Comparison of DSM-IV and DSM-5 criteria for alcohol use disorders in VA primary care patients with frequent heavy drinking enrolled in a trial.

BACKGROUND: Criteria for alcohol use disorders (AUD) in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) were intended to result in a similar prevalence of AUD as DSM-IV. We evaluated the prevalence of AUD using DSM-5 and DSM-IV criteria, and compared characteristics of patients who met criteria for: neither DSM-5 nor DSM-IV AUD, DSM-5 alone, DSM-IV alone, or both, among Veterans Administration (VA) outpatients in the Considering Healthier drinking Options In primary CarE (CHOICE) trial. METHODS: VA primary care patients who reported frequent heavy drinking and enrolled in the CHOICE trial were interviewed at baseline using the DSM-IV Mini International Neuropsychiatric Interview for AUD, as well as questions about socio-demographics, mental health, alcohol craving, and substance use. We compared characteristics across 4 mutually exclusive groups based on DSM-5 and DSM-IV criteria. RESULTS: Of 304 participants, 13.8% met criteria for neither DSM-5 nor DSM-IV AUD; 12.8% met criteria for DSM-5 alone, and 73.0% met criteria for both DSM-IV and DSM-5. Only 1 patient (0.3%) met criteria for DSM-IV AUD alone. Patients meeting both DSM-5 and DSM-IV criteria had more negative drinking consequences, mental health symptoms and self-reported readiness to change compared with those meeting DSM-5 criteria alone or neither DSM-5 nor DSM-IV criteria. CONCLUSIONS: In this sample of primary care patients with frequent heavy drinking, DSM-5 identified 13% more patients with AUD than DSM-IV. This group had a lower mental health symptom burden and less self-reported readiness to change compared to those meeting criteria for both DSM-IV and DSM-5 AUD. Trial Registration ClinicalTrials.gov NCT01400581. 2011 February 17.

Patient-centered primary care for adults at high risk for AUDs: the Choosing Healthier Drinking Options In primary CarE (CHOICE) trial.

BACKGROUND: Most patients with alcohol use disorders (AUDs) never receive alcohol treatment, and experts have recommended management of AUDs in primary care. The Choosing Healthier Drinking Options In primary CarE (CHOICE) trial was a randomized controlled effectiveness trial of a novel intervention for primary care patients at high risk for AUDs. This report describes the conceptual and scientific foundation of the CHOICE model of care, critical elements of the CHOICE trial design consistent with the Template for Intervention Description and Replication (TIDieR), results of recruitment, and baseline characteristics of the enrolled sample. METHODS: The CHOICE intervention is a multi-contact, extended counseling intervention, based on the Chronic Care Model, shared decision-making, motivational interviewing, and evidence-based options for managing AUDs, designed to be practical in primary care. Outpatients who received care at 3 Veterans Affairs primary care sites in the Pacific Northwest and reported frequent heavy drinking (≥4 drinks/day for women; ≥5 for men) were recruited (2011-2014) into a trial in which half of the participants would be offered additional alcohol-related care from a nurse. CHOICE nurses offered 12 months of patient-centered care, including proactive outreach and engagement, repeated brief motivational interventions, monitoring with and without alcohol biomarkers, medications for AUDs, and/or specialty alcohol treatment as appropriate and per patient preference. A CHOICE nurse practitioner was available to prescribe medications for AUDs. RESULTS: A total of 304 patients consented to participate in the CHOICE trial. Among consenting participants, 90% were men, the mean age was 51 (range 22-75), and most met DSM-IV criteria for alcohol abuse (14%) or dependence (59%). Many participants also screened positive for tobacco use (44%), depression (45%), anxiety disorders (30-41%) and non-tobacco drug use disorders (19%). At baseline, participants had a median AUDIT score of 18 [Interquartile range (IQR) 14-24] and a median readiness to change drinking score of 5 (IQR 2.75-6.25) on a 1-10 Likert scale. CONCLUSION: The CHOICE trial tested a patient-centered intervention for AUDs and recruited primary care patients at high risk for AUDs, with a spectrum of severity, co-morbidity, and readiness to change drinking. Trial registration The trial is registered at clinicaltrial.gov (NCT01400581).

