Alcohol Use Disorder in the ED: Screening and MAUD

Cases

Case 1: “Maybe it’s not just a broken bone”

A 50-year-old female presents to the ED with complaints of right ankle pain after a witnessed mechanical slip and fall. She is brought into intake and as part of the new triage protocol at your hospital, she is asked the Single Alcohol Screening Question and does endorse having multiple days per week where she drinks at least 8 glasses of wine. Her chart is updated with this information, X-rays are ordered, and she is moved into the ED for further evaluation.

Case 2: “Just Another Drunk” in the ED

It’s 2 AM on a Saturday and a 45-year-old man is brought in by EMS. He was found slumped over on a sidewalk outside a bar. There are no obvious signs of trauma. He is arousable, protecting his airway, but when awoken, he is combative and incoherent. After a more thorough evaluation, you recognize him, he’s been in your ED multiple times this month for alcohol intoxication. When left alone, the patient falls back asleep. You plan to reevaluate when he is sober and able to provide additional history.

Case 3: “I was diagnosed with alcohol use disorder in the past”

A 38-year-old woman presents to the ED with abdominal pain. While taking a history, she reports that she has been diagnosed with alcohol use disorder and endorses daily alcohol use. After a bit more questioning, she admits to drinking “a few bottles of wine each day” to cope with stress. She’s never sought help for it, but states that she is interested in resources for her alcohol use. You order labs and a GI cocktail and will reevaluate her later on.

As you think through these three cases, and plan your workup, you wonder: Could this be an opportunity to intervene in their alcohol use? What’s your next step? What can you offer them in the ED today to reduce their risk from Alcohol Use Disorder (AUD)? How can we break the cycle?

Background:

Alcohol Use Disorder (AUD) is a common condition, with roughly 29 million individuals throughout the United States meeting the DSM-5 criteria.^1,2 The DSM-5 specifically describes AUD as, “a problematic pattern of alcohol use leading to clinically significant impairment or distress.”² AUD is further stratified as mild, moderate, or severe, based on the number of symptoms present, out of the 11 outlined.² Criteria include: how often do you drink more than you intended, have you attempted to cut back, does your alcohol intake cause stress or familial problems?² Similar to other addiction-related disorders, it is characterized by cravings and a relapsing and remitting pattern of usage. The emergency department (ED) often deals with the repercussions of alcohol use, in a variety of ways. It is not always obvious that patients are struggling with AUD, and occasionally, it can be at the root of an ED visit, but often times it is an unrelated comorbid condition. This further increases the difficulty in effectively identifying patients struggling with this condition, and who would benefit from treatment. Alcohol related ED visits accounted for roughly 9 million of all ED visits between 2021 and 2023, twice the number of opioid-related visits.³ This represents a roughly 50% increase in alcohol related visits from the early 2000s.⁴ It’s among the leading causes of preventable death, contributing to countless health crises, such as liver disease, trauma, and other health crises.

Traditionally, ED management of alcohol-related visits has focused on putting out fires: treating acute intoxication or withdrawal and addressing the immediate threats (trauma, dehydration, electrolyte disturbances). While we can all rapidly identify and manage these cases, we often miss AUD when it is hidden behind unrelated complaints. The emergency department has become a critical initiation point for opioid use disorder treatment, but there continues to be a huge deficit in the management of AUD. Each ED visit for an alcohol-related issue, or for someone who has AUD, can be a window of opportunity, a chance to screen, educate, and even initiate evidence-based therapies that might prevent further complications.

Identifying Alcohol Use Disorder: Screening Tools

One of the major issues with treating alcohol use disorder is first identifying patients with AUD. Reports have noted that only roughly 8% of patients are ever screened in EDs for AUD.^5,6 This represents an important avenue for improvement. Integral to this is the concept of SBIRT, which is Screening, Brief Intervention, and Referral to Treatment, a paradigm of identifying substance use behaviors, counseling patients, and connecting them with resources. It has proven to be effective in primary care settings.^7–9 There are multiple methods to diagnose AUD, such as the DSM-5, the Michigan Alcoholism Screening Test (MAST), the short MAST (sMAST), and the Alcohol Use Disorders Identification Test (AUDIT). These are all longer surveys that are unlikely to be effectively integrated into routine ED workflow. But there are other, validated, and streamlined tools that could be seamlessly implemented in the ED. Below is a comparison of common AUD screening instruments:

