Emergency departments often care for individuals with alcohol use disorder, yet evidence-based medications like naltrexone are rarely initiated in this setting. This study examined real-world barriers faced by both clinicians and patients, and gathered feedback on strategies that could make prescribing naltrexone in the emergency department more routine.
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Alcohol use disorder is common among patients seen in emergency departments and remains a leading cause of preventable death. Although medications such as naltrexone have been shown to reduce heavy drinking and cravings, they are rarely prescribed in emergency department settings. In 2024, across all individuals and settings, fewer than 3% of individuals with alcohol use disorder received any medication to help reduce or stop their drinking. This study sought to identify real-world barriers – reported by both clinicians and patients – that limit the initiation of naltrexone, a medication that blocks the pleasurable effects of alcohol use, in the emergency department, and to identify strategies clinicians view as most valuable for increasing prescribing practices.
This study used a 2-part design to examine barriers and facilitators to initiating naltrexone for alcohol use disorder in the emergency department. First, the researchers shadowed emergency department clinicians at multiple sites within a large northeastern healthcare system, observing workflows and conducting interviews with 3 physicians, 2 physician assistants, 4 nurses, a social worker, and 6 patients with alcohol use disorder. These observations and interviews were analyzed for key themes, which then informed the design of an online survey. The survey was distributed to all emergency medicine faculty and trainees across the healthcare system and was completed by 97 staff members (61% response rate). It asked about clinicians’ prior prescribing practices specifically for alcohol use disorder, their comfort level with treating alcohol use disorder, and perceived barriers to prescribing naltrexone (rated from 1 = “not at all a barrier” to 10 = “very significant barrier”). Respondents also rated the perceived helpfulness of different strategies for supporting emergency department-initiated naltrexone for patients with alcohol use disorder (from 1 = “not at all helpful” to 10 = “very helpful”).
Barriers to naltrexone initiation were widespread among both clinicians and patients
Clinicians in the emergency department reported several obstacles to prescribing naltrexone. Some noted inconsistent screening for alcohol use disorder due to the lack of a standardized protocol, meaning patients with alcohol use disorder often went unidentified. Even when identified, clinicians demonstrated limited knowledge about medications for alcohol use disorder. While most were familiar with naltrexone by name, they often confused it with other medications or misunderstood its purpose. Some expressed a lack of motivation to prescribe naltrexone, citing stigmatizing beliefs that patients rarely recover, which discouraged them from initiating treatment and led them to defer discussions to primary care or other providers. Patients also reported limited knowledge about naltrexone and sometimes confused it with other medications for alcohol use disorder, such as disulfiram, which works very differently and can cause unpleasant side effects when alcohol is consumed. Patients also described experiencing discomfort in the emergency department setting, difficulty navigating pharmacies, and limited follow-up resources, all of which posed barriers to initiating treatment.
Clinicians were comfortable identifying patients with alcohol use disorder, but not with prescribing naltrexone or answering questions about the medication
As shown in the graph below, survey responses highlighted that most physicians reported they felt comfortable identifying patients with alcohol use disorder (81%) and advising patients to cut down on their drinking (85%). Nearly 2/3 (62%) reported having prescribed benzodiazepines for alcohol withdrawal symptoms on discharge, yet only 3% reported prescribing naltrexone for alcohol use disorder. In contrast, most physicians expressed discomfort with prescribing naltrexone (91%), answering questions about the medication (87%), or arranging follow-up care (65%). When asked to rate barriers, clinicians identified all options – such as limited time, lack of patient knowledge, and lack of referral resources – as significant, with the lack of available follow-up treatment rated as the single most important barrier.
Streamlined prescribing processes and education were seen as the most valuable interventions
When asked about strategies to improve prescribing of naltrexone in emergency department patients, clinicians rated several system-level changes highly. The most valued interventions were creating a standardized pathway for naltrexone (a treatment protocol that outlines when and how to initiate the medication in the emergency department; 8.6 out of 10), adding naltrexone to standard discharge order sets for patents with mild-to-moderate alcohol withdrawal (8.6 out of 10), and employing substance use navigators in the emergency department to help patients engage in care (8.6). Other interventions were also perceived as valuable, including text message follow-up with navigators after discharge and educational efforts to increase knowledge about naltrexone (e.g., presentation on indications, dosing, and side effects of naltrexone; one-pager addressing common patient misconceptions about how naltrexone works).
