A Randomized Controlled Trial of Brief Intervention by Interactive Voice Response.

AIMS: To determine the effect of an Interactive Voice Response (IVR) brief intervention (BI) to reduce alcohol consumption among adults seeking primary care. METHODS: Patients (N = 1855) with unhealthy drinking were recruited from eight academic internal medicine and family medicine clinics and randomized to IVR-BI (n = 938) versus No IVR-BI control (n = 917). Daily alcohol consumption was assessed at baseline, 3- and 6-months using the Timeline Followback. RESULTS: The IVR-BI was completed by 95% of the 938 patients randomized to that condition, and 62% of them indicated a willingness to consider a change in their drinking. Participants in both conditions significantly reduced consumption over time, but changes were not different between groups. Regardless of condition, participants with alcohol use disorder (AUD) showed significant decreases in drinking outcomes. No significant changes were observed in patients without AUD, regardless of condition. CONCLUSION: Although the IVR intervention was well accepted by patients, there was no evidence that IVR-BI was superior to No IVR-BI for reducing drinking in the subsequent 6 months. Because both the design and the intervention tested were novel, we cannot say definitively why this particular eHealth treatment lacked efficacy. It could be useful to evaluate the effect of the pre-randomization assessment alone on change in drinking. The high treatment engagement rate and successful implementation protocol are strengths, and can be adopted for future trials. SHORT SUMMARY: We examined the efficacy of a novel BI for patient self-administration by automated telephone. Alcohol consumption decreased over time but there were no between-group changes in consumption. Regardless of treatment condition, participants with alcohol use disorder (AUD) showed significant reduction in drinking but participants without AUD showed no change.

A Randomized Controlled Trial of IVR-Based Alcohol Brief Intervention to Promote Patient-Provider Communication in Primary Care.

BACKGROUND: Brief interventions for unhealthy drinking in primary care settings are efficacious, but underutilized. Efforts to improve rates of brief intervention though provider education and office systems redesign have had limited impact. Our novel brief intervention uses interactive voice response (IVR) to provide information and advice directly to unhealthy drinkers before a physician office visit, with the goals of stimulating in-office dialogue about drinking and decreasing unhealthy drinking. This automated approach is potentially scalable for wide application. OBJECTIVE: We aimed to examine the effect of a pre-visit IVR-delivered brief alcohol intervention (IVR-BI) on patient-provider discussions of alcohol during the visit. DESIGN: This was a parallel group randomized controlled trial with two treatment arms: 1) IVR-BI or 2) usual care (no IVR-BI). PARTICIPANTS: In all, 1,567 patients were recruited from eight university medical center-affiliated internal medicine and family medicine clinics. INTERVENTIONS: IVR-BI is a brief alcohol intervention delivered by automated telephone. It has four components, based on the intervention steps outlined in the National Institute of Alcohol Abuse and Alcoholism guidelines for clinicians: 1) ask about alcohol use, 2) assess for alcohol use disorders, 3) advise patient to cut down or quit drinking, and 4) follow up at subsequent visits. MAIN MEASURES: Outcomes were patient reported: patient-provider discussion of alcohol during the visit; patient initiation of the discussion; and provider's recommendation about the patient's alcohol use. KEY RESULTS: Patients randomized to IVR-BI were more likely to have reported discussing alcohol with their provider (52 % vs. 44 %, p = 0.003), bringing up the topic themselves (20 % vs. 12 %, p < 0.001), and receiving a recommendation (20 % vs. 14 %, p < 0.001). Other predictors of outcome included baseline consumption, education, age, and alcohol use disorder diagnosis. CONCLUSIONS: Providing automated brief interventions to patients prior to a primary care visit promotes discussion about unhealthy drinking and increases specific professional advice regarding changing drinking behavior.

Feasibility of automated pre-screening for lifestyle and behavioral health risk factors in primary care.

