Implementation of a Process for Initiating Naltrexone in Patients Hospitalized for Alcohol Detoxification or Withdrawal
BACKGROUND: Naltrexone trials have demonstrated improved outcomes for patients with alcohol use disorders. Hospital initiation of naltrexone has had limited study.
OBJECTIVES: To describe the implementation and impact of a process for counseling hospitalized patients with alcohol withdrawal about naltrexone.
DESIGN: A pre-post study analysis.
SETTING: A tertiary academic center.
PATIENTS: Patients hospitalized for alcohol withdrawal.
INTERVENTIONS: (1) Provider education about the efficacy and contraindications of naltrexone and (2) algorithms for evaluating patients for naltrexone.
MEASUREMENTS: The percentages of patients counseled about and prescribed naltrexone before discharge and the percentages of pre- and postintervention patients with 30-day emergency department (ED) revisits and rehospitalizations.
RESULTS: We identified 128 patient encounters before and 114 after implementation. The percentage of patients counseled about naltrexone rose from 1.6% preimplementation to 63.2% postimplementation (P < .001); the percentage of patients prescribed naltrexone rose from 1.6% to 28.1% (P < .001). Comparing preintervention versus postintervention groups, there were no unadjusted differences in 30-day ED revisits (25.8% vs 19.3%; P = .23) or rehospitalizations (10.2% vs 11.4%; P = .75). When adjusted for demographics and comorbidities, postintervention patients had lower odds of 30-day ED revisits (odds ratio [OR] = 0.47; 95% confidence interval [CI], 0.24-0.94) but no significant difference in rehospitalizations (OR = 0.76; 95% CI, 0.30-1.92). In subgroup analysis, postintervention patients counseled versus those not counseled about naltrexone were less likely to have 30-day ED revisits (9.7% vs 35.7%; P = .001) and rehospitalizations (2.8% vs 26.2%; P < .001).
CONCLUSIONS: The implementation of a process for counseling patients hospitalized for alcohol withdrawal about using naltrexone for the maintenance of sobriety was associated with lower 30-day ED revisits but no statistically significant difference in rehospitalizations.
© 2018 Society of Hospital Medicine
Alcohol use disorders (AUDs) are common, with an estimated lifetime prevalence of 17.8% for alcohol dependence.1 Alcohol misuse is costly, accounting for $24.6 billion in annual healthcare expenditures, including $5.1 billion for alcohol-related hospitalizations.2 A number of trials have demonstrated that naltrexone can help patients with AUDs maintain abstinence or diminish heavy drinking.3-10 A recent meta-analysis of pharmacotherapy trials for patients with AUDs reported that for patients using 50 mg of naltrexone daily, the number needed to treat was 12 to prevent a return to heavy drinking and 20 to prevent a return to any drinking.11 Despite good evidence for its effectiveness, naltrexone is not prescribed to the majority of patients with AUDs. In a study of veterans with AUDs cared for in the Veterans Affairs health system, only 1.9% of patients were prescribed naltrexone over the 6-month study period.12 A 2003 survey of 2 professional organizations for addiction treatment specialists reported that a mean of 13% of providers prescribed naltrexone to their patients.13
When naltrexone is prescribed, it is most frequently in the outpatient setting.3-10 Data for initiation of naltrexone in the inpatient setting are more limited. Wei et al.14 reported on the implementation of a discharge protocol, including counseling about naltrexone, for hospitalized patients with AUDs at an urban academic medical center. They reported a significant increase in the prescription of naltrexone to eligible patients by the time of discharge that was associated with a significant decrease in 30-day readmissions. Initiation of naltrexone in the inpatient versus the outpatient setting has some potential advantages. First, patients hospitalized for alcohol withdrawal have AUDs, obviating the need for screening. Second, the outpatient trials of naltrexone typically required 3 days of sobriety before initiation, which is generally achieved during hospitalization for detoxification or withdrawal.
Previous work at our institution centered on standardizing the process of evaluating patients needing alcohol detoxification at the time of referral for admission.15 The use of a standardized protocol reduced the number of inpatient admissions for alcohol-related diagnoses but had no effect on the 30-day readmission rate (28%) for those patients who were hospitalized. Our hospitalist group had no standardized process for discharging hospitalized patients with AUDs, and the discharge process rarely included counseling on medications for maintenance of sobriety. In this manuscript, we describe the implementation and impact of a process for counseling patients hospitalized for alcohol detoxification or withdrawal about naltrexone for maintenance of sobriety by the time of hospital discharge.
METHODS
Study Setting
The University of North Carolina (UNC) Hospitals is an 803-bed tertiary academic center. UNC Hospital Medicine is staffed by 29 physicians and 3 advanced practice providers (APPs). During the study period, there were 3 hospital medicine services at UNC Hospitals with a combined average daily census of approximately 40 patients, and each service was staffed by one attending physician every day of the week and one APP Monday through Friday.
Study Design
We used a pre-post study design, in which we implemented a new process for standardizing the discharge of hospitalized patients with AUDs, including a process for counseling about naltrexone by the time of discharge. We sought and received institutional review board (IRB) approval for this study (UNC IRB 15-1441).
Interventions
We formed an improvement team that included 3 physicians and an APP in hospital medicine, a general internist and a psychiatrist, both with expertise in the use of medications for maintenance of sobriety, the director of UNC’s Alcohol and Substance Abuse Program, and 2 case managers. The team developed a number of interventions, including group education, a process for patient identification, and algorithms for counseling about, prescribing, and documenting the discussion of naltrexone.
Group Education
We presented evidence about medications for the maintenance of sobriety at a regularly scheduled hospitalist meeting. An hour-long session on motivational interviewing techniques was also presented at a separate meeting. All created algorithms were circulated to the group electronically and posted at workstations in the hospitalist work area. As data were generated postimplementation, control charts of process measures were created, posted in the hospitalist work area, and presented at subsequent group meetings.