Despite strong evidence that naltrexone is a helpful treatment for alcohol use disorder, its use in emergency department settings remains rare, underscoring a persistent gap between research and practice. Emergency departments are an important point of contact for individuals with alcohol use disorder and have long been recognized as an ideal setting for screening, brief interventions, and referrals to ongoing care. Yet, as findings from this study show, naltrexone prescribing in the emergency department is limited by barriers affecting both clinicians and patients. For clinicians, limited knowledge about naltrexone was a central barrier. Most physicians surveyed reported feeling uncomfortable prescribing naltrexone or answering patient questions about the medication, even though they routinely prescribed other medications such as benzodiazepines for alcohol withdrawal. For patients, barriers included limited awareness of medication options, confusion between naltrexone and other medications like disulfiram, discomfort in the emergency department setting, difficulty navigating pharmacies, and lack of follow-up resources. It is important to note, however, that naltrexone is typically prescribed as an extended-release injection formulation known by the brand name “Vivitrol”. Whether providers and patients would have different perceptions and/or reactions to this monthly injection of the medication is unclear.
Addressing these challenges will likely require system-level solutions. Clinicians themselves highlighted the value of streamlining the prescribing process, such as incorporating naltrexone into discharge order sets or standardized protocols, and enhancing education to reduce misunderstandings about the medication. Importantly, substance use treatment navigator support also emerged as a promising strategy. This aligns with a growing body of evidence showing that peer recovery support specialists can help connect patients to treatment, improve engagement and retention, and support recovery in real-world settings, including the emergency department. Expanding these roles, alongside low-barrier follow-up options and ongoing navigator support (e.g., via text messaging), may be especially critical in helping patients transition from an emergency department encounter into sustained care.
The underuse of medications like naltrexone in emergency department settings for patients with alcohol use disorder is a multifaceted issue shaped by barriers for both healthcare staff and patients. It underscores the need for greater education and more streamlined processes to increase access to and engagement with naltrexone. For clinicians, limited knowledge about naltrexone, discomfort with prescribing it, and lack of standardized workflows may be barriers to adoption. For patients, confusion about medications for alcohol use disorder, challenges navigating care, and limited follow-up resources make it harder to start and continue naltrexone. Promising strategies to increase naltrexone uptake include seamlessly integrating it into emergency department workflows and providing human patient navigation support. This support can come from substance use treatment navigators or peer recovery support specialists, who can guide patients, answer questions, and connect them to follow-up care. These approaches may increase engagement with evidence-based medications like naltrexone and, in turn, help reduce the burden of alcohol use disorder – both for individuals and for the healthcare system, where alcohol-related emergency department visits carry substantial costs.
Covarrubias, I., Dart, H., Adams, L., Moon, J. C., Huo, S., O’Donnell, N., Ebert, J., Fagen, M., Yan, R., Perrone, J., & Delgado, K. (2025). Evaluation of barriers and interventions for emergency department-initiated naltrexone for the treatment of alcohol use disorder. The Journal of Emergency Medicine, 73, 63-70. doi: 10.1016/j.jemermed.2025.01.001.
l
Alcohol use disorder is common among patients seen in emergency departments and remains a leading cause of preventable death. Although medications such as naltrexone have been shown to reduce heavy drinking and cravings, they are rarely prescribed in emergency department settings. In 2024, across all individuals and settings, fewer than 3% of individuals with alcohol use disorder received any medication to help reduce or stop their drinking. This study sought to identify real-world barriers – reported by both clinicians and patients – that limit the initiation of naltrexone, a medication that blocks the pleasurable effects of alcohol use, in the emergency department, and to identify strategies clinicians view as most valuable for increasing prescribing practices.
This study used a 2-part design to examine barriers and facilitators to initiating naltrexone for alcohol use disorder in the emergency department. First, the researchers shadowed emergency department clinicians at multiple sites within a large northeastern healthcare system, observing workflows and conducting interviews with 3 physicians, 2 physician assistants, 4 nurses, a social worker, and 6 patients with alcohol use disorder. These observations and interviews were analyzed for key themes, which then informed the design of an online survey. The survey was distributed to all emergency medicine faculty and trainees across the healthcare system and was completed by 97 staff members (61% response rate). It asked about clinicians’ prior prescribing practices specifically for alcohol use disorder, their comfort level with treating alcohol use disorder, and perceived barriers to prescribing naltrexone (rated from 1 = “not at all a barrier” to 10 = “very significant barrier”). Respondents also rated the perceived helpfulness of different strategies for supporting emergency department-initiated naltrexone for patients with alcohol use disorder (from 1 = “not at all helpful” to 10 = “very helpful”).
