Limited pharmacotherapy initiation during veteran hospitalizations for alcohol use disorder

1. In this retrospective cohort study, approximately 30% of veterans hospitalized for alcohol use disorder received medications for alcohol use disorder during hospitalization or within 7 days of discharge.

2. Initiation was less common among older patients, male veterans, and American Indian or Alaska Native veterans, with substantial variation in initiation rates observed across hospitals.

Evidence Rating Level: 2 (Good)

Study Rundown: Veterans experience a disproportionately high burden of alcohol use disorder compared with the general population. Although medications for alcohol use disorder (MAUDs), such as naltrexone and acamprosate, are effective and approved treatments, they remain substantially underused in clinical practice. Hospitalization represents a key opportunity to initiate treatment; however, MAUD initiation during or shortly after inpatient care remains inconsistent. This study examined patterns of MAUD initiation among veterans hospitalized for alcohol use disorder across the United States. Overall, about one-third of hospitalizations involved initiation of MAUD during the inpatient stay or within seven days of discharge. The majority of initiations occurred during hospitalization, and most of these patients continued treatment after discharge, suggesting good early continuity once therapy is started. Oral naltrexone was the most commonly initiated medication, followed by injectable naltrexone and acamprosate. Less frequently used agents included topiramate and disulfiram. Initiation of MAUD was less common among male, older, and American Indian or Alaska Native veterans, as well as among those with greater medical complexity. In contrast, initiation was more likely among individuals with prior alcohol use disorder diagnoses, previous MAUD exposure, or involvement with psychiatry or addiction specialty services. There was substantial variation across hospitals in MAUD initiation rates, indicating inconsistent implementation of evidence-based treatment practices. Overall, this study suggests that while inpatient care represents an important opportunity to initiate treatment for alcohol use disorder, MAUDs are still not consistently prescribed. 

Click to read this study in AIM

Relevant Reading: Predicting Risk of Hospitalization or Death Among Patients Receiving Primary Care in the Veterans Health Administration

In-Depth [retrospective cohort]: This retrospective cohort study evaluated patterns of medications for alcohol use disorder (MAUD) initiation among veterans hospitalized for alcohol use disorder across the United States. Data were obtained from electronic health records, bar code medication administration data, and pharmacy fill records for all Veterans Health Administration hospitalizations for alcohol use disorder in 2022 and 2023. Hospitalizations were excluded if patients were discharged to skilled nursing facilities or non-Veterans Health Administration hospitals, or if they had received MAUD prescriptions within 180 days prior to admission. The primary outcome was MAUD initiation, defined as receipt of medication during hospitalization or a prescription fill or injectable administration within 7 days of discharge. Secondary outcomes included inpatient MAUD receipt and initiation within 30 days of discharge. Across 142 hospitals, 43,038 hospitalizations were identified. After exclusions, 29,041 hospitalizations representing 18,500 unique patients were included. The median age was 55 years (interquartile range [IQR], 41-64), and 94.4% were male. The cohort was 65.5% White, 17.1% Black, and 7.0% Hispanic. Most hospitalizations involved patients with a prior alcohol use disorder diagnosis, and about one-quarter had prior MAUD exposure more than 6 months before admission. Over half of patients received care on medicine services, and approximately 40% on psychiatry services. MAUD was initiated in 30.8% of hospitalizations during admission or within 7 days of discharge. Of these, about 70% began inpatient, and the remainder were initiated shortly after discharge. Among those started inpatient, nearly all continued MAUD within 30 days post-discharge. Oral naltrexone was most commonly used (57.9%), followed by injectable naltrexone (13.9%), acamprosate (16.5%), topiramate (3.8%), and disulfiram (3.6%). Initiation was less common among older patients, males, and American Indian or Alaska Native veterans, and among those with greater medical complexity. It was more common among patients with prior alcohol use disorder diagnoses, prior MAUD exposure, psychiatric involvement, or addiction consult services. Rates varied widely across hospitals. Hospital characteristics were not significantly associated with initiation, though substantial residual variation persisted, suggesting unmeasured institutional factors. Overall, MAUD initiation occurred in about one-third of hospitalizations with wide variation across patient and hospital factors.

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