Table 1. Screening Tools for Alcohol Use Disorder

The National Institute on Alcohol Abuse and Alcoholism developed the Single Alcohol Screening Question as a tool to help rapidly identify and increase the screening for alcohol use disorder.¹⁰ It was initially intended for use in the primary care setting, and when studied, it has been shown to have a roughly 82% sensitivity and 80% specificity for identifying unhealthy alcohol use.¹⁰ While the ED is a vastly different setting than primary care, a rapid identification tool with a sensitivity and specificity of over 80% would be useful for universal screening programs. On the other hand, the screening test for at-risk drinking (STAD) was developed from the longer AUDIT tool and was validated in the acute care setting. When used in emergency departments, it has been shown to have sensitivities above 83% and a specificity above 95%.¹⁴ While it has been shown to be effective at identifying patients with AUD, it is slightly longer, and may be challenging to implement in an intake setting, but could be a useful tool for providers to talk through with patients. The alcohol use disorders identification test – consumption of AUDIT-C is a three-question tool that was produced from the longer AUDIT tool, and in primary care validation studies, was shown to have a sensitivity of 100% and specificity above 85%.¹³ Compared to the shorter SASQ or STAD, three questions may be more cumbersome for all patients, but it is the most reliable, concise screening tool, and should be included in any screening program, in some capacity. These three screening tools can each be integrated into the ED, but providers will need to determine which may be best for their specific facility. Using STAD alone, or SASQ and then AUDIT-C could each be potential avenues for use.

Case Updates:

Case 1: “Maybe it’s not just a broken bone”

After the positive screening in intake with the SASQ, the ED provider was alerted with a pop-up message when they opened the patients chart. The ED provider evaluated the patient and examined her right ankle. And while obtaining further history, they began to discuss the patient’s alcohol use. She reported that while she was not intoxicated on this occasion, she has had multiple falls previously while intoxicated. She has tried to cut down on her drinking but has never been able to. The provider then goes through the AUDIT-C screening tool, and the patient scored an 8/12 (positive screening).

Case 2: “Just Another Drunk” in the ED

After a few hours, the patient has started to sober up and now is able to provide additional history. He reports that he was out drinking at a bar that he goes to each day. Had at least 12 drinks. Went outside, sat down and then fell asleep. At this point, he denies any additional complaints. The provider then asks the patient about his thoughts of his alcohol use, and if he has ever attempted or is interested in cutting down.

Case 3: “I was diagnosed with alcohol use disorder in the past”

Before reevaluating the patient, the ED provider skimmed through her chart, and read a prior note from her PCP, showing a full AUDIT screening, and diagnosis of alcohol use disorder. On reevaluation by the ED provider, and she reports that her abdominal discomfort has significantly improved. She goes on to say that she frequently has similar symptoms, which her regular physicians have attributed to her alcohol use. She states that while she has not been interested in the past, she is interested in resources or treatment for her alcohol use disorder now.

Integrating Screening in the ED:

Emergency departments are high-yield venues for detecting AUD, as many patients present with alcohol-related issues or have underlying alcohol use disorder. Our recommendation to improve this is for EDs to implement universal screening. We recommend that screening tools such as the SASQ or STAD be integrated into the intake/triage process and be asked to all patients who present. Nursing staff should be involved with this process to allow for more seamless integration. For positive screens, a notification or alert would be attached to the patient’s chart to prompt ED providers to screen further with the ADUIT-C. For patients who screen positive on AUDIT-C, discussions can be had regarding reducing drinking, resources or referral information, and consideration of medications for alcohol use disorder. To streamline this process, hospitals could develop AUD protocols that outline the screening and treatment process for all providers. 

Medications for Alcohol Use Disorder (MAUD):

Medications for AUD don’t “cure” the disease, but they can reduce cravings and relapse. Recent studies have demonstrated that the initiation of medications such as naltrexone, can effectively initiated in the emergency department.¹⁵ Additionally, in 2024 the Society for Academic Emergency Medicine (SAEM) published the Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4), for Alcohol Use Disorder, which outlined recommendations for treatment in the emergency department.¹⁶ In these recommendations, they highlight naltrexone and acamprosate as first-line treatment options, and recommend that any, “adult ED patients with AUD being discharged home, we suggest prescribing an anti-craving medication”.¹⁶ Below, we outline the primary medications that are used to treat alcohol use disorder.