Barriers to naltrexone initiation were widespread among both clinicians and patients
Clinicians in the emergency department reported several obstacles to prescribing naltrexone. Some noted inconsistent screening for alcohol use disorder due to the lack of a standardized protocol, meaning patients with alcohol use disorder often went unidentified. Even when identified, clinicians demonstrated limited knowledge about medications for alcohol use disorder. While most were familiar with naltrexone by name, they often confused it with other medications or misunderstood its purpose. Some expressed a lack of motivation to prescribe naltrexone, citing stigmatizing beliefs that patients rarely recover, which discouraged them from initiating treatment and led them to defer discussions to primary care or other providers. Patients also reported limited knowledge about naltrexone and sometimes confused it with other medications for alcohol use disorder, such as disulfiram, which works very differently and can cause unpleasant side effects when alcohol is consumed. Patients also described experiencing discomfort in the emergency department setting, difficulty navigating pharmacies, and limited follow-up resources, all of which posed barriers to initiating treatment.
Clinicians were comfortable identifying patients with alcohol use disorder, but not with prescribing naltrexone or answering questions about the medication
As shown in the graph below, survey responses highlighted that most physicians reported they felt comfortable identifying patients with alcohol use disorder (81%) and advising patients to cut down on their drinking (85%). Nearly 2/3 (62%) reported having prescribed benzodiazepines for alcohol withdrawal symptoms on discharge, yet only 3% reported prescribing naltrexone for alcohol use disorder. In contrast, most physicians expressed discomfort with prescribing naltrexone (91%), answering questions about the medication (87%), or arranging follow-up care (65%). When asked to rate barriers, clinicians identified all options – such as limited time, lack of patient knowledge, and lack of referral resources – as significant, with the lack of available follow-up treatment rated as the single most important barrier.
Streamlined prescribing processes and education were seen as the most valuable interventions
When asked about strategies to improve prescribing of naltrexone in emergency department patients, clinicians rated several system-level changes highly. The most valued interventions were creating a standardized pathway for naltrexone (a treatment protocol that outlines when and how to initiate the medication in the emergency department; 8.6 out of 10), adding naltrexone to standard discharge order sets for patents with mild-to-moderate alcohol withdrawal (8.6 out of 10), and employing substance use navigators in the emergency department to help patients engage in care (8.6). Other interventions were also perceived as valuable, including text message follow-up with navigators after discharge and educational efforts to increase knowledge about naltrexone (e.g., presentation on indications, dosing, and side effects of naltrexone; one-pager addressing common patient misconceptions about how naltrexone works).
Despite strong evidence that naltrexone is a helpful treatment for alcohol use disorder, its use in emergency department settings remains rare, underscoring a persistent gap between research and practice. Emergency departments are an important point of contact for individuals with alcohol use disorder and have long been recognized as an ideal setting for screening, brief interventions, and referrals to ongoing care. Yet, as findings from this study show, naltrexone prescribing in the emergency department is limited by barriers affecting both clinicians and patients. For clinicians, limited knowledge about naltrexone was a central barrier. Most physicians surveyed reported feeling uncomfortable prescribing naltrexone or answering patient questions about the medication, even though they routinely prescribed other medications such as benzodiazepines for alcohol withdrawal. For patients, barriers included limited awareness of medication options, confusion between naltrexone and other medications like disulfiram, discomfort in the emergency department setting, difficulty navigating pharmacies, and lack of follow-up resources. It is important to note, however, that naltrexone is typically prescribed as an extended-release injection formulation known by the brand name “Vivitrol”. Whether providers and patients would have different perceptions and/or reactions to this monthly injection of the medication is unclear.
Addressing these challenges will likely require system-level solutions. Clinicians themselves highlighted the value of streamlining the prescribing process, such as incorporating naltrexone into discharge order sets or standardized protocols, and enhancing education to reduce misunderstandings about the medication. Importantly, substance use treatment navigator support also emerged as a promising strategy. This aligns with a growing body of evidence showing that peer recovery support specialists can help connect patients to treatment, improve engagement and retention, and support recovery in real-world settings, including the emergency department. Expanding these roles, alongside low-barrier follow-up options and ongoing navigator support (e.g., via text messaging), may be especially critical in helping patients transition from an emergency department encounter into sustained care.