Prevalence and Factors Associated with Hazardous Alcohol Use Among Persons Living with HIV Across the US in the Current Era of Antiretroviral Treatment.

Hazardous alcohol use is associated with detrimental health outcomes among persons living with HIV (PLWH). We examined the prevalence and factors associated with hazardous alcohol use in the current era using several hazardous drinking definitions and binge drinking defined as ≥5 drinks for men versus ≥4 for women. We included 8567 PLWH from 7 U.S. sites from 2013 to 2015. Current hazardous alcohol use was reported by 27% and 34% reported binge drinking. In adjusted analyses, current and past cocaine/crack (odd ratio [OR] 4.1:3.3-5.1, p < 0.001 and OR 1.3:1.1-1.5, p < 0.001 respectively), marijuana (OR 2.5:2.2-2.9, p < 0.001 and OR 1.4:1.2-1.6, p < 0.001), and cigarette use (OR 1.4:1.2-1.6, p < 0.001 and OR 1.3:1.2-1.5, p < 0.001) were associated with increased hazardous alcohol use. The prevalence of hazardous alcohol use remains high in the current era, particularly among younger men. Routine screening and targeted interventions for hazardous alcohol use, potentially bundled with interventions for other drugs, remain a key aspect of HIV care.

Associations Between At-Risk Alcohol Use, Substance Use, and Smoking with Lipohypertrophy and Lipoatrophy Among Patients Living with HIV.

OBJECTIVE: To examine associations between lipohypertrophy and lipoatrophy and illicit drug use, smoking, and at-risk alcohol use among a large diverse cohort of persons living with HIV (PLWH) in clinical care. METHODS: 7,931 PLWH at six sites across the United States completed 21,279 clinical assessments, including lipohypertrophy and lipoatrophy, drug/alcohol use, physical activity level, and smoking. Lipohypertrophy and lipoatrophy were measured using the FRAM body morphology instrument and associations were assessed with generalized estimating equations. RESULTS: Lipohypertrophy (33% mild, 4% moderate-to-severe) and lipoatrophy (20% mild, 3% moderate-to-severe) were common. Older age, male sex, and higher current CD4 count were associated with more severe lipohypertrophy (p values <.001-.03). Prior methamphetamine or marijuana use, and prior and current cocaine use, were associated with more severe lipohypertrophy (p values <.001-.009). Older age, detectable viral load, and low current CD4 cell counts were associated with more severe lipoatrophy (p values <.001-.003). In addition, current smoking and marijuana and opiate use were associated with more severe lipoatrophy (p values <.001-.03). Patients with very low physical activity levels had more severe lipohypertrophy and also more severe lipoatrophy than those with all other activity levels (p values <.001). For example, the lipohypertrophy score of those reporting high levels of physical activity was on average 1.6 points lower than those reporting very low levels of physical activity (-1.6, 95% CI: -1.8 to -1.4, p < .001). CONCLUSIONS: We found a high prevalence of lipohypertrophy and lipoatrophy among a nationally distributed cohort of PLWH. While low levels of physical activity were associated with both lipohypertrophy and lipoatrophy, associations with substance use and other clinical characteristics differed between lipohypertrophy and lipoatrophy. These results support the conclusion that lipohypertrophy and lipoatrophy are distinct, and highlight differential associations with specific illicit drug use.

Not all non-drinkers with HIV are equal: demographic and clinical comparisons among current non-drinkers with and without a history of prior alcohol use disorders.

