Alcohol withdrawal was defined as a revised Clinical Institute Withdrawal Assessment for Alcohol score greater than or equal to 8.
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Sharma RA, Subedi K, Gbadebo BM, Wilson B, Jurkovitz C, Horton T. Alcohol Withdrawal Rates in Hospitalized Patients During the COVID-19 Pandemic. JAMA Netw Open. 2021;4(3):e210422. doi:10.1001/jamanetworkopen.2021.0422
Coronavirus disease 2019 (COVID-19) is disrupting communities across the globe, causing physical, mental, and financial distress.1 Economic crises have been associated with increased alcohol consumption.2 Necessary public health measures may exacerbate isolation and stress, negatively impacting those who are at risk for harmful alcohol use. Increased alcohol use has been documented in the US and other countries during the pandemic, and a recent study3 has identified associated consequences. Alcohol withdrawal (AW) is a potentially dangerous complication of alcohol use disorder (AUD) in up to 8% of all hospitalized patients with AUD.4 AW has been suspected to worsen after the COVID-19 stay-at-home orders,5 but, to our knowledge, no objective data have been reported in the literature. We hypothesized that AW rates in hospitalized patients with AUD increased during the pandemic and conducted a cohort study at Christiana Care, a large, tertiary care hospital system in Newark, Delaware.
After receiving institutional review board approval from Christiana Care, we extracted admission and demographic information from the electronic health records data warehouse for all patients hospitalized between January 1, 2018, and September 22, 2020. A limited data set as per institutional review board definition was used. Informed consent was waived by the Christiana Care institutional review board in accordance with the Office for Human Research Protections regulations 45 CFR 46.116(d). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines relevant to our study were followed.
We used a revised Clinical Institute Withdrawal Assessment for Alcohol6 score of 8 or higher to identify AW in hospitalized patients. Summary statistics were calculated for unique patients in 3 periods in 2020: before (January 1 to March 24), during (March 25 to May 31), and after (June 1 to September 22) the statewide stay-at-home period. Incidence rates for AW were computed for biweekly periods in 2018, 2019, and 2020. Furthermore, incidence rate ratios (IRRs) and 95% CIs were calculated for each period in 2020 using the same periods in 2019 and mean of 2018 and 2019 as reference, to account for seasonal variations. Significance was set at 2-tailed P < .05. SAS statistical software version 9.4 (SAS Institute) was used for all calculations. Data analysis was performed from October to December 2020.
The study population included 340 patients (overall mean [SD] age, 52.3 [14.2] years) who received a diagnosis of AW before the stay-at-home order (mean [SD] age, 52.6 [14.2] years; 101 women [29.7%]; 73 Black patients [21.5%]; 18 Hispanic patients [5.3%]), 231 patients who received a diagnosis during the stay-at-home period (mean [SD] age, 52.3 [14.8] years; 74 women [32.0%]; 44 Black patients [19.1%]; 12 Hispanic patients [5.2%]), and 507 patients who received a diagnosis after the stay-at-home period (mean [SD] age, 52.2 [13.4] years; 156 women [30.8%]; 114 Black patients [22.5%]; 25 Hispanic patients [4.9%]). Patient characteristics were similar among the 3 periods. The rate of AW in hospitalized patients was consistently higher in 2020 compared with both 2019 and the average of 2018 and 2019, although the difference was larger in the period after the stay-at-home order (Figure). The largest IRR in 2020 vs 2019 (IRR, 1.84; 95% CI, 1.30-2.60) occurred in the last 2 weeks of the stay-at-home order (Table). AW rates in hospitalized patients increased by 34% in 2020 during the pandemic (March 25 to September 22) compared with the same period in 2019 (IRR, 1.34; 95% CI, 1.22-1.48).
The association of the COVID-19 pandemic with AUD and AW has been much debated.5 This cohort study found an overall increase in AW rates in 2020, with a peak at the end of the stay-at-home order. Moreover, increased AW rates continued during the reopening phases. It is not clear why IRRs were higher in 2020 before the stay-at-home orders. Although the use of the revised Clinical Institute Withdrawal Assessment for Alcohol to identify AW limits the false-positive rate, it may underestimate the true AW rate and may be a limitation of the study. These findings suggest negative associations of the pandemic with AW.
Stress, anxiety, disrupted treatment plans, and increased alcohol use might be factors associated with higher rates of AW, because higher rates persisted during the reopening phases. With the recent surge in COVID-19 cases, many states might revert to stay-at-home orders and this trend may worsen. Increased vigilance to identify AW among hospitalized patients and to use systematic screening will be pivotal in the management of AW.
Accepted for Publication: January 11, 2021.
Published: March 3, 2021. doi:10.1001/jamanetworkopen.2021.0422
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Sharma RA et al. JAMA Network Open.
Corresponding Author: Ram A. Sharma MD, Department of Psychiatry, Christiana Care, 4735 Ogletown Stanton Rd, MAP 2, Ste 1201, Newark, DE 19713 (email@example.com).
Author Contributions: Dr Sharma had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Sharma, Subedi, Jurkovitz, Horton.
Acquisition, analysis, or interpretation of data: Sharma, Subedi, Gbadebo, Wilson, Jurkovitz.
Drafting of the manuscript: Sharma, Subedi.
Critical revision of the manuscript for important intellectual content: Sharma, Gbadebo, Wilson, Jurkovitz, Horton.
Statistical analysis: Sharma, Subedi.
Administrative, technical, or material support: Sharma, Wilson, Jurkovitz.
Supervision: Jurkovitz, Horton.
Conflict of Interest Disclosures: Dr Horton reported being a consultant for and serving on the advisory board of Masimo, a medical device company. No other disclosures were reported.
Funding/Support: Dr Jurkovitz is supported by an Institutional Development Award (IDeA) from the National Institute of General Medical Sciences of the National Institutes of Health under grant numbers U54-GM104941 and P20-GM103446. Mr Subedi is supported by an IDeA from the National Institute of General Medical Sciences of the National Institutes of Health under grant number U54-GM104941 (Principal Investigator: Hicks).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.