Alcohol Screening and Brief Interventions of Women

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Alcohol Screening and Brief Interventions of
Women

• Competency 2
• Midwest Regional Fetal Alcohol
• Syndrome Training Center
• 2006

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Learning Objectives

• 1. Be able to appropriately screen women of
  childbearing age for alcohol use
• 2. Be able to use demographic and other risk
  factors appropriately in prevention and screening
  activities
• 3. Be able to appropriately use alcohol screening
  methods/instruments
• 4. Be be able to conduct brief interventions with
  women

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Why Screen?

• Alcohol use during pregnancy is one of the
  leading preventable causes of birth defects and
  childhood disabilities in the United States!

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Who Should We Screen?

• All women of child-bearing age
• Pregnant women
• Nursing mothers

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Why Screen Women of Child-Bearing Age?

• Women who drink prior to pregnancy have an
  increased likelihood of drinking during pregnancy
• 53 of women are drinking
• Women may not volunteer information on alcohol
  intake
• Many women do not realize they are pregnant until
  after the 4th 6th week of gestation

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More on Alcohol Consumption by Women Primary
Care Data

• Frequency of alcohol use among women ages 18-30
  in a
• large-scale epidemiological survey of patients
  attending U.S. community-based primary care
  clinics

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Why Screen Pregnant Women?

• 10 of women continue to drink while pregnant
  despite efforts to educate on its dangers
• Alcohol use during pregnancy, even at low intake
  levels, has been associated with significant
  negative consequences, including FASD

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Alcohol Consumption Among Women
52.6
Percent Women
10.1
12.3
13.1
1.9
1.9
Categories of Alcohol Consumption
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Why Screen Nursing Mothers?

• Exposure to alcohol in mothers milk results in a
  delay in infant motor development
• Infants consume less milk when mothers consume
  alcohol before breastfeeding.
• Acute exposure to alcohol in mothers milk has
  been shown to interrupt an infants sleep/wake
  pattern
• Alcohol exposure may affect a childs response to
  alcohol in the future

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Are Women Being Screened?

• Despite potential risks and established clinical
  guidelines, recent data suggest that some
  individuals are not screened for problem drinking
• Physicians are less likely to detect alcohol
  problems in patients that they do not expect to
  have alcohol problems

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Risk Factors Who is Likely to Drink ?

• People who are alcohol dependent or previously
  abused alcohol while pregnant
• Previous biologic child with FASD or ARND
• Low or high socioeconomic status
• Unmarried
• Associated depression/other drug or tobacco use
• Partner/Family member heavy drinker
• African-American and American-Indian/Alaska-Native
  ethnicity

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What Tools are Available for Screening?

• They are numerous
• National Institute on Alcohol Abuse and
  Alcoholism (NIAAA) Quantity and Frequency Screen
• Standardized screening instruments
• no one gold standard exists
• most are less accurate when used in women
• Laboratory evaluation

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NIAAA Quantity/Frequency Screen

• Do you drink alcohol?
• On average, how many days a week do you drink?
• On a day when you drink alcohol, how many drinks
  do you have?
• What is the maximum number of drinks you consumed
  on any given occasion in the past month?

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Recommended Alcohol Screening Instruments in women

• Best instruments should be
• Brief
• Easy to administer and score
• Reliable/accurate in target population

• To be effective they must be
• Used routinely with EVERY patient
• In a pregnant patient, must be administered
  multiple times

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TWEAK

• 1. A How many drinks does it take to feel effects
  of alcohol? Tolerance ( 3 or more drinks 2
  points)
• 2. Have friends/relatives Worried about your
  drinking in the past year? Worried (yes 2
  points)
• 3. Ever drank first thing in the morning?
  Eye-opener (yes 1 point)
• 4. Ever drank but can't remember what you said or
  did in am? Amnesia (yes 1 point)
• 5. Ever feel the need to cut down on your
  drinking? K(C)ut down (yes 1 point)