BACKGROUND: Screening of primary care patients for unhealthy behaviors and mental health issues is recommended by numerous governing bodies internationally, yet evidence suggests that provider-initiated screening is not routine practice. The objective of this study was to implement systematic pre-screening of primary care patients for common preventive health issues on a large scale. METHODS: Patients registered for non-acute visits to one of 40 primary care providers from eight clinics in an Academic Medical Center health care network in the United States from May, 2012 to May, 2014 were contacted one- to three-days prior to their visit. Patients were invited to complete a questionnaire using an Interactive Voice Response (IVR) system. Six items assessed pain, smoking, alcohol use, physical activity, concern about weight, and mood. RESULTS: The acceptance rate among eligible patients reached by phone was 65.6 %, of which 95.5 % completed the IVR-Screen (N = 8,490; mean age 57; 57 % female). Sample demographics were representative of the overall primary care population from which participants were drawn on gender, race, and insurance status, but participants were slightly older and more likely to be married. Eighty-seven percent of patients screened positive on at least one item, and 59 % endorsed multiple problems. The majority of respondents (64.2 %) reported being never or only somewhat physically active. Weight concern was reported by 43.9 % of respondents, 36.4 % met criteria for unhealthy alcohol use, 23.4 % reported current pain, 19.6 % reported low mood, and 9.4 % reported smoking. CONCLUSIONS: The percent endorsement for each behavioral health concern was generally consistent with studies of screening using other methods, and contrasts starkly with the reported low rates of screening and intervention for such concerns in typical PC practice. Results support the feasibility of IVR-based, large-scale pre-appointment behavioral health/ lifestyle risk factor screening of primary care patients. Pre-screening in this population facilitated participation in a controlled trial of brief treatment for unhealthy drinking, and also could be valuable clinically because it allows for case identification and management during routine care.

Natural history of attempts to stop smoking.

INTRODUCTION: This study provides a prospective fine-grain description of the incidence and pattern of intentions to quit, quit attempts, abstinence, and reduction in order to address several clinical questions about self-quitting. METHODS: A total of 152 smokers who planned to quit in the next 3 months called nightly for 12 weeks to an Interactive Voice Response system to report cigarettes/day, quit attempts, intentions to smoke or not in the next day, and so forth. No treatment was provided. RESULTS: Most smokers (60%) made multiple transitions among smoking, reduction, and abstinence. Intention to not smoke or quit often did not result in a quit attempt but were still strong predictors of a quit attempt and eventual abstinence. Most quit attempts (79%) lasted less than 1 day; about one fifth (18%) of the participants were abstinent at 12 weeks. The majority of quit attempts (72%) were not preceded by an intention to quit. Such quit attempts were shorter than quit attempts preceded by an intention to quit (<1 day vs. 25 days). Most smokers (67%) used a treatment, and use of a treatment was nonsignificantly associated with greater abstinence (14 days vs. 3 days). Making a quit attempt and failing early predicted an increased probability of a later quit attempt compared to not making a quit attempt early (86% vs. 67%). Smokers often (17%) failed to report brief quit attempts on an end-of-study survey. CONCLUSIONS: Cessation is a more chronic, complex, and dynamic process than many theories or treatments assume.

Alcohol, moods and male-female differences: daily interactive voice response over 6 months.

AIMS: The goal of this study was to better understand the predictive relationship in both directions between negative (anger, sadness) and positive (happiness) moods and alcohol consumption using daily process data among heavy drinkers. METHODS: Longitudinal daily reports of moods, alcohol use and other covariates such as level of stress were assessed over 180 days using interactive voice response telephone technology. Participants were heavy drinkers (majority meeting criteria for alcohol dependence at baseline) recruited through their primary care provider. The sample included 246 (166 men, 80 women) mostly Caucasian adults. Longitudinal statistical models were used to explore the varying associations between number of alcoholic drinks and mood scores the next day and vice versa with gender as a moderator. RESULTS: Increased alcohol use significantly predicted decreased happiness the next day (P < 0.005), more strongly for females than males. Increased anger predicted higher average alcohol use the next day for males only (P < 0.005). CONCLUSION: This daily process study challenges the notion that alcohol use enhances positive mood for both males and females. Our findings also suggest a strong association between anger and alcohol use that is specific to males. Thus, discussions about the effects of drinking on one's feeling of happiness may be beneficial for males and females as well as anger interventions may be especially beneficial for heavy-drinking males.

A daily process examination of the bidirectional relationship between craving and alcohol consumption as measured via interactive voice response.

