Background
Alcohol misuse and alcohol use disorder are common, underrecognized, and often undertreated conditions seen in emergency departments. Many patients arrive with alcohol-related problems such as injury, withdrawal, intoxication, gastritis, falls, or worsening chronic disease. The emergency department is often the only point of contact with the health system for these patients, which makes it an important place to identify alcohol-related harm and begin treatment.
Naltrexone is an evidence-based medication used to reduce cravings and decrease heavy drinking in people with alcohol use disorder. Despite strong evidence supporting its use, it is not routinely started in emergency care. Common barriers include time pressure, uncertainty about eligibility, lack of screening, and missed opportunities during discharge.
This study evaluated a multicomponent “nudge-based” strategy designed to make it easier for emergency clinicians to recognize alcohol misuse and start treatment before discharge.
Study Objective
The investigators aimed to determine whether a combined emergency department workflow could increase the initiation of evidence-based treatment, specifically naltrexone prescribing, for patients discharged with alcohol-related diagnoses.
Methods
This was a real-world implementation study conducted within an academic health system with 6 hospitals. Four hospitals received the intervention, while the remaining 2 hospitals served as controls.
The intervention was introduced in 2 phases:
Phase 1, launched on May 20, 2024, added an emergency department discharge order set with clinical decision support. This kind of tool helps clinicians by embedding best-practice suggestions into the electronic health record at the moment of discharge.
Phase 2, launched on August 21, 2024, expanded the workflow to include screening for patient concerns about alcohol use and helping clinicians start treatment conversations. The goal was to reduce missed opportunities and normalize discussion of alcohol use during the ED visit.
The primary outcome was the proportion of emergency department patients with an alcohol-related discharge diagnosis who left with a naltrexone prescription. The researchers used multivariate logistic regression to compare outcomes with baseline, and they also performed a difference-in-difference analysis to compare intervention hospitals with control hospitals.
Key Results
Over the 43-month study period, 8,909 emergency department patients, or 2.0% of all ED discharges, had an alcohol-related diagnosis code.
At the intervention hospitals, naltrexone prescribing increased substantially after the workflow changes. During the baseline period, only 13 patients, or 0.2%, were discharged with a naltrexone prescription. This increased to 18 patients, or 2.7%, during phase 1 and 81 patients, or 3.2%, during phase 2.
At the control hospitals, prescribing remained essentially unchanged across the same periods: 0.0% at baseline, 0.0% during phase 1, and 0.3% during phase 2.
In the multivariate analysis, patients with alcohol-related diagnoses at intervention hospitals were much more likely to leave with naltrexone after implementation. Compared with baseline, the odds of naltrexone prescribing were 12.3 times higher in phase 1 and 14.6 times higher in phase 2.
The difference-in-difference analysis showed that intervention hospitals had a 2.9 percentage point greater absolute increase in naltrexone prescribing than control hospitals, indicating that the improvement was associated with the new ED protocol rather than broader trends alone.
Clinical Meaning
The findings suggest that small, workflow-based changes can meaningfully improve treatment for alcohol misuse in emergency care. Rather than relying solely on clinician memory or individual initiative, the system used several “nudges” at key moments: triage screening, electronic record prompts, and discharge decision support.
This approach is important because alcohol use disorder is often missed in the emergency department. Patients may come in for an acute issue but leave without any treatment plan for the underlying alcohol problem. By making alcohol screening and treatment conversations more routine, the ED can become a practical starting point for care.
Naltrexone is generally well tolerated, but it is not appropriate for every patient. Clinicians must consider contraindications, including current opioid use or opioid dependence, because naltrexone can precipitate opioid withdrawal and block opioid analgesics. Liver function and other clinical factors should also be reviewed when appropriate. A successful ED program therefore needs both electronic support and clinician judgment.
Why the Nudge-Based Strategy Worked
This study highlights how implementation design can change practice. Emergency clinicians are busy and face many competing priorities. When treatment requires extra steps, even evidence-based care may not happen. A nudge-based strategy reduces friction by making the desired action easier and more visible.
In this case, universal screening helped identify patients who might otherwise have been overlooked. Electronic health record banners reminded clinicians that alcohol-related issues were relevant to the visit. Clinical decision support then guided discharge prescribing, helping turn recognition into action.
The increase from 0.2% at baseline to more than 3% after implementation may sound modest at first glance, but in a busy emergency system it represents a meaningful shift. For a condition that is frequently untreated, even small increases can translate into many patients receiving medication that may reduce drinking and future harm.
Implications for Emergency Departments
This study suggests several practical lessons for hospitals and emergency medicine teams:
1. Screening matters. Alcohol misuse should be identified systematically, not only when it is obvious.
2. Discharge workflows matter. Embedding treatment options into existing order sets can improve prescribing.
3. Conversation support matters. Clinicians may be more likely to address alcohol use when the electronic record prompts them to do so.
4. Implementation should be feasible. Interventions that fit into existing ED workflow are more likely to succeed.
Hospitals interested in improving alcohol-related care may consider combining screening, clinician prompts, discharge order sets, and referral pathways to outpatient addiction treatment or primary care follow-up.
Limitations
Although the results are encouraging, several limitations should be kept in mind. This was an observational implementation study in a single health system, so results may not generalize to all emergency departments. The study measured prescribing, not whether patients filled the prescription or took the medication. It also did not directly measure long-term outcomes such as reduced drinking, fewer repeat ED visits, or improved quality of life.
In addition, implementation success may depend on local electronic health record design, clinician engagement, and availability of follow-up care. Naltrexone prescribing is only one part of treatment; effective alcohol care also includes counseling, brief intervention, and linkage to ongoing support.
Conclusion
A triage-based emergency department protocol that combined universal screening, electronic health record reminders, and clinical decision support increased initiation of naltrexone for patients with alcohol misuse and alcohol use disorder. The study shows that practical system-level nudges can help emergency departments move from identifying alcohol-related problems to actually treating them.
For many patients, the emergency department may be the best opportunity to begin evidence-based alcohol treatment. This study demonstrates that with the right workflow, that opportunity can be captured more consistently.