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The United States’ initial public health response to the COVID-19 pandemic included containment measures that varied by state but generally required closing or suspending schools, nonessential businesses, and travel (commonly called lockdown).1 During these periods, hospitalizations for serious and common conditions declined.2,3 In Massachusetts, a state of emergency was declared on March 10, 2020, which remained in place until May 18, 2020, when a phased reopening of businesses began.
Although the evidence on the mental health impact of containment periods has been mixed, it has been suggested that these measures could lead to increases in alcohol-related hospitalizations.4 Social isolation and increased psychosocial and financial stressors raise the risk of relapse among patients with substance use disorders.5-7 Marketing and survey data from the US and United Kingdom from the early months of the pandemic suggest that in-home alcohol consumption and sales of alcoholic beverages increased, while consumption of alcohol outside the home decreased.8-10 Other research has shown an increase in the percentage—but not necessarily the absolute number—of emergency department (ED) visits and hospitalizations for alcohol-related diagnoses during periods of containment.11,12 At least 1 study suggests that alcohol-related deaths increased beginning in the lockdown period and persisting into mid-2021.13
Because earlier studies suggest that lockdown periods are associated with increased alcohol consumption and relapse of alcohol use disorder, we hypothesized that the spring 2020 lockdown period in Massachusetts would be associated temporally with an increase in alcohol-related hospitalizations. To evaluate this hypothesis, we examined all hospitalizations in the US Department of Veterans Affairs (VA) Boston Healthcare System (VABHS) before, during, and after this lockdown period. VABHS includes a 160-bed acute care hospital and a 50-bed inpatient psychiatric facility.
Methods
We conducted an interrupted time-series analysis including all inpatient hospitalizations at VABHS from January 1, 2017, to December 31, 2020, to compare the daily number of alcohol-related hospitalizations across 3 exposure groups: prelockdown (the reference group, 1/1/2017-3/9/2020); lockdown (3/10/2020-5/18/2020); and postlockdown (5/19/2020-12/31/2020).
The VA Corporate Data Warehouse at VABHS was queried to identify all hospitalizations on the medical, psychiatry, and neurology services during the study period. Hospitalizations were considered alcohol-related if the International Statistical Classification of Diseases, Tenth Revision (ICD-10) primary diagnosis code (the main reason for hospitalization) was defined as an alcohol-related diagnosis by the VA Centralized Interactive Phenomics Resource (eAppendix 1, available online at doi:10.1278/fp.0404). This database, which has been previously used for COVID-19 research, is a catalog and knowledge-sharing platform of VA electronic health record–based phenotype algorithms, definitions, and metadata that builds on the Million Veteran Program and Cooperative Studies Program.14,15 Hospitalizations under observation status were excluded.
To examine whether alcohol-related hospitalizations could have been categorized as COVID-19 when the conditions were co-occurring, we identified 244 hospitalizations coded with a primary ICD-10 code for COVID-19 during the lockdown and postlockdown periods. At the time of admission, each hospitalization carries an initial (free text) diagnosis, of which 3 had an initial diagnosis related to alcohol use. The population at risk for alcohol-related hospitalizations was estimated as the number of patients actively engaged in care at the VABHS. This was defined as the number of patients enrolled in VA care who have previously received any VA care; patients who are enrolled but have never received VA care were excluded from the population-at-risk denominator. Population-at-risk data were available for each fiscal year (FY) of the study period (9/30-10/1); the following population-at-risk sizes were used: 38,057 for FY 2017, 38,527 for FY 2018, 39,472 for FY 2019, and 37,893 for FY 2020.
The primary outcome was the daily number of alcohol-related hospitalizations in the prelockdown, lockdown, and postlockdown periods. A sensitivity analysis was performed using an alternate definition of the primary outcome using a broader set of alcohol-related ICD-10 codes (eAppendix 2, available online at doi:10.1278/fp.0404).
Statistical Analysis
To visually examine hospitalization trends during the study period, we generated a smoothed time-series plot of the 7-day moving average of the daily number of all-cause hospitalizations and the daily number of alcohol-related hospitalizations from January 1, 2017, to December 31, 2020. We used multivariable regression to model the daily number of alcohol-related hospitalizations over prelockdown (the reference group), lockdown, and postlockdown. In addition to the exposure, we included the following covariates in our model: day of the week, calendar date (to account for secular trends), and harmonic polynomials of the day of the year (to account for seasonal variation).16
We also examined models that included the daily total number of hospitalizations to account for the reduced likelihood of hospital admission for any reason during the pandemic. We used generalized linear models with a Poisson link to generate rate ratios and corresponding 95% CIs for estimates of the daily number of alcohol-related hospitalizations. We estimated the population incidence of alcohol-related hospitalizations per 100,000 patient-months for the exposure periods using the population denominators previously described. All analyses were performed in Stata 16.1.
Results
During the study period, 27,508 hospitalizations were available for analysis. The 7-day moving average of total daily hospitalizations and total daily alcohol-related hospitalizations over time for the period January 1, 2017, to December 31, 2020, are shown in the Figure.
The incidence of alcohol-related hospitalizations in the population dropped from 72 per 100,000 patient-months to 10 per 100,000 patient-months during the lockdown period and increased to 46 per 100,000 patient-months during the postlockdown period (Table).
Our results were not substantially different when we ran a sensitivity analysis that excluded the total daily number of admissions from our model. Compared with the prelockdown period, the rate ratio for the number of alcohol-related hospitalizations during the lockdown period was 0.16 (95% CI, 0.08-0.30), and the rate ratio for the postlockdown period was 0.65 (95% CI, 0.52-0.82). We conducted an additional sensitivity analysis using a broader definition of the primary outcome to include all alcohol-related diagnosis codes; however, the results were unchanged.
Discussion
During the spring 2020 COVID-19 lockdown period in Massachusetts, the daily number of VABHS alcohol-related hospitalizations decreased by nearly 80% compared with the prelockdown period. During the postlockdown period, the daily number of alcohol-related hospitalizations increased but only to 72% of the prelockdown baseline by the end of December 2020. A similar trend was observed for all-cause hospitalizations for the same exposure periods.
