Worsening of alcohol abuse disorder in a Spanish population during the first twelve months of the COVID-19 pandemic and associated factors: retrospective, ecological and community study

Alcohol dependence and alcohol abuse or harmful use cause substantial morbidity and mortality [1]. It is estimated that there are 237 million men and 46 million women worldwide who suffer from alcohol use disorder. In 2016, the harmful use of this substance caused more than 3 million deaths across the globe (three-quarters of these in men), which accounts for 5% of the global burden of disease [2]. Globally, that same year, alcohol consumption was the seventh highest risk factor for premature death and disability, and was the main risk factor among the population aged between 15 and 49 [3]. Continued heavy alcohol use also accelerates the onset of heart disease, stroke, cancers, and liver cirrhosis, by affecting the cardiovascular, gastrointestinal, and immune systems. So that alcohol use disorders directly and indirectly contribute significantly to the health care cost [4]. Furthermore, the harmful consumption of alcohol not only has physical consequences, but also psychological and social ones [5]. Alcohol use disorders are commonly associated with depression or other mental illnesses (dual pathology), severe anxiety, insomnia, suicide, and the abuse of other drugs [1]. This way alcohol use disorder impairs quality of life damaging interpersonal and social roles (for example: family conflicts, violence or, unemployment) [5].

Alcohol use disorder is associated with important life events and problems. Since 2019, people may have consumed alcohol to reduce the intensity of negative feelings caused by the outbreak of the COVID-19 pandemic [6, 7]. To contain the spread of this new SARS-CoV-2 virus, the governments of many countries imposed restrictive measures that may have been stressful for the population such as restriction of social activities, limited mobility, and/or being locked down at home. Many studies have shown the psychological consequences of the pandemic and lockdown on the mental health of the general population. Several meta-analyses have concluded that the COVID-19 pandemic has exacerbated mental health problems among the global population, mainly the prevalence of depression, anxiety, and sleep disturbances [8‐11]. On the other hand, fewer studies have evaluated the effect of this pandemic and the consequent lockdown on alcohol consumption patterns.

In relation to changes in alcohol consumption patterns during the COVID-19 pandemic, several studies and reviews have been carried out, mainly performed on the general population, the results of which diverge significantly [3, 12‐16]. In all these studies, psychosocial distress has been recognised as a risk factor for relapse and increased alcohol consumption [17]. However, it is also relevant to analyse the effects of lockdowns and restrictions on alcohol consumption in patients with pre-existing alcohol use disorder. Regarding this last aspect, [17] concluded that lockdowns are a risk factor for increased alcohol consumption among people with alcohol use disorders, and for relapse for those who had previously been abstinent.

In addition, the impact of the COVID-19 crisis on essential healthcare services is of great concern, as healthcare systems and particularly Primary Health Care (PHC) have been focused on treating and detecting cases of the infection, following up positive cases and contact tracing. According to the results of the PULSE survey carried out by the World Health Organization (WHO) in 105 countries, most (90%) have suffered interruptions in essential healthcare services since the beginning of the pandemic [18]. These interruptions are likely to have serious adverse effects on the health of the most vulnerable populations, such as those with chronic diseases who need regular assistance and care, especially in PHC settings [19].

To the best of our knowledge, few studies have been performed which analyse the effect of the COVID-19 pandemic that consider not only the effects of the lockdown but also the health, social, political, and economic crisis, looking specifically at people with a history of alcohol abuse disorder, and using a longitudinal, ecological and community methodology. The use of data from PHC records allows us to quantify changes in clinical parameters, as well as the consumption of healthcare resources, with such changes possibly indicating a modification in the state of the illness. Primary healthcare is the gateway to the health system, and the closest community healthcare resource to the population. Furthermore, epidemiological analyses using real world data (RWD) such as data from primary healthcare records provide results related to decision-making from the perspective of health and social care.

Hence, the aims of this study are to analyse changes in clinical parameters and in the use of social healthcare resources by patients with alcohol abuse disorder between the six months prior to the start of lockdown and the twelve months after it was lifted. We will be focusing on primary healthcare patients diagnosed with alcohol abuse disorder in one of Spain’s 17 ‘autonomous communities’, Aragon, situated in the north of the country. We also aim to analyse the factors related to a worsening of clinical parameters among these patients.

In Aragon, on 14/09/2019 there were 11,384 patients diagnosed with alcohol abuse disorder by their GP, with males accounting for 84.1% of the total. These patients’ mean age is 56.04 (13.05), 71.5% of them had an annual income of less than 18,000 euros, and 8.1% had been infected with COVID-19. In terms of the presence of comorbidities, dyslipidaemia (45.3%), nicotine addiction (44.1%), hypertension (35.5%), depression and anxiety (35.5%), back pain (23.7%) and neoplasia (22.2%) were the most frequent chronic conditions in the study population. The analytical parameters that can indicate liver damage were found to show normal levels in both males (GPT: 29.62 SD: 17.29; GOT: 30.48 SD:15.96) and females (GPT: 20.43 SD:1.55; GOT:22.70 SD:9.75) before the pandemic outbreak. Other analytical parameters such as blood creatinine and glomerular filtration also showed normal levels. Table 1 describes the sample according to the studied variables.