Studies of persons living with HIV (PLWH) have compared current non-drinkers to at-risk drinkers without differentiating whether current non-drinkers had a prior alcohol use disorder (AUD). The purpose of this study was to compare current non-drinkers with and without a prior AUD on demographic and clinical characteristics to understand the impact of combining them. We included data from six sites across the US from 1/2013 to 3/2015. Patients completed tablet-based clinical assessments at routine clinic appointments using the most recent assessment. Current non-drinkers were identified by AUDIT-C scores of 0. We identified a prior probable AUD by a prior AUD diagnosis in the electronic medical record (EMR) or a report of attendance at alcohol treatment in the clinical assessment. We used multivariate logistic regression to examine factors associated with prior AUD. Among 2235 PLWH who were current non-drinkers, 36% had a prior AUD with more patients with an AUD identified by the clinical assessment than the EMR. Higher proportions with a prior AUD were male, depressed, and reported current drug use compared to non-drinkers without a prior AUD. Former cocaine/crack (70% vs. 25%), methamphetamine/crystal (49% vs. 16%), and opioid/heroin use (35% vs. 7%) were more commonly reported by those with a prior AUD. In adjusted analyses, male sex, past methamphetamine/crystal use, past marijuana use, past opioid/heroin use, past and current cocaine/crack use, and cigarette use were associated with a prior AUD. In conclusion, this study found that among non-drinking PLWH in routine clinical care, 36% had a prior AUD. We found key differences between those with and without prior AUD in demographic and clinical characteristics, including drug use and depression. These results suggest that non-drinkers are heterogeneous and need further differentiation in studies and that prior alcohol misuse (including alcohol treatment) should be included in behavioural health assessments as part of clinical care.

Suitability of the PROMIS alcohol use short form for screening in a HIV clinical care setting.

BACKGROUND: At-risk alcohol use is important to identify in clinical settings to facilitate interventions. The Patient-Reported Outcomes Measurement Information System (PROMIS) Alcohol Use Short Form was developed through an item response theory process, but its utility as a screening instrument in clinical care has not been reported. OBJECTIVE: To determine the ability of the PROMIS Alcohol Use Short Form to identify people with current or future at-risk alcohol use defined by the Alcohol Use Disorders Identification Test consumption (AUDIT-C) instrument. METHODS: Observational study of people living with HIV (PLWH) in clinical care at four sites across the US. Patients completed a tablet-based clinical assessment prior to seeing their providers at clinic appointments. We used 3 definitions of clinically-relevant at-risk alcohol use and determined the proportion of PLWH with current or future at-risk drinking identified by the PROMIS instrument. RESULTS: Of 2497 PLWH who endorsed ≥1 drink in the prior 12 months, 1500 PLWH (60%) endorsed "never" for all PROMIS items. In that group, 26% had clinically-relevant at-risk alcohol use defined by one or more AUDIT-C definitions. At follow-up (N=1608), high baseline PROMIS scores had 55% sensitivity for at-risk drinking among those with at-risk drinking at baseline, and 22% sensitivity among those without baseline risk. CONCLUSIONS: The PROMIS Alcohol Use Short Form cannot be used alone to identify PLWH with clinically-relevant at-risk alcohol use. Optimal assessment of problem drinking behavior is not clear, but there does not seem to be an important role for the PROMIS instrument in this clinical setting.

Addiction disorders.

Substance use disorders are common in primary care settings, but detection, assessment, and management are seldom undertaken. Substantial evidence supports alcohol screening and brief intervention for risky drinking, and pharmacotherapy is effective for alcohol use disorders. Substance use disorders can complicate the management of chronic noncancer pain, making routine monitoring and assessment for substance use disorders an important aspect of long-term opioid prescribing. Patients with opioid use disorders can be effectively treated with methadone in opioid treatment programs or with buprenorphine in the primary care setting.

Project ECHO: a model for complex, chronic care in the Pacific Northwest region of the United States.

