Prevalence of alcohol abuse in patients with rheumatic diseases participating in a clinical trial

Introduction

Alcohol is a popular stimulant. Unstable social and economic situations, including phenomena such as a pandemic, can cause many medical, psychological, and sociological problems (Babor et al. 2001). Included in this group is the increased consumption of alcohol and its associated health harms (Bartoszewicz and Obłąkowska 2021). Alcohol is a harmful substance whose excessive consumption translates into negative social consequences (Boscarino et al. 2011). Alcohol is now the fourth most common preventable cause of death in the US (Brodziak-Dopierała et al. 2020). Excessive drinking is also associated with increased violence, crime, poverty, sexually transmitted diseases, and several other significant public health harms (Cook and Duncan 2005; GBD 2016 Alcohol Collaborators 2018; Gruszczyńska et al. 2015; Keyes et al. 2012). Alcohol abuse is harmful to an individual’s health, causing physical and mental harm. When a significant part of the population abuses alcohol, it should be considered as a population health risk. Excessive alcohol consumption translates into an increase in the number of families with alcohol problems, trauma, the phenomenon of co-dependency, DDA syndrome, child neglect, and many other negative phenomena. Research shows that individuals experiencing stress often report increased alcohol consumption, and this relationship is widely documented (Khana et al. 2002). When individuals experience periods of economic or psychological stress, they often respond with increased alcohol consumption. This results in increased symptoms of alcohol abuse and dependence (Bartoszewicz and Obłąkowska 2021; Klimkiewicz 2008). Alcohol consumption and related harms can be exacerbated by stress caused by financial difficulties, social isolation, and uncertainty about the future. A similar mechanism has been observed in individuals experiencing post-traumatic stress disorder, and so, for example, adult residents of New York City diagnosed with post-traumatic stress disorder 2 years after the 2001 attacks on the World Trade Centre demonstrated an increase in alcohol consumption and compulsive binge drinking (Klimkiewicz 2008).
The mode of alcohol consumption correlates with the selected categories of diseases that alcohol causes. The risk of cancer increases as the average amount of alcohol consumed increases, while the risk of ischaemic disease increases as a result of heavy drinking sessions (National Institute of Health 2016). Its negative effects of nervous system function, cognitive function, and a range of mental as well as somatic disorders are well documented (Pfefferbaum and North 2020). The negative effects span the entire spectrum of somatic disorders involving the entire body. Ethyl alcohol is a toxic substance that, on its way through the digestive system into the bloodstream, damages further organs and systems it comes into contact with. These include, among others, the gastrointestinal tract, increasing the risk of stomach cancer. Negative effects are observed on the liver and pancreas, and as a result of complications, diabetes develops. The list of negative health effects cannot omit cardiovascular complications and endocrine and haematological disorders (Rowicka et al. 2020; Serwis Zdrowie 2022; Snowden 2019). Alcohol-dependent individuals often suffer serious health damage leading to premature death. The damage extends to members of alcoholic families and manifests itself primarily in the form of psychosomatic disorders and emotional disorders caused by chronic stress and demoralisation, poverty, and reduced chances of achieving a successful life career (Stahre et al. 2014).
The Central Statistical Office estimates the population of Poles who drink alcohol 5 days a week or more often at more than 820,000, which is about 2% of the population [17]. The profile of a drinker is most often male, aged 30-59 years, less educated, living in a relationship, and working or looking for work. However, this picture is inconsistent, for an analysis of the occupational categories of alcohol abuser’s places artists, writers, and journalists (21.5%), medical professionals (12.6%), engineers and architects and related professions (10.7%) at the top (Stelcer 2021).
The problem of risky drinking and addiction does not affect all adults. Most use it in ways that do not burden health or interfere with social functioning. However, recent reports show that more and more people in Poland are using alcohol, and statistics confirm the growing scale of problems related to alcohol use or abuse. In this study, attention will be paid to patterns of alcohol consumption, and data will be presented to indicate the current extent of dysfunctional drinking patterns as well as the consequences associated with pathological alcohol consumption.

Material and methods

Two standardised research tools and an author’s questionnaire were used. To measure the alcohol problem, the Baltimore test was used, which is a tool that facilitates the diagnosis of alcohol dependence, consists of 19 questions with Yes/No answers; one affirmative answer indicates the need for caution, because one can become addicted; 2 affirmative answers prove with high probability that one is addicted; while 3, according to the authors, definitively shows alcohol dependence (Stahre et al. 2014).
To measure the type of drinking, the AUDIT-4 (Alcohol Use Disorders Identification Test), was used, as recommended by the WHO. It is a tool consisting of 10 questions about the frequency of alcohol consumption and the emotional or social consequences experienced as a result. As the scores on the test increase, the depth of the disorder increases. Up to 7 points defines low-risk drinking, 8-15 points is risky drinking, 16-19 is harmful drinking, and 20 points and above indicates suspected alcohol dependence (Szymczak et al. 2009).
The author’s survey questionnaire collected psychodemographic data of the subjects. The study received approval from the PUMS Bioethics Committee (no. KB-424/23).
The study was performed in 2020-2022 in the Rheumatology Outpatient Clinic of the Jan Biziel University Hospital No. 2 in Bydgoszcz, Poland.
Group selection – subjects were those who met the inclusion criterion reporting to the rheumatology outpatient clinic after completion of participation in clinical trials or reporting for follow-up under the drug program, who consented to participate in the study.