Table 2. Medications for Alcohol Use Disorder

Naltrexone:

• Contraindicated in patients actively using opioids – may precipitate withdrawal¹⁷
• Naloxone Challenge – No consensus on trial dose (0.2 – 0.4mg IV), we recommend administering 0.4mg IV and observing for signs of withdrawal^17,18
• No longer a black box warning for use in patients with liver dysfunction, but may be beneficial to order baseline LFTs
• Evidence:
  • NNT of 12 to reduce the risk of return to heavy drinking
  • A pilot study demonstrated that initiation of 50 mg in the ED was feasible
  • Extended-release naltrexone was well-liked by patients and associated with significantly improved quality of life and reduced alcohol consumption^15,19,20

Acamprosate:

• Not metabolized by the liver, safe in patients with liver disease, contraindicated in patients with severe renal impairment
• A high daily pill burden may reduce adherence
• Evidence:
  • NNT of 11 to reduce return to heavy drinking^21,22
  • Significantly increases the likelihood of maintaining abstinence
  • Shown to be most effective when patients have already stopped drinking²¹
  • Demonstrated to be significantly more effect when compared to baclofen for reducing alcohol use²³

Disulfiram:

• Aversive agent
• Disulfiram reaction – Accumulation of acetaldehyde, leading to flushing, nausea, and vomiting
  • May reduce adherence
• Evidence:
  • Comparable to naltrexone in one study, for maintaining abstinence and reducing heavy drinking
  • Most effective when administered in a supervised program^24–26
  • Studies have demonstrated that disulfiram can help to maintain abstinence in well-selected patients, but RCTs have not shown efficacy^24,27,28
  • In a large meta-analysis, evidence for disulfiram was poor, and a NNT was unable to be calculated¹⁹

Gabapentin:

• Initially FDA-approved as an antiepileptic, then later to treat neuropathic pain, is not FDA-approved for alcohol use disorder²⁹
• Potential risk of misuse or abuse, but reports and data are inconclusive^16,30
• Evidence:
  • In an RCT of 150 patients, gabapentin was found to significantly increase abstinence rates, reduced heavy drinking days, and cravings when compared to placebo³¹
  • NNT of 8 (lower than naltrexone or acamprosate)³¹
  • Long-term trials have not displayed sustained efficacy

Use of AUD Medications in the ED:

Medications for alcohol use disorder are underutilized in the ED, with fewer than 1% of patients with AUD being started on treatment each year.³² We recommend that any patient who is positively screened for AUD, agrees to starting treatment, and is not actively taking opioids should be initiated on naltrexone. While there is no longer a black box warning for the use of naltrexone in patients with liver dysfunction, and research has shown that it is safe in these patients, checking initial liver function can still be a consideration, but it is not necessary. After naltrexone is thoroughly discussed, patients should be given a naloxone challenge, with a dose of 0.4 mg IV, to assess the risk of precipitated withdrawal with naltrexone administration. While a naloxone challenge is not necessary prior to naltrexone initiation, it does reduce the chance of precipitating withdrawal with its use. If withdrawal symptoms are not induced, then the patient may be given an initial dose of 50 mg PO or a 380 mg dose of IM naltrexone. If PO naltrexone is administered, then the patient should be discharged with a 14-to-30-day prescription for 50 mg naltrexone, and information for a follow-up visit with either a primary care physician or an addiction medicine specialist. If the IM formulation is administered, patients should be instructed to follow up in 1 month for another dose.

While naltrexone is the best option for AUD due to its safety profile, ease of use, and proven effectiveness, if patients are actively taking opioids, or there is concern regarding their liver function, then the next best option in most situations would be acamprosate. While its large pill burden makes it difficult to tolerate, systematic reviews have noted that it does significantly reduce heavy drinking.²⁴ In patients who understand the potential adherence challenges and are highly motivated to maintain their abstinence, acamprosate is a suitable alternative to naltrexone. Less likely to be initiated in the ED, is disulfiram, which works as an aversive agent, leading to an accumulation of acetaldehyde. Disulfiram has had inconsistent data, with some studies demonstrating no benefit, and others showing a benefit only when used in a supervised program.^25,26,28 Gabapentin, is occasionally used off-label for the treatment of AUD, and is recommended as a third-line agent by the SAEM GRACE-4.¹⁶ While there are limited studies demonstrating its effectiveness, it is thought to work well in individuals whose alcohol use is triggered specifically by their withdrawal symptoms.¹⁶ Yet, gabapentin has been misused throughout the country and has potentially been linked to numerous overdose-related deaths.^16,30

In patients suitable for naltrexone initiation, begin treatment. The other MAUD options are probably helpful, but each presents different challenges.

Figure 1. Algorithm to Select MAUD from the SAEM GRACE 4¹⁶

From: Borgundvaag B, Bellolio F, Miles I, et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department.

