Variation in initiation of medications for alcohol use disorder during alcohol withdrawal hospitalizations in a large health system: A retrospective cohort study

Background Alcohol withdrawal hospitalizations present unmet opportunities to initiate medications for alcohol use disorder (MAUD). Objective To examine patient and hospital factors associated with MAUD initiation during hospitalizations. Methods We conducted a retrospective cohort study of alcohol withdrawal hospitalizations in a large health system using electronic health record and pharmacy data from 2022 to 2024. The outcome was MAUD initiation defined as inpatient administration of injectable naltrexone or prescriptions for outpatient oral naltrexone, acamprosate, disulfiram, topiramate, or baclofen. We excluded patients who filled MAUD in the prior 90 days. We used a multivariable linear model with socioeconomic, clinical, and hospitalization factors as fixed effects and individual patients and hospital sites as random effects to account for clustering. Results Among 5993 alcohol withdrawal hospitalizations across 12 hospitals, 19.8% (range: 5.1%– 43.2%) initiated MAUD. Oral naltrexone was the most common MAUD initiated, while topiramate was the least common (66.9% and 1.2% of MAUD initiated, respectively). Patients less likely to initiate MAUD were age ≥ 65 years (absolute adjusted difference −6.89 percentage points [pp] vs. age 18–29; 95% confidence interval [CI] −12.20, −1.58) and those without cirrhosis and liver enzymes >200 U/L (−3.46 pp vs. liver enzymes ≤ 200 U/L; 95% CI: −6.87, −0.01). Four hospitals initiated MAUD at significantly lower rates, and two at higher rates including the only hospital with an addiction consult service. Conclusion MAUD initiation during alcohol withdrawal hospitalizations was low and varied by patient factors and hospital sites. Factors driving this variation can inform interventions to address MAUD underutilization.