Veterans Hospitalized for Alcohol Use Disorder Often Miss Medication Initiation Opportunities

Bridging the Gap in Hospital-Based Alcohol Use Disorder Care

Alcohol use disorder remains a leading cause of preventable morbidity and mortality in the United States, yet evidence-based pharmacotherapies like naltrexone and acamprosate continue to be underutilized in clinical practice [1]. While these medications are established first-line treatments that significantly reduce the risk of returning to heavy drinking, many patients never receive a prescription even after experiencing severe alcohol-related health crises [2, 1]. Hospitalization for alcohol-related complications provides a unique window for clinicians to initiate long-term recovery strategies, including both oral and extended-release injectable formulations [3, 4]. However, the transition from acute inpatient stabilization to outpatient maintenance is a period of high clinical vulnerability where many patients are lost to follow-up [5]. A retrospective cohort study of the Veterans Health Administration system now examines how often this inpatient opportunity is utilized and which patient populations are most likely to be left without pharmacological support.

Quantifying the Utilization of Pharmacotherapy

To evaluate how frequently clinicians utilize the inpatient setting to start evidence-based treatments, researchers conducted a retrospective cohort study within the Veterans Health Administration. This large-scale analysis included 29,041 hospitalizations for veterans with a primary diagnosis of alcohol use disorder occurring in 2022 or 2023. The study spanned 142 different hospitals to provide a comprehensive view of prescribing practices across a national healthcare system. To ensure the data reflected new treatment initiations, the researchers specifically selected participants who had no active prescription for medication for alcohol use disorder at baseline. The study population had a median age of 55 years, and 94 percent of the participants were male, reflecting the typical demographic profile of the veteran population seeking acute care for alcohol-related issues. Despite the high clinical need in this cohort, the findings revealed a significant gap in the delivery of pharmacotherapy. In only 8,932 hospitalizations (30.8 percent) was a medication for alcohol use disorder initiated either during the inpatient stay or within seven days of discharge. For the practicing physician, this rate suggests that more than two-thirds of eligible patients leave the hospital without receiving a prescription for first-line medications, representing a missed opportunity for secondary prevention during a critical period of medical stabilization.

Prescribing Patterns and Post-Discharge Continuity

Among the 8,932 instances where medication for alcohol use disorder was successfully initiated, clinicians demonstrated a clear preference for specific pharmacologic agents. Oral naltrexone was the most frequently prescribed medication, accounting for 57.9 percent of all initiations. This preference for naltrexone, an opioid antagonist that reduces alcohol cravings and the reinforcing effects of drinking, suggests it remains the primary choice for clinicians in the acute hospital setting. In contrast, acamprosate accounted for 16.5 percent of initiations, while injectable naltrexone was utilized in 13.9 percent of cases. These data highlight the current clinical hierarchy of treatment options, with oral formulations of naltrexone serving as the mainstay of therapy for patients transitioning from inpatient care to outpatient recovery. The timing of treatment initiation appears to be a critical factor in establishing a continuum of care. The study found that 6,221 initiations (69.6 percent) occurred during the inpatient stay, while the remaining 30.4 percent of initiations took place within seven days of discharge. This distribution emphasizes that the period of hospitalization itself is the primary window for starting evidence-based therapy. Furthermore, initiating treatment while the patient is still in the hospital strongly correlates with short-term adherence. Among the veterans who began their medication as inpatients, 97.7 percent had a documented prescription for the medication within 30 days after discharge. This high rate of follow-through suggests that starting pharmacotherapy before the patient leaves the hospital is a highly effective strategy for ensuring that treatment continues during the high-risk period immediately following discharge.

