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

Anderson, Eric G.; Chamberlin, Mac; Zuluaga, Marisa; Ullal, Monish; Hawk, Kathryn; McCormack, Ryan; D’Onofrio, Gail; Herring, Andrew A.

doi:10.1016/j.annemergmed.2021.05.013

Cited by 15 publications

(22 citation statements)

References 9 publications

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“…Like other recent studies [37][38][39], our analysis confirmed that the overall prevalence of naltrexone prescriptions in AUD admissions is low. However, we note that the follow-up rate in formal addiction treatment using naltrexone could reach about 15%, according to a recent study [40]. Considering that naltrexone for AUD constitutes evidence-based care and that it is the recommended first-line treatment for AUD, the relatively marginal increase in naltrexone prescriptions over the past two decades is worrisome.…”

Section: Discussionmentioning

confidence: 78%

Trends in the Use of Naltrexone for Addiction Treatment among Alcohol Use Disorder Admissions in U.S. Substance Use Treatment Facilities

Qeadan

Mensah

et al. 2021

IJERPH

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Background: Naltrexone, a medication for addiction treatment (MAT), is an FDA-approved medication recommended for the treatment of alcohol use disorder (AUD). Despite the high prevalence of AUD and efficacy of naltrexone, only a small percentage of individuals with AUD receive treatment. Objectives: To identify trends for the prescription of naltrexone in AUD admissions in substance use treatment centers across the U.S. Methods: Data from the 2000–2018 U.S. Treatment Episode Data Set: Admissions (TEDS-A) were used in temporal trend analysis of naltrexone prescription in admissions that only used alcohol. Data from the 2019 National Survey of Substance Abuse Treatment Services (N-SSATS) were also used to characterize medication use among AUD clients across different treatment service settings. Results: Treatment of AUD with naltrexone was 0.49% in 2000 and tripled from 0.53% in 2015 to 1.64% in 2018 in AUD admissions (p < 0.0001 for the Cochran–Armitage trend test). Women, middle-aged adults, and admissions for clients living in the Northeast U.S. were more likely to be prescribed naltrexone than their respective counterparts, as were admissions with prior treatment episodes and referrals through alcohol/drug use care providers, who paid for treatment primarily through private insurance, used alcohol daily in the month prior to admission, and waited 1–7 days to enter treatment. Naltrexone was more commonly prescribed by AUD admissions compared to acamprosate and disulfiram and was more frequently prescribed in residential and outpatient services as opposed to hospital inpatient services. Conclusions: Naltrexone remains underutilized for AUD, and factors that influence prescription of medication are multifaceted. This study may contribute to the creation of effective interventions aimed at reducing naltrexone disparities for AUD.

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Section: Discussionmentioning

confidence: 78%

Trends in the Use of Naltrexone for Addiction Treatment among Alcohol Use Disorder Admissions in U.S. Substance Use Treatment Facilities

Qeadan

Mensah

et al. 2021

IJERPH

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“…One recent study demonstrated the feasibility of prescribing NTX from the ED, however reported limited follow-up and poor patient-centered efficacy for naltrexone among recipients [25]. This study demonstrates both the difficulty of introducing an intervention into a new clinical setting and raises questions as to why outcomes differed from the primary care literature.…”

Section: Introductionmentioning

confidence: 81%

Provider perspectives on emergency department initiation of medication assisted treatment for alcohol use disorder