These results differ from 2 related studies on the effect of the COVID-19 pandemic on alcohol-related hospitalizations.10,11 In a retrospective study of ED visits to 4 hospitals in New York City, Schimmel and colleagues reported that from March 1 to 31, 2020 (the initial COVID-19 peak), hospital visits for alcohol withdrawal increased while those for alcohol use decreased.10 However, these results are reported as a percentage of total ED visits rather than the total number of visits, which are vulnerable to spurious correlation because of concomitant changes in the total number of ED visits. In their study, the absolute number of alcohol-related ED visits did not increase during the initial 2020 COVID-19 peak, and the number of visits for alcohol withdrawal syndrome declined slightly (195 in 2019 and 180 in 2020). However, the percentage of visits increased from 7% to 10% because of a greater decline in total ED visits. This pattern of decline in the number of alcohol-related ED visits, accompanied by an increase in the percentage of alcohol-related ED visits, has been observed in at least 1 nationwide surveillance study.17 This apparent increase does not reflect an absolute increase in ED visits for alcohol withdrawal syndrome and represents a greater relative decline in visits for other causes during the study period.
Sharma and colleagues reported an increase in the percentage of patients who developed alcohol withdrawal syndrome while hospitalized in Delaware per 1000 hospitalizations during consecutive 2-week periods during the pandemic in 2020 compared with corresponding weeks in 2019.11 The greatest increase occurred during the last 2 weeks of the Delaware stay-at-home order. The Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) score of > 8 was used to define alcohol withdrawal syndrome. The American Society of Addiction Medicine does not recommend using CIWA-Ar to diagnose alcohol withdrawal syndrome because the scale was developed to monitor response to treatment, not to establish a diagnosis.18
Although the true population incidence of alcohol-related hospitalizations is difficult to estimate because the size of the population at risk (ie, the denominator) often is not known, the total number of hospitalizations is not a reliable surrogate.19 Individuals hospitalized for nonalcohol causes are no longer at risk for alcohol-related hospitalization.
In our study, we assume the population at risk during the study period is constant and model changes in the absolute number—rather than percentage—of alcohol-related ED visits. These absolute estimates of alcohol-related hospitalizations better reflect the true burden on the health care system and avoid the confounding effect of declining total ED visits and hospitalizations that could lead to artificially increased percentages and spurious correlation.20 The absolute percentage of alcohol-related hospitalizations also decreased during this period; therefore, our results are not sensitive to this approach.
Several factors could have contributed to the decrease in alcohol-related hospitalizations. Our findings suggest that patient likelihood to seek care and clinician threshold to admit patients for alcohol-related conditions are influenced by external factors, in this case, a public health lockdown. Although our data do not inform why hospitalizations did not return to prelockdown levels, our experience suggests that limited bed capacity and longer length of stay might have contributed. Other hypotheses include a shift to outpatient care, increased use of telehealth (a significant focus early in the pandemic), and avoiding care for less severe alcohol-related complications because of lingering concerns about exposure to COVID-19 in health care settings reported early in the pandemic. Massachusetts experienced a particularly deadly outbreak of COVID-19 in the Soldiers’ Home, a long-term care facility for veterans in Holyoke.21
Evidence suggests that in-home consumption of alcohol increased during lockdowns.8-10 Our results show that during this period hospitalizations for alcohol-related conditions decreased at VABHS, a large urban VA medical system, while alcohol-related deaths increased nationally.13 Although this observation is not evidence of causality, these outcomes could be related.
In the 2 decades before the pandemic, alcohol-related deaths increased by about 2% per year.22 From 2019 to 2020, there was a 25% increase that continued through 2021.13 Death certificate data often are inaccurate, and it is difficult to determine whether COVID-19 had a substantial contributing role to these deaths, particularly during the initial period when testing was limited or unavailable. Nonetheless, deaths due to alcohol-associated liver disease, overdoses involving alcohol, and alcohol-related traffic fatalities increased by > 10%.13,23 These trends, along with a decrease in hospitalization for alcohol-related conditions, suggest missed opportunities for intervention with patients experiencing alcohol use disorder.
Limitations
In this study, hospitalizations under observation status were excluded, which could underestimate the total number of hospitalizations related to alcohol. We reasoned that this effect was likely to be small and not substantially different by year. ICD-10 codes were used to identify alcohol-related hospitalizations as any hospitalization with an included ICD-10 code listed as the primary discharge diagnosis code. This also likely underestimated the total number of alcohol-related hospitalizations. An ICD-10 code for COVID-19 was not in widespread use during our study period, which prohibited controlling explicitly for the volume of admissions due to COVID-19. The prelockdown period only contains data from the preceding 3 years, which might not be long enough for secular trends to become apparent. We assumed the population at risk remained constant when in reality, the net movement of patients into and out of VA care during the pandemic likely was more complex but not readily quantifiable. Nonetheless, the large drop in absolute number of alcohol-related hospitalizations is not likely to be sensitive to this change. In the absence of an objective measure of care-seeking behavior, we used the total daily number of hospitalizations as a surrogate for patient propensity to seek care. The total daily number of hospitalizations also reflects changes in physician admitting behavior over time. This allowed explicit modeling of care-seeking behavior as a covariate but does not capture other important determinants such as hospital capacity.
Conclusions
In this interrupted time-series analysis, the daily number of alcohol-related hospitalizations during the initial COVID-19 pandemic–associated lockdown period at VABHS decreased by 80% and remained 28% lower in the postlockdown period compared with the prepandemic baseline. In the context of evidence suggesting that alcohol-related mortality increased during the COVID-19 pandemic, alternate strategies to reach vulnerable individuals are needed. Because of high rates of relapse, hospitalization is an important opportunity to engage patients experiencing alcohol use disorder in treatment through referral to substance use treatment programs and medication-assisted therapy. Considering the reduction in alcohol-related hospitalizations during lockdown, other strategies are needed to ensure comprehensive and longitudinal care for this vulnerable population.
