Background: Unhealthy alcohol use is common and associated with an increased a range of adverse health outcomes, including several types of cancer. Guidelines recommend that screening adults and adolescents for unhealthy alcohol use and delivering evidence-based interventions (behavioral or pharmacological) to reduce unhealthy use. Despite these recommendations, adoption of evidence-based screening and treatment for unhealthy alcohol use has been low in the US and globally. 
 
Objective: We sought to develop and evaluate complementary programs to help identify and treat unhealthy alcohol use in a large regional health system serving a population with significant barriers to care.
 
Methods: Based on a review of prior interventions, an assessment of existing resources, and experience in development of other cancer screening and prevention programs, we developed and implemented two linked programs for identification and treatment of unhealthy alcohol use in a large safety net health system in Central Texas. The first program focused on developing an effective means of identifying and treating unhealthy alcohol use in a large academic primary care practice that served a diverse patient population. The program used existing screening data and supplemented that data with telephone-based additional risk assessment and the delivery of a brief, two session intervention by a trained social worker. Patients who screened positive and had highly elevated risk scores on AUDIT-10 suggestive of possible alcohol use disorder were also offered pharmacological treatment to reduce unhealthy use. The second program was based in the system’s acute care hospital. Patients were routinely screened for unhealthy alcohol use prior to the program; after implementation, trained, language-concordant social workers assessed patients who had screened positive or been admitted for alcohol-related conditions. All screen-positive patients received brief intervention to reduce unhealthy use and those at high risk of AUD were offered pharmacological treatment and additional outpatient care, including the option of peer support. For both programs, we measured AUDIT-10 after initial treatment to ensure fidelity and equity of the intervention.
Results: Over 5 years, we have successfully developed and implemented primary care and inpatient screening and treatment for unhealthy alcohol use. Key learning points from implementation include:  1) the importance of capacity-building through social work-trained counselor-navigators; 2) the importance of longitudinal therapeutic relationships to build trust and ensure adherence and the utility of providing such support telephonically (especially important during the acute phases of the COVID-19 pandemic); 3) the ongoing challenge of ensuring that high-risk patients are offered pharmacological therapy to reduce cravings; 4) the challenges of transitioning care from inpatient to ambulatory settings; 5) the opportunity to address other cancer-related risk concurrently through also offering tobacco counseling and pharmacotherapy to patients with concurrent tobacco use.
 
Conclusions and implications for policy: We have successfully implemented scalable evidence-based alcohol screening and brief intervention in safety net health care settings. Policy work is needed to expand and sustain such programs to reduce the burden of alcohol-related related conditions including cancer.