The Pacific Northwest of the US is a large, sparsely populated region. A telehealth programme called Project ECHO (Extension for Community Health Outcomes) was tested in this region in 2009. Weekly videoconferences were held in the areas of hepatitis C, chronic pain, integrated addictions and psychiatry, and HIV/AIDS. Rural clinicians presented cases to a panel of experts at an academic medical centre and received management advice and access to best practices. During the trial, more than 900 clinicians participated, and more than 700 patient cases were presented. At the end of June 2012, a total of 23 videoconference clinics for hepatitis C had been held, 16 clinics in addiction and psychiatry, 97 in chronic pain and 13 in HIV/AIDS. The Project ECHO model improves access to health care. It may provide a way to bring specialist care to rural areas in developing countries.

"Hooked on" prescription-type opiates prior to using heroin: results from a survey of syringe exchange clients.

The availability and diversion of prescription-type opioids increased dramatically in the first decade of the twenty-first century. One possible consequence of increased prescription opioid use and accessibility is the associated rise in opioid dependence, potentially resulting in heroin addiction. This study aimed to determine how common initial dependence on prescription-type opioids is among heroin injectors; associations with demographic and drug-using characteristics were also examined. Interview data were collected at syringe exchanges in King County, Washington in 2009. Among the respondents who had used heroin in the prior four months, 39% reported being "hooked on" prescription-type opioids first. Regression analysis indicated that younger age, sedative use and no recent crack use were independently associated with self-report of being hooked on prescription-type opioids prior to using heroin. These data quantify the phenomenon of being hooked on prescription-type opioids prior to initiating heroin use. Further research is needed to characterize the epidemiology, etiology and trajectory of prescription-type opioid and heroin use in the context of continuing widespread availability of prescription-type opioids.

Problems and concerns of patients receiving chronic opioid therapy for chronic non-cancer pain.

The value of chronic opioid therapy (COT) for chronic non-cancer pain (CNCP) patients is determined by a balance of poorly understood benefits and harms. Traditionally, this balance has been framed as the potential for improved pain control versus risks of iatrogenic addiction, drug diversion, and aberrant drug-related behaviors. These potential harms are typically defined from the providers' perspective. This paper seeks to clarify difficulties with the long-term use of opioids for CNCP from the patients' perspective. We used the Prescribed Opioids Difficulties Scale (PODS) to assess current problems and concerns attributed to opioid use by 1144 adults receiving COT. Subjects were grouped into low (56.9%), medium (25.6%) and high (17.5%) PODS scorers. Among patients with high PODS scores, 64% were clinically depressed and 78% experienced high levels of pain-related interference with activities, compared to 28% depressed and 60% with high interference with activities among those with low PODS scores. High levels of opioid-related problems and concerns were not explained by differences in pain intensity or persistence. Patients with medium to high PODS scores were often concerned about their ability to control their use of opioid medications, but prior substance abuse diagnoses and receiving excess days supply of opioids were much less common in these patients than depression and pain-related interference with activities. These results suggest two types of potential harm from COT attributed by CNCP patients to opioids: psychosocial problems that are distinct from poor pain control and opioid control concerns that are distinct from opioid misuse or addiction.

Relationship of opioid use and dosage levels to fractures in older chronic pain patients.

BACKGROUND: Opioids have been linked to increased risk of fractures, but little is known about how opioid dose affects fracture risk. OBJECTIVE: To assess whether risk of fracture increases with opioid dose among older patients initiating sustained use of opioids for chronic non-cancer pain. DESIGN: A cohort study that uses Cox proportional hazards models to compare fracture risk among current opioid users vs. persons no longer using opioids. PARTICIPANTS: Members of an integrated health care plan (N = 2,341) age 60 years and older who received 3+ opioid prescriptions within a 90-day period for chronic, non-cancer pain between 2000 and 2005. MEASUREMENTS: Time-varying measures of opioid use and average daily dose in morphine equivalents were calculated from automated data. Fractures were identified from automated data and then validated through medical record review. RESULTS: Compared with persons not currently using opioids, opioid use was associated with a trend towards increased fracture risk (1.28 (95% CI (0.99, 1.64 )). Higher dose opioid use (>or=50 mg/day) was associated with a 9.95% annual fracture rate and a twofold increase in fracture risk (2.00 (95% CI (1.24, 3.24)). Of the fractures in the study cohort, 34% were of the hip or pelvis, and 37% were associated with inpatient care. CONCLUSIONS: Higher doses (>or=50 mg/day) of opioids for chronic non-cancer pain were associated with a 2.00 increase in risk of fracture confirmed by medical record review. Clinicians should consider fracture risk when prescribing higher-dose opioid therapy for older adults.

