Underutilization of Medications for Alcohol Use Disorder in United States Emergency Departments

Medications for alcohol use disorder (MAUD), including naltrexone, acamprosate, and gabapentin, reduce high-risk alcohol use and are recommended by the Society for Academic Emergency Medicine’s GRACE-4 guidelines. Despite their efficacy, real-world emergency department (ED) prescribing patterns remain poorly characterized. National data on MAUD prescribing in emergency settings are essential to guide quality improvement. We aimed to assess MAUD use across a large, diverse sample of U.S. EDs using the American College of Emergency Physicians’ E-QUAL quality improvement network.

As part of their participation in the E-QUAL program, enrolled EDs reported data from a random sample of discharged visits with an alcohol-related ICD-10 diagnosis code (F10.x: “alcohol use,” “alcohol abuse,” or “alcohol dependence”). Data abstraction occurred across four reporting periods between May 2024 and November 2025. Sites submitted structured data on demographics, visit characteristics, and whether MAUD - specifically naltrexone, acamprosate, or gabapentin - was prescribed. Descriptive statistics were calculated. Regression analysis was not performed due to low event frequency.

A total of 19,780 visits from 428 geographically diverse EDs across 30 states were included. Mean patient age was 44.0 years (SD 15.4), and 67.4% (n=13,328) were male. Payers were: Medicaid (30.2%, n=5,964), commercial/private (26.5%, 5,232), self-pay/uninsured (25.4%, n=5,032), Medicare (16.8%, n=3,331). Alcohol intoxication was the most common presenting complaint (40.0%, n=7,905), followed by “other” (i.e. non-alcohol-related chief complaint, 27.9%, n=5,506) Alcohol withdrawal represented 11.7% (n=2,312) of visits. MAUD prescribing was infrequent: naltrexone (0.3%, n=51), acamprosate (<0.1%, n=10), and gabapentin (0.5%, n=90).

In this large national sample, MAUD prescribing in the ED was exceedingly rare, despite guideline-based recommendations. These findings reveal a major gap in ED-based care for alcohol use disorder (AUD). Standardized metrics and targeted education could improve uptake and support broader integration of evidence-based AUD treatment into emergency care pathways.