(7) Naltrexone Prescribing from the Emergency Department

Naltrexone Prescribing from the Emergency Department
Eva Duvalyan, PharmD*; Israel Falade, BS*; Winnie Fan, BS*; Audrey Mvemba, BS*; Jay Zussman, BS*; Kathy LeSaint, Curt Geier, and Sally Graglia, MD, MPH
*Co-first authors

INTRODUCTION
Alcohol-use disorder (AUD) affects 18% of the US population and is the primary drug for substance-use related hospital admissions in San Francisco County. Although existing treatments for AUD are primarily non-pharmacologic (e.g rehabilitation programs) with less focus on pharmacologic management, naltrexone decreases craving and self-administration of alcohol in patients with AUD. While oral naltrexone and extended-release naltrexone have been long utilized in primary care and inpatient hospital settings, the use of naltrexone in the Emergency Department (ED) is limited.

METHODS
This study implemented an ED naltrexone prescribing protocol at a large safety net, academic, urban hospital. ED naltrexone prescriptions before and after implementation were analyzed to evaluate efficacy of the intervention. We conducted a baseline assessment of perspectives on naltrexone prescribing through standardized interviews with 22 multidisciplinary ED providers. The interview results guided design of a prescribing protocol that addressed identified barriers. Interventions included provider education through a presentation at faculty meeting and resident educational conference, visible provider education posted in the ED, a dot phrase for the electronic medical record (EMR) upon patient discharge, and naltrexone tablets supplied by the ED pharmacy to patients upon discharge at no cost.

RESULTS
Our baseline needs assessment and structured interviews revealed: 1) low naltrexone prescription rates, 2) high 30-day ED re-visit rate for alcohol-related presentations, 3) inadequate education and training on naltrexone use, 4) lack of a systematic protocol for identifying eligible patients, and 5) limited patient and provider naltrexone educational materials. Before our intervention (9/1/19-8/31/20), 1644 ED encounters had a primary diagnosis or chief complaint containing the term “alcohol.” Only 5 of 753 unique ED patients with AUD (0.66%) were prescribed naltrexone. Within a two-month sample period of 6/1/20-7/31/20, 15/106 (14.2%) unique patients had a repeat ED encounter within 30 days of initial presentation.

Following intervention implementation on 4/13/2021 through 8/1/2021, there were 11 oral naltrexone prescriptions from the ED. This represents roughly 33 ED oral naltrexone prescriptions per year, a 560% increase over the previous year. Two of these 11 patients (18%) returned to the ED within 30 days of their initial presentation.

CONCLUSION
We successfully implemented a naltrexone prescribing protocol for AUD from the ED. With interventions addressing lack of provider education and prescribing resources, oral naltrexone prescription rate increased 560% year-over-year. Longer-term follow-up is needed to assess the efficacy and sustainability of these interventions. Future studies could include a systematic review of naltrexone-prescribed patient demographics to evaluate for possible racial, gender, and other biases that may prevent underserved patient communities from receiving pharmacologic AUD therapy.

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