(73) Increasing Naltrexone Prescriptions for Hospitalized Patients with Alcohol Use Disorder

Introduction:
Alcohol use disorder (AUD) is associated with high morbidity and mortality in the United States and is the third leading preventable cause of death (SAMHSA, 2019). Although medications are considered first-line treatment for moderate and severe AUD, prescribing rates remain low (Harris et al., 2012; Reickmann et al., 2016). The aim of this quality improvement project was to increase the rate of naltrexone prescriptions at hospital discharge for patients with moderate to severe AUD.

Methods:
The project was deemed HSRD exempt by University of Iowa IRB. We gathered baseline data on patients who had alcohol withdrawal scale ordered during hospitalization on one of six inpatient internal medicine teams at a single academic institution between September and November 2019. For PDSA cycle 1, which took place from December 2019 to October 2020, four resident-based teaching teams received an educational intervention while two non-teaching teams served as control. Two ten-minute information sessions on naltrexone were provided, and summary emails were sent following the sessions. Team workspaces were outfitted with decision aids and visual reminders. For PDSA cycle 2, which took place between November 2020 and February 2021, emergency medicine providers and internal medicine teaching teams were tasked with distributing educational handouts about naltrexone to patients to encourage patient uptake of naltrexone. Post intervention data were collected from December 2019 to February 2021. The primary outcome was the rate of naltrexone prescriptions upon discharge. Secondary outcomes included rate of acamprosate prescriptions and Addiction Medicine consultations.

Results:
There were 153 identified admissions during the baseline period and 475 following the intervention (367 following PDSA 1 and 108 following PDSA 2). Following PDSA 1, naltrexone prescriptions on teaching teams increased from a monthly average of 8.4% to an average of 13.6%, but remained virtually unchanged in the non-teaching control group, going from 3.7% to 3.0%. Naltrexone prescribing rates after PDSA 2 remained at 13.2%. After both interventions, acamprosate prescribing rates increased from 4% to 6% on teaching teams and decreased from 11% to 5% on non-teaching control. Addiction Medicine consultation rates were similar between groups and were unchanged post intervention. Teaching team use of medication therapy overall (naltrexone + acamprosate) increased from 12.6% to 19.8% after both interventions, a more than a 50%, but non-significant increase (χ2=1.78, df=1, p=0.18). However, while baseline prescribing rates between teaching team and control were similar (χ2=2.4, df=1, p=0.12), the intervention group had significantly higher prescribing rates post-intervention when compared to the control group (χ2=6.8, df=1, p=0.009).

Conclusion:
Simple educational interventions led to a statistically significant increase in naltrexone prescription rate among teaching teams in an academic hospital when compared to the control group. The intervention group had significantly higher naltrexone prescribing rates at the end of the study, although baseline prescribing rates had been similar between intervention and control. Acamprosate prescribing rates also increased in the resident teams. These increases in prescribing rates were not driven by higher Addiction Medicine consult rates, suggesting that improved awareness among providers is sufficient to increase medication prescribing for patients with AUD.

References: 1. Substance Abuse and Mental Health Services Administration (SAMHSA). Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health.; 2019. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf.

2. Reickmann T, Muench J, McBurnie MA, Leo MC, Crawford P, Ford D. Medication-assisted treatment for substance use disorders within a national community health center research network. Subst Abus. 2016;37(4):625-634.

3. Harris A, Oliva E, Bowe T, Humphreys K, Kivlahan D, Trafton J. Pharmacotherapy of alcohol use disorders by the Veterans Health Administration: patterns of receipt and persistence. Psychiatr Serv. 2012;63(7):679-685. doi:10.1176/APPI.PS.201000553

Diversity, Equity, and Inclusion: The University of Iowa Health Care (UIHC) is the only academic healthcare system in the state and serves as the primary safety net hospital for non-insured and underinsured Iowans. As of October 2019, approximately 18% of Iowans were Medicaid enrollees with another 5% of the population remaining uninsured. Since the start of the pandemic, the rate of Medicaid enrollees has increased by 133% based on state reports (Kaiser Family Foundation). Therefore, a large percentage of UIHC patients experience poverty and underemployment that limits access to evidence-based care and treatment of their substance use disorders. This QI project aims to increase provider education as well as patient awareness and access to alcohl use disorder treatment.