COVID Isn’t the Only Crisis: We Have to Get AUD Treatment Right!

Yes, there is a pandemic going on, and our efforts are appropriately targeted on this rapidly changing, and sadly worsening, global pandemic. Let’s not lose focus on that. Before COVID, our focus was on the opioid crisis that resulted in almost 67k deaths in 2018. But sadly, for decades, we have paid less attention to the acute and chronic issues due to alcohol related diseases leading to 88k deaths per year  and the 14.4 million people in the US that are suffering from Alcohol Use Disorder. I am sure every hospitalist knows, even in the time of COVID, alcohol-related diseases are devastating our patients and filling our hospitals. And as this pandemic continues, and when it eventually ends, this problem will likely have worsened due to the stress, isolation, and economic impacts of COVID. This worsening will manifest as patients leave their homes to return to work and must curb alcohol use patterns that may have developed when at home. We need to be ready to offer effective treatment. This is some of our bread and butter, hospital medicine!

Unfortunately, alcohol use disorder (AUD) and acute alcohol withdrawal (AAW) have never received the level of attention that they should within medicine, especially considering the breadth of their impact on global populations. Despite the lack of continued robust research in this area, there are accepted and proven standards of practice that are not widely used. Hospital medicine is uniquely poised to both recognize this pervasive disease, and to treat it effectively. Many of these patients will not interact with healthcare in any other setting than emergency departments and inpatient admissions, and we are the specialty, in combination with EM, that can best identify and initiate effective treatments for these patients.

First, let’s talk about the treatment of Acute Alcohol Withdrawal. Many of you are likely continuing to use alcohol withdrawal protocols that have not been updated in decades. Or you are doing whatever was done during your residency. You may be using symptom-based protocols – or some may still be using vital signs – that are leading to some type of benzodiazepine treatment. Some of you are using phenobarbital or gabapentin. Many of our programs leave it to the nurse’s or provider’s discretion to start a lorazepam drip, and the drip titration has limited specific guidance for escalation (i.e., titrate to effect). We are slow to start treatment when withdrawal symptoms develop, undertreat it initially, then recover with too much. We have too many transfers to the ICU when differing maximum drip rates are reached on the floor and then prolonged hospitalizations for patients who received much more benzodiazepine than was needed due to the drip not being titrated effectively or increased inappropriately for temporary inadequately treated symptoms.

We can do better than this. I know there are programs out there that have found better ways to do this, and we all need to establish and adopt these practices. At the University of New Mexico, we are happy to share our approach and learn from others.

But the area that we a failing our patients most is in treating the underlying AUD that led to the patient’s admission in the first place. How many of our programs hand a discharging patient a list of community alcohol resources as our only intervention? It should be considered appalling how low our collective use of standard-of-care medication-assisted therapy (MAT) for AUD is at discharge for our patients. This must change.

I would encourage each of our programs to work on 3 interventions to benefit AUD patients. The first step is effective screening of all inpatients for AUD, and when recognized, patients should receive this bundle of care (LINK to these resources):

1. Perform a brief negotiated interview to help reinforce motivation and resources patients need to be successful. There are effective models to follow. An example we use at UNM is the Structured Brief Negotiated Interview adapted by Dr. Jennie Wei based on work by Stephen Rollnick. It can be accomplished by asking 3 questions and generally takes less than 5-10 minutes.
2. Prescribe medication-assisted therapy with naltrexone or acamprosate. Every patient should leave the hospital with a prescription for standard of care medication-assisted therapy. Ideally, this can be started inpatient to help with adherence; however, I even offer these to patients who are resistant to start because I want them to have the medication on hand at home at the moment they are ready in the future.
3. Encouraging participation in a peer support or 12-step program like Alcoholics Anonymous. These programs are proven to work, and our highest rates of success are in patient who combine MAT with these programs. I counsel all of my patients that there are a wide variety of programs, some religious-based, some secular, some large and some small – it is important for them to explore and find a group they fit with. Also remind them that despite COVID restrictions, many programs have adapted in order to continue.

The combination of the above bundle of interventions offers our patients the best chance of success. All hospital medicine programs should reliably implement and offer these, in combination with an effective withdrawal protocol, to all patients with AUD and AAW. To make it easy to do the right thing, programs should develop order sets that include all of these interventions and should train and practice the negotiated interview. We should teach interventions to our residents and students and champion ensuring that our emergency departments are also offering these interventions.

We often feel helpless caring for patients with AUD, thinking there is very little we can do for them except get them through their withdrawal. But that is not true! We can do so much, and even if they are not successful this visit, they may be on the next. We must remain non-judgmental and just be sure they have the tools they need when they are ready.  If there is interest, we can do follow-up blogs with more details on each of the interventions above. Let’s get this right!