(85) Alcohol Use Disorder Medication Initiation During Alcohol Withdrawal Hospitalizations

Background & Introduction: Alcohol withdrawal contributes to a high rate of hospitalizations at a frequency comparable to other chronic conditions like Diabetes Mellitus and heart failure (1). These events present a critical opportunity to promote treatment initiation and behavior change. Unfortunately, evidence-based medications for alcohol use disorder (MAUD) are often underutilized with prescribing rates ranging from 1% among hospitalized Medicare beneficiaries with alcohol use disorder to 51% among patients with alcohol withdrawal admitted to Veteran Health Administration hospitals (2, 3). Initiation of MAUD upon discharge is associated with a 15% absolute reduction in 30-day all-cause emergency room visits and readmissions, indicating there is a critical need to optimize treatment during this time (4).

Prior studies describing hospital-based MAUD initiation have mostly focused on specific populations (e.g. Medicare or Veterans Health Administration hospitals) and evaluated provision of MAUD prior to the COVID-19 pandemic which brought about increased rates of alcohol use and hospitalizations (2, 3). An understanding of variability in post-pandemic MAUD prescribing rates during alcohol withdrawal hospitalizations across a variety of insurers and hospitals is needed to inform hospital-based interventions to promote equitable access to AUD treatment.

Methods: We conducted a retrospective cohort study using electronic health record data from 2022-2024 across 15 hospitals in a large healthcare system with over 170,000 annual hospitalizations. Pharmacy data were obtained from Surescripts which includes electronically prescribed dispensing records from nearly all major US pharmacies. The primary outcome was MAUD initiation, defined as prescriptions of oral naltrexone, acamprosate, or disulfiram and/or administration of injectable naltrexone prior to hospital discharge. Our analytic sample included the first hospitalization with an alcohol withdrawal discharge diagnosis code among treatment eligible adults (≥ 18 years) who were discharged alive and without a discharge disposition to hospice. We excluded patients already receiving MAUD, defined as any pharmacy fill for MAUD in the 90 days prior to admission.

First, we described MAUD initiation rates overall and by medication type. Second, we described the unadjusted variation in MAUD initiation rates across hospitals, excluding hospitals with fewer than 50 alcohol withdrawal hospitalizations. Third, we performed a multivariable logistic regression to identify patient-level (demographics, clinical laboratory values, medical and psychiatric comorbidities) and hospital level factors (hospital service and Addiction Medicine or Psychiatry consultation) associated with MAUD initiation. We used individual hospitals as fixed effects to account for potential confounding by hospitals.

Results: After excluding 551 patients who recently received MAUD and 53 who had missing geographic data, we identified 5,557 adults hospitalized with alcohol withdrawal who were eligible for MAUD initiation. The mean age was 46.7 years (SD 14.0), 28.8% were female, 18.0% were Hispanic, 8.2% were non-Hispanic Black, and 68.7% were non-Hispanic White. The most common insurance was Medicaid (49.2%). In terms of comorbidities, 9.8% had liver injury (elevations in liver enzymes ≥ 5 times the upper limit of normal) and 1.2% had reduced renal function (estimated glomerular filtration rate ≤ 30 milliliters/minute). Comorbid psychiatric illnesses were common; 33.3% had depression or psychosis, 5.7% had opioid use disorder, and 9.9% had stimulant use disorder.

Overall, 19.1% of patients received MAUD initiation. The most common MAUD was oral naltrexone (68.9%), followed by acamprosate (25.8%), injectable naltrexone (5.7%), and disulfiram (3.0%). After excluding patients from three hospitals with few alcohol withdrawal hospitalizations (n=29 patients), we identified variability in MAUD initiation rates across the remaining 12 hospitals. The hospital with the highest rate of patients with MAUD initiation, the only hospital in the health system with an Addiction Medicine consultation service, had a rate of 43.8%. The second highest prescribing hospital had an MAUD initiation rate of 20.2%, while the lowest prescribing hospital had an MAUD initiation rate of 5.0%.

In the multivariable analysis, age 65 years or older was associated with lower odds of MAUD initiation compared to age 18-29 years (aOR 0.52; 95% CI 0.32-0.82). Those insured by the “other” insurance category (i.e. not commercial, Medicare, Medicaid, or uninsured) were more likely to initiate MAUD compared to those with commercial insurance (aOR 1.67; 95% CI 1.11-2.49). This category mostly included coverage by Veterans Affairs or Tricare. There were no differences in medication initiation by sex, race and ethnicity, or social vulnerability index. Patients with liver injury or reduced renal function were less likely to initiate MAUD (aOR 0.74; 95% CI 0.54-0.99 and aOR 0.27; 95% CI 0.10-0.63, respectively). Patients with comorbid opioid use disorder were also less likely to initiate MAUD (aOR 0.44; 95% CI 0.30-0.62). In terms of hospital factors, those admitted to surgical services were less likely to initiate MAUD (aOR 0.36; 95% CI 0.25-0.52) while those who had an Addiction Medicine or Psychiatry consultation were more likely (aOR 4.42; 95% CI 3.64-5.40).

Conclusion & Discussion: In this study of patients hospitalized with alcohol withdrawal in a large health system, 4 out of 5 did not receive initiation of evidence-based MAUD. Prescribing rates varied considerably across hospitals, from 5% to 44%. The highest prescribing hospital is the only one with an Addiction Medicine consult service, which has been associated with increased MAUD prescribing in prior studies (2, 5). Patients age 65 years or older and those with liver injury or reduced renal function were less likely to initiate MAUD highlighting opportunities for targeted interventions. Patients with liver disease face the greatest risk of alcohol-related harms. Under-prescribing in this group could be related to concerns about the safety of naltrexone in patients with liver disease and suggests a need to explore prescriber-focused interventions in this population.

Our findings are limited by the inability to account for pre-hospitalization use of injectable naltrexone and may have limited generalizability to other health systems. However, they suggest that substantial care gaps in alcohol use disorder treatment exist across hospitals even within the same health system. Further research is needed to identify reasons for variation in hospital-based MAUD prescribing to improve evidence-based treatment for patients with AUD.

References:
1. Steel TL, Matson TE, Hallgren KA, et al. Incidence of Hospitalizations Involving Alcohol Withdrawal Syndrome in a Primary Care Population. JAMA Network Open. 2024;7(10):e2438128. doi:10.1001/jamanetworkopen.2024.38128

2. Bernstein EY, Baggett TP, Trivedi S, Herzig SJ, Anderson TS. Pharmacologic Treatment Initiation Among Medicare Beneficiaries Hospitalized With Alcohol Use Disorder. Ann Intern Med. Published online June 27, 2023. doi:10.7326/M23-0641

3. Allaudeen N, Akwe J, Arundel C, et al. Medications for alcohol-use disorder and follow-up after hospitalization for alcohol withdrawal: A multicenter study. J Hosp Med. 2024;19(12):1122-1130. doi:10.1002/jhm.13458

4. Bernstein EY, Baggett TP, Trivedi S, Herzig SJ, Anderson TS. Outcomes After Initiation of Medications for Alcohol Use Disorder at Hospital Discharge. JAMA Network Open. 2024;7(3):e243387. doi:10.1001/jamanetworkopen.2024.3387

5. Singh-Tan S, Torres-Lockhart K, Jakubowski A, et al. Addiction Consult Service and Inpatient Outcomes Among Patients with Alcohol Use Disorder. J Gen Intern Med. 2023;38(14):3216-3223. doi:10.1007/s11606-023-08202-7