Novel Pharmacotherapies for AUD

One of the most intriguing new avenues for the treatment of AUD is the use of GLP-1 agonists, such as semaglutide and liraglutide. These medications are theorized to work in substance use disorders by modulating dopamine in the brain regions involved with reward and addiction.³³ In an RCT, semaglutide significantly reduced cravings and the number of drinks when started at initial doses of 0.25 mg.³⁴ A retrospective study, which evaluated both semaglutide and liraglutide, demonstrated that they each significantly reduced hospitalizations due to AUD, and were more effective than other forms of MAUD.³⁵ While these are interesting new treatment options, further research is necessary, and at this time, they are unlikely to be prescribed in the ED for AUD.

Case Conclusions:

Case 1: “Maybe it’s not just a broken bone”

Imaging was negative and she states that her pain has improved after the initial medications. After she had the positive screening with AUDIT-C, the ED provider discussed her alcohol use and treatment options with her. She said that naltrexone sounded like a good option and wanted to start it if possible. She denies any recent opioid use, but to reduce any risk of precipitating withdrawal with naltrexone, the ED provider administered a naloxone challenge dose of 0.4mg IV. She did not display any withdrawal symptoms. She was given an initial dose of 50 mg of naltrexone and then provided a 14-day prescription for 50 mg daily. She was also given a follow up appointment with an addiction medicine provider in 1 week.

Case 2: “Just Another Drunk” in the ED

The patient is now clinically sober, and when speaking with the provider, he says that he is not interested in any alcohol-related resources, as he does not see his alcohol use as a problem. He is seen by peer recovery specialists and given information for addiction services in the area and then discharged home.

Case 3: “I was diagnosed with alcohol use disorder in the past”

The patient felt much better and was now interested in starting treatment for her alcohol use. She says that she is not always the best at remembering to take medications daily, and therefore IM naltrexone was agreed upon. She was given a dose of naloxone, and then an IM injection of 380 mg of naltrexone. She was provided with information for a primary care physician and then discharged with instructions to follow up in one month for another dose of naltrexone.

These cases illustrate that AUD can present in numerous ways, but it is our job to identify and treat as many of these patients as possible. The ED serves as the gateway between the community and the healthcare system, and alcohol use disorder is a monumental barrier that we can help to overcome. While these occurrences may make it more difficult for us to follow through on treating AUD, the hope is that with persistence, these patients will grow comfortable with the ED and may one day be willing to accept help and treatment.

Summary

• AUD Prevalence & Impact: Alcohol Use Disorder affects millions and is associated with numerous detrimental health-related outcomes. Even if this is the 10^th time a patient has been intoxicated or presenting with complaints that are completely unrelated to their alcohol use, every interaction is an opportunity for treatment.
• Screening and Brief Intervention: Routine screening in the ED can identify patients who would benefit from treatment. ED-initiated conversations that destigmatize AUD will help to eliminate barriers that patients routinely face.
• Medications for AUD: Don’t hesitate to start these medications in the ED. All patients with AUD should be offered these medications. Naltrexone (50 mg PO daily or monthly IM) and acamprosate are first-line treatments that significantly improve outcomes.
• ED Workflow and Recommendations: Universal screening, use tools such as SASQ or STAD in triage/intake, and involve nursing staff. If positive screening in intake, then screen patients with AUDIT-C. If MAUD is suitable, then naltrexone is the best option. Administer a trial dose of naloxone prior to naltrexone administration. Ensure that patients have adequate follow-up.

References:

1. Alcohol Use Disorder (AUD) in the United States: Age Groups and Demographic Characteristics | National Institute on Alcohol Abuse and Alcoholism (NIAAA). Accessed July 18, 2025. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-use-disorder-aud-united-states-age-groups-and-demographic-characteristics
2. Alcohol Use Disorder: A Comparison Between DSM–IV and DSM–5 | National Institute on Alcohol Abuse and Alcoholism (NIAAA). Accessed July 18, 2025. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-use-disorder-comparison-between-dsm
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• Authors: Nicholas S. Imperato, DO, MPH (@nickimperato14, Emergency Medicine Resident, Rutgers New Jersey Medical School); Howard A. Greller MD (@heshiegreshie.bsky.social, Medical Toxicology Fellowship Director, Emergency Medicine, Medical Toxicology, Addiction Medicine, Rutgers New Jersey Medical School); Christopher Meaden MD, MS (Director of Medical Toxicology Outpatient Services, Assistant Professor, Emergency Medicine, Medical Toxicology, Addiction Medicine, Rutgers New Jersey Medical School) // Reviewed by: Tony Spadaro MD, MPH (Medical Toxicology and Addiction Medicine Fellow, Rutgers New Jersey Medical School); Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

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