Opioid misuse might not be the only addiction-related problem that has worsened over the course of the COVID-19 pandemic. Researchers from Washington University School of Medicine in St. Louis highly suspect a 34% increase in alcohol sales in recent months means there has been a rise in the number of patients with alcohol use disorder (AUD), too. But will these patients receive treatment for their AUD? If current trends hold true, not nearly enough, according to data on more than 200,000 people with and without alcohol use problems.1

After reviewing data gathered between 2015 and 2019 as part of the National Survey on Drug Use and Health, researchers found even though most individuals with AUD accessed healthcare regularly, fewer than one of every 10 of these patients received treatment for AUD. This was true among the roughly 70% of patients who self-reported when a provider asked about their drinking.

The FDA has approved three medications for AUD.2 Treatment programs, such as Alcoholics Anonymous, exist. Still, in speaking with experts about the issue, numerous barriers remain. Nevertheless, emergency providers often are uniquely positioned to help patients toward recovery.

Most emergency providers regularly encounter patients with AUD. A 2018 report revealed the rate of alcohol-related visits to the ED increased by nearly 50% between 2006 and 2014. During this period, the number of patients presenting to the ED with alcohol-related emergencies increased from 3 million to 5 million annually, representing a significant burden on the healthcare system.3

Charles Murphy, MD, associate clinical professor of emergency medicine at the University of California, San Francisco, says some EDs use validated screening tools, such as the Alcohol Use Disorders Identification Test (AUDIT) or the four-item CAGE screening questionnaire, to diagnose AUD.4 More often, providers identify the condition when patients present in alcohol withdrawal. Either way, counseling on the disorder may not occur because of a lack of time, real or perceived. “I would say that emergency providers do a lot of counseling that is not well documented in the medical record and not billed for, which can make it hard to identify retrospectively,” Murphy observes.

That said, emergency providers may not prescribe medications for AUD, either because they are unfamiliar with available medications or they may believe such prescriptions are better left to a patient’s primary care provider. Further, Murphy acknowledges stigma may play a role in some cases. “Although we have made progress in this area, many people still hold a belief that those with alcohol use disorder suffer from a lack of character/strength of will, rather than a treatable medical condition,” he says.

However, considering the primary focus of emergency providers is recognizing and treating acute illness or the acute decompensation of a chronic illness, Murphy says emergency providers are comfortable treating alcohol withdrawal, even in its most extreme form, delirium tremens. “It’s an acute decompensation of the chronic disease of AUD and is potentially life-threatening,” he explains. “Stabilizing a patient in alcohol withdrawal is exactly what we are trained to do.”

What emergency providers have not been trained to do, historically, is treat the underling chronic disease. Murphy notes some emergency physicians do not believe it is their job to do so. “The lack of training means that we do not even think about offering MAT [medication-assisted treatment] most of the time,” he says. “When we do, we may not be familiar with the medications and their contraindications.”

While unfamiliarity with the treatment options for AUD is one barrier, Wilson Compton, MD, MPE, deputy director of the National Institute on Drug Abuse, believes the single largest contributor to the undertreatment of AUD is patients with the condition resist the idea they need help. “When people are asked whether they think they need treatment, over 90% say they don’t see a need for treatment, even when they are objectively telling you about the problems that alcohol is causing and they are reporting symptoms related to alcohol consumption,” he explains. “They still don’t recognize that they have a condition that may benefit from treatment.”

Compton notes a common scenario involving AUD would be a patient who tried to quit or better control his drinking but could not. In fact, the patient might have made several attempts to quit, but was unsuccessful. “That is a very classic sign of losing control over consumption,” Compton says. “[Patients] may continue their use of alcohol despite harms. The harms can be physical, [such as] upset stomach, gastrointestinal irritation, bleeding, or more severe things like liver disease or heart disease.”

There also are mental harms. For instance, Compton notes some people become remarkably depressed and melancholy after drinking heavily; yet, they still might continue to drink — even though the drinking is causing those problems. “There can also be social problems, problems with family, friends, and work ... and some may continue to drink despite recognizing that it has caused those problems,” Compton says. “These are the kind of symptoms that I would use as a clinician to diagnose somebody [with AUD].”

Patients might resist help for AUD because they surmise that abstinence is the only solution, but that is not necessarily the case. “Abstinence may be the healthiest and best long-term outcome, but I am thrilled if people cut down on their drinking, reduce the harms, and improve outcomes in any other way,” Compton says. “Focusing on ways to reduce the consequences and reduce the high-risk drinking may be the most successful approach. That is a way to get around that all-or-nothing approach, recognizing that some people may not be able to maintain those lower levels [of alcohol consumption]. Abstinence may be the only approach for them.”

