Patient perspectives on emergency department initiation of medication for alcohol use disorder

Abstract

Objective: Alcohol use disorder (AUD) is a leading cause of preventable death and is a frequent diagnosis in the emergency department (ED). Treatment in the ED, however, typically focuses on managing the sequelae of AUD, such as acute withdrawal, rather than addressing the underlying addiction. For many patients, these ED encounters are a missed opportunity to connect with medication for AUD. In 2020, our ED created a pathway to offer patients with AUD treatment with naltrexone (NTX) during their ED visit. The aim of this study was to identify what barriers and facilitators patients perceive to NTX initiation in the ED.

Methods: Adopting the theoretical framework of the behavior change wheel (BCW), we conducted qualitative interviews with patients to elicit their perspectives on ED initiation of NTX. Interviews were coded and analyzed using both inductive and deductive approaches. Themes were categorized according to patients' capabilities, opportunities, and motivations. Barriers were then mapped through the BCW to design interventions that will improve our treatment pathway.

Results: Twenty-eight patients with AUD were interviewed. Facilitators of accepting NTX included having recently experienced sequelae of AUD, rapid management of withdrawal symptoms by the ED provider, having a choice between intramuscular and oral formulations of the medication, and experiencing positive interactions in the ED that destigmatized the patient's AUD. Barriers to accepting treatment included lack of provider knowledge about NTX, dependence on alcohol as self-treatment for psychiatric trauma and physical pain, perceived discriminatory treatment and stigma about AUD, aversion to potential side effects, and lack of access to continued treatment.

Conclusions: Initiation of treatment of AUD with NTX in the ED is acceptable to patients and can be facilitated by knowledgeable ED providers who create a destigmatizing environment, effectively manage withdrawal symptoms, and connect patients to providers who will continue treatment.

Keywords: addiction; alcohol use disorder; alcoholism; behavior change wheel; implementation science; medication‐assisted treatment; naltrexone.