Quality Improvement Project: Medication Assisted Treatment for Alcohol Use Disorder


 

Background

Alcohol use disorder (AUD) is widespread and associated with considerable morbidity and mortality.  In the United States it is estimated that as many as 65,000 deaths and 3.5 million disability adjusted life years are associated with AUD annually [1]. The 2016 National Survey on Drug Use and Health estimated that 14.6 million adults in the US (~ 6% of the population) meet the DSM-IV criteria for alcohol abuse or dependence.  Medications such as naltrexone and acamprosate have shown some promise in helping patients with AUD to reduce alcohol consumption and achieve or maintain sobriety [3,4]. Long acting naltrexone injections in particular have shown good efficacy in reducing the number of heavy drinking days among patients with AUD [5]. Unfortunately at this time only 24.1% of people with lifetime alcohol dependence receive any kind of treatment for AUD and only a fraction of these (<10%) receive medication assisted treatment (MAT) [4,6]. There are likely many factors which contribute to the underutilization of MAT among patients with AUD. One possible barrier to treatment is the fact that while most MAT programs are administered through outpatient primary care clinics, many patients with AUD may have limited or no interaction with the primary care system. By contrast, patients with AUD frequently present to the emergency department (ED) with an estimated 3.9 million alcohol-related ED visits between 2010 and 2011 [7]. There is a growing trend of ED initiated MAT for opiate use disorder [8]. We speculate that ED initiation of MAT for AUD may be equally feasible and efficacious. 

 

Aim

Our aim is to provide high quality treatment for AUD to high risk patients from the ED. For the purposes of this project we define “high risk” patients as those with documented history or clinical evidence of alcohol withdrawal and/or greater than one annual ED visit for alcohol related complaints (intoxication, withdrawal, etc.). We define “high quality” treatment as being coordinated, timely, and available around the clock. High quality treatment for AUD should combine MAT with prompt referral and rapid engagement with psychosocial resources such as 12-step programs, detoxification centers, rehabilitation programs, halfway houses, etc. 

 

Current Condition

The current state of AUD treatment in the Highland Hospital Emergency Department is abysmal. ED initiation of MAT for AUD is infrequent and sporadic. In 2018 there were only 16 prescriptions for Naltrexone issued from the Highland ED. To put this number into context, in 2018 there were 859 ED visits in which phenobarbital was administered. If we consider phenobarbital administration (typically used to treat alcohol withdrawal) as a marker for high risk AUD then we could conclude that we miss the opportunity to start MAT in 98% of cases. This likely underestimates the true rate of missed opportunities to start MAT as it does not capture ED visits for uncomplicated alcohol intoxication, trauma related to alcohol use, withdrawal treated with benzodiazepines, etc. 

 

Why The Current Condition?

There are many factors which contribute to the current state of underutilization of MAT for AUD in the Highland ED. Chief among these is a poor understanding of MAT options among providers, a general perception of futility among staff, and also difficulties associated with the altered mental status and problematic behavior that often accompanies alcohol intoxication and withdrawal. However, one of the most significant barriers to regular MAT initiation in the ED is the culture of “metabolize to freedom” (MTF). 

Though not a true ED Protocol, MTF essentially functions as an informal treatment pathway within the Highland ED. After an initial (often brief) assessment of the intoxicated or withdrawing patient by an ED provider, further care including gait assessment, PO challenge, and even administration and titration of phenobarbital is driven by nursing and proceeds somewhat automatically. While this practice boosts efficiency and allows providers to cognitively offload their AUD patients, it is detrimental to cultivating meaningful interactions between patients and providers, assessing for interest in MAT options, and referral to psychosocial resources.

Furthermore, many providers may be unaware that it is appropriate to consult the Substance Use Navigators (SUNs) for AUD patients (in addition to opiate use disorder patients). SUNs can help reinforce the plan for MAT, connect patients with the Highland Bridge Clinic, and also make referrals to other psychosocial services. 

 

Ideal State

The ideal state would be one in which anyone with high risk AUD is identified, connected with a SUN, engage with psychosocial interventions from the ED, and leave the ED with medications to treat protracted alcohol withdrawal (as necessary) and reduce craving and risk of relapse.  

 

Future State

An acceptable future state would be one in which at least 25% of high risk AUD patients are identified, connected with a SUN, and initiated on MAT. 

 

Interventions to Achieve Future State

To help us achieve our desired future state we will take the following actions. 

  1. Develop a protocol for the initiation of MAT for AUD in the ED. 

  2. Launch a campaign to publicize and educate providers about the new protocol and also change the current culture of MTF and general perception of futility with regard to AUD patients.  

  3. Create a website that acts as a quick reference for providers and also a repository for other useful resources regarding ED initiation of MAT.  

  4. Develop “dot phrases” (in conjunction with impending SAPPHIRE go-live)  that facilitate initiation of MAT for AUD and also help capture demographic information for future data collection. 

 

Data Collection

In order to assess the efficacy of our interventions we will collect the following data:

  1. Number of patients  with high risk AUD identified and started  on Naltrexone or gabapentin. 

  2. Number of patients started on Naltrexone or gabapentin who attend one follow up appointment in the Bridge Clinic. 

  3. Number of these patients who are engaged in care 30 days after ED discharge.    

  4. Number of ED visits per month for patients receiving IM or PO Naltrexone or a discharge prescription for MAT. 

  5. Percentage increase in providers who prescribed MAT for AUD

  6. Percentage increase in patients who present the diagnosis of alcohol withdrawal who are treated according to our protocol.


 

 

Bibliography:

 

  1. Rehm J, Dawson D, Frick U, et al. Burden of Disease Associated with Alcohol Use Disorders in the United States. Alcohol Clin Exp Res. 2014;38(4):1068-1077.

  2. Bose J, Hedden SL, Lipari RN, Park-Lee E, Tice P. Use and Mental Health Indicators in the United States: Results from the 2017 National Survey on Drug Use and Health Recommended Citation Substance Abuse and Mental Health Services Administration.; 2018. 

  3. Berglund M, Thelander S, Salaspuro M, Franck J, Andréasson S, Öjehagen A. Treatment of Alcohol Abuse: An Evidence-Based Review. In: Alcoholism: Clinical and Experimental Research. Vol 27. ; 2003:1645-1656. 

  4. Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: A systematic review and meta-analysis. JAMA - J Am Med Assoc. 2014;311(18):1889-1900. 

  5. Garbutt JC, Kranzler HR, O’Malley SS, et al. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: A randomized controlled trial. J Am Med Assoc. 2005;293(13):1617-1625. 

  6. Hasin, D. S., Stinson, F. S., Ogburn, E., & Grant, B. F. (2007). Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: Results from the national epidemiologic survey on alcohol and related conditions. Archives of General Psychiatry, 64(7), 830–842. 

  7. Mullins PM, Mazer-Amirshahi M, Pines JM. Alcohol-Related Visits to US Emergency Departments, 2001-2011. Alcohol Alcohol. 2017;52(1):119-125. 

  8. Herring AA, Perrone J, Nelson LS. Managing Opioid Withdrawal in the Emergency Department With Buprenorphine. Ann Emerg Med. 2019;73(5):481-487.