In emergency departments across the University of Pennsylvania Health System, a small shift in how doctors encounter their patients—a pre-populated prescription form here, a triage question there—has transformed the treatment of alcohol use disorder from a rare offering into something approaching standard care. The change is dramatic: researchers at Penn Medicine's Nudge Unit have increased the likelihood that a patient will leave the ED with a prescription for naltrexone, a medication that can blunt cravings and dull the rewarding effects of alcohol, by 15-fold.
The scale of missed opportunity has been staggering. Nationally, only 1.9% of people with alcohol use disorder receive any medication to treat their condition. In emergency departments specifically, that figure plummets to just 0.5%—a gap that persists despite naltrexone's proven effectiveness. Research shows that one in eleven patients with alcohol use disorder quit drinking entirely when taking the medication, while the typical patient cuts their heavy drinking days by one to two days per month.
Jeffrey Ebert, Ph.D., director of Applied Behavioral Science at Penn Medicine's Nudge Unit and lead author of the study published in the Annals of Emergency Medicine, saw this disparity as a problem of systems design rather than evidence. "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," Ebert said. "Our work shows that it only takes a small adjustment to make a huge impact on who gets the medicine they need."
The intervention unfolded in two phases across four University of Pennsylvania hospitals, with two others serving as controls. In the first phase, beginning in March 2024, the team established standardized care steps for patients presenting with alcohol use disorder or problematic drinking, along with a discharge order form that came pre-populated with a naltrexone prescription. At baseline—measuring two-and-a-half years before the nudges—only 0.2% of patients with an alcohol-related diagnosis received naltrexone from the ED. When Phase 1 launched, that jumped to 2.7%.
Three months later, in August 2024, the second phase added screening questions about alcohol to routine triage and created a banner alert in patients' electronic health records. When a physician saw the alert and clicked through, they were guided directly to the standardized treatment protocol and prepopulated order. This phase pushed prescriptions higher still: 3.2% of eligible patients received naltrexone, translating to 99 prescriptions in just over a year.
What made the difference wasn't a new drug or a major clinical breakthrough—it was removing friction from existing practice. As M. Kit Delgado, MD, MS, senior author and faculty director of the Nudge Unit, explained, the team was careful to avoid overwhelming busy clinicians. "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."
The control hospitals, where no nudging occurred, saw naltrexone prescribing remain near baseline at 0.3%. The contrast is striking: small design choices in how information is presented and how work is structured can reshape access to lifesaving treatment. For patients struggling with alcohol use disorder—a condition that claims tens of thousands of lives annually—the difference between 0.2% and 3.2% represents a genuine second chance.