1. Commonwealth of Massachussets, Executive Office of Health and Human Services, Department of Public Health. COVID-19 state of emergency. Accessed June 29, 2023. https://www.mass.gov/info-details/covid-19-state-of-emergency
2. Lange SJ, Ritchey MD, Goodman AB, et al. Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute life-threatening conditions-United States, January-May 2020. MMWR Morb Mortal Wkly Rep. 2020;69(25):795-800. doi:10.15585/mmwr.mm6925e2
3. Birkmeyer JD, Barnato A, Birkmeyer N, Bessler R, Skinner J. The impact of the COVID-19 pandemic on hospital admissions in the United States. Health Aff (Millwood). 2020;39(11):2010-2017. doi:10.1377/hlthaff.2020.00980
4. Prati G, Mancini AD. The psychological impact of COVID-19 pandemic lockdowns: a review and meta-analysis of longitudinal studies and natural experiments. Psychol Med. 2021;51(2):201-211. doi:10.1017/S0033291721000015
5. Yazdi K, Fuchs-Leitner I, Rosenleitner J, Gerstgrasser NW. Impact of the COVID-19 pandemic on patients with alcohol use disorder and associated risk factors for relapse. Front Psychiatry. 2020;11:620612. doi:10.3389/fpsyt.2020.620612
6. Ornell F, Moura HF, Scherer JN, Pechansky F, Kessler FHP, von Diemen L. The COVID-19 pandemic and its impact on substance use: Implications for prevention and treatment. Psychiatry Res. 2020;289:113096. doi:10.1016/j.psychres.2020.113096
7. Kim JU, Majid A, Judge R, et al. Effect of COVID-19 lockdown on alcohol consumption in patients with pre-existing alcohol use disorder. Lancet Gastroenterol Hepatol. 2020;5(10):886-887. doi:10.1016/S2468-1253(20)30251-X
8. Pollard MS, Tucker JS, Green HD Jr. 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
9. Castaldelli-Maia JM, Segura LE, Martins SS. The concerning increasing trend of alcohol beverage sales in the U.S. during the COVID-19 pandemic. Alcohol. 2021;96:37-42. doi:10.1016/j.alcohol.2021.06.004
10. Anderson P, O’Donnell A, Jané Llopis E, Kaner E. The COVID-19 alcohol paradox: British household purchases during 2020 compared with 2015-2019. PLoS One. 2022;17(1):e0261609. doi:10.1371/journal.pone.0261609
11. Schimmel J, Vargas-Torres C, Genes N, Probst MA, Manini AF. Changes in alcohol-related hospital visits during COVID-19 in New York City. Addiction. 2021;116(12):3525-3530. doi:10.1111/add.15589
12. 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
13. White AM, Castle IP, Powell PA, Hingson RW, Koob, GF. Alcohol-related deaths during the COVID-19 pandemic. JAMA. 2022;327(17):1704-1706. doi:10.1001/jama.2022.4308
14. Dhond R, Acher R, Leatherman S, et al. Rapid implementation of a modular clinical trial informatics solution for COVID-19 research. Inform Med Unlocked. 2021;27:100788. doi:10.1016/j.imu.2021.100788
15. Cohn BA, Cirillo PM, Murphy CC, Krigbaum NY, Wallace AW. SARS-CoV-2 vaccine protection and deaths among US veterans during 2021. Science. 2022;375(6578):331-336. doi:10.1126/science.abm0620
16. Peckova M, Fahrenbruch CE, Cobb LA, Hallstrom AP. Circadian variations in the occurrence of cardiac arrests: initial and repeat episodes. Circulation. 1998;98(1):31-39. doi:10.1161/01.cir.98.1.31
17. Esser MB, Idaikkadar N, Kite-Powell A, Thomas C, Greenlund KJ. Trends in emergency department visits related to acute alcohol consumption before and during the COVID-19 pandemic in the United States, 2018-2020. Drug Alcohol Depend Rep. 2022;3:100049. doi:10.1016/j.dadr.2022.100049
18. The ASAM clinical practice guideline on alcohol withdrawal management. J Addict Med. 2020;14(3S):1-72. doi:10.1097/ADM.0000000000000668
19. Council of State and Territorial Epidemiologists. Developmental indicator: hospitalizations related to alcohol in the United States using ICD-10-CM codes. Accessed June 29, 2023. https://cste.sharefile.com/share/view/s1ee0f8d039d54031bd7ee90462416bc0
20. Kronmal RA. Spurious correlation and the fallacy of the ratio standard revisited. J R Stat Soc Ser A Stat Soc. 1993;156(3):379-392. doi:10.2307/2983064
21. Gullette MM. American eldercide. In: Sugrue TJ, Zaloom C, eds. The Long Year: A 2020 Reader. Columbia University Press; 2022: 237-244. http://www.jstor.org/stable/10.7312/sugr20452.26
22. White AM, Castle IP, Hingson RW, Powell PA. Using death certificates to explore changes in alcohol-related mortality in the United States, 1999 to 2017. Alcohol Clin Exp Res. 2020;44(1):178-187. doi:10.1111/acer.14239
23. National Highway Traffic Safety Administration. Overview of Motor Vehicle Crashes in 2020. US Department of Transportation; 2022. https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/813266
The United States’ initial public health response to the COVID-19 pandemic included containment measures that varied by state but generally required closing or suspending schools, nonessential businesses, and travel (commonly called lockdown).1 During these periods, hospitalizations for serious and common conditions declined.2,3 In Massachusetts, a state of emergency was declared on March 10, 2020, which remained in place until May 18, 2020, when a phased reopening of businesses began.
Although the evidence on the mental health impact of containment periods has been mixed, it has been suggested that these measures could lead to increases in alcohol-related hospitalizations.4 Social isolation and increased psychosocial and financial stressors raise the risk of relapse among patients with substance use disorders.5-7 Marketing and survey data from the US and United Kingdom from the early months of the pandemic suggest that in-home alcohol consumption and sales of alcoholic beverages increased, while consumption of alcohol outside the home decreased.8-10 Other research has shown an increase in the percentage—but not necessarily the absolute number—of emergency department (ED) visits and hospitalizations for alcohol-related diagnoses during periods of containment.11,12 At least 1 study suggests that alcohol-related deaths increased beginning in the lockdown period and persisting into mid-2021.13
Because earlier studies suggest that lockdown periods are associated with increased alcohol consumption and relapse of alcohol use disorder, we hypothesized that the spring 2020 lockdown period in Massachusetts would be associated temporally with an increase in alcohol-related hospitalizations. To evaluate this hypothesis, we examined all hospitalizations in the US Department of Veterans Affairs (VA) Boston Healthcare System (VABHS) before, during, and after this lockdown period. VABHS includes a 160-bed acute care hospital and a 50-bed inpatient psychiatric facility.
Methods
We conducted an interrupted time-series analysis including all inpatient hospitalizations at VABHS from January 1, 2017, to December 31, 2020, to compare the daily number of alcohol-related hospitalizations across 3 exposure groups: prelockdown (the reference group, 1/1/2017-3/9/2020); lockdown (3/10/2020-5/18/2020); and postlockdown (5/19/2020-12/31/2020).
