(37) Administration and Prescribing of Medications for Alcohol Use Disorder During COVID-19

Background & Introduction: Excessive alcohol consumption is a leading cause of morbidity and mortality in the United States, contributing to more than 140,000 deaths and 5 million emergency department (ED) visits annually. Approximately 1.7% ED visits were related to alcohol use disorders (AUD) in 2019, with a 7-24% increase per quarter in 2020. Although the onset of the COVID-19 pandemic caused a decline in total ED visits, alcohol-related ED visits increased to at least 7.1% in 2020 and there was an increase in ED screens for problem drinking. The pandemic might have contributed to shaping patterns of alcohol use and its associated harms.

The U.S. Food and Drug Administration (FDA) has approved three medications for the treatment of AUD: disulfiram, naltrexone, and acamprosate. According to the National Survey on Drug Use and Health (NSDUH), 29.5 million people aged 12 and older were diagnosed with AUD in 2022, however only 2.1% received medication treatments. The emergency department is often a critical access point that could serve as a setting for MAUD initiation.

Consequently, the goal of this investigation is to determine whether the COVID-19 pandemic had an impact on utilization of medications for alcohol use disorder (MAUD) in the ED setting utilizing national data.

Methods: We conducted a retrospective study utilizing available data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 2019 and 2021. We considered 2019 the pre-COVID-19 era, and 2020 onwards as being the COVID-19 timeframe. Our primary outcome was the change in proportion of all ED visits where medications for alcohol use disorder (including naltrexone, acamprosate, and disulfiram) were prescribed at ED discharge. Secondarily, we compared the proportion of visits where MAUDs were administered and prescribed between time frames, and determined the proportion of times each type of MAUD was prescribed. All absolute numbers were either normalized using the number of ED visits for that year as the denominator, or by using the total number of visits where MAUD was prescribed. We also described the visit characteristics such as patient age, gender, race, and insurance. We reported our findings using descriptive statistics, and used the chi-squared difference of proportions tests to compare proportions between time frames. We used IBM SPSS ® Statistical software to conduct our analysis. All findings were reported to the 0.05 significance level.

Results: Between the years 2019 and 2021, there were a total of 47,528 visits (0.01% of all ED visits) where patients were prescribed a MAUD at ED discharge. A majority of the patients that were prescribed MAUD were within age ranges 25-44 (17,003, 35.8% of all visits where MAUD was prescribed) or 45-64 (17,050, 35.9%) years. Most patients were female (31,946, 67.2%) and White (35,374, 74.4%). All A majority of patients prescribed MAUD had Medicaid or other state-based insurance (25,659, 54.0%).
In 2019, there were 8,394 (0.01%) visits where patients were prescribed MAUD at ED discharge, in 2020, there were 5,067 (0.004%, p< 0.001) visits, and in 2021, there were 34,067 (0.02%, p< 0.001) visits. Between 2019 and 2021, there was a 100% increase in rate. Between 2020 and 2021, there was a 572.3% absolute increase and a 531.5% increase in rate. The most common MAUD prescribed was naltrexone (26,980 visits, 56.8% of all visits where MAUD was prescribed), followed by disulfiram (14,160 visits, 30.0%).

During the study period, there were a total of 74,265 visits where MAUD was administered during the ED visit. In 2019, there were 6,368 (0.005%) such visits, in 2020 there were 30,857 (0.02%, p< 0.001) visits, and in 2021, there were 37,040 (0.03%, p< 0.001) visits where MAUD was administered in the ED. Between 2019 and 2021, there was a 482% absolute increase and a 527% change in rate. Between 2020 and 2021, there was a 20% absolute increase and a 12.78% in rate. The most common MAUD administered was naltrexone (41,114 visits, 55.4%) followed by acamprosate (30,857 visits, 41.5%).

Conclusion & Discussion: Our study found that during the beginning of the pandemic in 2020, there was a decrease in MAUD prescribing at ED discharge but then a sharp increase in the subsequent year. In contrast, there was a sharp increase in visits where MAUD was administered in the ED in 2020, followed by a continued increase in 2021. The increase in administrations could be the result of increasing substance use (including alcohol) during COVID-19, lack of access to care during the pandemic, and long term implications of resultant AUD. Additionally, increased utilization of naltrexone, could be the result of data showing feasibility of utilization in the ED setting. The decrease in discharge prescriptions could be the consequence of interruptions in the healthcare system such as staff shortages or the limited options for referring patients. Future studies should further investigate reasons for this sudden change as well as factors associated with prescribing of MAUD in the ED setting.

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