New Guidance on Treating Alcohol Use Disorder in the Emergency Department

In this video, Jeremy Faust, MD, editor-in-chief of MedPage Today, sits down with Reuben Strayer, MD, to talk about Strayer's new guidance in the Journal of Emergency Medicine on treating alcohol use disorder (AUD) in the emergency department (ED).

The following is a transcript of their remarks:

Faust: Hello, I'm Jeremy Faust, editor in chief of MedPage Today. Today, we're going to be joined by Dr. Reuben Strayer.

Dr. Strayer is an emergency physician at Maimonides Medical Center in Brooklyn and he is the author of emupdates.com. Dr. Strayer is the first author on a new document in the Journal of Emergency Medicine, and it's entitled: "Emergency Department Management of Patients With Alcohol Intoxication, Alcohol Withdrawal and Alcohol Use Disorder: A White Paper Prepared for the American Academy of Emergency Medicine."

Reuben Strayer, thank you so much for joining us.

Strayer: Hi, Jeremy. Nice to be with you.

Faust: Let me look at a tweet that you posted last week in conjunction with your new article and read it directly right now. You wrote: "EM expanded its scope to confront a new opioid addiction crisis, but we've done little to address alcoholism despite always having had a front row seat to the saddest show on earth. Here is the first comprehensive guidance to the emergency management of AUD."

Behind your tweet and behind your messaging is a subtext, which is that while that interest has taken foot while we've gotten better with opioids, we've sort of let another big problem -- alcohol use disorder (AUD) -- really simmer and not improve at all. Why do you think that is?

Strayer: That's exactly right, and what we're doing with this guidance and this guideline that we just published is we're trying to bring the same approach to alcohol.

The big difference here is that the opioid addiction and overdose crisis is something that came upon us. It happened to us like a meteor hitting the earth, and suddenly we were faced with a new challenge and droves of patients who were obviously affected with opioid use disorder, who were dying from opioid use disorder [OUD]. This is something that happened to us relatively all of a sudden.

On the other hand, alcohol use disorder and the myriad consequences of unhealthy alcohol use have been part of emergency medicine practice for as long as emergency medicine has been a specialty. But because it's so prevalent, because the harms are so easily overlooked and so slow-moving -- especially alcohol use disorder and the way that it destroys people's lives, not in seconds or minutes, which can happen with an opioid overdose, but over years and decades -- it's easily overlooked.

That's what we've done in emergency medicine until now. And I think more generally, that's what we as a society have done with alcohol and nicotine-related addiction and harms.

Faust: Coming back to a statistic in your guideline, which is that 5.4% of emergency department patients who have two or more ED visits in a year die within a year. And then there's a subset of patients on top of that who have more than five presentations, and their all-cause mortality is 8.8% within a year. That's just staggering to me.

We now with opioid use disorder have buprenorphine, we have bridge clinics, we have all kinds of things. What can we offer our patients in the future for alcohol use disorder so that those numbers aren't anywhere near that in the future?

Strayer: You're right Jeremy, that the numbers are staggering, and these patients are some of the sickest patients with the highest mortality that we see come through our doors. Yet we don't think of it that way. We don't think of it as the acute medical emergency that it really is.

Unfortunately, we don't have the great replacement therapy for alcohol use disorder like we do with opioid use disorder -- buprenorphine. When you substitute buprenorphine for the patient's usually illicitly obtained opioid, you abolish cravings, abolish withdrawal, and you protect the patient from all of the harms associated with using illicitly purchased opioids of uncertain composition and harm. You essentially instantly treat the condition and protect that patient as long as they're taking the buprenorphine. It really is almost like a miracle drug for OUD.

We don't have a similar miracle drug for AUD, for alcohol use disorder. We don't have a great replacement therapy like buprenorphine is for OUD. So we have to make use of a multifaceted approach to address whatever the harms are that we see these patients coming in with.

So for example, patients who are heavy alcohol users and chronic alcohol users often have a variety of comorbid psychiatric social and medical problems that we often dismiss because they're, for example, picked up on the street intoxicated. The usual paradigm for care is to park them in the corner of the department, allow them to return to sobriety, and then allow them to basically walk out and return to their drinking, usually.

Faust: And this is where I think things can change. Now I know with my opioid use disorder patients I have something to offer, either it's a medication or it's a resource, it's a social work consult, it's a clinic. But in the guideline, you talk about some of the things we can offer that's better than the standard of care, which is to have patients return to sobriety and walk out and return to the same cycle that you were talking about, the same destructive cycle. There's a list of options.

I've never once started a patient on naltrexone, acamprosate, disulfiram, gabapentin, topiramate, all agents that you talk about in the guideline. Should acute providers in emergency settings, urgent cares, wherever it is -- should we be offering those medications? And what dent do you think you would have?

Strayer: The answer to your question is, yes, we absolutely should be doing this.

What you're referring to are anti-craving medications. This is an aspect of treatment of AUD that has been totally overlooked in acute care settings. Until now, the anti-craving drugs, most easily and notably naltrexone, oral naltrexone or its long-acting intramuscular equivalent trade name Vivitrol, are modestly effective agents to curb cravings and allow motivated patients to reduce or eliminate their alcohol use. So they're not a magic bullet in the same way that buprenorphine is.

