Take-Home Point:

Naltrexone is a safe and effective medication for patients with alcohol use disorder that can improve morbidity by decreasing alcohol intake, and most importantly, can be initiated in the emergency department (ED).

The Problem: Alcohol Use Disorder in the Emergency Department

Alcohol use and its varied consequences, from trauma to withdrawal, are frequently encountered in the ED. Despite being ubiquitous in the ED, alcohol use disorder (AUD) often goes under-recognized and undertreated in the ED. The numbers are staggering– approximately 29 million individuals across the country and 400 million across the globe meet criteria for AUD [1]. Yet few patients ever actively receive any treatment, and far fewer are connected to resources from the ED [2].

This represents a massive missed opportunity. While there is a long-held belief that the ED is not an ideal setting to screen and treat patients with various substance use disorders, as emergency physicians, we have been trailblazers in the management of opioid use disorder. It’s time to apply the same innovative approach to AUD. The tools exist—brief screening instruments, effective medications (such as naltrexone [3]), and growing institutional support—but implementation remains limited.

An enduring myth that AUD is simply a “moral failing” may contribute to treatment gap. In reality, AUD is a chronic relapsing disorder with neurobiological foundations, and evidence-based treatments can significantly improve outcomes.

This article will briefly review key AUD screening tools but primarily focus on medication-based treatment of AUD with naltrexone in the ED.

Screening for AUD in the Emergency Department

Identifying AUD in the emergency department is an essential first step, as the ED may be the only healthcare interaction for many patients. While the ED can often be a hectic environment, there are several brief, validated screening tools that can effectively identify AUD in patients.

1. SASQ (Single Alcohol Screening Question)

• Question: “How many times in the past year have you had X or more drinks in a day?” (X = 5 for men, 4 for women)
• Threshold: ≥1 day is a positive response
• Pros [4]:
  • Quickest screening option
  • >80% sensitivity
  • Could easily integrate into triage process
• Cons:
  • Only captures heavy episodic drinking and may miss chronic daily drinking below binge threshold (e.g., someone who has 3 drinks every single day would screen “0 times” yet is over weekly limits)
  • A positive result does not distinguish severity and needs further screening

2. AUDIT-C (Alcohol Use Disorders Identification Test – Consumption)

•  Assesses frequency, quantity, and binge drinking (MDCalc calculation)
  • Frequency: “How often do you have a drink containing alcohol?” (score 0-4 ranging from never to 4+ times/week)
  • Quantity: “On a typical drinking day, how many drinks do you have?” (score 0-4 ranging from 1–2 drinks to 10+ drinks)
  • Binge Drinking: “How often do you have ≥6 drinks (for women, ≥4 drinks) on one occasion?”
• Pros [5, 6]:
  •  Brief
  • >90% sensitivity and specificity
  • Well-validated
• Cons:
  • Slightly longer than SASQ tool
  • May miss patients who drink modestly, but chronically
  • Can yield false positives in some heavy-but-controlled drinkers
  • Slightly lower specificity than full AUDIT for AUD

3. STAD (Screening Tool for At-Risk Drinking)

• 2 questions derived from full AUDIT tool
  • Frequency: “How often do you have 6 or more drinks on one occasion?”
  • Guilt: “How often during the last year have you felt guilt or remorse after drinking?”
• Pros [7]:
  • Brief
  • Performs similarly to AUDIT-C (sensitivity >80% and specificity >95%) in detecting at-risk drinking despite being a shorter tool
  • Designed specifically for high-volume settings like EDs
• Cons:
  • Newer tool with limited research
  • Does not directly ask about dependence behaviors and primarily focuses on binge drinking
  • Requires further screening if positive

Once patients with AUD are identified, the next step is connecting them with valuable resources and starting treatment. One option is naltrexone, a medication that is FDA-approved to treat alcohol use disorder and reduce cravings [8].