The VA Corporate Data Warehouse at VABHS was queried to identify all hospitalizations on the medical, psychiatry, and neurology services during the study period. Hospitalizations were considered alcohol-related if the International Statistical Classification of Diseases, Tenth Revision (ICD-10) primary diagnosis code (the main reason for hospitalization) was defined as an alcohol-related diagnosis by the VA Centralized Interactive Phenomics Resource (eAppendix 1, available online at doi:10.1278/fp.0404). This database, which has been previously used for COVID-19 research, is a catalog and knowledge-sharing platform of VA electronic health record–based phenotype algorithms, definitions, and metadata that builds on the Million Veteran Program and Cooperative Studies Program.14,15 Hospitalizations under observation status were excluded.
To examine whether alcohol-related hospitalizations could have been categorized as COVID-19 when the conditions were co-occurring, we identified 244 hospitalizations coded with a primary ICD-10 code for COVID-19 during the lockdown and postlockdown periods. At the time of admission, each hospitalization carries an initial (free text) diagnosis, of which 3 had an initial diagnosis related to alcohol use. The population at risk for alcohol-related hospitalizations was estimated as the number of patients actively engaged in care at the VABHS. This was defined as the number of patients enrolled in VA care who have previously received any VA care; patients who are enrolled but have never received VA care were excluded from the population-at-risk denominator. Population-at-risk data were available for each fiscal year (FY) of the study period (9/30-10/1); the following population-at-risk sizes were used: 38,057 for FY 2017, 38,527 for FY 2018, 39,472 for FY 2019, and 37,893 for FY 2020.
The primary outcome was the daily number of alcohol-related hospitalizations in the prelockdown, lockdown, and postlockdown periods. A sensitivity analysis was performed using an alternate definition of the primary outcome using a broader set of alcohol-related ICD-10 codes (eAppendix 2, available online at doi:10.1278/fp.0404).
Statistical Analysis
To visually examine hospitalization trends during the study period, we generated a smoothed time-series plot of the 7-day moving average of the daily number of all-cause hospitalizations and the daily number of alcohol-related hospitalizations from January 1, 2017, to December 31, 2020. We used multivariable regression to model the daily number of alcohol-related hospitalizations over prelockdown (the reference group), lockdown, and postlockdown. In addition to the exposure, we included the following covariates in our model: day of the week, calendar date (to account for secular trends), and harmonic polynomials of the day of the year (to account for seasonal variation).16
We also examined models that included the daily total number of hospitalizations to account for the reduced likelihood of hospital admission for any reason during the pandemic. We used generalized linear models with a Poisson link to generate rate ratios and corresponding 95% CIs for estimates of the daily number of alcohol-related hospitalizations. We estimated the population incidence of alcohol-related hospitalizations per 100,000 patient-months for the exposure periods using the population denominators previously described. All analyses were performed in Stata 16.1.
Results
During the study period, 27,508 hospitalizations were available for analysis. The 7-day moving average of total daily hospitalizations and total daily alcohol-related hospitalizations over time for the period January 1, 2017, to December 31, 2020, are shown in the Figure.
The incidence of alcohol-related hospitalizations in the population dropped from 72 per 100,000 patient-months to 10 per 100,000 patient-months during the lockdown period and increased to 46 per 100,000 patient-months during the postlockdown period (Table).
Our results were not substantially different when we ran a sensitivity analysis that excluded the total daily number of admissions from our model. Compared with the prelockdown period, the rate ratio for the number of alcohol-related hospitalizations during the lockdown period was 0.16 (95% CI, 0.08-0.30), and the rate ratio for the postlockdown period was 0.65 (95% CI, 0.52-0.82). We conducted an additional sensitivity analysis using a broader definition of the primary outcome to include all alcohol-related diagnosis codes; however, the results were unchanged.
Discussion
During the spring 2020 COVID-19 lockdown period in Massachusetts, the daily number of VABHS alcohol-related hospitalizations decreased by nearly 80% compared with the prelockdown period. During the postlockdown period, the daily number of alcohol-related hospitalizations increased but only to 72% of the prelockdown baseline by the end of December 2020. A similar trend was observed for all-cause hospitalizations for the same exposure periods.
These results differ from 2 related studies on the effect of the COVID-19 pandemic on alcohol-related hospitalizations.10,11 In a retrospective study of ED visits to 4 hospitals in New York City, Schimmel and colleagues reported that from March 1 to 31, 2020 (the initial COVID-19 peak), hospital visits for alcohol withdrawal increased while those for alcohol use decreased.10 However, these results are reported as a percentage of total ED visits rather than the total number of visits, which are vulnerable to spurious correlation because of concomitant changes in the total number of ED visits. In their study, the absolute number of alcohol-related ED visits did not increase during the initial 2020 COVID-19 peak, and the number of visits for alcohol withdrawal syndrome declined slightly (195 in 2019 and 180 in 2020). However, the percentage of visits increased from 7% to 10% because of a greater decline in total ED visits. This pattern of decline in the number of alcohol-related ED visits, accompanied by an increase in the percentage of alcohol-related ED visits, has been observed in at least 1 nationwide surveillance study.17 This apparent increase does not reflect an absolute increase in ED visits for alcohol withdrawal syndrome and represents a greater relative decline in visits for other causes during the study period.
Sharma and colleagues reported an increase in the percentage of patients who developed alcohol withdrawal syndrome while hospitalized in Delaware per 1000 hospitalizations during consecutive 2-week periods during the pandemic in 2020 compared with corresponding weeks in 2019.11 The greatest increase occurred during the last 2 weeks of the Delaware stay-at-home order. The Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) score of > 8 was used to define alcohol withdrawal syndrome. The American Society of Addiction Medicine does not recommend using CIWA-Ar to diagnose alcohol withdrawal syndrome because the scale was developed to monitor response to treatment, not to establish a diagnosis.18
Although the true population incidence of alcohol-related hospitalizations is difficult to estimate because the size of the population at risk (ie, the denominator) often is not known, the total number of hospitalizations is not a reliable surrogate.19 Individuals hospitalized for nonalcohol causes are no longer at risk for alcohol-related hospitalization.
In our study, we assume the population at risk during the study period is constant and model changes in the absolute number—rather than percentage—of alcohol-related ED visits. These absolute estimates of alcohol-related hospitalizations better reflect the true burden on the health care system and avoid the confounding effect of declining total ED visits and hospitalizations that could lead to artificially increased percentages and spurious correlation.20 The absolute percentage of alcohol-related hospitalizations also decreased during this period; therefore, our results are not sensitive to this approach.
