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Aims: This study examined differential changes in alcohol use during the COVID-19 pandemic among adults with unhealthy alcohol use., Methods: Among 62 924 adults identified with unhealthy alcohol use in primary care prepandemic (1 January 2019 to 29 February 2020), changes in alcohol use during the pandemic (1 March 2020 to 30 June 2022) were examined using electronic health record data from Kaiser Permanente Northern California. Outcomes were changes in heavy drinking days in the past three months (HDDs) and overall consumption (drinks/week), including continuous and categorical measures. Differences in outcomes by sex, age, race/ethnicity, and alcohol use disorder (AUD) were examined., Results: On average, drinking was reduced by 3.0 HDDs (in the past three months) (SD = 18.4) and 4.1 drinks/week (SD = 12.2), but women, certain age groups, White patients, and patients without AUD had smaller decreases than their counterparts. Overall, 9.1% increased, 34.4% maintained, and 56.5% decreased HDDs, and 20.2% increased, 19.8% maintained, and 60.1% decreased drinks/week. Women, patients aged ≥35 years, White patients, and patients with AUD had higher odds of increasing versus decreasing HDDs, and maintaining versus decreasing, compared to their counterparts. Patients aged 18-20 years, White patients, and patients without AUD had higher odds than their counterparts of increasing versus decreasing drinks/week. Women, patients aged 18-20 years, Asian/Pacific Islander, and Latino/Hispanic patients had higher odds of maintaining versus decreasing drinks/week., Conclusions: While alcohol use decreased overall among this sample of primary care patients with unhealthy drinking prepandemic, certain subgroups were more likely to increase drinking, suggesting a greater risk of alcohol-related problems., (© The Author(s) 2024. Medical Council on Alcohol and Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)