Clinical Drivers and Barriers to Treatment

To identify the clinical and structural factors that influenced the likelihood of starting medication for alcohol use disorder, the researchers utilized adjusted logistic regression models (statistical tools that isolate the impact of individual variables while controlling for confounding factors). Adjusted analyses showed that medication initiation was significantly more likely for hospitalizations involving a specialty addiction consultation. This finding suggests that the involvement of clinicians with specific expertise in substance use disorders is a primary driver of evidence-based prescribing. Furthermore, the specific hospital service managing the patient proved to be a decisive factor. Patients receiving care from a psychiatry service were more likely to have medication initiated compared to those receiving care from a general medicine service. This difference may reflect varying levels of comfort with psychiatric pharmacotherapy or different clinical priorities between mental health and internal medicine teams during an acute hospital stay. In contrast, certain clinical settings served as significant barriers to the initiation of therapy. Patients treated in the intensive care unit were less likely to have medication for alcohol use disorder initiated. In these high-acuity environments, the focus on immediate physiological stabilization likely overshadows the planning required for long-term recovery. Ultimately, these service-level disparities indicate that integrating addiction medicine expertise directly into general medical and critical care workflows could substantially improve prescribing rates.

Demographic and Comorbidity Disparities

Beyond the care setting, the researchers identified several demographic subgroups where the initiation of medication for alcohol use disorder was significantly less frequent, highlighting potential inequities in care delivery. Initiation was less likely for patients aged 65 years or older, a finding that may reflect clinician concerns regarding polypharmacy, hepatic clearance, or age-related physiological changes in the geriatric population. Gender also influenced treatment patterns, as men were less likely to have medication initiated compared to women. Furthermore, the study documented racial disparities in prescribing; American Indian or Alaska Native veterans were less likely to receive medication initiation compared to White veterans. This disparity suggests that systemic barriers or differences in clinical engagement may influence the standard of care across different racial and ethnic groups. Clinical complexity and the presence of co-occurring conditions further reduced the probability of receiving evidence-based pharmacotherapy during the peri-hospitalization period. Frail veterans, characterized by reduced physiological reserve and increased vulnerability to stressors, were less likely to have medication for alcohol use disorder initiated. This suggests that clinicians may prioritize the management of acute medical instability or physical rehabilitation over the initiation of long-term addiction treatment in patients perceived as medically vulnerable. Additionally, veterans diagnosed with comorbid opioid use disorder were less likely to receive medication for alcohol use disorder, indicating a potential gap in the integrated management of polysubstance use. For the practicing physician, these findings underscore the need for targeted strategies to ensure that high-risk and complex patient populations receive equitable access to evidence-based medications.

Institutional Variation and Systemic Implications

The analysis of 142 Veterans Health Administration facilities revealed significant heterogeneity in how frequently medications for alcohol use disorder were prescribed during the peri-hospitalization period. The median hospital-level rate of medication initiation was 29.9 percent, indicating that in a typical facility, fewer than one in three eligible patients received evidence-based treatment during or immediately following their stay. This variation suggests that the likelihood of a patient receiving pharmacotherapy is heavily dependent on the specific institution where they are admitted rather than clinical need alone, pointing to a lack of standardized protocols across the health system. The researchers further quantified this disparity by calculating the interquartile range for hospital-level initiation rates, which spanned from 22.6 percent to 36.3 percent. This interquartile range (a statistical measure representing the middle 50 percent of the data) demonstrates that while some facilities are more successful at integrating addiction pharmacotherapy into acute care, others fall significantly below the national median. For the practicing clinician and hospital administrator, these data highlight a systemic gap in the delivery of care. Addressing these inconsistencies requires the identification and dissemination of successful hospital-based strategies, such as automated electronic health record prompts or standardized order sets, to ensure that every hospitalization for alcohol use disorder serves as a reliable entry point for long-term recovery.

References

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2. Amsterdam JV, Brink WVD. Explaining increased efficacy of naltrexone in the treatment of alcohol dependent patients with a family history of alcohol use disorder: A systematic review on the role of reward sensitivity and sweet liking.. Alcohol (Fayetteville, N.Y.). 2025. doi:10.1016/j.alcohol.2025.06.004

3. Elmosalamy A, Sirohi A, Moustafa A, et al. Extended-release naltrexone versus oral naltrexone for substance use disorders: A systematic review and meta-analysis.. Drug and alcohol dependence. 2025. doi:10.1016/j.drugalcdep.2025.112789

4. Magane KM, Dukes KA, Fielman S, et al. Oral vs Extended-Release Injectable Naltrexone for Hospitalized Patients With Alcohol Use Disorder: A Randomized Clinical Trial.. JAMA internal medicine. 2025. doi:10.1001/jamainternmed.2025.0522

5. Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017. doi:10.1136/bmj.j1550