Several factors could have contributed to the decrease in alcohol-related hospitalizations. Our findings suggest that patient likelihood to seek care and clinician threshold to admit patients for alcohol-related conditions are influenced by external factors, in this case, a public health lockdown. Although our data do not inform why hospitalizations did not return to prelockdown levels, our experience suggests that limited bed capacity and longer length of stay might have contributed. Other hypotheses include a shift to outpatient care, increased use of telehealth (a significant focus early in the pandemic), and avoiding care for less severe alcohol-related complications because of lingering concerns about exposure to COVID-19 in health care settings reported early in the pandemic. Massachusetts experienced a particularly deadly outbreak of COVID-19 in the Soldiers’ Home, a long-term care facility for veterans in Holyoke.21
Evidence suggests that in-home consumption of alcohol increased during lockdowns.8-10 Our results show that during this period hospitalizations for alcohol-related conditions decreased at VABHS, a large urban VA medical system, while alcohol-related deaths increased nationally.13 Although this observation is not evidence of causality, these outcomes could be related.
In the 2 decades before the pandemic, alcohol-related deaths increased by about 2% per year.22 From 2019 to 2020, there was a 25% increase that continued through 2021.13 Death certificate data often are inaccurate, and it is difficult to determine whether COVID-19 had a substantial contributing role to these deaths, particularly during the initial period when testing was limited or unavailable. Nonetheless, deaths due to alcohol-associated liver disease, overdoses involving alcohol, and alcohol-related traffic fatalities increased by > 10%.13,23 These trends, along with a decrease in hospitalization for alcohol-related conditions, suggest missed opportunities for intervention with patients experiencing alcohol use disorder.
Limitations
In this study, hospitalizations under observation status were excluded, which could underestimate the total number of hospitalizations related to alcohol. We reasoned that this effect was likely to be small and not substantially different by year. ICD-10 codes were used to identify alcohol-related hospitalizations as any hospitalization with an included ICD-10 code listed as the primary discharge diagnosis code. This also likely underestimated the total number of alcohol-related hospitalizations. An ICD-10 code for COVID-19 was not in widespread use during our study period, which prohibited controlling explicitly for the volume of admissions due to COVID-19. The prelockdown period only contains data from the preceding 3 years, which might not be long enough for secular trends to become apparent. We assumed the population at risk remained constant when in reality, the net movement of patients into and out of VA care during the pandemic likely was more complex but not readily quantifiable. Nonetheless, the large drop in absolute number of alcohol-related hospitalizations is not likely to be sensitive to this change. In the absence of an objective measure of care-seeking behavior, we used the total daily number of hospitalizations as a surrogate for patient propensity to seek care. The total daily number of hospitalizations also reflects changes in physician admitting behavior over time. This allowed explicit modeling of care-seeking behavior as a covariate but does not capture other important determinants such as hospital capacity.
Conclusions
In this interrupted time-series analysis, the daily number of alcohol-related hospitalizations during the initial COVID-19 pandemic–associated lockdown period at VABHS decreased by 80% and remained 28% lower in the postlockdown period compared with the prepandemic baseline. In the context of evidence suggesting that alcohol-related mortality increased during the COVID-19 pandemic, alternate strategies to reach vulnerable individuals are needed. Because of high rates of relapse, hospitalization is an important opportunity to engage patients experiencing alcohol use disorder in treatment through referral to substance use treatment programs and medication-assisted therapy. Considering the reduction in alcohol-related hospitalizations during lockdown, other strategies are needed to ensure comprehensive and longitudinal care for this vulnerable population.
The United States’ initial public health response to the COVID-19 pandemic included containment measures that varied by state but generally required closing or suspending schools, nonessential businesses, and travel (commonly called lockdown).1 During these periods, hospitalizations for serious and common conditions declined.2,3 In Massachusetts, a state of emergency was declared on March 10, 2020, which remained in place until May 18, 2020, when a phased reopening of businesses began.
Although the evidence on the mental health impact of containment periods has been mixed, it has been suggested that these measures could lead to increases in alcohol-related hospitalizations.4 Social isolation and increased psychosocial and financial stressors raise the risk of relapse among patients with substance use disorders.5-7 Marketing and survey data from the US and United Kingdom from the early months of the pandemic suggest that in-home alcohol consumption and sales of alcoholic beverages increased, while consumption of alcohol outside the home decreased.8-10 Other research has shown an increase in the percentage—but not necessarily the absolute number—of emergency department (ED) visits and hospitalizations for alcohol-related diagnoses during periods of containment.11,12 At least 1 study suggests that alcohol-related deaths increased beginning in the lockdown period and persisting into mid-2021.13
Because earlier studies suggest that lockdown periods are associated with increased alcohol consumption and relapse of alcohol use disorder, we hypothesized that the spring 2020 lockdown period in Massachusetts would be associated temporally with an increase in alcohol-related hospitalizations. To evaluate this hypothesis, we examined all hospitalizations in the US Department of Veterans Affairs (VA) Boston Healthcare System (VABHS) before, during, and after this lockdown period. VABHS includes a 160-bed acute care hospital and a 50-bed inpatient psychiatric facility.
Methods
We conducted an interrupted time-series analysis including all inpatient hospitalizations at VABHS from January 1, 2017, to December 31, 2020, to compare the daily number of alcohol-related hospitalizations across 3 exposure groups: prelockdown (the reference group, 1/1/2017-3/9/2020); lockdown (3/10/2020-5/18/2020); and postlockdown (5/19/2020-12/31/2020).
The VA Corporate Data Warehouse at VABHS was queried to identify all hospitalizations on the medical, psychiatry, and neurology services during the study period. Hospitalizations were considered alcohol-related if the International Statistical Classification of Diseases, Tenth Revision (ICD-10) primary diagnosis code (the main reason for hospitalization) was defined as an alcohol-related diagnosis by the VA Centralized Interactive Phenomics Resource (eAppendix 1, available online at doi:10.1278/fp.0404). This database, which has been previously used for COVID-19 research, is a catalog and knowledge-sharing platform of VA electronic health record–based phenotype algorithms, definitions, and metadata that builds on the Million Veteran Program and Cooperative Studies Program.14,15 Hospitalizations under observation status were excluded.
