Nudge increases prescriptions of drinking medication

A “nudging” strategy in the emergency department (ED) may be a path for prescribing a medication that can blunt cravings for alcohol—and dull its effects—offering an effective treatment for people with alcohol use disorder (AUD) who might not otherwise receive it.

Researchers used two behavioral science-backed methods to prompt clinicians to prescribe the medication, called naltrexone, to qualified patients, resulting in a 15-fold increase in the likelihood that a patient would leave the emergency department with a prescription. The research from the Perelman School of Medicine at the University of Pennsylvania was recently published in the Annals of Emergency Medicine.

“Nationally, because of stigma and a lack of awareness, we are missing out on a huge opportunity to offer effective treatment to patients who struggle with alcohol,” said first author Jeffrey Ebert, PhD, the director of Applied Behavioral Science at Penn Medicine’s Nudge Unit. “Our work shows that it only takes a small adjustment to make a huge impact on who gets the medicine they need.”

Demonstrating an effective medication with few prescriptions

A 2023 national study found that only 1.9 percent of people with AUD received medication to treat their condition. The initiation of naltrexone in the emergency department is significantly lower: Just 0.5 percent of patients presenting with alcohol use disorder received a prescription from the emergency department.

But, the positive effects of naltrexone have been demonstrated: Compared to those taking placebos, 1 in 11 patients with alcohol use disorder quit drinking altogether when taking naltrexone, with the typical patient reducing their heavy drinking days—characterized as four-plus drinks a day for women, and five-plus for men—by one to two days per month.

With this in mind, the Nudge Unit researchers decided to use Penn Medicine’s own emergency departments to establish a potential solution to spur higher naltrexone prescription numbers.

They employed nudges in two phases:

• The first phase, initiated in March 2024 involved establishing a standardized set of steps for caring for a patient potentially presenting with alcohol use disorder or other forms of problematic drinking, and a formatted discharge order that included a prepopulated order for a naltrexone prescription.
• The second phase began three months later, in August 2024. This phase added questions about alcohol to the typical triage questions nurses asked, and a banner alert in patients’ electronic health records if they had screened potentially positive for harmful drinking. Clicking on it immediately sent the physician to the standardized steps for treating these types of patients and the naltrexone order.

“We were very cognizant of the ‘alert fatigue’ that clinicians experience, so we were sure to make the emergency department electronic health record screening prompts and pre-populated orders seamless, user-friendly, and removed some dated components to make sure there was no extra clutter or time burden,” said senior author M. Kit Delgado, MD, MS, faculty director of the Nudge Unit and an associate professor of Emergency Medicine.

Seeing big increases

The nudges were implemented in four hospitals across the University of Pennsylvania Health System, with two others serving as controls.

At baseline, which included data from two-and-a-half years before the nudges started, only 13 (0.2 percent) of patients with an alcohol-related diagnosis received a naltrexone prescription from the emergency department.

When the nudges began, however, 2.7 percent of these patients were prescribed naltrexone during Phase 1. In Phase 2, that rate increased to 3.2 percent, resulting in 99 patients being prescribed naltrexone in just over a year.

In comparison, at the hospitals with no nudging, naltrexone prescribing remained close to 0 (just 0.3 percent of patients with an alcohol-related diagnosis received a prescription).

The jumps in ordering at the nudge hospitals translated to a 12-fold increase in the likelihood of receiving a naltrexone prescription in the Phase 1 period, and a 15-fold increase during Phase 2.

“Before our intervention, only a handful of experts prescribed naltrexone, and only one patient every couple months left with a prescription,” Ebert explained. “It just wasn’t something routinely done in the emergency department. After our intervention, 46 different clinicians prescribed it, with two patients each week, on average, getting a prescription.”

Implemented elsewhere in Philly…and Bhutan

Amid their findings, study-co-author Jeanmarie Perrone, MD, a professor of Emergency Medicine and the founding director of the Penn Medicine Center for Addiction Medicine and Policy, emphasized the opportunity for spreading the word to other physicians about naltrexone.

“There are highly effective, underutilized, low-cost medications for alcohol use disorder, a disease that affects roughly one in 10 Americans,” said Perrone. “It’s something that, likely, many in our own community have been affected by in their loved ones or personally, so it would be helpful to spread information about these good, accessible treatments.”

Already, the team is working to apply their methods to other emergency departments in the health system that didn’t originally get the nudges.

The team was also called upon to implement their work in low-resource settings like Philadelphia’s Puentes de Salud. The learnings are also being applied further afield: Emergency departments in Bhutan are adopting the nudges, too.

The researchers are also exploring how they could expand screening for alcohol misuse in primary care and effectively connect people to treatment.

This study was supported by philanthropic donations directed to the Penn Medicine Nudge Unit.