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A 30 y/o M w/ a history of alcohol use disorder, presents with a chief complaint of fever and alcohol relapse.  The patient had been abstinent from alcohol for three months, but relapsed 3 weeks ago.  He made an appointment with his PCP to discuss options for alcohol cessation pharmacotherapy, however developed a subjective fever and chills at home and decided to present to the emergency department.  The patient’s vital signs were normal.  His physical exam demonstrated minor abdominal distention but no tenderness.  He was not jaundiced.  A bedside ultrasound showed no ascites. He had a respiratory pathogen panel which was positive for Rhino/Enterovirus.  His CBC, BMP, and LFTs were within normal limits. The patient was diagnosed with a viral syndrome. He was given tylenol and motrin.  Given that he was already in the emergency department, he asked for a prescription for antabuse (disulfiram) as that had worked for him before.  He also asked to discuss other pharmacotherapy for alcohol cessation.

Diagnosis

Viral syndrome, Alcohol Use Disorder

Discussion

Alcohol is a leading cause of death in the United States.  It contributes to 18.5% of emergency department visits.  However, initiation of safe, evidence-based pharmacotherapy for alcohol use disorder is rarely, if ever, prescribed in the ED.[1][2]  There are currently three FDA-approved medications for the treatment of alcohol use disorder: naltrexone, disulfiram, and acamprosate.  Multiple studies have shown that both acamprosate and naltrexone are both associated with reduction in return to drinking. There is less data to support the efficacy of disulfiram, and alcohol use is contraindicated as it causes a profoundly uncomfortable experience.[3]  Naltrexone is suggested as the ideal medication to prescribe in the ED as it not only reduces return to heavy drinking but also may retain efficacy in actively drinking patients . Additionally, it is available in a 30-day depot formulation, which is ideal for patients with reduced medication compliance.

Murphy et al. produced the first study evaluating the feasibility and efficacy of ED administration of a long-acting injectable naltrexone.  The study found reductions in daily alcohol consumption and improved quality of life among a cohort of ED patients with suspected or confirmed alcohol use disorder.  The intervention was most effective when patients followed up with a substance abuse counselor as well.  Naltrexone can be safely prescribed in the ED.[4]

Exclusion Criteria

Naltrexone is a long acting mu-receptor antagonist, so it is contraindicated for patients who have active coexisting opioid use disorder.  At our institution, a dose of 0.4 mg IV naloxone or 25 mg oral naltrexone is required to be given as a test dose and the patient is monitored for any signs of opioid withdrawal.  Patients also cannot have used opioids in the last 7 days.  Other exclusion criteria include decompensated cirrhosis (Childs-Pugh class 3 or greater), pregnancy, and allergy to naltrexone.  It is also important to advise patients that they cannot receive the injectable naltrexone if they are having surgery in the next 30 days.

Dosing

At our institution, there are two options:

50 mg oral naltrexone tablet once daily

380 mg IM naltrexone (once monthly)

Case Resolution

The patient was educated about the option to begin naltrexone in the emergency department.  He had no contraindications, and he received a test dose of IV naloxone without any signs of opioid withdrawal.  He elected to begin oral naltrexone and was discharged with a 30 day prescription.  The patient already had a substance abuse counselor and PCP with whom he planned to follow up. 

Takeaways

1)    The emergency department is an important place to discuss alcohol use and pharmacologic options for alcohol cessation.

2)    Naltrexone is an ideal medication to prescribe in the ED due to its IM depot formulation, low side effect profile, and proven effectiveness in patients who do not plan on completely abstaining from alcohol.

3)    It is important to evaluate patients for exclusion criteria and contraindications to naltrexone prior to prescribing.

Author: Michael Tcheyan, MD is a 4th year Emergency Medicine Resident at Brown University/Rhode Island Hospital

Faculty Reviewer: Otis Warren, MD is an attending physician/faculty at Brown Emergency Medicine.

References

[1]National Institute of Alcohol Abuse and Alcoholism Alcohol facts and statistics.

https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-facts-and-statistics#

Date accessed: March 31, 2023

[2]Hawk KF, D'Onofrio G. Time to Treat Alcohol Use Disorder in the Emergency Department. Ann Emerg Med. 2023 Apr;81(4):450-452. doi: 10.1016/j.annemergmed.2022.11.013. Epub 2023 Feb 11. PMID: 36775724.

[3]Jonas DE, Amick HR, Feltner C, Bobashev G, Thomas K, Wines R, Kim MM, Shanahan E, Gass CE, Rowe CJ, Garbutt JC. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014 May 14;311(18):1889-900. doi: 10.1001/jama.2014.3628. PMID: 24825644. 

[4]Extended-Release Naltrexone and Case Management for Treatment of Alcohol Use Disorder in the Emergency Department. Murphy, Charles E. et al.
Annals of Emergency Medicine, Volume 81, Issue 4, 440 - 449