Group

Inclusion criteria for the study were as follows: having a minimum of primary education; being 18 years of age or older; having a diagnosis of chronic rheumatic disease – rheumatoid arthritis, systemic lupus, psoriatic arthritis, systemic scleroderma, ankylosing spondylitis, Still’s disease; having completed participation in a phase 3 clinical trial for biologic drugs or treatment under a drug program; and having given consent to participate in the study.
The criteria were met by 128 patients between the ages of 18 and 77 years (M = 46.88, SD = 13.80) with disease duration of 1-46 years (M = 12.30, SD = 8.53). In the study, more than half (57.8%) were women, most of the subjects (60.2%) were economically active, 74.2% of the subjects were not addicted to tobacco, 61.7% of the subjects were in a relationship, 52.3% of the patients were participating in a drug program at the time of the study, and 23.4% of the subjects had completed participation in clinical trials.
With regard to the norms set by the authors of the Baltimore test, it was recognised that 24 people (18.8%) had an alcohol problem, medium risk of disease applied to 6 people (4.7%), low risk of disease applied to 12 people (9.4%), and no alcohol problem applied to 86 people (67.2%).
Regarding the norms set by the authors of the Audit test, the type of risky drinking or addiction applied to 33 people (25.8%) and no problem applied to 91 people (71.1%); 4 people (3.1%) incorrectly completed the test.

Results

All Statistics were calculated using SPSS Statistics 28 software, and α = 0.05 was taken as the borderline level of significance.
The results of the Kolmogorov-Smirnov test, presented in Table 1, indicate that the 2 study variables do not follow a normal distribution. Therefore, all analyses were performed using non-parametric chi-square, Fi Yula, Cramer’s V, and Spearman’s rho tests.
The statistical analysis recognised whether gender is related to the presence of risk of alcohol problem and type of drinking (risky/dependent). The results of the chi-square test shown in Table 2 indicate that there is no relationship between the gender of the subjects and the risk of alcohol problem and type of drinking.
The results of the chi-square test shown in Table 3 indicate that there is a weak (Fi = 23) relationship between the subjects’ occupational activity and the type of drinking, and no relationship between the subjects’ occupational activity and the alcohol problem. It can be concluded that it is more common for economically active people to drink alcohol in a risky manner.
The results of the chi-square test shown in Table 4 indicate that there is a weak (V = 0.29) relationship between the subjects’ smoking and alcohol problem, and there is a weak (Fi = 0.23) relationship between the subjects’ smoking and type of drinking.
The results of the chi-square test shown in Table 5 indicate that there is no relationship between the family status of the subjects and the alcohol problem and type of drinking.
The results of the chi-square test shown in Table 6 indicate that there is no relationship between the subjects’ participation in the drug program and the alcohol problem and type of drinking.
The results of the chi-square test shown in Table 7 indicate that there is no relationship between the subjects’ participation in clinical trials and the alcohol problem and type of drinking.
The results of Spearman’s rho test, shown in Table 8, indicate that there are significant weak negative relationships between age and type of drinking, and between duration of illness and alcohol problem.
This means that as the respondents get older, they drink in an increasingly risky manner, and as the duration of the disease increases, the alcohol problem becomes more severe.

