Hospital stays represent critical intervention windows that healthcare systems consistently underutilize for addiction treatment. Despite decades of evidence supporting medications like naltrexone and acamprosate for alcohol use disorder, most hospitalized patients leave without these potentially life-saving prescriptions. A comprehensive analysis of Veterans Health Administration data reveals concerning gaps in evidence-based care delivery. Among nearly 30,000 hospitalizations specifically for alcohol use disorder across 142 VA hospitals during 2022-2023, only 31% of veterans received medication initiation either during their stay or within the critical first week following discharge. The most frequently prescribed medications were oral naltrexone (58% of cases), acamprosate (17%), and long-acting injectable naltrexone (14%). Veterans were significantly more likely to receive these medications when addiction specialists were consulted or when treated on psychiatry rather than general medicine services. However, concerning disparities emerged: older veterans, men, American Indian and Alaska Native veterans, and those with frailty were systematically less likely to receive medications. This pattern suggests both missed clinical opportunities and potential bias in treatment decisions. The finding that 98% of patients who started medications as inpatients received continued prescriptions within 30 days demonstrates the importance of hospital initiation for establishing ongoing care. Given that alcohol use disorder contributes to over 140,000 annual deaths in the United States, these results highlight a substantial treatment gap even within an integrated healthcare system specifically designed to address veteran health needs comprehensively.