcement Submissions and Increases in Synthetic Opioid-Involved Overdose Deaths – 27 States, 2013-2014. MMWR Morb Mortal Wkly Rep. Aug 2016;65(33):837-843
3.Pollard MS, Tucker JS, Green HD. Changes in Adult Alcohol Use and Consequences During the COVID-19 Pandemic in the US. JAMA Netw Open. 2020;3(9):e2022942. doi:10.1001/jamanetworkopen.2020.22942