Implementation of a Hospital-Based Screening and Treatment Program for Unhealthy Alcohol Use
Alcohol use is a major driver of preventable illness, injury, and early death, yet it often goes unrecognized in busy hospital settings. Many hospitalized patients with unhealthy alcohol use, including those with alcohol use disorder (AUD), never receive formal screening, brief counseling, or medication treatment. This study examined whether a comprehensive hospital-based program could close that gap and reduce alcohol-related risk.
Background
Unhealthy alcohol use includes drinking patterns that increase the risk of harm, such as heavy drinking, binge drinking, and alcohol dependence. AUD is the more severe end of this spectrum and can lead to liver disease, pancreatitis, withdrawal symptoms, falls, injuries, depression, and repeated hospitalizations. Professional guidelines recommend routine screening and treatment, but implementation in hospital settings has been inconsistent.
Hospitals may be an especially important place to intervene because many patients are already experiencing health consequences from alcohol use and may be more open to help during admission. The challenge is that alcohol care must fit into a short hospital stay, compete with other urgent medical needs, and be delivered to a diverse patient population, including people who are uninsured, unhoused, or have limited access to outpatient follow-up.
Study Objective
The goal of this quality improvement study was to determine whether a structured screening and treatment protocol for unhealthy alcohol use could be successfully delivered to hospitalized patients and whether it might help reduce alcohol use risk over time.
How the Program Worked
The program was implemented at a single safety-net hospital from September 2022 through September 2024. A safety-net hospital serves a large share of patients who are uninsured, underinsured, or socially vulnerable, making it a particularly meaningful setting for this type of intervention.
Patients were identified in two main ways:
First, admitted patients were screened using the AUDIT-PC, a brief alcohol screening tool. Of 27,914 patients admitted during the study period, 18,146 patients, or 65.0%, were screened. A score of 5 or higher was considered a positive screen, and 1,085 screened positive.
Second, substance use navigators (SUNs) also identified additional patients with unhealthy alcohol use through referral pathways. These navigators are trained staff members who can engage patients, provide counseling, connect them with treatment, and help coordinate follow-up care. Through these referral methods, 257 more patients were identified.
Altogether, 1,342 patients were eligible for intervention.
Intervention Details
Eligible patients were approached by SUNs, who completed the full Alcohol Use Disorders Identification Test, commonly known as AUDIT, and provided brief behavioral counseling. Brief counseling typically includes personalized feedback, discussion of alcohol-related risks, motivational support, and collaborative goal-setting. The aim is not only to inform the patient, but also to help them consider change in a respectful, nonjudgmental way.
Patients with higher risk, defined as an AUDIT score of 12 or greater, were offered medications for alcohol use disorder, often referred to as MAUD. Common evidence-based medications for AUD include naltrexone and acamprosate; other options may include disulfiram in selected patients. These medications can reduce cravings, reduce heavy drinking, and support abstinence depending on the patient’s goals and clinical situation. In this program, medication could be started during the hospital stay and continued at discharge.
Who Was Screened and Treated
Among the 1,342 intervention-eligible patients, the population was socially and clinically diverse. Eighty-one percent were men, and the average age was 51 years. The racial and ethnic composition included 54% Caucasian, 30% Hispanic/Latinx, and 9% Black patients. Seventeen percent were unhoused and 18% were uninsured, highlighting the importance of low-barrier treatment approaches.
Of the 1,342 eligible patients, 800, or 59.6%, engaged in the intervention. Their mean AUDIT score was 15, with a median of 14 and an interquartile range of 8 to 21, indicating that many had clinically significant alcohol-related risk.
Among the 489 patients with AUDIT scores of 12 or greater, 231 patients, or 47.2%, were started on medication before discharge. This finding is notable because starting AUD medication in the hospital is often difficult in real-world practice, despite strong rationale for early treatment.
Main Findings
The study found that the screening and treatment program was feasible to implement in a hospital with a diverse and medically complex patient population. More than half of eligible patients engaged with the intervention, and nearly half of those at higher risk received medication before leaving the hospital.
A subset of patients returned for repeat AUDIT testing. Among the 126 patients with repeat AUDIT assessments, or 25.8% of those eligible for follow-up measurement, the average score dropped by 14.2 points. This is a large reduction and suggests meaningful short-term improvement in alcohol-related risk among patients who were reached again.
The program also examined 30-day return hospital encounters, defined as readmission or emergency department visits. Among patients with AUDIT scores of 12 or greater, 128 patients, or 26.2%, had a return hospital encounter within 30 days of discharge.
Importantly, patients who did not return for another hospital encounter had larger decreases in AUDIT scores than those who did return. Their mean reduction was 16.2 points compared with 9.1 points in the return-encounter group, a difference of 7.1 points. This association does not prove causation, but it suggests that patients who improved more may have been less likely to come back to the hospital in the short term.
Why These Results Matter
This study shows that hospital-based alcohol screening is not just possible in theory; it can be integrated into routine care and paired with active treatment. That matters because many patients with unhealthy alcohol use are missed if hospitals rely only on informal recognition or outpatient referral.
The results also support the idea of risk-stratified care. Patients with lower-risk alcohol use may benefit from counseling and monitoring, while those with higher-risk AUD may need medication and more intensive follow-up. Matching treatment intensity to risk can make care more efficient and more patient-centered.
Another important point is equity. Safety-net hospitals care for patients with high social and economic vulnerability, including people without stable housing or insurance. A program that works in this environment suggests the approach may be scalable to other hospitals that serve complex populations.
Clinical and Practical Implications
Several lessons emerge from this implementation effort. First, structured screening using a brief tool like AUDIT-PC can identify many more patients than unstructured clinical recognition alone. Second, substance use navigators can play a key role in bridging the gap between screening and treatment, especially when physicians and nurses are stretched thin. Third, starting medication for AUD during hospitalization may improve access for patients who might otherwise never reach outpatient addiction care.
The study also reinforces the value of brief behavioral counseling. Even short conversations can help patients reflect on alcohol use, understand medical risks, and take the first steps toward change. In many cases, hospitalization may be a teachable moment when people are more willing to consider treatment.
At the same time, this kind of program is not a complete solution. Some patients did not engage, some did not receive follow-up testing, and only a portion started medication. Ongoing barriers may include stigma, withdrawal symptoms, competing medical priorities, limited time before discharge, and difficulty arranging outpatient support. Future work will need to improve engagement, strengthen continuity after discharge, and evaluate long-term outcomes such as sustained drinking reduction, liver-related complications, and mortality.
Limitations
This was a single-center quality improvement study rather than a randomized controlled trial, so the findings may not apply equally to all hospitals. The follow-up AUDIT data were available only for a subset of patients, which may introduce selection bias. In addition, the study mainly assessed short-term changes, so it cannot determine whether improvements were durable over months or years.
Even with these limitations, the study provides practical evidence that a hospital-based alcohol screening and treatment pathway can be delivered at scale and may produce meaningful early improvements.
Conclusion
A comprehensive hospital program using routine alcohol screening, navigator-led counseling, and medication for higher-risk patients was feasible in a diverse safety-net population. The intervention reached many patients, supported initiation of medication for alcohol use disorder, and was associated with substantial short-term reductions in AUDIT scores among those followed up.
These findings suggest that hospitals can play a more active role in identifying and treating unhealthy alcohol use, potentially improving outcomes for patients who might otherwise go untreated.