The underuse of medications like naltrexone in emergency department settings for patients with alcohol use disorder is a multifaceted issue shaped by barriers for both healthcare staff and patients. It underscores the need for greater education and more streamlined processes to increase access to and engagement with naltrexone. For clinicians, limited knowledge about naltrexone, discomfort with prescribing it, and lack of standardized workflows may be barriers to adoption. For patients, confusion about medications for alcohol use disorder, challenges navigating care, and limited follow-up resources make it harder to start and continue naltrexone. Promising strategies to increase naltrexone uptake include seamlessly integrating it into emergency department workflows and providing human patient navigation support. This support can come from substance use treatment navigators or peer recovery support specialists, who can guide patients, answer questions, and connect them to follow-up care. These approaches may increase engagement with evidence-based medications like naltrexone and, in turn, help reduce the burden of alcohol use disorder – both for individuals and for the healthcare system, where alcohol-related emergency department visits carry substantial costs.
Covarrubias, I., Dart, H., Adams, L., Moon, J. C., Huo, S., O’Donnell, N., Ebert, J., Fagen, M., Yan, R., Perrone, J., & Delgado, K. (2025). Evaluation of barriers and interventions for emergency department-initiated naltrexone for the treatment of alcohol use disorder. The Journal of Emergency Medicine, 73, 63-70. doi: 10.1016/j.jemermed.2025.01.001.
l
Alcohol use disorder is common among patients seen in emergency departments and remains a leading cause of preventable death. Although medications such as naltrexone have been shown to reduce heavy drinking and cravings, they are rarely prescribed in emergency department settings. In 2024, across all individuals and settings, fewer than 3% of individuals with alcohol use disorder received any medication to help reduce or stop their drinking. This study sought to identify real-world barriers – reported by both clinicians and patients – that limit the initiation of naltrexone, a medication that blocks the pleasurable effects of alcohol use, in the emergency department, and to identify strategies clinicians view as most valuable for increasing prescribing practices.
This study used a 2-part design to examine barriers and facilitators to initiating naltrexone for alcohol use disorder in the emergency department. First, the researchers shadowed emergency department clinicians at multiple sites within a large northeastern healthcare system, observing workflows and conducting interviews with 3 physicians, 2 physician assistants, 4 nurses, a social worker, and 6 patients with alcohol use disorder. These observations and interviews were analyzed for key themes, which then informed the design of an online survey. The survey was distributed to all emergency medicine faculty and trainees across the healthcare system and was completed by 97 staff members (61% response rate). It asked about clinicians’ prior prescribing practices specifically for alcohol use disorder, their comfort level with treating alcohol use disorder, and perceived barriers to prescribing naltrexone (rated from 1 = “not at all a barrier” to 10 = “very significant barrier”). Respondents also rated the perceived helpfulness of different strategies for supporting emergency department-initiated naltrexone for patients with alcohol use disorder (from 1 = “not at all helpful” to 10 = “very helpful”).
Barriers to naltrexone initiation were widespread among both clinicians and patients
Clinicians in the emergency department reported several obstacles to prescribing naltrexone. Some noted inconsistent screening for alcohol use disorder due to the lack of a standardized protocol, meaning patients with alcohol use disorder often went unidentified. Even when identified, clinicians demonstrated limited knowledge about medications for alcohol use disorder. While most were familiar with naltrexone by name, they often confused it with other medications or misunderstood its purpose. Some expressed a lack of motivation to prescribe naltrexone, citing stigmatizing beliefs that patients rarely recover, which discouraged them from initiating treatment and led them to defer discussions to primary care or other providers. Patients also reported limited knowledge about naltrexone and sometimes confused it with other medications for alcohol use disorder, such as disulfiram, which works very differently and can cause unpleasant side effects when alcohol is consumed. Patients also described experiencing discomfort in the emergency department setting, difficulty navigating pharmacies, and limited follow-up resources, all of which posed barriers to initiating treatment.
