ED Nudge Strategy Increases Naltrexone Prescribing for Alcohol Misuse

Enhancing Alcohol Use Disorder Care in Acute Settings

Alcohol use disorder represents a substantial public health challenge, contributing to significant morbidity and mortality, yet it often goes undiagnosed and undertreated in various clinical settings [1]. While pharmacotherapies such as naltrexone have demonstrated efficacy in reducing alcohol consumption, their utilization remains low [2, 3]. Emergency departments (EDs) frequently encounter patients with alcohol-related issues, presenting a crucial, albeit often missed, opportunity for intervention [4]. Despite the availability of effective medications, systemic barriers to prescribing and patient engagement persist [5]. A recent study now details a structured, multicomponent strategy designed to overcome these barriers by integrating evidence-based treatment initiation directly into the ED workflow.

Study Design and Intervention Components

To test a more systematic method for initiating treatment, researchers implemented a multicomponent strategy across a large academic health system. The study was set in 6 hospitals, with interventions deployed in the EDs of 4 hospitals and the remaining 2 serving as controls for comparison. This design allowed the authors to assess the real-world impact of their protocol against standard care.

The intervention was introduced sequentially in two phases to evaluate the contribution of each component. Phase 1, launched on May 20, 2024, focused on provider behavior by embedding an ED discharge order set with clinical decision support directly into the electronic health record. This feature prompted physicians and simplified the process of prescribing. Subsequently, Phase 2, initiated on August 21, 2024, added a patient-facing component, incorporating systematic screening for concerns about alcohol use and tools to facilitate treatment conversations. The primary outcome was the proportion of ED patients with an alcohol-related discharge diagnosis who were discharged with a naltrexone prescription, a direct measure of the strategy's success in starting medication-assisted treatment.

Statistical Approach and Patient Cohort

The researchers used rigorous statistical methods to isolate the intervention's effect. A multivariate logistic regression analysis was performed to calculate the odds of a patient receiving a naltrexone prescription, a technique that statistically adjusts for other patient factors to ensure the observed increase was due to the intervention itself and not other variables. To further strengthen their findings, they conducted a difference-in-difference analysis. This method compares the change in prescribing rates at the intervention hospitals to the change at the control hospitals over the same period, effectively subtracting out any system-wide trends to reveal the true impact of the protocol.

These analyses were applied to a large and clinically relevant patient population. Over the 43-month study period, a total of 8,909 ED patients, representing 2.0% of all ED discharges, had an alcohol-related diagnosis code. This substantial cohort underscores the frequent opportunities for intervention that exist within the acute care setting and the potential scale of impact for an effective protocol.

Significant Increase in Naltrexone Prescribing

The protocol produced a marked and sustained increase in the initiation of naltrexone at the intervention hospitals. Before the study, the baseline rate of naltrexone prescribing for patients with alcohol-related diagnoses was just 0.2% (13 patients). After the implementation of the electronic health record order set in phase 1, the rate increased more than tenfold to 2.7% (18 patients). The addition of systematic screening and facilitated conversations in phase 2 further boosted the rate to 3.2% (81 patients). In stark contrast, the control hospitals demonstrated virtually no change, with prescribing rates of 0.0% at baseline, 0.0% during phase 1, and 0.3% during phase 2.

The statistical significance of these findings was robust. Compared to baseline, the multivariate analysis showed that patients at intervention hospitals were 12.3 times more likely (95% confidence interval: 6.0 to 25.7) to be discharged with naltrexone during phase 1. This effect was maintained in phase 2, with patients being 14.6 times more likely (95% confidence interval: 8.4 to 27.4) to receive a prescription. The difference-in-difference analysis confirmed that the protocol was responsible for a 2.9% absolute increase (95% confidence interval: 2.4% to 3.5%) in naltrexone prescribing at intervention hospitals compared to controls.

Clinical Implications of a Structured ED Protocol

The study demonstrates that a structured, systems-level intervention can successfully integrate the initiation of medication-assisted treatment for alcohol use disorder into the fast-paced ED environment. The key finding for clinicians is that a triage-based protocol combining universal screening, electronic health record alerts, and clinical decision support significantly increased naltrexone prescribing. This provides a practical, scalable model for converting a common clinical encounter from a missed opportunity into a critical first step toward treatment.

For the practicing physician, this type of systemized approach reduces individual barriers to prescribing. By automating screening and providing clear, accessible prescribing pathways through the electronic health record, the protocol helps clinicians efficiently identify appropriate candidates and act on evidence-based guidelines without adding significant time or cognitive load. Initiating naltrexone in the ED can serve as a vital bridge, stabilizing patients and connecting them to outpatient follow-up for a chronic condition that is too often left unaddressed after an acute visit.

References

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2. Palpacuer C, Laviolle B, Boussageon R, Reymann JM, Bellissant É, Naudet F. Risks and Benefits of Nalmefene in the Treatment of Adult Alcohol Dependence: A Systematic Literature Review and Meta-Analysis of Published and Unpublished Double-Blind Randomized Controlled Trials. PLoS Medicine. 2015. doi:10.1371/journal.pmed.1001924

3. Palpacuer C, Duprez R, Huneau A, et al. Pharmacologically controlled drinking in the treatment of alcohol dependence or alcohol use disorders: a systematic review with direct and network meta‐analyses on nalmefene, naltrexone, acamprosate, baclofen and topiramate. Addiction. 2017. doi:10.1111/add.13974

4. Glass JE, Bobb JF, Lee AK, et al. Study protocol: a cluster-randomized trial implementing Sustained Patient-centered Alcohol-related Care (SPARC trial). Implementation Science. 2018. doi:10.1186/s13012-018-0795-9

5. Barrio P, Gual A. Patient-centered care interventions for the management of alcohol use disorders: a systematic review of randomized controlled trials. Patient Preference and Adherence. 2016. doi:10.2147/ppa.s109641