Gender differences in chronic medical, psychiatric, and substance-dependence disorders among jail inmates.

OBJECTIVES: We investigated whether there were gender differences in chronic medical, psychiatric, and substance-dependence disorders among jail inmates and whether substance dependence mediated any gender differences found. METHODS: We analyzed data from a nationally representative survey of 6982 US jail inmates. Weighted estimates of disease prevalence were calculated by gender for chronic medical disorders (cancer, hypertension, diabetes, arthritis, asthma, hepatitis, and cirrhosis), psychiatric disorders (depressive, bipolar, psychotic, posttraumatic stress, anxiety, and personality), and substance-dependence disorders. We conducted logistic regression to examine the relationship between gender and these disorders. RESULTS: Compared with men, women had a significantly higher prevalence of all medical and psychiatric conditions (P < or = .01 for each) and drug dependence (P < .001), but women had a lower prevalence of alcohol dependence (P < .001). Gender differences persisted after adjustment for sociodemographic factors and substance dependence. CONCLUSIONS: Women in jail had a higher burden of chronic medical disorders, psychiatric disorders, and drug dependence than men, including conditions found more commonly in men in the general population. Thus, there is a need for targeted attention to the chronic medical, psychiatric, and drug-treatment needs of women at risk for incarceration, both in jail and after release.

Trends in long-term opioid therapy for chronic non-cancer pain.

OBJECTIVE: To report trends and characteristics of long-term opioid use for non-cancer pain. METHODS: CONSORT (CONsortium to Study Opioid Risks and Trends) includes adult enrollees of two health plans serving over 1 per cent of the US population. Using automated data, we constructed episodes of opioid use between 1997 and 2005. We estimated age-sex standardized rates of opioid use episodes beginning in each year (incident) and on-going in each year (prevalent), and the per cent change in rates annualized (PCA) over the 9-year period. Long-term episodes were defined as > 90 days with 120+ days supply or 10+ opioid prescriptions in a given year. RESULTS: Over the study period, incident long-term use increased from 8.5 to 12.1 per 1000 at Group Health (GH) (6.0% PCA), and 6.3 to 8.6 per 1000 at Kaiser Permanente of Northern California (KPNC) (5.5% PCA). Prevalent long-term use doubled from 23.9 to 46.8 per 1000 at GH (8.5% PCA), and 21.5 to 39.2 per 1000 at KPNC (8.1% PCA). Non-Schedule II opioids were the most commonly used opioid among patients engaged in long-term opioid therapy, particularly at KPNC. Long-term use of Schedule II opioids also increased substantially at both health plans. Among prevalent long-term users in 2005, 28.6% at GH and 30.2% at KPNC were also regular users of sedative hypnotics. CONCLUSION: Long-term opioid therapy for non-cancer pain is increasingly prevalent, but the benefits and risks associated with such therapy are inadequately understood. Concurrent use of opioids and sedative-hypnotics was unexpectedly common and deserves further study.

Trends in prescribed opioid therapy for non-cancer pain for individuals with prior substance use disorders.

