KA Bradley MD MPH, Northwest Health Services Research and Development Center of Excellence; Primary and Specialty Medical Care Service, VA Puget Sound Health Care System; Departments of Medicine and Health Services, University of Washington; JL Sporleder BS, Northwest Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System; DR Kivlahan PhD, Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System; Department of Psychiatry and Behavioral Sciences, University of Washington; M Burman MD MPH, Northwest Health Services Research and Development Center of Excellence; Primary and Specialty Medical Care Service, VA Puget Sound Health Care System; Departments of Medicine, University of Washington; MB McDonell MS, Northwest Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System; SD Fihn MD MPH, Northwest Health Services Research and Development Center of Excellence; Primary and Specialty Medical Care Service, VA Puget Sound Health Care System; Departments of Medicine and Health Services, University of Washington.

Objectives: Although 20% of primary care patients screen positive for at-risk drinking, "denial" or lack of readiness to change could result in those at highest risk being resistant to brief counseling or specialized treatment. We evaluated differences in readiness to change reported by low, moderate, and high-risk patients who screened positive for at-risk drinking.

Methods: The Ambulatory Care Quality Improvement Project (ACQUIP) surveyed all General Internal Medicine patients at 7 sites using a screening questionnaire that included items for at-risk drinking. Patients who screened positive for at-risk drinking on a previously validated 7-item augmented CAGE questionnaire or a question about episodic heavy drinking were mailed Drinking Practices Questionnaires (DPQs) that included the Alcohol Use Disorders Identification Test (AUDIT) and questions about alcohol treatment history and readiness to change drinking. In the present analysis, we used the first DPQ returned by each at-risk-drinking patient during Year 1 and excluded patients who skipped questions about alcohol treatment or any of the 3 AUDIT questions about alcohol dependence. At-risk drinkers were divided into three groups. "Low-risk drinkers" reported drinking above recommended levels but scored less than 8 on the AUDIT and reported no past-year adverse consequences due to drinking. "Moderate-risk" drinkers reported at least one past-year adverse consequence due to drinking, but scored < 8 on the AUDIT. "High-risk drinkers" had AUDIT scores >= 8.

Results: Among 4,946 eligible Drinking Practices Questionnaire respondents, 995 (20.1%) were low-risk drinkers, 2,383 (48.2%) moderate-risk drinkers, and 1,568 (31.7%) high-risk drinkers. Of high-risk drinkers, 902 (57.5%) reported at least one symptom of dependence in the past year, compared to only 157 (5.8%) of moderate risk drinkers. High-risk drinkers were most likely to report readiness-to-change. Among high-risk drinkers, 1,224 (78.1%) reported they possibly, probably, or definitely drank more than they should, and 1,348 (86.0%) indicated readiness to change drinking, compared to 173 (17.4%) and 468 (47.0%), respectively, among low-risk drinkers. Moderate risk drinkers were intermediate between the other two groups. Although they often expressed interest in drinking less, 210 (13.4%) high-risk drinkers indicated they had tried unsuccessfully to cut down. Because self-reported previous alcohol treatment was associated with both the severity of at-risk drinking and readiness to change, we used multivariate logistic regression to evaluate the relationship between readiness to change and severity of at-risk drinking, while controlling for previous alcohol treatment. Compared to low-risk drinkers, the relative odds of being ready to change drinking were 2.2 (1.9-2.6) in moderate risk drinkers, and 6.9 (5.7-8.6) in high-risk drinkers, controlling for self-reported previous alcohol treatment.

Conclusions: Among VA general medicine outpatients, those at highest risk due to drinking were most likely to recognize their drinking as excessive, and 86% of high-risk drinkers reported that they were interested in drinking less.

Impact: The VA has mandated annual alcohol screening for all primary care patients. Because a majority of patients at highest risk from drinking are interested in changing their drinking, programs are needed to help these high-risk drinkers successfully reduce their alcohol consumption or abstain.