BACKGROUND: Craving is a central component to alcohol use disorders, although there are contradictory findings in the literature regarding the importance of craving in alcohol use. The study goal was to examine the bidirectional relationship between craving and alcohol consumption in heavy drinkers. METHODS: Participants received brief alcohol interventions from their primary care physicians and then were asked to make daily reports of craving and alcohol consumption to an interactive voice response (IVR) telephone system for 180 days. The study sample included 246 participants (166 men) with mean age of 46. Ninety-seven percent were Caucasian and 66% met criteria for alcohol dependence. Analysis used generalized estimating equations (GEE) to evaluate whether craving intensity predicted next day alcohol consumption and whether alcohol consumption predicted next day craving intensity. Significant interactions with gender led to stratified analyses. RESULTS: GEE analyses revealed a significant bidirectional relationship between craving and drinking, where craving intensity predicted next day total drinks consumed (p = 0.001), and total drinks predicted next day craving intensity (p = 0.02). Exploratory analysis found that gender significantly moderated the craving-drinking relationship (p = 0.002) with men increasing next day alcohol use more (b = 0.19) than women (b = 0.08). CONCLUSIONS: Findings suggest a bidirectional relationship between craving and drinking may contribute to the development or maintenance of heavy drinking, particularly for men. Based on our findings, we recommend that during brief interventions, physicians address both drinking and craving and provide advice for coping with craving.

Monitoring daily affective symptoms and memory function using interactive voice response in outpatients receiving electroconvulsive therapy.

OBJECTIVE: Recently, there has been a gradual shift from inpatient-only electroconvulsive therapy (ECT) toward outpatient administration. Potential advantages include convenience and reduced cost. But providers do not have the same opportunity to monitor treatment response and adverse effects as they do with inpatients. This can obviate some of the potential advantages of outpatient ECT, such as tailoring treatment intervals to clinical response. Scheduling is typically algorithmic rather than empirically based. Daily monitoring through an automated telephone, interactive voice response (IVR), is a potential solution to this quandary. METHODS: To test feasibility of clinical monitoring via IVR, we recruited 26 patients (69% female; mean age, 51 years) receiving outpatient ECT to make daily IVR reports of affective symptoms and subjective memory for 60 days. The IVR also administered a word recognition task daily to test objective memory. Every seventh day, a longer IVR weekly interview included questions about suicidal ideation. RESULTS: Overall daily call compliance was high (mean, 80%). Most participants (96%) did not consider the calls to be time-consuming. Longitudinal regression analysis using generalized estimating equations revealed that participant objective memory functioning significantly improved during the study (P < 0.05). Of 123 weekly IVR interviews, 41 reports (33%) in 14 patients endorsed suicidal ideation during the previous week. CONCLUSIONS: Interactive voice response monitoring of outpatient ECT can provide more detailed clinical information than standard outpatient ECT assessment. Interactive voice response data offer providers a comprehensive, longitudinal picture of patient treatment response and adverse effects as a basis for treatment scheduling and ongoing clinical management.

Predictive relationships between chronic pain and negative emotions: a 4-month daily process study using Therapeutic Interactive Voice Response (TIVR).

This article examines temporal relationships between negative emotions and pain in a cohort of 33 patients with chronic musculoskeletal pain enrolled in a telephone-based relapse prevention program (Therapeutic Interactive Voice Response [TIVR]), after 11 weeks of group cognitive behavioral therapy (CBT). Patients were asked to make daily reports to the TIVR system for 4 months after CBT. Patients' daily reports were analyzed with path analysis to examine temporal relationships between 3 emotion variables (anger, sadness, and stress) and 2 pain variables (pain and pain control). As expected, same-day correlations were significant between emotion variables and both pain and pain control. The lagged associations revealed unidirectional relationships between pain and next-day emotions: increased pain predicted higher reports of sadness the following day (P < .05). Conversely, increased pain control predicted decreased sadness and anger the following day (P < .05). Unlike some previous studies, this study did not reveal that an increase of negative emotions predicted increased next-day pain. We speculate that CBT treatment followed by the relapse prevention program teaches patients how to modulate negative emotions such that they no longer have a negative impact on next-day pain perception. The clinical implications of our findings are discussed.

Interactive voice response technology can deliver alcohol screening and brief intervention in primary care.

