Background & Introduction: Alcohol is a leading cause of preventable death in the United States. Approximately 30 million Americans are living with Alcohol Use Disorder (AUD), a treatable chronic condition, yet only 1% have received pharmacotherapy in the past year. Primary care physicians (PCPs) often serve as the first point of contact for AUD and expanding their role in AUD management is necessary to bridge the treatment gap. Physician mentorship, clinical workflow enhancements, decision support tools (DSTs) for electronic health records, and drug formulary changes are associated with changes in prescribing habits. In the obesity drug era, there has been emerging evidence that 'weight loss' medications such as semaglutide can treat patients with AUD and greater awareness that medications for AUD like naltrexone can support weight loss. This paper describes a practice improvement (PI) initiative designed for PCPs that leveraged changes in obesity pharmacotherapy protocols to demystify and facilitate naltrexone prescribing in the outpatient management of AUD at Kaiser Permanente San Diego Medical Center.
Methods: A PI initiative was launched in February 2023 through joint collaboration with the Addiction Medicine, Primary Care (Family Medicine, Internal Medicine) and Clinical Pharmacy departments of Kaiser Permanente San Diego. The multimodal intervention included PCP training about medications for AUD, follow-up messaging to PCPs and DSTs (EPIC SmartRx) to streamline prescribing. The PI coincided with 2023 formulary changes to naltrexone that included both alcohol and obesity diagnoses. A pre-post study design analyzed prescriber data from the integrated pharmacy system from 2021-2025, to cover 2 years before and after the PI initiative. Naltrexone prescriptions were filtered to include all outpatient PCPs (FM, IM) and the subset associated with one of 43 unique Alcohol diagnoses identified. Prescriptions from other specialty departments were excluded. Monthly prescription trends and SmartRx utilization was tracked over the 4-year observation period and linear regression was used to estimate trends in prescriptions during the pre/post-PI period. Acamprosate prescriptions were tracked as a balancing measure. Demographic trends related to naltrexone prescribing (for 'Alcohol' and 'All Diagnoses') were grouped by four 12-month periods. Categorical variables were analyzed using chi-square test of independence and continuous variables analyzed using paired t-tests. The Kaiser Permanente Institutional Review Board Approved this study.
Results: Among 302 salaried PCPs, 212 (70%) received the live educational session in February 2023 and all received the recording and Microsoft Teams chat. In addition, another 19 FM residents and >70 per diem physicians worked within the department each given year. All physicians were exposed to the PI intervention through sharing of clinical pearls and department-wide messaging over 6-months that emphasized DSTs. A total of 388 unique PCPs prescribed Naltrexone at least once during the 4-year study period. Total Naltrexone prescriptions rose from 420 and 455, for Alcohol and All Prescriptions, respectively, in Year 1 to 1196 and 5114 for Alcohol and All Prescriptions, respectively, in Year 4 (p < 0.001). Patients prescribed Naltrexone had Mean Age of 52.3 for Alcohol and 50.4 for All Diagnoses and there were no statistically significant changes over time. More men received naltrexone for Alcohol (262 in Year 1 compared to 623 in Year 4) and more women received Naltrexone for both Alcohol (573 in Year 4; 158 in Year 1) and All Diagnoses (3614 in Year 4; 182 in Year 1) - this represented a 3-fold increase in the number of patients prescribed naltrexone for AUDs and was statistically significant at p< 0.0001. There were no significant changes in Race over the 4-year period. The number of total prescribers per year gradually increased from 191 in Year 1 to 327 by Year 4. Rates of high-volume prescribers (defined as >10 patients/year treated) increased annually from 7% (14/191) in Year 1 to 26% (84/327) by Year 4. Overall, there were approximately 3-fold increases in the number of naltrexone prescribers, number of patients treated for AUDs and number of high-volume naltrexone prescribers post-PI intervention. Linear regression estimated trends in the number of Naltrexone prescriptions for AUD over time. For the pre-PI period, the intercept was 52.25 (SE = 5.39, p < 0.01) and slope was 1.49 (SE = 0.38, p < 0.01, indicating an average increase of 1.49 prescriptions/month. During the post-PI period, intercept was 94.11 (SE = 12.46, p < 0.01) and the slope was 6.36 (SE = 0.87, p < 0.01), indicating an average increase of 6.36 prescriptions/month. A comparison of slopes indicated statistically significant difference between the pre and post time periods (F-test p < 0.0001). There were no statistically significant changes in Acamprosate prescription rates over time.
Conclusion & Discussion: Effective strategies for improving PCP prescribing of naltrexone for AUD can include physician education campaigns with interdepartmental support, DSTs for clinical practice, formulary enhancements, and culture change within a large group practice. Embedding these approaches within a larger strategy to expand obesity pharmacotherapy can increase the number of patients treated for AUDs, as was the case with Kaiser Permanente San Diego. Increases in the number of high-volume naltrexone prescribers over time is consistent with the observation that PCPs who start prescribing naltrexone tend to keep prescribing naltrexone over time - a promising trend that can reduce significant care disparities for patients with AUD and enhance physician-patient relationships over time.
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Disclosure(s):
Payam Sazegar, MD, FASAM: No financial relationships to disclose
Alaina Martinez, MD, DABFM, FASAM: No financial relationships to disclose
Learning Objectives:
Describe similarities and differences between medications that are FDA-approved for the treatment of obesity and alcohol use disorders.
Identify five components of an effective practice improvement project for primary care physicians aimed to reduce care disparities for patients with substance use disorders.
Explain the meaning of low threshold medication assisted therapy and how clinical operations leadership can support this strategy within your care delivery system.
