• Inhibits aldehyde dehydrogenase, leading to an accumulation of acetaldehyde, causing flushing, nausea, and vomiting, which may reduce adherence.

Initiating Medications for Alcohol Use Disorder in the ED

Our recommendation is that patients who screen positive for AUD and are interested in medications to reduce cravings, want to start treatment, do not have a history of opioid use disorder, and are not actively taking opioids, should be initiated on naltrexone. Prior to naltrexone initiation, a “naloxone challenge” should be trialed. This challenge dose of 0.4 mg IV naloxone is given to reduce the risk of naltrexone causing precipitated withdrawal. Trialing this dose of naloxone is not necessary, but it will reduce the risk of precipitating withdrawal, especially if the IM version of naltrexone is given. Following a successful naloxone challenge (absence of precipitated withdrawal), an initial dose of 50 mg PO or the 380 mg IM naltrexone can be administered.

Upon discharge, the patient should be given a prescription for up to 30 days of 50 mg naltrexone if the PO formulation was administered. If the IM version was provided, the patient should be provided with information for a primary care provider, an addiction medicine specialist if available, or outpatient addiction treatment facilities, as well as a follow-up appointment in one month.

While naltrexone is the best option for AUD due to its safety profile, ease of use, and proven effectiveness, if patients are actively taking opioids, then the next best option would be acamprosate. While its large pill burden (six pills daily) makes it difficult to tolerate, systematic reviews have noted that it does significantly reduce heavy drinking.²⁴ In patients who understand the potential adherence challenges, acamprosate is a suitable alternative to naltrexone. Disulfiram is less likely to be initiated in the ED and has yielded inconsistent data, with some studies demonstrating no benefit and others showing a benefit only when used in a supervised program.^24,25,27 Gabapentin is occasionally used off-label for the treatment of AUD, and while there are limited studies demonstrating its effectiveness, it is thought to work well in individuals whose alcohol use is triggered specifically by their withdrawal symptoms.¹² Yet, gabapentin has been misused throughout the country and has potentially been linked to numerous overdose-related deaths.^12,22