Acamprosate, another FDA-approved medication for AUD, shows promise in treating AUD. Acamprosate promotes abstinence, but has not demonstrated efficacy in individuals who continue to drink alcohol.¹¹ Though it may be better for patients who are highly motivated to abstain, it is dosed three times a day, making it problematic for some patients. Ultimately, the treatment selection should be tailored to the individual, what medications your pharmacy has available, and any relevant medical co-morbidities which may make certain options contraindicated. AUD, associated with considerable morbidity and mortality, is a classic example of a mismatch between a treatment offered in the outpatient setting and those with limited or no interaction with this part of the health care system. As emergency physicians, we see these patients, but often miss a critical window of opportunity by not evaluating our patients for their interests in reducing alcohol consumption or achieving sobriety. The current literature suggests that expanded access to medication assisted treatment (MAT) for opiate use disorder was associated with significant cost-saving reductions in morbidity and mortality.¹⁵ Similarly, MAT for AUD will likely prove cost effective. Time need not be a barrier as implementing appropriate  protocols and ancillary staff can ease opportunity cost of integrating these valuable discussions into our practice.

Treating the acute complications of AUD is like fixing a hole in a dam that is about to burst. Emergency physicians need to shift away from the “metabolize to freedom” culture and move towards routinely offering MAT in conjunction with counseling and psychosocial resources whenever indicated. Laying the foundation for long-term recovery of addiction may not be a role chosen by all of us when we signed up for emergency medicine, we can choose to shoulder the responsibility thrust upon us, provide the best care for our patients, and optimize ED use for AUD.

Dr. Mahmoud-Werthmann is an emergency physician and social emergency medicine fellow.

References

1. Understanding alcohol use disorder | national institute on alcohol abuse and alcoholism (NIAAA). Accessed December 9, 2022. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder.
2. White AM, Slater ME, Ng G, et al. Trends in alcohol-related emergency department visits in the united states: results from the nationwide emergency department sample, 2006 to 2014. Alcohol Clin Exp Res. 2018;42(2):352-359.
3. Preliminary findings from drug-related emergency department visits, 202. SAMHSA.gov. https://www.samhsa.gov/data/report/dawn-2021-preliminary-findings-report. Accessed December 9, 2022.
4. Peterson SM, Harbertson CA, Scheulen JJ, et al. Trends and characterization of academic emergency department patient visits: a five-year review. Academic Emergency Medicine. 2019;26(4):410-419.
5. Schmidt LA. Recent developments in alcohol services research on access to care. Alcohol Res. 2016;38(1):27-33.
6. Cunningham RM, Harrison SR, McKay MP, et al. National survey of emergency department alcohol screening and intervention practices. Ann Emerg Med. 2010;55(6):556-562.
7. NIAAA Publications. https://pubs.niaaa.nih.gov/publications/aa76/aa76.htm. Accessed December 9, 2022.
8. Mason BJ, Quello S, Goodell V, et al. Gabapentin treatment for alcohol dependence: a randomized clinical trial. JAMA Intern Med. 2014;174(1):70-77.
9. Groves C, Griffin L, Bradford JL. Alcohol use disorder: pharmacologic treatment options. FPIN’s Clinical Inquiries. Accessed December 9, 2022.
10. Singh D, Saadabadi A. Naltrexone. StatPearls. Stat-Pearls Publishing; 2022. http://www.ncbi.nlm.nih.gov/books/NBK534811/. Accessed December 9, 2022.
11. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and metaanalysis research, methods, statistics. JAMA. JAMA Network. https://jamanetwork.com/journals/jama/fullarticle/1869208. Accessed December 9, 2022.
12. Murphy CE, Wang RC, Montoy JC, Wet al. Effect of extended-release naltrexone on alcohol consumption: a systematic review and meta-analysis. Addiction. 2022;117(2):271-281.
13. Murphy CE 4th, Coralic Z, Wang RC, Montoy JCC, Ramirez B, Raven MC. Extended-Release Naltrexone and Case Management for Treatment of Alcohol Use Disorder in the Emergency Department [published online ahead of print, 2022 Oct 31]. Ann Emerg Med. 2022;S0196-0644(22)01042-3.
14. Anderson ES, Chamberlin M, Zuluaga M, et al. Implementation of oral and extended-release naltrexone for the treatment of emergency department patients with moderate to severe alcohol use disorder: feasibility and initial outcomes. Ann Emerg Med. 2021;78(6):752-758.
15. Fairley M, Humphreys K, Joyce VR, et al. Cost-effectiveness of treatments for opioid use disorder. JAMA Psychiatry. 2021;78(7):1-11.