BACKGROUND: Alcohol screening and brief intervention (BI) is an effective primary care preventive service, but implementation rates are low. Automating BI using interactive voice response (IVR) may be an efficient way to expand patient access to needed information and advice. OBJECTIVE: To develop IVR-based BI and pilot test it for feasibility and acceptability. DESIGN: Single-group pre-post feasibility study. PARTICIPANTS: Primary care patients presenting for an office visit. INTERVENTIONS: IVR-BI structured to correspond to the provider BI method recommended by NIAAA: (1) Ask about use; (2) Assess problems; (3) Advise and Assist for change, and (4) Follow up for continued support. Advice was tailored to patient readiness and preferences. MEASUREMENTS: Utilization rate, call duration, and patients' subjective reports of usefulness, comfort and honesty with the IVR-BI. Pre-post evaluation of motivation to change and change in alcohol consumption as measured by Timeline Follow Back. RESULTS: Call duration ranged from 3-7 minutes. Subjective reactions were generally positive or neutral. About 40% of subjects indicated IVR-BI had motivated them to change. About half of the patients had discussed drinking with their provider at the visit. These tended to be heavier drinkers with greater concerns about drinking. Patients who reported a provider-delivered BI and called the IVR-BI endorsed greater comfort and honesty with the IVR-BI. On average, a 25% reduction in alcohol use was reported two weeks after the clinic visit. CONCLUSIONS: Using IVR technology to deliver BI in a primary care setting is feasible and data suggest potential for efficacy in a larger trial.

Utility of prompting physicians for brief alcohol consumption intervention.

A comprehensive prompting strategy designed to maximize the rate of Brief Intervention (BI) for "heavy drinking" was implemented from 2001 to 2003 for a randomized controlled trial of a post-BI treatment enhancement. Thirty-one internists at four outpatient practices in a county of 150,000 in a rural US state documented their BI's using an intervention checklist. The prompting procedures implemented in this study yielded documented BI for 39% of identified cases, but participation rates varied by physician and clinic and over time. The overall rate was lower than expected. Implications and recommendations for future BI research and training are offered; the paper's limitations are discussed.

A dimensional option for the diagnosis of substance dependence in DSM-V.

In this paper we discuss the creation of dimensional equivalents for categorically defined substance use disorders (SUDs) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), which now is being created. We begin with a review of the considerable literature that has accumulated on the dimensional properties of the SUDs. These studies have primarily examined the alcohol use disorders, but work relevant to other substances is reviewed as well. The weight of evidence indicates that SUDs fit well into a unidimensional concept. We next discuss potential advantages, drawbacks, and challenges in developing a dimensional alternative for the SUDs and highlight some issues for an ongoing research agenda to further explore the challenges. Finally we offer a specific proposal for a SUDs dimensional option for DSM-V. The model we propose is based on, and would relate directly back to, the categorical criteria that will be created for the SUDs by the substance use diagnostic workgroup. It is our contention that offering a dimensional equivalent for the DSM-V categories would be of great value, but that the categorical and dimensional definitions should be based on the same symptoms and closely linked. A dimensional scale that does not relate directly to the categorical definition would be counterproductive.

Should there be both categorical and dimensional criteria for the substance use disorders in DSM-V?

AIMS: As discussed in the following literature review, the relative advantages of categorical and dimensional criteria for classifying the substance use disorders (SUDs) have been debated for many years. The scheduled revision of the Diagnostic and Statistical Manual (DSM) offers an opportunity to re-examine this question. Both categorical and dimensional approaches to diagnosis offer advantages, both may in fact be necessary for a comprehensive taxonomy. METHODS: One means of resolving debate about the direction to take in revising DSM-V and simultaneously of achieving maximum taxonomic utility is to include both categorical and dimensional criteria in DSM-V. This could be accomplished by first defining a set of categorical criteria, as in the previous editions of the DSM. Corresponding dimensional criteria could then be created using a more empirical methodology. In this paper we review some of the relevant literature, offer a specific proposal for a dimensional component for the DSM-V substance use disorders that also preserves the categorical definitions and suggest areas for additional research relevant the this agenda. RESULTS: There is evidence that alcohol and other forms of substance abuse and dependence are heterogeneous categories and that the SUDs can be conceptualized viably as arrayed along a continuum. Amplifying clinically derived categorical definitions with more empirically derived dimensional components to better capture this variability is a particularly important consideration for a substance use research agenda for DSM-V. CONCLUSIONS: It is crucial that a dimensional approach be offered in some form in DSM-V; but it is also vital that any dimensional approach be linked to the categorical definition. The proposal offered herein provides a model for amplifying categorical definitions with a dimensional component in a way that is evolutionary and not disruptive to the existing taxonomy.