Discussion

The past few years have been characterised by unprecedented dynamics of change occurring in all areas of human activity. Lifestyles and their standards are being transformed, requiring readiness to constantly adapt to new life circumstances. The presented study took place during the COVID-19 pandemic, which brought with it a profound and unprecedented social and psychological impact (Szczeklik 2016). In Poland, frequent drinking was estimated at 16.5% based on the Audit test after the pandemic (2022). The results correspond with data obtained in a broad study (EZOP II) involving a comprehensive survey of the state of society’s mental health and its determinants. The program was coordinated by the Institute of Psychiatry and Neurology in Warsaw and implemented with funds from the National Health Program 2016-2020. In this broad project, alcohol abuse in the population of adults aged 18 and older was shown at 7.1%, while addiction was found in 1.9%.
It is unclear to what extent the current findings apply to selected populations, such as students or selected professional groups. The data collected for the current study illustrate the drinking pattern of adults during the COVID-19 pandemic as risky, with reduced drinking of low-proof alcohol in favour of high-proof alcohol. This had a significant impact on daily life, One in 10 respondents admitted that they were now neglecting their responsibilities due to drinking alcohol – more people than in the pandemic (9.2%) and definitely more than before 2020 (7.6%) indicated that chronically ill people were also more likely to drink alcohol each week during the pandemic, even though they were receiving modern drug treatment (Toomey et al. 2012). It is worth noting that at the time mentioned above, access to treatment was severely hampered, and it took a lot of determination to systematically receive specialist care. Medical control in this regard was also difficult. In our study, the main goal was to identify whether patients abuse alcohol during treatment despite the fact that such activity is a contraindication to treatment. The results indicate a high prevalence of alcohol drinking, abuse, or risk of addiction. However, it is not clear whether this is related to a stressful situation – a pandemic – or whether it is a relatively constant problem in this population of people. However, it is worth mentioning that for those living in Poland, the stress burden is chronic. Other events have emerged in subsequent years that similarly cause stress, lower the standard of living, and isolate socially (e.g. the economic crisis of 2020-2022 and the war in Ukraine), affecting the way survey questionnaires are answered. Moreover, the cross-sectional nature of the current data precludes causal interpretation of the relationships analysed. Further research is needed to confirm the observed relationships. An additional variable that would provide important information is an assessment of how the study participants’ life situations have changed as a result, and how this may affect alcohol consumption in the context of mental health assessment. To proceed, future studies are needed to monitor alcohol consumption as the social situation changes dynamically. The present study found that economically active individuals engage in a greater pattern of risky drinking and alcoholism than inactive individuals. Therefore, consequences of drinking can be expected if the current pattern of alcohol consumption does not change. There is a risk of health, mental, physical, and social damage even if there is no basis for alcohol dependence.
This study found a weak association between smoking and problematic alcohol consumption. The study indicates that the stress experienced is related to unhealthy eating. It is therefore advisable to further explore the issue of health behaviour, giving a picture of habits such as consumption of sugars, poor quality of meals, etc.
However, a small but consistent positive relationship was shown between drinking pattern and smoking (Tables 4 and 5). This can probably be interpreted in the context of neglecting the importance of health behaviour along with the adverse health behaviour of using stimulants. The present study did not cover the relationship between cigarette smoking, alcohol consumption, and the increasing use of other psychoactive substances, such as drugs and legal highs (https://hh24.pl/alkoholizm). The above fact indicates the need to deepen knowledge of the mechanisms responsible for changing health-enhancing behaviours so that they are a normal, everyday part of people’s life activities. The responses of those surveyed confirmed the importance of the issue of treatment of alcohol addicts in the context of the use of other psychoactive substances besides alcohol.
The study showed no relationship between family status and the severity of the alcohol problem (Table 8). This means that the analysed pattern of alcohol consumption was not related to the fact of living alone or in a family environment. This does not diminish the significance of the fact that the real drama of an addict takes place in his closest environment, i.e. in the family. The effects of the disease affect all its members, who, finding no other way out of a painful situation, try to adapt to the rules, principles, and chaos that are the result of the alcoholic’s deepening destruction (Woronowicz 2009; Wu et al. 2008).
It is worth pointing out that regardless of the form of treatment (clinical trial, drug program), the frequency of drinking and the pattern of drinking at risk for addiction appear significantly high (Table 7) (Zhongshu 2002). Unfortunately, this can significantly affect medication adherence and treatment effectiveness. Therefore, the authors recommend controlling drinking behaviour during the applied innovative, high-cost treatment, even by means of the tests cited and used in the study.
A factor limiting of the study’s conclusions is undoubtedly the circumstances surrounding the COVID-19 pandemic. The high level of anxiety associated with the pandemic may have negatively affected the respondents’ lifestyles and weakened their coping mechanisms to deal with stress. This period was accompanied by limited access to doctors and a narrowing of previously available forms of social support. The second limitation is that the group size was small. This fact did not allow for analyses related to the category of age and the accompanying psychosocial situation. Adulthood is a long phase of life that spans from around 18 years of age until the end of one’s working life. Other developmental tasks and personality traits of people in early and middle adulthood are undoubtedly a factor worth including in further research. Another factor worth analysing is the evaluation of alcohol drinking in the context of the time passed since the diagnosis of rheumatic diseases.

Conclusions

Alcohol drinking is a problem among for nearly one-fifth of patients treated in drug programs and clinical trials.
Smoking is significantly associated with alcohol abuse and drinking patterns.
It is necessary to control with alcohol drinking questionnaires during treatment with expensive drugs, to identify alcohol abuse or risky drinking patterns as a factor that reduces compliance.

Disclosures

The research supported by financial sources of Department of Clinical Psychology PUMS – statute sources. The research had no commercial interests.
The study was approved by the Bioethics Committee of the Poznan University of Medical Sciences (Approval No. KB-424/23).
The authors declare no conflict of interest.

References