Long-term opioid therapy for non-cancer pain has increased. Caution is advised in prescribing for persons with substance use disorders, but little is known about actual health plan practices. This paper reports trends and characteristics of long-term opioid use in persons with non-cancer pain and a substance abuse history. Using health plan data (1997-2005), the study compared age-sex-standardized rates of incident, incident long-term and prevalent long-term prescription opioid use, and medication use profiles in those with and without substance use disorder histories. The CONsortium to Study Opioid Risks and Trends study included adult enrollees of two health plans, Kaiser Permanente of Northern California (KPNC) and Group Health Cooperative (GH) of Seattle, Washington. At KPNC (1999-2005), prevalence of long-term use increased from 11.6% to 17.0% for those with substance use disorder histories and from 2.6% to 3.9% for those without substance use disorder histories. Respective GH rates (1997-2005), increased from 7.6% to 18.6% and from 2.7% to 4.2%. Among persons with an opioid disorder, KPNC rates increased from 44.1% to 51.1%, and GH rates increased from 15.7% to 52.4%. Long-term opioid users with a prior substance abuse diagnosis received higher dosage levels, were more likely to use Schedule II and long-acting opioids, and were more often frequent users of sedative-hypnotic medications in addition to their opioid use. Since these patients are viewed as higher risk, the increased use of long-term opioid therapy suggests the importance of improved understanding of the benefits and risks of opioid therapy among persons with a history of substance abuse, and the need for more careful screening for substance abuse history than is the usual practice.

Measurement of opioid problems among chronic pain patients in a general medical population.

INTRODUCTION: Chronic opioid therapy for non-malignant pain has greatly expanded, increasing the urgency of identifying those experiencing problems related to prescribed opioids. The Prescription Drug Use Questionnaire (PDUQ), which shares substantial content with subsequently developed instruments, was developed within a pain clinic setting designed to identify problematic opioid use. The utility of the PDUQ and its relationship with the DSM-IV approach needs to be established for patients being treated in general medical settings. METHODS: Patients (n=704) from a large HMO prescribed opioids chronically were interviewed using the PDUQ and the Composite International Diagnostic Interview (CIDI) DSM-IV opioid abuse and dependence instrument. The internal reliability of the PDUQ was assessed. Factor analytic procedures were utilized to determine the factor structure of the PDUQ alone and in combination with CIDI DSM-IV. RESULTS: The internal reliability of the PDUQ in this population was poor (Cronbach's coefficient alpha=0.56) compared to the original development study (alpha=0.81). Factor analysis of a reduced set of PDUQ items yielded three factors: addictive behaviors, addictive concerns, and pain treatment problems. Factor analysis combining DSM-IV and PDUQ items indicated abuse and dependence were a single, distinct factor. CONCLUSIONS: In this study of chronic pain patients on opioids in a general medical population, the PDUQ performed differently than in previously described pain clinic populations. CIDI DSM-IV items were distinct from a reduced set of PDUQ items, suggesting the need to reconsider approaches to the measurement of opioid problems for these patients. The four factors identified deserve further study, as they may signal the need for distinct interventions to improve the care of patients prescribed chronic opioid therapy for pain.

How primary care providers talk to patients about alcohol: a qualitative study.

BACKGROUND: Alcohol misuse is a common and well-documented source of morbidity and mortality. Brief primary care alcohol counseling has been shown to benefit patients with alcohol misuse. OBJECTIVE: To describe alcohol-related discussions between primary care providers and patients who screened positive for alcohol misuse. DESIGN: An exploratory, qualitative analysis of audiotaped primary care visits containing discussions of alcohol use. PARTICIPANTS: Participants were 29 male outpatients at a Veterans Affairs (VA) General Internal Medicine Clinic who screened positive for alcohol misuse and their 14 primary care providers, all of whom were participating in a larger quality improvement trial. MEASUREMENTS: Audiotaped visits with any alcohol-related discussion were transcribed and coded using grounded theory and conversation analysis, both qualitative research techniques. RESULTS: Three themes were identified: (1) patients disclosed information regarding their alcohol use, but providers often did not explore these disclosures; (2) advice about alcohol use was typically vague and/or tentative in contrast to smoking-related advice, which was more common and usually more clear and firm; and (3) discomfort on the part of the provider was evident during alcohol-related discussions. LIMITATIONS: Generalizability of findings from this single-site VA study is unknown. CONCLUSION: Findings from this single site study suggest that provider discomfort and avoidance are important barriers to evidence-based brief alcohol counseling. Further investigation into current alcohol counseling practices is needed to determine whether these patterns extend to other primary care settings, and to inform future educational efforts.