To examine whether alcohol-related hospitalizations could have been categorized as COVID-19 when the conditions were co-occurring, we identified 244 hospitalizations coded with a primary ICD-10 code for COVID-19 during the lockdown and postlockdown periods. At the time of admission, each hospitalization carries an initial (free text) diagnosis, of which 3 had an initial diagnosis related to alcohol use. The population at risk for alcohol-related hospitalizations was estimated as the number of patients actively engaged in care at the VABHS. This was defined as the number of patients enrolled in VA care who have previously received any VA care; patients who are enrolled but have never received VA care were excluded from the population-at-risk denominator. Population-at-risk data were available for each fiscal year (FY) of the study period (9/30-10/1); the following population-at-risk sizes were used: 38,057 for FY 2017, 38,527 for FY 2018, 39,472 for FY 2019, and 37,893 for FY 2020.
The primary outcome was the daily number of alcohol-related hospitalizations in the prelockdown, lockdown, and postlockdown periods. A sensitivity analysis was performed using an alternate definition of the primary outcome using a broader set of alcohol-related ICD-10 codes (eAppendix 2, available online at doi:10.1278/fp.0404).
Statistical Analysis
To visually examine hospitalization trends during the study period, we generated a smoothed time-series plot of the 7-day moving average of the daily number of all-cause hospitalizations and the daily number of alcohol-related hospitalizations from January 1, 2017, to December 31, 2020. We used multivariable regression to model the daily number of alcohol-related hospitalizations over prelockdown (the reference group), lockdown, and postlockdown. In addition to the exposure, we included the following covariates in our model: day of the week, calendar date (to account for secular trends), and harmonic polynomials of the day of the year (to account for seasonal variation).16
We also examined models that included the daily total number of hospitalizations to account for the reduced likelihood of hospital admission for any reason during the pandemic. We used generalized linear models with a Poisson link to generate rate ratios and corresponding 95% CIs for estimates of the daily number of alcohol-related hospitalizations. We estimated the population incidence of alcohol-related hospitalizations per 100,000 patient-months for the exposure periods using the population denominators previously described. All analyses were performed in Stata 16.1.
Results
During the study period, 27,508 hospitalizations were available for analysis. The 7-day moving average of total daily hospitalizations and total daily alcohol-related hospitalizations over time for the period January 1, 2017, to December 31, 2020, are shown in the Figure.
The incidence of alcohol-related hospitalizations in the population dropped from 72 per 100,000 patient-months to 10 per 100,000 patient-months during the lockdown period and increased to 46 per 100,000 patient-months during the postlockdown period (Table).
Our results were not substantially different when we ran a sensitivity analysis that excluded the total daily number of admissions from our model. Compared with the prelockdown period, the rate ratio for the number of alcohol-related hospitalizations during the lockdown period was 0.16 (95% CI, 0.08-0.30), and the rate ratio for the postlockdown period was 0.65 (95% CI, 0.52-0.82). We conducted an additional sensitivity analysis using a broader definition of the primary outcome to include all alcohol-related diagnosis codes; however, the results were unchanged.
Discussion
During the spring 2020 COVID-19 lockdown period in Massachusetts, the daily number of VABHS alcohol-related hospitalizations decreased by nearly 80% compared with the prelockdown period. During the postlockdown period, the daily number of alcohol-related hospitalizations increased but only to 72% of the prelockdown baseline by the end of December 2020. A similar trend was observed for all-cause hospitalizations for the same exposure periods.
These results differ from 2 related studies on the effect of the COVID-19 pandemic on alcohol-related hospitalizations.10,11 In a retrospective study of ED visits to 4 hospitals in New York City, Schimmel and colleagues reported that from March 1 to 31, 2020 (the initial COVID-19 peak), hospital visits for alcohol withdrawal increased while those for alcohol use decreased.10 However, these results are reported as a percentage of total ED visits rather than the total number of visits, which are vulnerable to spurious correlation because of concomitant changes in the total number of ED visits. In their study, the absolute number of alcohol-related ED visits did not increase during the initial 2020 COVID-19 peak, and the number of visits for alcohol withdrawal syndrome declined slightly (195 in 2019 and 180 in 2020). However, the percentage of visits increased from 7% to 10% because of a greater decline in total ED visits. This pattern of decline in the number of alcohol-related ED visits, accompanied by an increase in the percentage of alcohol-related ED visits, has been observed in at least 1 nationwide surveillance study.17 This apparent increase does not reflect an absolute increase in ED visits for alcohol withdrawal syndrome and represents a greater relative decline in visits for other causes during the study period.
Sharma and colleagues reported an increase in the percentage of patients who developed alcohol withdrawal syndrome while hospitalized in Delaware per 1000 hospitalizations during consecutive 2-week periods during the pandemic in 2020 compared with corresponding weeks in 2019.11 The greatest increase occurred during the last 2 weeks of the Delaware stay-at-home order. The Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) score of > 8 was used to define alcohol withdrawal syndrome. The American Society of Addiction Medicine does not recommend using CIWA-Ar to diagnose alcohol withdrawal syndrome because the scale was developed to monitor response to treatment, not to establish a diagnosis.18
Although the true population incidence of alcohol-related hospitalizations is difficult to estimate because the size of the population at risk (ie, the denominator) often is not known, the total number of hospitalizations is not a reliable surrogate.19 Individuals hospitalized for nonalcohol causes are no longer at risk for alcohol-related hospitalization.
In our study, we assume the population at risk during the study period is constant and model changes in the absolute number—rather than percentage—of alcohol-related ED visits. These absolute estimates of alcohol-related hospitalizations better reflect the true burden on the health care system and avoid the confounding effect of declining total ED visits and hospitalizations that could lead to artificially increased percentages and spurious correlation.20 The absolute percentage of alcohol-related hospitalizations also decreased during this period; therefore, our results are not sensitive to this approach.
Several factors could have contributed to the decrease in alcohol-related hospitalizations. Our findings suggest that patient likelihood to seek care and clinician threshold to admit patients for alcohol-related conditions are influenced by external factors, in this case, a public health lockdown. Although our data do not inform why hospitalizations did not return to prelockdown levels, our experience suggests that limited bed capacity and longer length of stay might have contributed. Other hypotheses include a shift to outpatient care, increased use of telehealth (a significant focus early in the pandemic), and avoiding care for less severe alcohol-related complications because of lingering concerns about exposure to COVID-19 in health care settings reported early in the pandemic. Massachusetts experienced a particularly deadly outbreak of COVID-19 in the Soldiers’ Home, a long-term care facility for veterans in Holyoke.21
Evidence suggests that in-home consumption of alcohol increased during lockdowns.8-10 Our results show that during this period hospitalizations for alcohol-related conditions decreased at VABHS, a large urban VA medical system, while alcohol-related deaths increased nationally.13 Although this observation is not evidence of causality, these outcomes could be related.