As for new diagnoses of psychiatric comorbidity in this population, in the 6 months before the lockdown, there were 115 (1%) new diagnoses of nicotine addiction, 186 (1.6%) of depression and anxiety, 92 (0.8%) of insomnia and 15 (0.1%) attempted suicides. However, in the 6-month period after lockdown and the 6 months thereafter, there were, respectively, 31 (0.3%) and 11 (0.1%) new diagnoses of nicotine addiction, 143 (1.3%) and 34 (0.3%) of depression and anxiety, 69 (0.6%) and 19 (0.2%) of insomnia, and 20 (0.2%) and 2 (0.01%) suicide attempts. As can be observed, there is a decrease in the incidence of psychiatric pathology.

The number and percentage of patients with alcohol abuse disorder and their clinical parameters (GPT, GOT, blood creatinine and glomerular filtration) at 6 months and 12 months post-lockdown are shown in Table 2. As can be observed, between 44% and 54% of the patients suffered a decline in every clinical parameter (increase in GPT, GOT and blood creatinine and decrease in glomerular filtration), both at 6 months post-lockdown and at 12 months post-lockdown. Approximately 50% of people with alcoholism worsen in the parameters related to this pathology at each time point.

As is seen in Table 3, the number of PHC nursing and GP visits, ordinary and/or continuous, at the healthcare centre and/or home visits, reduced significantly during the first six months post-lockdown, but also from 6 to 12 months post-lockdown. The number of social worker visits decreased significantly the first 6 months post-lockdown. Visits to hospital services (no. of visits to A&E services and no. of hospitalisations) also decreased significantly during the study period. On the other hand, the number of visits to specialised care increased significantly during the period from 6 to 12 months post-lockdown. On the other hand, it should be noted that the number of people who needed or requested home care, both nursing and family medicine, comparing the period prior to the pandemic, the 6 months after the onset and from 6 to 12 months, increased significantly in the last period of time collected (6 to 12 months).

As regards the associated factors related to deterioration of alcohol abuse disorder, to examine the patients whose GPT and/or GOT levels worsened at 6 months or 12 months post-lockdown, a multivariable logistic regression was performed, the results of which are displayed in Table 4. A significant model was obtained (p-value = 0.001), with a Cox and Snell R-squared of 0.108. Having an income of over 18,000 euros/year (p-value 0,003) and not having visited the social worker (p-value 0,022) are associated with a deterioration in the clinical parameters that would indicate a worsening of alcohol abuse disorder during the first year of the COVID-19 pandemic. Being younger than 40 years old was also found to be significant in this sense (p-value 0,075). Figure 1 shows the ROC curve of the logistic regression model.

This study analyses the evolution of a sample consisting of patients who had been diagnosed with alcohol abuse disorder before the COVID-19 pandemic, at least six months before lockdown. Exposure to other serious infectious diseases (SARS) has already been associated with alcohol abuse/dependence [24]. Nevertheless, SARS outbreak had less global impact than SARS-CoV-2 and the measures implemented were less restrictive. COVID-19 pandemic is an exceptional and unprecedented situation so its effects on alcohol abuse/dependence can be expected to be greater [25]. The stressful situation experienced by the population and the saturation of the healthcare system could have caused a deterioration of the disease. The results of our study, considering that an increase in the analytical parameters indicate a worsening of the illness, show that around the 50% of patients saw a deterioration in these biological markers. This could be indicative of a higher consumption of alcohol during the period under study.

Some studies show results which indicate that the population with alcohol use disorder increased their alcohol consumption during the health crisis [17, 26‐28], as well as an increase in the number of relapses during the months of lockdown. Those who experienced emotional distress or lived alone at the onset of the pandemic had a higher risk of quitting abstinence. On the other hand, other studies show stability [29] or even a decrease in alcohol consumption [30, 31] during the COVID-19 pandemic.

This disparity in results may be explained by the data resources used, but also by the periods under study and the care provided during the COVID-19 pandemic. Some studies [17, 29, 31] collected data through self-reported questionnaires without evaluating biological markers. Barrio et al.’s study [26], which uses biological markers and was also carried out in Spain, shows results similar to our own.

The point of data collection may be also relevant when explaining the results, since some studies analysed data during lockdown, and immediately or 6 months after it was lifted [26, 29]. Our study looks at the 12 months post-lockdown. The COVID-19 pandemic has lasted for over two years, so it is necessary to analyse the repercussions on the population’s health, not only in the short term but also in the long term.

Fear of infection and the collapse of the healthcare system, especially primary care services, during every wave of the pandemic has interrupted continuous healthcare services for all patients [18, 32, 33]. This may have caused psychopathological imbalances. In our study, a general decrease in the number of visits to primary health care centres by patients with alcohol abuse disorder is observed, compared to the six months pre-lockdown.