The Evidence for ED Initiation of Naltrexone

Traditionally, initiating AUD medications has not been part of routine emergency care – but this is changing. While there are numerous medications currently approved for use in alcohol use disorder, only roughly 1% of patients receive treatment each year [9]. There was a recent study that demonstrated that initiation of oral naltrexone was not only effective but also feasible in the ED setting [10]. In this study, patients were initiated on 50 mg PO naltrexone in the ED, and then prescribed a 14-day starter pack with outpatient follow-up arranged. They found significant improvements in quality of life, reduction in cravings for alcohol, and, importantly, a decrease in the number of drinks per day. Encouragingly, one-third of patients were engaged in treatment at 1-month [10]. These are all promising results, which further emphasize the importance of treating this condition in the ED.

Don’t just take our word for it. Professional organizations are following suit and taking a more active role in improving the care of patients struggling with AUD. For instance, the recent SAEM Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4) have further emphasized the importance of medications for AUD. They have developed protocols and recommendations for medications such as naltrexone, acamprosate, disulfiram, and gabapentin. One of their primary recommendations is that for any “adult ED patients with AUD being discharged home, we suggest prescribing an anti-craving medication” [11].

Barriers to Naltrexone Initiation

Unfortunately, there are barriers to implementing any form of medication for AUD in the ED.

1. Screening for AUD is relatively uncommon in the ED setting. As discussed earlier, there are screening tools that can be rapidly utilized in acute care settings.
2. ED providers may lack training or knowledge of naltrexone.
3. ED providers felt that there was a deficit of educational materials for patients, when discussing possible treatment options [12].
4. There often is no formalized protocol within an institution to initiate medications for AUD.

These can hopefully be overcome, with the recent publication of the SAEM GRACE-4 guidelines. Many of these barriers can also be alleviated by discussing these cases with local poison centers or toxicology services within your institutions.

Naltrexone Fast Facts

Mechanism of Action

• Competitive antagonist at mu-opioid receptors [8]
• Alcohol’s pleasurable and reinforcing effects are partly mediated by alcohol-induced release of endogenous opioids, which stimulate mu-receptors and, in turn increase dopamine in reward pathways
• Blunts the euphoric and rewarding effects of alcohol, leading to reduced craving and reduced “high” if a patient does drink

Dosing and Formulations [8]

• Standard oral dose: 50 mg once daily
• Extended-release injectable (brand name Vivitrol): 380 mg intramuscularly every 4 weeks
  • The long-acting injection may enhance adherence by removing the need for daily pill-taking.

Safety

• Contraindications:
  • History of opioid use disorder – risk of precipitating withdrawal
  • Includes patients actively suboxone (buprenorphine) or methadone
• Pregnancy – Currently pregnancy category C, ACOG does not have definitive recommendations on its use, likely needs further research specifically in this population
• Liver disease – Previously had a black box warning for use in liver disease [13]
  • Black box was removed in 2013 due to a lack of evidence of harm in this patient population.
  • Some physicians may feel more comfortable ordering LFTs prior to initiation, but it is not necessary.

Patient Selection

• Ideal patient
  • No recent opioid use
  • Interested in cutting back on alcohol use
  • Wants medications to reduce cravings
  • Positive screening on tools such as SASQ, AUDIT-C, AUDIT, or STAD
• Naloxone challenge [14]
  • Prior to naltrexone initiation, a dose of 0.4 mg IV naloxone can be administered to ensure that naltrexone will not precipitate withdrawal when being taken,

Efficacy

• A 2023 meta-analysis found oral naltrexone (50 mg/d) reduced the risk of returning to heavy drinking (defined often as ≥5 drinks for men/≥4 drinks for women), with a number needed to treat (NNT) of roughly 11 [15].
• A large multi-hospital study found that patients with AUD who were started on naltrexone during an inpatient admission had significantly fewer heavy drinking days post-discharge [16].
• The long-acting injection may enhance adherence by removing the need for daily pill-taking. A 2025 RCT showed that both oral and injectable naltrexone were similarly effective in reducing heavy drinking; after 3 months, patients initiated on either form had over a 40% reduction in the number of heavy-drinking days [17].