In the 2 decades before the pandemic, alcohol-related deaths increased by about 2% per year.22 From 2019 to 2020, there was a 25% increase that continued through 2021.13 Death certificate data often are inaccurate, and it is difficult to determine whether COVID-19 had a substantial contributing role to these deaths, particularly during the initial period when testing was limited or unavailable. Nonetheless, deaths due to alcohol-associated liver disease, overdoses involving alcohol, and alcohol-related traffic fatalities increased by > 10%.13,23 These trends, along with a decrease in hospitalization for alcohol-related conditions, suggest missed opportunities for intervention with patients experiencing alcohol use disorder.
Limitations
In this study, hospitalizations under observation status were excluded, which could underestimate the total number of hospitalizations related to alcohol. We reasoned that this effect was likely to be small and not substantially different by year. ICD-10 codes were used to identify alcohol-related hospitalizations as any hospitalization with an included ICD-10 code listed as the primary discharge diagnosis code. This also likely underestimated the total number of alcohol-related hospitalizations. An ICD-10 code for COVID-19 was not in widespread use during our study period, which prohibited controlling explicitly for the volume of admissions due to COVID-19. The prelockdown period only contains data from the preceding 3 years, which might not be long enough for secular trends to become apparent. We assumed the population at risk remained constant when in reality, the net movement of patients into and out of VA care during the pandemic likely was more complex but not readily quantifiable. Nonetheless, the large drop in absolute number of alcohol-related hospitalizations is not likely to be sensitive to this change. In the absence of an objective measure of care-seeking behavior, we used the total daily number of hospitalizations as a surrogate for patient propensity to seek care. The total daily number of hospitalizations also reflects changes in physician admitting behavior over time. This allowed explicit modeling of care-seeking behavior as a covariate but does not capture other important determinants such as hospital capacity.
Conclusions
In this interrupted time-series analysis, the daily number of alcohol-related hospitalizations during the initial COVID-19 pandemic–associated lockdown period at VABHS decreased by 80% and remained 28% lower in the postlockdown period compared with the prepandemic baseline. In the context of evidence suggesting that alcohol-related mortality increased during the COVID-19 pandemic, alternate strategies to reach vulnerable individuals are needed. Because of high rates of relapse, hospitalization is an important opportunity to engage patients experiencing alcohol use disorder in treatment through referral to substance use treatment programs and medication-assisted therapy. Considering the reduction in alcohol-related hospitalizations during lockdown, other strategies are needed to ensure comprehensive and longitudinal care for this vulnerable population.
1. Commonwealth of Massachussets, Executive Office of Health and Human Services, Department of Public Health. COVID-19 state of emergency. Accessed June 29, 2023. https://www.mass.gov/info-details/covid-19-state-of-emergency
2. Lange SJ, Ritchey MD, Goodman AB, et al. Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute life-threatening conditions-United States, January-May 2020. MMWR Morb Mortal Wkly Rep. 2020;69(25):795-800. doi:10.15585/mmwr.mm6925e2
3. Birkmeyer JD, Barnato A, Birkmeyer N, Bessler R, Skinner J. The impact of the COVID-19 pandemic on hospital admissions in the United States. Health Aff (Millwood). 2020;39(11):2010-2017. doi:10.1377/hlthaff.2020.00980
4. Prati G, Mancini AD. The psychological impact of COVID-19 pandemic lockdowns: a review and meta-analysis of longitudinal studies and natural experiments. Psychol Med. 2021;51(2):201-211. doi:10.1017/S0033291721000015
5. Yazdi K, Fuchs-Leitner I, Rosenleitner J, Gerstgrasser NW. Impact of the COVID-19 pandemic on patients with alcohol use disorder and associated risk factors for relapse. Front Psychiatry. 2020;11:620612. doi:10.3389/fpsyt.2020.620612
6. Ornell F, Moura HF, Scherer JN, Pechansky F, Kessler FHP, von Diemen L. The COVID-19 pandemic and its impact on substance use: Implications for prevention and treatment. Psychiatry Res. 2020;289:113096. doi:10.1016/j.psychres.2020.113096
7. Kim JU, Majid A, Judge R, et al. Effect of COVID-19 lockdown on alcohol consumption in patients with pre-existing alcohol use disorder. Lancet Gastroenterol Hepatol. 2020;5(10):886-887. doi:10.1016/S2468-1253(20)30251-X
8. Pollard MS, Tucker JS, Green HD Jr. 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
9. Castaldelli-Maia JM, Segura LE, Martins SS. The concerning increasing trend of alcohol beverage sales in the U.S. during the COVID-19 pandemic. Alcohol. 2021;96:37-42. doi:10.1016/j.alcohol.2021.06.004
10. Anderson P, O’Donnell A, Jané Llopis E, Kaner E. The COVID-19 alcohol paradox: British household purchases during 2020 compared with 2015-2019. PLoS One. 2022;17(1):e0261609. doi:10.1371/journal.pone.0261609
11. Schimmel J, Vargas-Torres C, Genes N, Probst MA, Manini AF. Changes in alcohol-related hospital visits during COVID-19 in New York City. Addiction. 2021;116(12):3525-3530. doi:10.1111/add.15589
12. 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
13. White AM, Castle IP, Powell PA, Hingson RW, Koob, GF. Alcohol-related deaths during the COVID-19 pandemic. JAMA. 2022;327(17):1704-1706. doi:10.1001/jama.2022.4308
14. Dhond R, Acher R, Leatherman S, et al. Rapid implementation of a modular clinical trial informatics solution for COVID-19 research. Inform Med Unlocked. 2021;27:100788. doi:10.1016/j.imu.2021.100788
15. Cohn BA, Cirillo PM, Murphy CC, Krigbaum NY, Wallace AW. SARS-CoV-2 vaccine protection and deaths among US veterans during 2021. Science. 2022;375(6578):331-336. doi:10.1126/science.abm0620