Prevalence of DSM/ICD-defined nicotine dependence.

We conducted a qualitative review to estimate for adults (1) the lifetime and current prevalence of DSM/ICD-defined nicotine dependence and (2) the prevalence of individual DSM/ICD dependence criteria. Systematic computer searches and other methods located eleven population-based surveys of adults (>or=18 year olds) and two of young adults (18-30 year olds). In the USA and Germany, about 25% of adults had been dependent on nicotine in their lifetime, including 15% who were currently dependent. Similar or higher rates were seen in Asian men but <5% of Asian women had been dependent. About a third of ever-smokers and half of current smokers either had been or were currently dependent on nicotine and this did not consistently differ by age, country or sex. Impaired control over tobacco use was the most commonly endorsed criteria and giving up activities to use and spending lots of time with nicotine were the least commonly endorsed. Nicotine dependence is one of the most common mental disorders; however, about half of current smokers do not meet DSM/ICD dependence criterion.

An experimental test of assessment reactivity within a web-based brief alcohol intervention study for college students.

OBJECTIVE: Web-based brief alcohol intervention (WBI) programs have efficacy in a wide range of college students and have been widely disseminated to universities to address heavy alcohol use. In the majority of efficacy studies, web-based research assessments were conducted before the intervention. Web-based research assessments may elicit reactivity, which could inflate estimates of WBI efficacy. The current study tested whether web-based research assessments conducted in combination with a WBI had additive effects on alcohol use outcomes, compared to a WBI only. METHODS: Undergraduate students (n=856) from universities in the United States and Canada participated in this online study. Eligible individuals were randomized to complete 1) research assessments+WBI or 2) WBI-only. Alcohol consumption, alcohol-related problems, and protective behaviors were assessed at one-month follow up. RESULTS: Multiple regression using 20 multiply imputed datasets indicated that there were no significant differences at follow up in alcohol use, alcohol-related problems, or protective behaviors used when controlling for variables with theoretical and statistical relevance. A repeated measures analysis of covariance revealed a significant decrease in peak estimated blood alcohol concentration in both groups, but no differential effects by randomized group. There were no significant moderating effects from gender, hazardous alcohol use, or motivation to change drinking. CONCLUSIONS: Web-based research assessments combined with a web-based alcohol intervention did not inflate estimates of intervention efficacy when measured within-subjects. Our findings suggest universities may be observing intervention effects similar to those cited in efficacy studies, although effectiveness trials are needed.

Recruiting 9126 Primary Care Patients by Telephone: Characteristics of Participants Reached on Landlines, Basic Cell Phones, and Smartphones.

In primary care, collecting information about patient health behaviors between appointments can be advantageous. Physicians and researchers who embrace phone-based technology may find valuable ways to monitor patient-reported outcome measures of health (PROM). However, the level of phone technology sophistication should be tailored to the phone use of the population of interest. Despite the growing use of telephones as a means to gather PROM, little is known about phone use among primary care patients. As part of an ongoing study, the authors recruited primary care patients (N = 9126) for a health behavior screening study by calling them on the primary contact number listed in their medical record. The current study evaluated the frequency with which individuals were reached on landlines, basic cell phones, and smartphones, and examined participant characteristics. The majority of participants (63%) used landlines as their primary contact. Of the 37% using cell phones on the recruitment call, most (71%) were using smartphones. Landline users were significantly older than cell phone users (61.4 vs. 46.2 years; P = .001). Cell phone use did not differ significantly between participants with a college education and those without (37% vs. 38%; P = .82); however, smartphone use did differ (61% vs. 77%; P = .01). The majority of participants sampled used landlines as their primary telephone contact. Researchers designing phone-based PROM studies for primary care may have the broadest intervention reach using interactive voice response telephone technology, as patients could report health outcomes from any type of phone, including landlines. (Population Health Management 2016;19:212-215).

Efficacy of automated telephone continuing care following outpatient therapy for alcohol dependence.

