Predictors of naltrexone prescribing for alcohol use disorder from the emergency department

Excessive alcohol use is a leading cause of preventable death in the United States, with the emergency department (ED) serving as a critical touchpoint for individuals with alcohol use disorder (AUD). Despite clinical guidelines recommending initiation of medication for AUD (MAUD), such as naltrexone, ED prescribing remains rare. The objective of this study is to characterize clinician naltrexone prescribing practices for ED patients with hazardous drinking or AUD and identify patient- and encounter-level predictors of naltrexone prescribing within a large, integrated health system. We conducted a retrospective cohort study of adult ED encounters across 12 hospitals from 2022 to 2024. Eligible encounters included patients with a positive Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) screen, indicating hazardous alcohol use or an active AUD, who had no exclusion criteria contraindicating naltrexone and were discharged from the ED. The primary outcome was provision of a naltrexone prescription at ED discharge, and the secondary outcome was prescription fill. We used a multivariable logistic regression model with generalized estimating equation (GEE) to identify predictors of prescribing. Of 52,701 treatment-eligible ED encounters, only 0.5% resulted in a naltrexone prescription. Prescriptions were more likely in encounters involving younger, male patients with higher AUDIT-C scores, alcohol-related complaints, and those occurring at an academic ED. In the logistic GEE model, academic setting, alcohol withdrawal diagnosis, and greater alcohol misuse severity were independently associated with increased prescribing. Nearly half (45%) of ED naltrexone prescriptions were filled. Naltrexone prescribing among treatment-eligible patients is rare. Encouragingly, nearly half of patients receiving a prescription proceeded to fill it, highlighting a promising opportunity for ED-based prescribing of naltrexone to initiate AUD treatment. To improve AUD care, systematic ED-based strategies are urgently needed that go beyond universal screening to address barriers to MAUD initiation.