Readiness to change in primary care patients who screened positive for alcohol misuse.

PURPOSE: Readiness to change drinking may influence the content or effectiveness of brief alcohol counseling. This study was designed to assess readiness to change and its relationship to alcohol misuse severity among primary care patients whose screening questionnaire was positive for alcohol misuse. METHODS: This study was a cross-sectional analysis of data collected from 2 consecutive mailed questionnaires. Male outpatients at 7 Veterans Affairs (VA) general medicine clinics were eligible if they returned both questionnaires, screened positive for alcohol misuse (augmented CAGE Questionnaire > or =1 point), responded to 3 readiness-to-change questions, and completed the Alcohol Use Disorders Identification Test (AUDIT). A validated algorithm based on 3 standardized questions categorized participants into 3 readiness groups (precontemplation, contemplation, action). Measures of alcohol misuse severity included AUDIT, CAGE, and the 3 consumption questions from the AUDIT (AUDIT-C). Analyses were descriptive; linear-by-linear associations between alcohol misuse severity and readiness were tested with chi2 statistics. RESULTS: Response rates to the first and second surveys were 59% and 55%, respectively. Of the 6,419 eligible outpatients who screened positive for alcohol misuse, 4,797 (75%) reported any readiness to change (contemplation 24%, action 51%). Among patients with AUDIT scores >8, more than 90% indicated that they drank more than they should and/or had contemplated drinking less. Greater readiness was significantly associated with greater alcohol misuse severity (P <.001 for all measures). CONCLUSIONS: Most primary care patients who screen positive for alcohol misuse indicate some readiness to change. Contrary to stereotypes of denial, those with greater alcohol misuse severity are more likely to report readiness to change.

Alcohol-related advice for Veterans Affairs primary care patients: Who gets it? Who gives it?

OBJECTIVE: Most patients who misuse alcohol do not receive alcohol counseling from their providers. This study evaluated primary care patient and provider characteristics associated with receipt of alcohol-related advice and whether patients were advised to drink less or to abstain. METHOD: Outpatients from seven Veterans Affairs (VA) general medicine clinics were eligible if they screened positive for alcohol misuse, completed the Alcohol Use Disorders Identification Test (AUDIT) and answered questions about alcohol-related treatment and advice. Hierarchical logistic regression was used to evaluate patient and provider characteristics associated with patient reports of alcohol-related advice from a primary care provider in the past year. RESULTS: Among 5191 patients with alcohol misuse in the past year, 1554 (30%) reported receiving alcohol-related advice from their primary care provider during that time. Of patients advised, 73% reported advice to abstain. The likelihood of reporting advice increased as AUDIT scores increased: from 13% of patients with AUDIT scores <8 to 71% of those with scores > or =20. After adjustment for important confounders, measures reflecting the severity of alcohol misuse were most strongly associated with receipt of alcohol-related advice. Adjusted analyses also revealed increased odds of receiving advice among patients who reported liver disease, hypertension, current smoking or continuity of care. No measured provider characteristic was associated with giving advice in the fully adjusted model. CONCLUSIONS: This multisite VA study found that most patients with alcohol misuse did not receive alcohol counseling from a primary care provider. Moreover, providers predominantly offered advice to abstain, and they appeared to focus on patients with the most severe problems due to drinking or medical contraindications to drinking.