Philippine

Forsgren

DeWitt

et al. 2022

BMC Health Serv Res

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Background Alcohol use disorder (AUD) is ubiquitous and its sequelae contribute to high levels of healthcare utilization, yet AUD remains undertreated. The ED encounter represents a missed opportunity to initiate medication assisted treatment (MAT) for patients with AUD. The aims of this study are to identify barriers and facilitators to the treatment of AUD in the ED, and to design interventions to address identified barriers. Methods Using an implementation science approach based on the Behavior Change Wheel framework, we conducted qualitative interviews with staff to interrogate their perspectives on ED initiation of AUD treatment. Subjects included physicians, nurses, nurse practitioners, clinical social workers, and pharmacists. Interviews were thematically coded using both inductive and deductive approaches and constant comparative analysis. Themes were further categorized as relating to providers’ capabilities, opportunities, or motivations. Barriers were then mapped to corresponding intervention functions. Results Facilitators at our institution included time allotted for continuing education, the availability of clinical social workers, and favorable opinions of MAT based on previous experiences implementing buprenorphine for opioid use disorder. Capability barriers included limited familiarity with naltrexone and difficulty determining which patients are candidates for therapy. Opportunity barriers included the limited supply of naltrexone and a lack of clarity as to who should introduce naltrexone and assess readiness for change. Motivation barriers included a sense of futility in treating patients with AUD and stigmas associated with alcohol use. Evidence-based interventions included multi-modal provider education, a standardized treatment algorithm and order set, selection of clinical champions, and clarification of roles among providers on the team. Conclusions A large evidence-practice gap exists for the treatment of AUD with Naltrexone, and the ED visit is a missed opportunity for intervention. ED providers are optimistic about implementing AUD treatment in the ED but described many barriers, especially related to knowledge, clarification of roles, and stigma associated with AUD. Applying a formal implementation science approach guided by the Behavior Change Wheel allowed us to transform qualitative interview data into evidence-based interventions for the implementation of an ED-based program for the treatment of AUD.

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“…One recent study demonstrated the feasibility of prescribing NTX from the ED, however reported limited follow-up and poor patient-centered e cacy for naltrexone among recipients. 21 This study demonstrates both the di culty of introducing an intervention into a new clinical setting and raises questions as to why outcomes differed.…”

Section: Introductionmentioning

confidence: 92%

Provider Perspectives on Emergency Department Initiation of Medication Assisted Treatment for Alcohol Use Disorder

Philippine

Forsgren

DeWitt

et al. 2022

Preprint

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BackgroundAlcohol use disorder (AUD) is ubiquitous and its sequelae contribute to high levels of healthcare utilization, yet AUD remains undertreated. The ED encounter represents a missed opportunity to initiate medication assisted treatment (MAT) for patients with AUD. The aim of this study is to first identify barriers and facilitators to the treatment of AUD in the ED, and second to design interventions to address identified barriers. MethodsUsing an implementation science approach based in the Behavior Change Wheel framework, we conducted qualitative interviews with staff to interrogate their perspectives on ED initiation of AUD treatment. Subjects included physicians, nurses, nurse practitioners, clinical social workers, and pharmacists. Interviews were thematically coded using both inductive and deductive approaches and constant comparative analysis. Themes were further categorized as relating to providers’ capabilities, opportunities, or motivations. Barriers were then mapped to corresponding intervention functions. ResultsFacilitators at our institution included time allotted for continuing education, the availability of clinical social workers, and favorable opinions of MAT based on previous experiences implementing buprenorphine for opioid use disorder. Capability barriers included limited familiarity with naltrexone and difficulty determining which patients are candidates for therapy. Opportunity barriers included the limited supply of naltrexone and a lack of clarity as to who should introduce naltrexone and assess readiness for change. Motivation barriers included a sense of futility in treating patients with AUD and stigmas associated with alcohol use. Evidence-based interventions included multi-modal provider education, a standardized treatment algorithm and order set, selection of clinical champions, and clarification of roles among providers on the team. ConclusionsWe used the Behavior Change Wheel framework to transform qualitative interview data into evidence-based interventions to guide the ED rollout of MAT for patients with AUD.

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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

Cited by 15 publications

References 9 publications

Trends in the Use of Naltrexone for Addiction Treatment among Alcohol Use Disorder Admissions in U.S. Substance Use Treatment Facilities

Trends in the Use of Naltrexone for Addiction Treatment among Alcohol Use Disorder Admissions in U.S. Substance Use Treatment Facilities

Provider perspectives on emergency department initiation of medication assisted treatment for alcohol use disorder

Provider Perspectives on Emergency Department Initiation of Medication Assisted Treatment for Alcohol Use Disorder

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