BACKGROUND: Relapse rates following cognitive behavioral therapy (CBT) for alcohol dependence are high. Continuing care programs can prolong therapeutic effects but are underutilized. Thus, there is need to explore options having greater accessibility. METHODS: This randomized controlled trial tested the efficacy of a novel, fully automated continuing care program, Alcohol Therapeutic Interactive Voice Response (ATIVR). ATIVR enables daily monitoring of alcohol consumption and associated variables, offers targeted feedback, and facilitates use of coping skills. Upon completing 12weeks of group CBT for alcohol dependence, participants were randomly assigned to either four months of ATIVR (n=81) or usual care (n=77). Drinking behavior was assessed pre- and post-CBT, then at 2weeks, 2months, 4months, and 12months post-randomization. RESULTS: Drinking days per week increased over time for the control group but not the intervention group. There were no significant differences between groups on the other alcohol-related outcome measures. Comparisons on the subset of participants abstinent at the end of CBT (n=72) showed higher rates of continuous abstinence in the experimental group. Effect sizes for the other outcome variables were moderate but not significant in this subgroup. CONCLUSIONS: For continuing care, ATIVR shows some promise as a tool that may help clients maintain gains achieved during outpatient treatment. However, ATIVR may not be adequate for clients who have not achieved treatment goals at the time of discharge.

Recruiting U.S. and Canadian college students via social media for participation in a web-based brief intervention study.

OBJECTIVE: Recruiting young adults for health research is challenging. Social media provides wide access to potential research participants. We evaluated the feasibility of recruiting students via free message postings on Facebook and Twitter to participate in a web-based brief intervention study. The sample comprised students attending U.S. and Canadian universities. METHOD: During three semesters, institutional review board-approved recruitment messages were posted in 281 Facebook groups, 7 Facebook pages, and 27 message "tweets" on Twitter. RESULTS: A total of 708 eligible participants were recruited from Facebook. The mean enrollment rate per Facebook group was 0.21%; the rate was higher for host university groups (1.56%) compared with groups at other universities (0.10%). We recruited seven participants from Twitter. The sample was predominantly female (70%) with a mean age of 20.0 years. There were no significant differences between host university participants recruited through social media and traditional methods. The web-based intervention completion rate was 65%, and participants from the host university were more likely to complete the intervention than were groups at other universities (p = .01). CONCLUSIONS: Social media provides access to a large number of potential participants, and social media recruitment may be useful to researchers who can harness this broad reach. Facebook recruitment was feasible and free and resulted in a large number of enrolled participants. Social media recruitment for researchers at their own universities may be particularly fruitful. Despite wide access to students with Twitter, recruitment was slow. Social media recruitment allowed us to extend web-based intervention access to students in the United States and Canada.

Brief Intervention for Heavy Drinking in Primary Care: Role of Patient Initiation.

BACKGROUND: Alcohol brief intervention (BI) in primary care (PC) is effective, but remains underutilized despite multiple efforts to increase provider-initiated BI. An alternative approach to promote BI is to prompt patients to initiate alcohol-related discussions. Little is known about the role of patients in BI delivery. OBJECTIVES: To determine the characteristics of PC patients who reported initiating BI with their providers, and to evaluate the association between the initiator (patient vs provider) and drinking after a BI. METHODS: In the context of clinical trial, patients (n = 267) who received BI during a PC visit reported on the manner in which the BI was initiated, readiness to change, demographics, and recent history of alcohol consumption. Drinking was assessed again at 6-months after the BI. RESULTS: Fifty percent of patients receiving a BI reported initiating the discussion of drinking themselves. Compared with those who reported a provider-initiated discussion, self-initiators were significantly younger (43.7 years vs 47.1 years; P = 0.03), more likely to meet Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for current major depression (24% vs 14%; P = 0.04), and more likely to report a history of alcohol withdrawal symptoms (68% vs 52%; P < 0.01). Baseline readiness to change, baseline consumption rates, and current DSM-IV alcohol dependence were not different between groups. In the 2 to 3 weeks after BI, self-initiators reported greater decreases in drinks per week (5.7 vs 2.4; P = 0.02), and drinking days per week (1.0 vs 0.3; P = 0.002). At 6-month follow-up, self-initiators showed significantly greater reductions in weekly drinking compared to those whose provider initiated the BI (P = 0.002). CONCLUSIONS: Patient- and provider-initiated BI occurred with equal frequency, and patient-initiated BIs were associated with greater reductions in alcohol use. Future efforts to increase the BI rate in PC should include a focus on prompting patients to initiate alcohol-related discussions.