Especially when combined with some of the other aspects of care like withdrawal management -- giving people who are motivated to reduce their drinking medications to treat their withdrawal that they will experience as soon as they walk out of the emergency department and go to the bar and get another drink immediately -- if you offer them an alternative to that by using medications like gabapentin or chlordiazepoxide, and you can combine that with anti-craving medications like Naltrexone, you can absolutely transition a person who has been using heavy quantities of alcohol daily to someone who either uses much less alcohol, which is an enormous win, or is able to abstain entirely.

This is well within the purview of emergency medicine and acute care and primary care. These medications are not hard to prescribe, they're relatively inexpensive, and it's something we should be doing. We hope that with documents like the one that we produced and encouragement from professional organizations, this is something we'll see more and more of over the coming years.

Faust: I mean, there are guidelines for so many things that are far less deadly than this. And what I mean by guidelines is government guidelines. There are things that we're supposed to do to show that we're treating our patients with the best available evidence and the highest levels of care.

What's it going to take for this idea to become mainstream? It took a lot of effort for even the idea of medication-assisted therapy to be accepted by our field, even in the face of a lot of evidence, and I would say that we still have a ways to go. What's it going to take to get people to have the same level of motivation?

My residents, they meet a patient who has opioid use disorder and they're more excited about helping that patient than I was coming up trying to save some guy by intubating in critical care. They are so focused on these patients, which is great, but we ignore these alcohol use patients in the same way. What's it going to take to put the light on other than putting out a guideline? Do we need a higher up breathing down our backs on this? What's the approach?

Strayer: Well, we hope that we're going to see a concerted PR campaign coming from a number of different angles in the same way that we saw this with the treatment of OUD.

Again, alcoholism and alcohol use disorder has been a simmering crisis for decades and decades, not to say that it hasn't crested in the pandemic -- it's gotten much worse. The harms have gotten much more severe. We saw a 20% spike in mortality in 2020 and 2021. So, it's another epidemic along with the viral pandemic and the epidemic of opioid addiction and overdose that we've been seeing.

My hope is that, similar to the use of buprenorphine and the de-stigmatization of opioid use disorder in the emergency departments, that across the country will see a relatively robust uptake among a set of really motivated clinicians. For example, you in your department. It just takes one doc to start prescribing to get other people excited.

The fact is that many of the patients that are picked up intoxicated by paramedics on the street and delivered to the emergency department will come in day after day. We try to ignore them in many ways. We don't feel as though we have a lot to offer them. And I think that there is an appetite for emergency clinicians to try to meaningfully intervene on what we see year after year, the slow decline of these patients and, ultimately many times, their demise.

There's an opportunity to do better. I think that we've learned with the way we've been able to intervene on OUD, opioid use disorder, that we can do better. And I'm optimistic that we're going to take that same energy and apply it to alcohol use disorder.

Faust: Another question in the document is about discharging patients with intoxication who are now sober, and I'll read it. It says, "What are the key considerations when discharging a patient who presented with alcohol intoxication?"

I was particularly drawn in by this discussion of what's humane, because very frequently there's this sort of witching hour of two or three in the morning. It's like, "If I don't get them out, they're going to sleep there until the morning." Part of me is thinking with this hat of the emergency department is not a safe place for people to use as a hotel. It's not a safe place to be. Bad things happen. There are all kinds of risks, you can get the wrong medication, there's crowding -- we need the resources, the nurses, and everyone else we work with needs to be able to focus on the patients who need them.

On the other hand, it's two or three in the morning and it's freezing outside and they're sober enough to go. Is that the wrong thing to do? When you think about embracing the role of the emergency department as a safety net for society's ills, how do you approach that problem?

Strayer: Well, that's a hard problem. We in emergency medicine exist in a broader context of public health and a social safety net that's provided by us, but also by many other services. Especially the sickest patients with alcohol use disorder often have many walls of what I call 'The House of Health' that have fallen down. The House of Health having at least four walls: medical, social, substance, and psychiatric.

Many of the sickest AUD patients, the ones who present frequently to emergency departments, often have multiple if not all four walls of their House of Health that have fallen down. Yes, if they're sober enough to go at 2:00 a.m., you can medicolegally ask them to leave. That's a very common practice. But you haven't done anything to improve their situation. You haven't done anything really to help them.

That's not to say that every patient with AUD wants help, and you're not going to be able to solve a problem that often developed over decades of slow deterioration. You're often not going to be able to solve that instantly. But the goal here is to balance your need to manage the department for everyone else, to keep those beds available, to keep the flow moving in the department, to balance those needs with the needs of the patient in front of you.

The largest goal of the guideline that we just published is to get emergency clinicians to consider the person with AUD or at high-risk for AUD in front of them and ask the question, the simple question, how can I help them? What can I do to improve their lot? In the same way that we do for every other patient that comes through our doors.

Faust: Well, when I read your guideline, I had this immediate 'aha' moment. I couldn't even believe that I hadn't thought about this in the same way. So, I think you've already accomplished it for one doc.

Thanks for highlighting it and for joining us and sharing these views on MedPage Today.

Strayer: Thank you, Jeremy, and I hope that other emergency clinicians have a similar reaction and that we can bend the curve on alcohol use disorder.

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