However, Compton explains while survey data suggest clinicians are asking patients about alcohol consumption patterns more routinely, they are not necessarily trying to help patients change that behavior.

Murphy, who has conducted research into the efficacy of medications for AUD, believes all patients with moderate to severe AUD should be offered appropriate pharmacotherapy whenever possible.5 “Of the three FDA-approved medications for AUD, one is not conducive to use in the ED [disulfiram], one is not particularly effective in active drinkers [acamprosate], and one may interfere with treating acute and chronic pain [naltrexone],” he says. “None are perfect for the ED setting. Because we are not trained to use them, [such prescribing] requires a little thought. This increases cognitive load because we must look up the information prior to offering treatment. That is a big barrier.”

Nonetheless, Murphy recommends offering one of the medications any time a clinician believes a patient has an alcohol problem. “For example, any patient in alcohol withdrawal in the ED almost certainly meets the criteria for moderate to severe AUD. Any time you are treating a patient with withdrawal, offer [him or her] MAT to treat AUD unless there is a clear reason not to do so,” Murphy advises. “If your patient is amenable to starting MAT, and you have easy access to these medications in your ED, go ahead and give them a dose. If you don’t have access to them, just write a prescription for a one-month supply, congratulate the patient on their decision, and refer to them to ongoing treatment.”

Of the three available medications, Murphy believes naltrexone probably is the best choice for ED patients, followed by acamprosate. “Gabapentin is not FDA-approved for treatment of AUD, but it can be a useful adjuvant as well,” he adds.

Compton notes many patients want to try to quit or cut down on their drinking on their own. “While that is successful for many, we know that adding medications can improve the outcomes and increase their chances of reducing alcohol-related harms and alcohol-related consequences,” he says.

While views may differ among clinicians on what the role of emergency providers should be regarding managing patients with AUD, Murphy believes most providers would consider it a standard of care to provide patients diagnosed with AUD with resources on how to access treatment in the community. Furthermore, he notes the American College of Emergency Physicians (ACEP) wrote a policy statement supporting the use of screening, brief intervention, and referral to treatment (SBIRT) for ED patients with suspected AUD.6 ACEP also offers a resource kit designed to make the process as easy as possible for emergency physicians who are unfamiliar with SBIRT.7

“As emergency providers, we see patients with AUD every shift. Many have repeated visits related to alcohol use. We see them for withdrawal, trauma, pancreatitis, altered mental status, [and] hypothermia,” Murphy observes. “Often, we treat the acute issue, and then send them out, and the cycle repeats.”

In such cases, the patients often feel helpless, and providers feel powerless to help them. “This contributes to burnout and leads to the belief that these patients are beyond our help and are unlikely to recover,” Murphy says. “We can fix that problem by simply offering [approved medications] to our patients.”

Many patients will decline treatment, but Murphy says more patients will accept treatment than emergency providers might expect. For example, he recalls one emergency patient who was invited to enroll in treatment as part of a pilot study on extended-release naltrexone and case management for AUD treatment. The patient initially declined. Two or three days later, he called back asking if he could enroll because he wanted to make a change. “This happened many times throughout the trial. It showed me how important it was to just offer help during the ED visit,” Murphy stresses. “Even if the patient declines the offer [of treatment], you have planted the seed that change is possible and help is available.”

“What we have seen with opioid use disorder is that by starting treatment in the ED before that person leaves, you can improve their outcomes,” Compton says. “That might be an approach to consider for AUD as well, not just referring the patient for treatment but making sure that there is active engagement in treatment while they are still undergoing clinical care.” 

REFERENCES

  1. Mintz CM, Hartz SM, Fisher SL, et al. A cascade of care for alcohol use disorder: Using 2015-2019 National Survey on Drug Use and Health data to identify gaps in past 12-month care. Alcohol Clin Exp Res 2021;45:1276-1286.
  2. Winslow BT, Onysko M, Hebert M. Medications for alcohol use disorder. Am Fam Physician 2016;93:457-465.
  3. National Institutes of Health. NIH study shows steep increase in rate of alcohol-related ER visits. Jan. 12, 2018.
  4. National Institute on Alcohol Abuse and Alcoholism. Screening tests.
  5. Murphy CE 4th, Wang RC, Montoy JC, et al. Effect of extended-release naltrexone on alcohol consumption: A systematic review and meta-analysis. Addiction 2021; May 25. doi: 10.1111/add.15572. 
  6. American College of Emergency Physicians. Alcohol screening in the emergency department. Approved January 2017.
  7. American College of Emergency Physicians. Alcohol screening and brief intervention in the ED.