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T-ACE

• 1. Does it take more than it used to for you to
  get high? Tolerance (yes - 2 points)
• 2. Have you become Angry or Annoyed when others
  express concern about your use? (yes - 1 point)
• 3. Have you tried to Cut down or quit? (yes - 1
  point)
• 4. Have you ever had a drink first thing in the
  am? Eye opener (yes -1 point)

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CRAFFT

• 1. Have you ever ridden in a Car driven by
  someone (including yourself) who was high or had
  been using alcohol or drugs? (Yes 1 point)
• 2. Do you ever use alcohol or drugs to Relax,
  feel better about yourself, or fit in? (Yes 1
  point)
• 3. Do you ever use alcohol or drugs while you
  are by yourself (Alone)? (Yes 1 point)
• 4. Do you ever Forget things you did while using
  alcohol or drugs? (Yes 1 point)
• 5. Do your Family or Friends ever tell you that
  you should cut down on your drinking or drug use?
  (Yes 1 point)
• 6. Have you ever gotten into Trouble while you
  were using alcohol or drugs? (Yes 1 point)

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Laboratory Evaluation

• None are of much clinical use
• Alcohol is metabolized too quickly to use blood
  levels to determine use
• Most of the others indicate only long-term use
  problems

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Strategies for Overcoming Barriers to Effective
Screening

• Increase provider knowledge
• Increase provider comfort
• Designate support staff to assist with screening
• Screen EVERY patient in conjunction with
  broader health behavior assessment screening
• Using clinic-based system protocols (e.g. patient
  questionnaires) to prompt provider
• Research alcohol treatment programs prior to need
• Educate payers
• These strategies have worked for smoking
  cessation, breast cancer screening, diabetes
  education, etc.

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If Screen is Positive

• Determine Drinking Pattern
• Drinking Patterns
• 1 Abstainers
• 2 Low-risk
• 3 At-risk
• 4 Problem
• 5 Alcohol dependent

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A Review of the 5 Patterns of Drinking

• 1 Abstainers
• no alcohol or fewer than 12 drinks/year
• 2 Low-risk drinking
• 3 At-risk drinking
• 4 Problem drinking
• 5 Alcohol dependent drinking

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5 Drinking Patterns (cont.)

• 1 Abstainers
• 2 Low-risk drinking
• 7 or fewer drinks/week
• no more than 1 standard drink/day
• no alcohol use before driving, when pregnant or
  breast feeding, or with certain medications
• 3 At-risk drinking
• 4 Problem drinking
• 5 Alcohol dependent drinking

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5 Drinking Patterns (cont.)

• 1 Abstainers
• 2 Low-risk drinking
• 3 At-risk drinking
• more than 7 standard drinks/week
• more than 3 standard drinks/occasion
• drink while pregnant, breast feeding
• absence of negative consequences from drinking
• 4 Problem drinking
• 5 Alcohol dependent drinking

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5 Drinking Patterns (cont.)

• 1 Abstainers
• 2 Low-risk drinking
• 3 At-risk drinking
• 4 Problem drinking
• more than 7 standard drinks/week
• more than 3 standard drinks/occasion
• drink while pregnant, breast feeding
• experience negative consequences from drinking
  (DUIs, MVAs, divorce, loss of employment, etc.)
• 5 Alcohol dependent drinking

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5 Drinking Patterns (cont.)

• 1 Abstainers
• 2 Low-risk drinking
• 3 At-risk drinking
• 4 Problem drinking
• 5 Alcohol dependent drinking
• cant stop drinking once started (loss of
  control)
• repeated negative consequences from drinking
• heavy drinking has led to a physical need for
  alcohol (e.g. tolerance, withdrawal)

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Brief Interventions

• Brief intervention in the office setting
• For women with at-risk or problem drinking
  patterns
• Non-pregnant woman with intake above low risk
  drinking
• Sexually active, non-pregnant woman NOT using
  effective contraception
• Trying to conceive or Pregnant drinking at any
  level
• Referral to alcohol treatment specialist
• For women with dependent drinking patterns
• Brief intervention has been shown to motivate

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What We Know About Brief Interventions?

