Substance and Alcohol Use Disorders in Crohn’s Disease Flare Hospitalizations: Prevalence, Outcomes and Racial Disparities in a National Cohort

INTRODUCTION Psychiatric comorbidities are common in Crohn’s disease (CD) and worsen outcomes and costs. Depression and anxiety are well studied, but substance use disorder (SUD) and alcohol use disorder (AUD) remain understudied despite biologic plausibility and clinical relevance. They increase length of stay (LOS), hospitalization costs and morbidity in general populations, yet their impact in CD is poorly defined. METHODS We conducted a retrospective cohort study of adult CD flare admissions in the 2020–2021 National Inpatient Sample (NIS), identifying SUD and AUD from secondary diagnoses. Outcomes included LOS, hospitalization cost, and in-hospital mortality, analyzed using weighted regression adjusted for demographics, comorbidities, and hospital factors, with subgroup analyses by race and ethnicity. RESULTS Among 24,506 weighted admissions, 6.5% had SUD, 1.5% AUD, and 0.4% both. In adjusted analyses, SUD was linked to higher mean LOS (5.3 vs 5.1 days, p < 0.05) and costs ($54,837 vs $52,688, p < 0.05), with no mortality difference (0.1% vs 1.0%, p = 0.21). AUD alone was not associated with longer LOS (4.9 vs 5.1 days, p = 0.31) and showed slightly lower costs ($51,155 vs $52,852, p = 0.04), with similar mortality (0.6% vs 1.0%, p = 0.44). Patients with both SUD and AUD had the highest utilization, with longer LOS (5.6 vs 5.1 days, p < 0.01) and higher costs ($62,845 vs $52,691, p < 0.01), though mortality is not significant. Hispanic patients had the highest adjusted mean costs despite equal or shorter LOS, including $68,806 vs $57,377 in White patients with SUD (p < 0.01) and $69,702 vs $54,597 in Whites with AUD (p < 0.01). With both disorders, Hispanic patients exceeded $70,000 vs $59,822 in Whites (p < 0.01). Black patients had shorter LOS (4.1–4.7 days, p < 0.05) and lower costs ($32,489–$47,257, p < 0.05). Asian and Native American patients showed the lowest utilization, with LOS 2.8–3.8 days and costs $25,579–$36,449, though small samples limited precision. Mortality was not different across racial groups. DISCUSSION This nationally representative study shows SUD and AUD are underrecognized yet clinically and economically important in CD flare hospitalizations. SUD associated with modest but significant increases in LOS and costs, AUD alone had little effect, and combined disorders conferred the greatest burden. Hispanic patients consistently had the highest costs despite similar or shorter LOS, suggesting inequities in IBD care. Black, Asian, and Native American patients had shorter LOS and lower costs, which may reflect differences in access, coding, or treatment. Mortality was uniformly low, underscoring that the main consequences are economic and resource-driven. These findings support systematic screening for SUD and AUD in CD and integration of culturally responsive behavioral health into IBD care to reduce disparities and improve outcomes.