(43) Improving Linkage to Addiction Treatment with Extended-release Naltrexone

Background & Introduction: Patients admitted to an inpatient unit for medically managed alcohol withdrawal (“detox” unit) often fail to successfully link to post-discharge outpatient addiction treatment. While there have been studies looking at several ways to improve this linkage, to our knowledge, there are no published studies that have evaluated whether medication for alcohol use disorder (AUD, MAUD) improves post-discharge outcomes from a detox unit. We sought to evaluate whether continuation or initiation of MAUD is associated with improved rates of successful linkage to post-discharge outpatient addiction treatment by performing a retrospective review of patients admitted for management of alcohol withdrawal.

Methods: This study took place in an American Society of Addiction Medicine (ASAM) level IV unit for medically managed withdrawal embedded in an academic community hospital in Boston, MA. The unit provides pharmacotherapy for the treatment of alcohol withdrawal and AUD and robust social work support for aftercare planning. All patients receive counseling on all MAUD options and have the option of continuing or initiating MAUD during their hospitalization. This primarily includes the FDA-approved medications: extended-release (XR) naltrexone, oral naltrexone, acamprosate, and disulfiram. Patients requesting XR-naltrexone receive the injection prior to discharge. Patients receiving non-injectable medications receive an outpatient prescription at the time of discharge.
We performed a retrospective electronic chart review of all patients admitted for alcohol withdrawal during the time of September 2021 to November 2022. We defined successful linkage to care as confirmation in our electronic health record of attendance at the planned post-discharge visit within 30-days of discharge.
Analyses were conducted using STATA and descriptive statistics were used to summarize the results. Chi-square or t-test for categorical and continuous variables were used to compare those with and without confirmed linkage to care, and logistic regression was used to conduct adjusted analyses.

Results: Three-hundred and twenty-five unique patient encounters were extracted. A total of 312 encounters remained after thirteen patients were excluded due to having an admitting diagnosis other than alcohol withdrawal. Of the remaining encounters, 76% were White, 15.4% were Black and approximately 8% were categorized as other. The majority of patients were male (71%) and the average age was 51 years. Co-occurring psychiatric conditions were present in most of the patients including depression (55%) and anxiety (49%). The most prevalent co-occurring substance use disorder was tobacco (49%) followed by opioids (19%).
Linkage to care was confirmed in fifty-three patients (17%). Compared to those patients without linkage to care, the patients were noted to drink less (16% vs. 21%, p=0.0081), were less likely to have a history of alcohol withdrawal seizures (26% vs. 41%, p=0.049), and more likely to have stable housing (84% vs. 74%, p=0.043). Otherwise, no significant differences were noted in demographic or clinical variables examined.
MAUD was continued or initiated on 127 patients (41%): gabapentin (27%), PO-naltrexone (18%), acamprosate (17%), XR-naltrexone (14%), topiramate (2%), and disulfiram (2%). XR-naltrexone was the only medication associated with a significantly greater likelihood of successful linkage to formal addiction treatment (28% compared to 11%, p=0.001). A logistic regression model was used with age, home status, drinking amount, patient-directed discharges, and receipt of XR-naltrexone entered as covariates. Significant predictors of linkage to care were determined to be those receiving XR-naltrexone prior to discharge (aOR 2.7, 95% CI 1.3-5.6, p=0.009) and drinks per drinking day (aOR 0.96, 95% CI 0.92-0.99, p=0.016).

Conclusion & Discussion: Forty-one percent of patients admitted to the ASAM level IV unit for medically managed alcohol withdrawal were either continued or initiated onto medication for alcohol use disorder. Only XR-naltrexone was associated with improved linkage to post-discharge addiction treatment (aOR 2.7, 95% CI 1.3-5.6, p=0.009). XR-naltrexone requires a once-monthly injection which inherently improves adherence and confirmation of adherence compared to oral MAUD formulations. The results of this study suggest that XR-naltrexone may increase the chances that patients discharged from a unit for medically managed withdrawal adhere to follow-up outpatient addiction treatment.
Multiple recent emergency department-based studies have shown similar promising results supporting an association between the administration of XR-naltrexone and higher rates of community-based linkage to care1-3. There is an NIH-funded trial (NCT02478489) awaiting publication that is evaluating post-hospital outcomes of patients with alcohol use disorder who received XR-naltrexone compared to those who were prescribed PO-naltrexone that may provide additional insights on the impact of naltrexone prescribed in the inpatient setting. Overall, more research is needed examining the potential role of MAUD in improving AUD-related outcomes after inpatient withdrawal treatment.

References: Murphy CE 4th, Coralic Z, Wang RC, et al. Extended-Release Naltrexone and Case Management for Treatment of Alcohol Use Disorder in the Emergency Department. Ann Emerg Med. 2023;81(4):440-449.

Anderson ES, Chamberlin M, Zuluaga M, et al. Implementation of Oral and Extended-Release Naltrexone for the Treatment of Emergency Department Patients With Moderate to Severe Alcohol Use Disorder: Feasibility and Initial Outcomes. Ann Emerg Med. 2021;78(6):752-758.

Hartung DM, McCarty D, Fu R, et al. Extended-release naltrexone for alcohol and opioid dependence: a meta-analysis of healthcare utilization studies. J Subst Abuse Treat. 2014;47(2):113-121.