Naltrexone Initiation in the Inpatient Setting for Alcohol Use Disorder: A Systematic Review of Clinical Outcomes

Abstract

Alcohol use disorder (AUD) is a highly prevalent health issue in the United States. The number of those receiving medication-assisted treatment (MAT) is limited, despite strong evidence for their effectiveness. The inpatient setting may represent an important opportunity to initiate MAT. The goal of this study was to summarize the data on naltrexone initiation in the emergency department or inpatient setting for the management of AUDs. We searched ClinicalTrials.gov, Ovid EBM Reviews, Ovid Embase, Ovid Medline, Ovid PsycINFO, Scopus, and Web of Science from inception through October 31, 2019. Search strategies were created using a combination of keywords (Supplemental Appendix 1, available online at http://www. mcpiqojournal.org) and standardized index terms related to naltrexone therapy for medically hospitalized patients with AUD. Two uncontrolled pre-post study designs evaluated naltrexone prescription rates, 30day readmission rates, and rehospitalization rates. Two authors independently abstracted data on study characteristics, results, and study-level risk of bias. The research team collaborated to assess the strength of evidence across studies. Two studies reported that implementing a protocol for naltrexone initiation increased MAT rates, with one study noting a substantial decrease in 30-day hospital readmissions. Overall, we found that there is a paucity of data on naltrexone initiation in the inpatient setting for AUDs. This likely reflects the nature of current clinical practice and prescriber comfortability. There is a need for further studies evaluating MAT initiation in the inpatient setting. Furthermore, efforts to increase provider knowledge of these therapeutic options are in need of further exploration.

Assessing Naltrexone Prescribing and Barriers to Initiation for Alcohol Use Disorder: A Multidisciplinary, Multisite Survey

“…Clinical barriers to prescribing naltrexone for AUD may include the risk of hepatotoxicity and a need for patients to be opioid free for a minimum of 7 to 10 days before the drug is begun ( 17 ). Other described barriers are related to prescribers' knowledge and perception of naltrexone treatment for AUD ( 5 , 18 ). To better understand the potential barriers to prescribing naltrexone, a multidisciplinary survey was conducted across 3 sites of a large academic medical enterprise.…”

Single-dose intravenous ketamine or intramuscular naltrexone for high-utilization inpatients with alcohol use disorder: pilot trial feasibility and readmission rates

“…To better isolate the effects of the pharmacological interventions, inpatient teams were instructed not to prescribe oral naltrexone (or acamprosate or disulfiram) on discharge, although participants could receive any medication at follow-up if appropriate. Notably, prescribing discharge medications for AUD is rare; a recent systematic review [ 24 ] found just two studies implementing naltrexone prescribing for AUD on discharge. Their baseline prescribing rates were 0.0 and 1.6%.…”

“…Their baseline prescribing rates were 0.0 and 1.6%. Additionally, evidence showing effectiveness of in-hospital prescribing of AUD medications is scarce [ 24 ]. Therefore we did not consider lack of oral AUD medication prescription on discharge to be an egregious departure from standard of care.…”

“…Studies on IM naltrexone—which releases over 4 weeks after a transient initial peak—have shown better long-term medication continuation compared to PO naltrexone [ 22 ] and fewer heavy drinking days compared to placebo [ 23 ]. To date, there are few published data on initiation of PO [ 24 ] or IM [ 25 ] naltrexone before hospital discharge.…”

Off-label and investigational drugs in the treatment of alcohol use disorder: A critical review

“…It is therefore used to maintain strict abstinence and should prevent relapse ( Mutschler et al, 2016 ). The other two medications for which the main therapeutic goal is to maintain abstinence due to reduction of alcohol-craving are the NMDA receptor antagonist acamprosate ( Kiefer and Mann, 2010 ), and the long-acting opioid receptor antagonist naltrexone ( Kirchoff et al, 2021 ). Various meta-analyses and reviews have described the effectiveness of these medications in treating alcohol use disorder ( Garbutt et al, 1999 ; Kenna et al, 2004a , 2004b ; Soyka and Roesner, 2006 ; Jonas et al, 2014 ; Soyka and Mutschler, 2016 ).…”