🧭 REBEL Rundown
📌 Key Points
- 💊 FDA-Approved Options: Three primary medications for AUD — Naltrexone, Acamprosate, and Disulfiram — should be considered standard therapy.
- 🩺 Naltrexone First-Line: Safe, effective, and easy to start in the ED, with an NNT of 12 to prevent heavy drinking relapse.
- ⚠️ Before Starting Naltrexone: Always check for recent opioid use and consider a naloxone test dose to avoid precipitated withdrawal.
- 💊 Second-Line Therapies: Gabapentin, topiramate, and emerging treatments like GLP-1 agonists (e.g., semaglutide) are options for specific patients.
- 🏥 ED Initiation Matters: Starting medications during the ED visit can bridge gaps in care and increase follow-up treatment engagement.
📝 Introduction
Emergency medicine physicians were trailblazers during the opioid epidemic, and now we have the same opportunity with alcohol use disorder (AUD). Treating AUD deserves the same attention we give to opioid overdose, diabetic ketoacidosis, or hypertensive emergencies. Even when alcohol use doesn’t present as an immediate crisis, each Emergency Department (ED) encounter is a chance to intervene—one that could help prevent future withdrawal, traumatic injury, or upper gastrointestinal bleed. Naltrexone and other Medications for Alcohol Use Disorder (MAUD) can reduce alcohol use, and just 12 patients need treatment to prevent one from returning to heavy drinking.1 By recognizing alcohol use disorder as a critical health issue and leveraging simple, evidence-based tools, emergency physicians can transform routine encounters into life-changing opportunities.
Initiating MAUD in the ED is feasible and impactful.2 Even a single dose of naltrexone can jump-start treatment and is generally safe and well-tolerated. However, MAUD has rarely been offered in the ED, but the growing evidence suggests it increases treatment engagement and reduces drinking.3 Many of these medications have been thoroughly investigated, are safe to administer, and are effective at reducing alcohol consumption. Furthermore. In 2024, the Society for Academic Emergency Medicine (SAEM) published Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4) on alcohol use disorder and recommend prescribing MAUD.4
Many patients with alcohol use disorder face numerous societal obstacles and are less likely to access follow-up care. Therefore, initiating MAUD in the emergency department might be the only opportunity to start treatment.
💊 Medications for Alcohol Use Disorder
Currently, three FDA-approved medications are available for AUD:1
- Naltrexone
- Acamprosate
- Disulfiram.
These agents should be considered routine therapy—just as buprenorphine has become standard for opioid use disorder (OUD). By normalizing their use in the ED, we can close a critical treatment gap and offer patients evidence-based care that changes outcomes.
Other medications such as gabapentin, topiramate, or benzodiazepines are often used as second-line options, and novel agents such as GLP-1 agonists (e.g., semaglutide, etc.) are actively being investigated for use in AUD and other substance use disorders.
Treatments work through different mechanisms. Some reduce cravings (naltrexone, acamprosate), others act as aversive agents (disulfiram), and some serve as substitutes for alcohol during withdrawal management (benzodiazepines). Emerging therapies, such as GLP-1 agonists, are more experimental but show promise. When appropriately selected, each can play a valuable role in patient care.
🩺 Treatment Algorithm
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.
📝 Comparison of Meds for AUD
💡 Our Recommendations
- Offer Medications:
- For patients who screen positive for AUD or express interest in reducing alcohol intake, discuss evidence-based options such as naltrexone or acamprosate.
- If No Screening Protocol Exists:
- Use the full AUDIT tool or simply ask patients if they would like medications to help reduce cravings.
- Before Starting Naltrexone:
- Ask about opioid use history.
- Administer a 0.4 mg IV naloxone challenge dose.
- If no precipitated withdrawal occurs, proceed with treatment.
- Initiate Treatment:
- Oral: Start with 50 mg PO naltrexone.
- Injectable: Start with 380 mg IM naltrexone.
- Discharge Planning:
- If PO naltrexone is given, discharge with a 14–30 day prescription (50 mg daily).
- If IM naltrexone is given, schedule follow-up in one month with primary care or addiction medicine.
- Ensure Continuity of Care:
- Connect all patients started on therapy with both addiction medicine and primary care for ongoing follow-up.
🚨 Clinical Bottom Line
Naltrexone is the best option to treat AUD in the ED, due to its safety profile and proven effectiveness. For patients who are interested in anti-craving medications and screened positive for AUD, trial a dose of naloxone 0.4mg IV, then administer a 50mg PO dose of naltrexone.
🔄 REBEL Recap
📚 References
- Winslow BT, Onysko M, Hebert M. Medications for Alcohol Use Disorder. afp. 2016;93(6):457-465. PMID: 26977830.
- Cowan E, O’Brien-Lambert C, Eiting E, et al. Emergency department–initiated oral naltrexone for patients with moderate to severe alcohol use disorder: A pilot feasibility study. Academic Emergency Medicine. 2025;32(5). PMID: 39776077.
- Englander H, King C, Nicolaidis C, et al. Predictors of opioid and alcohol pharmacotherapy initiation at hospital discharge among patients seen by an inpatient addiction consult service. J Addict Med. 2020;14(5):415-422. PMID: 31868830.
- 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. Academic Emergency Medicine. 2024;31(5):425-455. PMID: 38747203.
- Singh D, Saadabadi A. Naltrexone. In: StatPearls. StatPearls Publishing; 2025. Accessed July 30, 2025. http://www.ncbi.nlm.nih.gov/books/NBK534811/
- Harlow TR, PharmDa, Peters; Jacob R., et al. Successful Naloxone Challenge Test in a Patient With Atrial Flutter. Psychiatrist.com. Accessed July 31, 2025. PMID: 31125192.
- National Institute of Health. [Box], EXHIBIT 3C.1. Naloxone Challenge. 2018. Accessed July 31, 2025. https://www.ncbi.nlm.nih.gov/books/NBK574913/
- Maisel NC, Blodgett JC, Wilbourne PL, Humphreys K, Finney JW. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: When are these medications most helpful? Addiction. 2013;108(2):275-293. PMID: 23075288.
- Murphy CE, Coralic Z, Wang RC, Montoy JCC, Ramirez B, Raven MC. Extended-Release Naltrexone and Case Management for Treatment of Alcohol Use Disorder in the Emergency Department. Ann Emerg Med. 2023;81(4):440-449. PMID: 36328851.
- Agabio R, Lopez-Pelayo H, Bruguera P, et al. Efficacy of medications for the treatment of alcohol use disorder (AUD): A systematic review and meta-analysis considering baseline AUD severity. Pharmacological Research. 2024;209:107454. PMID: 39396764.
Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), and Marco Propersi, DO (X: @Marco_Propersi)
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