To overcome these interruptions, telemedicine was established as the most frequently used option to replace in-person appointments and to offer psychosocial support to patients [33, 34]. Telemedicine was consolidated as one of the most frequently used and effective alternatives to overcome these interruptions [35, 36], and could explain the increase in the number of ordinary face-to-face or telephone GP visits observed in our study during the first 6 months of the pandemic. Virtual or face-to-face consultations during the pandemic have been shown to be instrumental in reducing relapses (p = 0.075; OR 0.303, 95% CI 0.110–0.839) and helping people to begin abstaining (p = 0.035; OR 1.118, 95% CI 0.032–0.432), compared with those who did not have contact with a health professional [17].

The increase in demand for social services in the first months after the pandemic is also significant, reflected by the notable increase in the number of consultations with social workers. This data, according to Druss´ study [37], is consistent with the social and economic impact of COVID-19 and evinces the devastating psychological distress vulnerable people have suffered from. The relationship between mental health and economic crisis is well established in the literature [38‐41].

Looking at the long term, it is worth highlighting the increase in the number of visits to specialised care and hospital admissions at 12 months post-lockdown. This may indicate a physical and psychological imbalance in these patients’ health. This idea is supported by most of the existing literature [8, 10, 11, 29, 37, 42‐44]. However, there have been fewer new diagnoses (especially psychiatric diagnoses) among these patients by their GPs, which could indicate an underdiagnosis in primary health care.

Factors associated with a worsening of clinical parameters include having an income of over 18,000 euros/year and not having visited the social worker at the health centre. In relation to patient’s socio-economic situation, several studies have evaluated the cross-sectional relationship between socio-economic status and alcohol abuse, concluding that medium and high incomes were correlated with a greater frequency of alcohol abuse, higher than among those with a lower income [45, 46]. In addition, there is a higher prevalence among young adults whose families have greater economic wealth [47]. Likewise, more affluent neighbourhoods present a higher prevalence of alcohol consumption, especially if there is a great disparity in income, causing greater consumption among lower socio-economic groups [45, 48‐50]. Even so, it is necessary to view these data with caution, given that several studies contemplate other social determinants that can alter said evidence for the male sex, such as socio-economic status and employment status, with a relationship having been identified between educational poverty and unemployment with higher alcohol intake and consequently high mortality rates related to substance abuse [51‐55]. High income is associated with ‘hazardous use’ of alcohol, a DSM-V substance abuse criterion, such as driving after consuming alcohol [56].

On the other hand, in relation to visits to a health centre social worker, during the first year of the pandemic various studies indicate that there has been a negative impact on the quality of life of those sick with COVID-19 and of the general population, at a physical, mental, social and economic level [57, 58], as well as an increase in discomfort in the family home [59‐61]. All this data has been used to promote social work referrals, which has facilitated the consideration of different treatment options for various health problems such as alcohol abuse. Social work professionals have practical tools to promote prevention and complement psychosocial rehabilitation treatment for addiction to alcohol and other drugs, which can alleviate the effects of withdrawal and various problems that may contribute to a relapse [62‐65]. This, in turn, contributes to avoiding a worsening of clinical parameters among affected patients.

The results of our study may help improve the prevention and health care of people with alcohol use disorder. The factors related to a worsening of this disease make it possible to know the most vulnerable population. In this way, preventive strategies must address different population groups and, especially, the one obtained in this study: being under 40 years of age, having an income of more than 18,000 euros/year and not having visited the social worker. These results, added to the increase in demand after the pandemic, make it necessary to strengthen the specialized care network of the health system, offering greater coverage. Special mention for social work professionals as a key player in the care of people with alcohol abuse disorder.

Our study has some significant strengths. Its main strength is the availability of a large population database and the use of clinical-administrative data from the electronic health records of Primary Care. The evidence generated provides greater knowledge about the consequences of the pandemic in vulnerable populations such as patients with alcohol use disorder. On the other hand, it has limitations. The first limitation is that we have considered only data from electronic medical records in three time periods, what prevented knowing changes in clinical parameters during all the twelve months. The second limitation is that we do not have access to a quantified record of alcohol consumption in standard drinking units, nor to some of the specific structured questionnaires used in PC such as the CAGE or the Alcohol Use Disorders Identification Test (AUDIT). The third limitation is that we have considered an increase in the analytical parameters as an indication of deterioration, without determining whether these increases were significant. If we compare clinical parameters before and after the pandemic, these increases may not be significant [63], but may simply indicate a trend. Lastly, we do not have self-reported data about the lifestyles maintained by patients during these months and neither about the current status of the patients (detoxification, cessation or rehabilitation) therefore our results should be interpreted with caution.

It would be interesting to carry out studies with a qualitative approach. That would give us more information about the perceptions that these patients have about the impact of COVID-19 on their health. Also, the use of geographic information systems would allow us to represent through maps the most affected basic health areas identifying geographic clusters.

Our study sheds some light on the consequences of the COVID-19 pandemic in a large sample of people diagnosed with alcohol abuse disorder from a longitudinal, ecological and community perspective. The results suggest that the impact of COVID-19 on this group has been high, and the social care offered to this group of patients plays a significant role in minimising the repercussions of the pandemic.