• Decreases alcohol use in both women and men
• Decreases health care utilization/cost
• 1 - 4 sessions at 20-30 minutes, scheduled at 2-4
  week intervals are effective
• Primary care providers can be trained to conduct
  brief interventions

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Steps in a Brief Intervention - FRAMES
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Feedback

• I am very concerned about how your drinking is
  affecting your health (e.g. sleeping, social
  issues, increased BP, headaches, elevated LFTs)
• I am concerned about your risk for developing
  liver disease
• There is no known safe limit for drinking during
  pregnancy. You may be causing harm to your baby

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Responsibility

• What you do about your drinking is up to you
• No one else can make you decide to change
• Are you willing to work with me on
  reducing/stopping your alcohol use?

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Advice

• I am worried about the level at which you are
  currently drinking
• The currently recommendations for you would be to
  drink less than one drink per day

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Menu of Ways toReduce/Stop Drinking

• I would like for you to read this pamphlet that
  discusses the use of alcohol and suggest ways to
  help you cut down/stop drinking
• I would like you to sign a Drinking Reduction
  Agreement
• I would like for you to keep a log of every drink
  you take and what you were doing at the time

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Empathetic Counseling Style

• I see from your drinking diary that you drank 5
  beers last Saturday. It is important that we
  begin to identify what situations are proving to
  be risky for you so can you share with me what
  you were doing when you had those 5 drinks? NOT
  Why did you drink 5 beers last Saturday?

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Project TrEAT Subsample of Women Patients of
Childbearing Age

• 64 physicians, 17 clinics in 10 Wisconsin
  counties
• 5,979 female subjects screened with the health
  screening survey
• 205 subjects enrolled
• - 103 experimental
• - 102 control
• Follow-up
• 174 subjects completed 48-month interview (85)
• 97 of subjects completed at least one follow-up
  interview

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Self Efficacy

• Can you share with me some ways that you think
  you could cope with going to that party where all
  of your friends will be drinking?
• I want you to remind yourself daily that you can
  reduce your drinking.

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Follow-up

• Schedule follow-up visit or phone call every 2
  weeks or so during the early part of a brief
  intervention.
• Follow-up with office visit at 1 month, then at
  2-4 week intervals
• Review progress, drinking diary, revise drinking
  agreements
• Review goals or set new ones

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TrEAT Subsample Women of Childbearing Age
plt.05
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TrEAT Subsample Women of Childbearing Age
(more than 13 drinks per week)
plt.10
plt.05
plt.01
plt.05
Control Treatment
Treatment Control reduction
from base to 6 months 57.4 40.7 bas
e to 12 months 57.4 42.6 base to 24
months 61.7 38.9 base to 36
months 68.1 38.9 base to 48
months 68.1 57.4
Repeated measures overall p lt 0.001
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Useful Websites for Providers Who Care for Women

• http//www.projectcork.org/clinical_tools/
• http//www.niaaa.nih.gov/
• http//pathwayscourses.samhsa.gov/vawp/vawp_7_pg2.
  htm
• http//alcoholism.about.com/library/blnaa56.htm
• http//www.cdc.gov/search.do?actionsearchqueryTe
  xtalcoholscreeninginwomenx0y0

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Useful websites for providers who care for women

• http//www.mimh.edu/fas/Powerpoint20Presentations
  /MRFASTIC20Atlanta20Presentation20July202003.p
  pt
• http//nofas.org/healthcare/
• http//www.mimhcetv.com/catalog/clin.html

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Conclusions I

• Identifying at-risk women involves assessment of
  maternal high-risk behavior and appropriate
  screening
• Screens should be brief, reliable and
  ethnic/gender sensitive
• Positive screens should initiate more complete
  assessment of alcohol use and appropriate
  intervention

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Conclusions II

• Brief Intervention has been shown to be a
  low-cost, effective treatment alternative for
  alcohol problems
• Brief intervention can fit into the context of
  busy, high-volume practice settings
• Dependent and Problem drinkers, whether pregnant
  or not, should be referred to specialized alcohol
  treatment programs however, Brief Intervention
  has been shown to facilitate this referral.

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