“Metabolize to freedom” or “MTF” as it is commonly known to emergency physicians is too frequently the instructions that accompany sign out to a colleague. Alcohol use disorder (AUD), a preventable and treatable medical condition, results in over 2 million annual emergency department (ED) encounters, accruing an annual cost of $15 billion.^1,2 Accounting for nearly 40 percent of all substance use related-ED visits in 2021, data suggests that alcohol-related ED visits are steadily increasing.³ Emergency departments faced with unprecedented boarding challenges cannot afford to ignore this persistent public health burden, particularly in light of evidence-based interventions and medications that can treat AUD.⁴

Yet, there remains a significant treatment gap for patients with AUD. Of the more than 18 million people in the United States who need treatment, fewer than 10 percent receive appropriate medication.5 Additionally, there is a significant evidence-practice gap. Even though a considerable body of literature demonstrates the benefits of using FDA-approved medications in the treatment of AUD, few emergency departments have a protocol in place to initiate these medications and help patients achieve goals of reduced alcohol consumption or abstinence.⁶ Intoxicated or withdrawing patients are observed until sobriety, treated for their acute complication, and ultimately discharged without addressing their underlying AUD.

Naltrexone and Acamprosate

Three medications are FDA-approved for the treatment of AUD—naltrexone, acamprosate, and disulfiram, and several others show off label benefit.^7,8 Here I will focus on naltrexone and acamprosate, since those are both first-line treatments and have the best evidence supporting their benefits.⁹ Naltrexone, an opioid antagonist, is available in two formulations: oral daily naltrexone and intra-muscular, extended-release naltrexone (vivitrol) administered monthly.¹⁰ Naltrexone reduces heavy drinking and is an ideal option for patients who would like to reduce their alcohol consumption rather than quit.¹¹ Vivitrol offers the added benefit of once-a-month dosing, which may positively impact compliance especially in patients who face socioeconomic barriers to access care.¹² A recent study found that initiating vivitrol in the ED in collaboration with case management demonstrated significant reductions in overall alcohol consumption as well as improved quality of life. Importantly, nearly 80 percent of patients completed all follow up appointments and 69 percent of the patients continued vivitrol after the study.¹³ Another study found that in comparison to oral naltrexone, patients who received vivitrol in the ED had higher rates of follow up within 30 days. Of note, patients in both arms were seen by a substance use navigator.¹⁴

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

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