16. Peckova M, Fahrenbruch CE, Cobb LA, Hallstrom AP. Circadian variations in the occurrence of cardiac arrests: initial and repeat episodes. Circulation. 1998;98(1):31-39. doi:10.1161/01.cir.98.1.31
17. Esser MB, Idaikkadar N, Kite-Powell A, Thomas C, Greenlund KJ. Trends in emergency department visits related to acute alcohol consumption before and during the COVID-19 pandemic in the United States, 2018-2020. Drug Alcohol Depend Rep. 2022;3:100049. doi:10.1016/j.dadr.2022.100049
18. The ASAM clinical practice guideline on alcohol withdrawal management. J Addict Med. 2020;14(3S):1-72. doi:10.1097/ADM.0000000000000668
19. Council of State and Territorial Epidemiologists. Developmental indicator: hospitalizations related to alcohol in the United States using ICD-10-CM codes. Accessed June 29, 2023. https://cste.sharefile.com/share/view/s1ee0f8d039d54031bd7ee90462416bc0
20. Kronmal RA. Spurious correlation and the fallacy of the ratio standard revisited. J R Stat Soc Ser A Stat Soc. 1993;156(3):379-392. doi:10.2307/2983064
21. Gullette MM. American eldercide. In: Sugrue TJ, Zaloom C, eds. The Long Year: A 2020 Reader. Columbia University Press; 2022: 237-244. http://www.jstor.org/stable/10.7312/sugr20452.26
22. White AM, Castle IP, Hingson RW, Powell PA. Using death certificates to explore changes in alcohol-related mortality in the United States, 1999 to 2017. Alcohol Clin Exp Res. 2020;44(1):178-187. doi:10.1111/acer.14239
23. National Highway Traffic Safety Administration. Overview of Motor Vehicle Crashes in 2020. US Department of Transportation; 2022. https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/813266
1. Commonwealth of Massachussets, Executive Office of Health and Human Services, Department of Public Health. COVID-19 state of emergency. Accessed June 29, 2023. https://www.mass.gov/info-details/covid-19-state-of-emergency
2. Lange SJ, Ritchey MD, Goodman AB, et al. Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute life-threatening conditions-United States, January-May 2020. MMWR Morb Mortal Wkly Rep. 2020;69(25):795-800. doi:10.15585/mmwr.mm6925e2
3. Birkmeyer JD, Barnato A, Birkmeyer N, Bessler R, Skinner J. The impact of the COVID-19 pandemic on hospital admissions in the United States. Health Aff (Millwood). 2020;39(11):2010-2017. doi:10.1377/hlthaff.2020.00980
4. Prati G, Mancini AD. The psychological impact of COVID-19 pandemic lockdowns: a review and meta-analysis of longitudinal studies and natural experiments. Psychol Med. 2021;51(2):201-211. doi:10.1017/S0033291721000015
5. Yazdi K, Fuchs-Leitner I, Rosenleitner J, Gerstgrasser NW. Impact of the COVID-19 pandemic on patients with alcohol use disorder and associated risk factors for relapse. Front Psychiatry. 2020;11:620612. doi:10.3389/fpsyt.2020.620612
6. Ornell F, Moura HF, Scherer JN, Pechansky F, Kessler FHP, von Diemen L. The COVID-19 pandemic and its impact on substance use: Implications for prevention and treatment. Psychiatry Res. 2020;289:113096. doi:10.1016/j.psychres.2020.113096
7. Kim JU, Majid A, Judge R, et al. Effect of COVID-19 lockdown on alcohol consumption in patients with pre-existing alcohol use disorder. Lancet Gastroenterol Hepatol. 2020;5(10):886-887. doi:10.1016/S2468-1253(20)30251-X
8. Pollard MS, Tucker JS, Green HD Jr. 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
9. Castaldelli-Maia JM, Segura LE, Martins SS. The concerning increasing trend of alcohol beverage sales in the U.S. during the COVID-19 pandemic. Alcohol. 2021;96:37-42. doi:10.1016/j.alcohol.2021.06.004
10. Anderson P, O’Donnell A, Jané Llopis E, Kaner E. The COVID-19 alcohol paradox: British household purchases during 2020 compared with 2015-2019. PLoS One. 2022;17(1):e0261609. doi:10.1371/journal.pone.0261609
11. Schimmel J, Vargas-Torres C, Genes N, Probst MA, Manini AF. Changes in alcohol-related hospital visits during COVID-19 in New York City. Addiction. 2021;116(12):3525-3530. doi:10.1111/add.15589
12. 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
13. White AM, Castle IP, Powell PA, Hingson RW, Koob, GF. Alcohol-related deaths during the COVID-19 pandemic. JAMA. 2022;327(17):1704-1706. doi:10.1001/jama.2022.4308
14. Dhond R, Acher R, Leatherman S, et al. Rapid implementation of a modular clinical trial informatics solution for COVID-19 research. Inform Med Unlocked. 2021;27:100788. doi:10.1016/j.imu.2021.100788
15. Cohn BA, Cirillo PM, Murphy CC, Krigbaum NY, Wallace AW. SARS-CoV-2 vaccine protection and deaths among US veterans during 2021. Science. 2022;375(6578):331-336. doi:10.1126/science.abm0620
16. Peckova M, Fahrenbruch CE, Cobb LA, Hallstrom AP. Circadian variations in the occurrence of cardiac arrests: initial and repeat episodes. Circulation. 1998;98(1):31-39. doi:10.1161/01.cir.98.1.31
17. Esser MB, Idaikkadar N, Kite-Powell A, Thomas C, Greenlund KJ. Trends in emergency department visits related to acute alcohol consumption before and during the COVID-19 pandemic in the United States, 2018-2020. Drug Alcohol Depend Rep. 2022;3:100049. doi:10.1016/j.dadr.2022.100049
18. The ASAM clinical practice guideline on alcohol withdrawal management. J Addict Med. 2020;14(3S):1-72. doi:10.1097/ADM.0000000000000668
19. Council of State and Territorial Epidemiologists. Developmental indicator: hospitalizations related to alcohol in the United States using ICD-10-CM codes. Accessed June 29, 2023. https://cste.sharefile.com/share/view/s1ee0f8d039d54031bd7ee90462416bc0
20. Kronmal RA. Spurious correlation and the fallacy of the ratio standard revisited. J R Stat Soc Ser A Stat Soc. 1993;156(3):379-392. doi:10.2307/2983064
21. Gullette MM. American eldercide. In: Sugrue TJ, Zaloom C, eds. The Long Year: A 2020 Reader. Columbia University Press; 2022: 237-244. http://www.jstor.org/stable/10.7312/sugr20452.26
22. White AM, Castle IP, Hingson RW, Powell PA. Using death certificates to explore changes in alcohol-related mortality in the United States, 1999 to 2017. Alcohol Clin Exp Res. 2020;44(1):178-187. doi:10.1111/acer.14239
23. National Highway Traffic Safety Administration. Overview of Motor Vehicle Crashes in 2020. US Department of Transportation; 2022. https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/813266