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New diagnoses of alcohol use disorder (AUD) increased during multiple periods of the pandemic in people with COVID-19 infection, when compared to those with other respiratory infections only, but this link may have more to do with the context of the pandemic rather than the actual infection, according to a retrospective cohort study.

During the first 3 months of the pandemic, for example, a significantly increased risk of a new AUD diagnosis was observed in the 3 months following an infection for people who had COVID-19 (HR 2.53, 95% CI 1.82-3.51), reported Pamela Davis, MD, PhD, of Case Western Reserve University in Cleveland, and colleagues.

Another surge in AUD diagnoses after COVID infection versus other infection occurred from January to April 2021 (HR 1.30, 95% CI 1.08-1.56) and April to July 2021 (HR 1.80, 95% CI 1.47-2.21), they noted in .

"Elevated risk for AUD after COVID-19 infection compared with non-COVID-19 respiratory infections during some time frames may suggest an association of SARS-CoV-2 infection with the pandemic-associated increase in AUD," Davis and team wrote. "The reasons for this temporal variation remain to be determined definitively, but contextual factors of SARS-CoV-2 infection and the pandemic itself are likely important factors."

The social context of the pandemic offers the most plausible explanation for the two surges, they noted, including "anxiety, fear, social isolation, stress, and other contextual factors." This would have been particularly true at the beginning of the pandemic when the first surge in AUD cases was seen, when there were high rates of hospitalization and death.

As the pandemic continued, the introduction of an effective vaccine "may have alleviated anxiety and stress," they added.

During the Delta wave, a "modestly" elevated risk of a new AUD diagnosis was seen in both the 3 months following a COVID infection (HR 1.18, 95% CI 1.02-1.38) that extended to the 3 to 6 months following infection (HR 1.30, 95% CI 1.11-1.53).

Delta caused an increase in COVID cases and led to "great consternation and fear," Davis and colleagues noted. "With the shift to the highly contagious but less-severe Omicron variant, which also has lower risk for long COVID, the surge in AUD encounter diagnoses abated."

Furthermore, the higher hazard ratios for AUD in those with COVID infection compared with other respiratory infections "might suggest some biological association of the virus, which is supported by the modest increase in HR after infection in the Delta variant-predominant phase, if the characteristics of the virus itself are associated with an AUD diagnosis," they wrote.

However, this explanation doesn't hold up when you factor in the decrease in absolute risk for a new AUD diagnosis after COVID, they said.

Davis and colleagues also proposed that frequency of contact with the medical system may have led to an increase in AUD diagnoses, due to more opportunities for detection. But when compared with patients with bone fractures, which also require follow-up visits, patients with COVID still showed an increased risk of AUD at the beginning of the pandemic, and the association followed a similar pattern to the comparison with other respiratory infections, they said.

"Future work is required to clarify the relative associations of COVID-19 itself and the pandemic context in increasing risk for addictive disease," they concluded.

For this study, the researchers used electronic health records of 2,821,182 U.S. patients ages 12 and older, including 1,201,082 patients with COVID (mean age 46.2, 56.9% women, 65.7% white) and 1,620,100 patients with other respiratory infections who had never had COVID (mean age 44.5, 60.4% women, 71.1% white).

Davis and colleagues divided patients from each group into eight cohorts by 3-month blocks of time based on the time of initial infection from Jan. 20, 2020 to Jan. 27, 2022.

They noted that since their study was observational and retrospective, they could not determine causation, which was a limitation. Moreover, COVID may have been misclassified over the study period, with the growing availability of at-home testing.

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