Clinicians were comfortable identifying patients with alcohol use disorder, but not with prescribing naltrexone or answering questions about the medication
As shown in the graph below, survey responses highlighted that most physicians reported they felt comfortable identifying patients with alcohol use disorder (81%) and advising patients to cut down on their drinking (85%). Nearly 2/3 (62%) reported having prescribed benzodiazepines for alcohol withdrawal symptoms on discharge, yet only 3% reported prescribing naltrexone for alcohol use disorder. In contrast, most physicians expressed discomfort with prescribing naltrexone (91%), answering questions about the medication (87%), or arranging follow-up care (65%). When asked to rate barriers, clinicians identified all options – such as limited time, lack of patient knowledge, and lack of referral resources – as significant, with the lack of available follow-up treatment rated as the single most important barrier.
Streamlined prescribing processes and education were seen as the most valuable interventions
When asked about strategies to improve prescribing of naltrexone in emergency department patients, clinicians rated several system-level changes highly. The most valued interventions were creating a standardized pathway for naltrexone (a treatment protocol that outlines when and how to initiate the medication in the emergency department; 8.6 out of 10), adding naltrexone to standard discharge order sets for patents with mild-to-moderate alcohol withdrawal (8.6 out of 10), and employing substance use navigators in the emergency department to help patients engage in care (8.6). Other interventions were also perceived as valuable, including text message follow-up with navigators after discharge and educational efforts to increase knowledge about naltrexone (e.g., presentation on indications, dosing, and side effects of naltrexone; one-pager addressing common patient misconceptions about how naltrexone works).
Despite strong evidence that naltrexone is a helpful treatment for alcohol use disorder, its use in emergency department settings remains rare, underscoring a persistent gap between research and practice. Emergency departments are an important point of contact for individuals with alcohol use disorder and have long been recognized as an ideal setting for screening, brief interventions, and referrals to ongoing care. Yet, as findings from this study show, naltrexone prescribing in the emergency department is limited by barriers affecting both clinicians and patients. For clinicians, limited knowledge about naltrexone was a central barrier. Most physicians surveyed reported feeling uncomfortable prescribing naltrexone or answering patient questions about the medication, even though they routinely prescribed other medications such as benzodiazepines for alcohol withdrawal. For patients, barriers included limited awareness of medication options, confusion between naltrexone and other medications like disulfiram, discomfort in the emergency department setting, difficulty navigating pharmacies, and lack of follow-up resources. It is important to note, however, that naltrexone is typically prescribed as an extended-release injection formulation known by the brand name “Vivitrol”. Whether providers and patients would have different perceptions and/or reactions to this monthly injection of the medication is unclear.
Addressing these challenges will likely require system-level solutions. Clinicians themselves highlighted the value of streamlining the prescribing process, such as incorporating naltrexone into discharge order sets or standardized protocols, and enhancing education to reduce misunderstandings about the medication. Importantly, substance use treatment navigator support also emerged as a promising strategy. This aligns with a growing body of evidence showing that peer recovery support specialists can help connect patients to treatment, improve engagement and retention, and support recovery in real-world settings, including the emergency department. Expanding these roles, alongside low-barrier follow-up options and ongoing navigator support (e.g., via text messaging), may be especially critical in helping patients transition from an emergency department encounter into sustained care.
The underuse of medications like naltrexone in emergency department settings for patients with alcohol use disorder is a multifaceted issue shaped by barriers for both healthcare staff and patients. It underscores the need for greater education and more streamlined processes to increase access to and engagement with naltrexone. For clinicians, limited knowledge about naltrexone, discomfort with prescribing it, and lack of standardized workflows may be barriers to adoption. For patients, confusion about medications for alcohol use disorder, challenges navigating care, and limited follow-up resources make it harder to start and continue naltrexone. Promising strategies to increase naltrexone uptake include seamlessly integrating it into emergency department workflows and providing human patient navigation support. This support can come from substance use treatment navigators or peer recovery support specialists, who can guide patients, answer questions, and connect them to follow-up care. These approaches may increase engagement with evidence-based medications like naltrexone and, in turn, help reduce the burden of alcohol use disorder – both for individuals and for the healthcare system, where alcohol-related emergency department visits carry substantial costs.
Covarrubias, I., Dart, H., Adams, L., Moon, J. C., Huo, S., O’Donnell, N., Ebert, J., Fagen, M., Yan, R., Perrone, J., & Delgado, K. (2025). Evaluation of barriers and interventions for emergency department-initiated naltrexone for the treatment of alcohol use disorder. The Journal of Emergency Medicine, 73, 63-70. doi: 10.1016/j.jemermed.2025.01.001.
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