Naltrexone Initiation in the ED

1. Develop and implement a plan for universal screening:
   • Implement a universal screening program in your emergency department, using tools such as SASQ, STAD, or AUDIT-C.
   • Use STAD or SASQ for all patients in triage or intake, and for those who screen positive, screen further with AUDIT-C in the ED.
   • If a screening protocol has not been developed or implemented within your institution, then use the full AUDIT tool or ask patients if they would like medications to help reduce cravings
2. Offer medications for AUD:
   • For patients who screen positive for AUD or express interest in reducing alcohol intake, discuss evidence-based options such as naltrexone.
3. Prior to naltrexone initiation:
   • Ask about opioid use history – or if currently on buprenorphine or methadone
   • Administer a 0.4 mg IV naloxone challenge dose – Will help to determine if naltrexone would precipitate withdrawal
   • If no precipitated withdrawal occurs, proceed with treatment
4. Start naltrexone treatment:
   • Oral: Start with 50 mg PO naltrexone
   • Injectable: Start with 380 mg IM naltrexone
5. Discharge planning:
   • If PO naltrexone is given, then discharge the patient with a prescription for up to 30 days (50 mg daily).
   • If IM naltrexone is given, ensure that the patient has a follow-up appointment in one month.
   • Ensure that all patients have follow-up appointments with primary care or addiction medicine physicians.

Other Medication Options for AUD

While several other medications exist for AUD treatment, naltrexone offers the best combination of safety, efficacy, and practical implementation in the ED setting.

FDA-Approved Alternatives

1. Acamprosate [15]
   • Second-line option
   • Similar NNT to naltrexone (approximately 11)
   • Major drawback: Requires 6-9 tablets daily
   • High pill burden significantly impacts adherence
   • More complex dosing for busy ED implementation
   • Safe for patients with liver disease and opioid use disorder
2. Disulfiram [18-21]
   • Works as aversive agent, causing “disulfiram reaction” from accumulation of acetaldehyde, when combined with alcohol
   • Recent RCTs show no significant benefit for reducing alcohol use
   • Poor adherence due to fear of severe side effects
   • Less likely to be prescribed in the ED, as naltrexone is a better option.
   • Due to reduced adherence, disulfiram but may be suitable for patients who are highly motivated to reduce their alcohol consumption.

Off-Label Options

• Gabapentin
  • Lower NNT of 8 for preventing return to heavy drinking [22]
  • Not FDA-approved for AUD
  • Limited long-term safety data
  • Potentially associated with cases of abuse and overdose [23, 24]
  • Less ideal for ED initiation due to abuse liability

GLP-1 Agonists

An area of recent interest has been on the potential use of GLP-1 agonists, such as semaglutide and liraglutide, for the treatment of AUD. It is believed that these medications work by modulating dopamine in the reward and addiction regions of the brain [25]. One RCT, investigating semaglutide, demonstrated that it significantly reduced cravings and the number of drinks with an initial dose of 0.25 mg [26]. Another retrospective study, which compared semaglutide and liraglutide, found a reduction in hospitalizations secondary to AUD, and demonstrated that they were more effective than other medications for AUD [27]. While early data is impressive, further research is necessary, especially to determine their use in the acute care settings.

Conclusion

While there are numerous options to treat AUD, naltrexone is the most effective and safest option. In the past, there has been limited screening for and initiation of treatment for AUD in the ED, but there are both tools and medications that can feasibly be utilized in this setting. As ED providers, we have an opportunity to save lives, connect patients with resources, and reduce the detrimental impact of alcohol consumption on our patients’ lives. Screen for AUD, offer naltrexone, use a naloxone challenge prior to initiation, and connect patients with outpatient follow-up.

References

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