Brief Alcohol Interventions to Reduce the Risk of an Alcohol-Exposed Pregnancy: Lessons from the Field

Georgiana Wilton, PhDUniversity of Wisconsin

Department of Family Medicine

CityMatCH Practice CollaborativeOctober 17-19, 2011

Examples for Illustration

The Healthy Moms StudyHealthy Choices

NOTE: Variations on a Theme

Healthy Moms Study: Overview

Goal: To reduce alcohol use in postpartum womenRecruitment and Follow-up: July 2002 – April 2005Recruitment Methods:– Brief Prescreen (6-week postpartum visit)– Baseline Assessment Interview (BAI)– Eligible women were randomized Tx/Control

Healthy Moms Study, cont.

Brief Intervention– 2 face-to-face visits– 2 follow-up phone calls (1 after each visit)– Follow-up interviews at 6- and 12-months post

intervention

Healthy Moms Intervention

Education Component: The Harmful

Effects of Alcohol Use

Define Risky Drinking

Compare Client use…

Make a Plan

Homework

Self-HelpAction Plan

Study Results

Significant reduction in alcohol use at 6-month follow-up– 19% reduction in daily alcohol use– 21% reduction in number of drinking days– 36% reduction in heavy drinking days

Support clinical findings i.e., Floyd et al., 2007, Chang et al., 2005, O’Connor and Whaley, 2007)

Significant reduction in mean depression score compared to baseline in women who received the intervention

Success StoryClaudia* is a professional woman with a high-level job in sales. She participated in two intervention sessions and one brief check-in. She successfully reduced her drinking—below her goal of 2-3 drinks per week. On her last check-in with her interventionist she reported, “My husband feels like he has the ‘old me’ back. I don’t sleep ‘till noon on the weekends. I spend more time with him and my children. I feel like I wasted so much time drinking—and so much energy was lost.”

*Not her real name

Karla* was completing her first intervention session when it became clear that she was depressed. The interventionist provided a brief ‘screen’ per study protocol, and followed the clinic’s protocol in seeking immediate help when it was determined that the woman was suicidal.

A hospital social worker was called, and Karla received immediate clinical intervention.

Upon notification of her physician (per hospital protocol), he indicated, “I provided prenatal care for her for 9 months and never guessed she drank.”

*Not her real name

Success Story

The Healthy Choices Study

The Study in Context…Centers for Disease Control and Prevention Cooperative Agreement

– #U84-CCU524082

One level of a four-tiered ‘dream’ project– Fetal Alcohol Spectrum Disorders Prevention

and Intervention Project (PIP)Awareness campaignSurveillanceMultidisciplinary clinicRandomized clinical trial

The Healthy Choices Study

Randomized trial to test the efficacy of a BI in reducing the risk of an alcohol-exposed pregnancy– Testing difference between in-person

administration and telephone administration– 2-4 session adapted from previous models

within the dept. of family medicine and CDCHealthy Moms; CHIPs, Project ChoicesCombination of motivational interviewing/cognitive behavior therapy

Screening/Intake ProtocolTarget Population:– Sexually active, fertile women ages 18-44– Not using effective contraception

Start Date: August 2006Recruitment End Date: January 2009Recruitment Sites:– Health Clinics (HMO, Public Health)– Institutions of Higher Learning– Community Events– Callers to Healthy Choices Information Line

Health reviewTargeted health informationAlcohol use comparisonAssessment of “readiness to change” Identification of life goalsMaking a planTools for tracking

Content

Key ComponentsLikes/Don’t Likes Health Risks

Key ComponentsComparison of Drinking Readiness to Change

Key ComponentsGoals Goals

Prescreen ResultsN = 3,051

EligibleConsent

EligibleNo Consent

NotEligible

N = 3,051 899 296 1856Average Age 24 24 26*Drank in Past 90 Days 100% 100% 64%Binged in Past 90 Days 98% 99% 25%Binged in Past 90 Days AND Intercourse in Past 90 Days

98% 99% 6%

Smoked in Past 90 Days 43% 42% 24%

Baseline ResultsN = 131

In-Person Telephone

N=131 63 68

Average Age 25 26

Average Education 13 yrs 14 yrs

Race White Black Hispanic Other

65%26%* 6% 3%

62%15% 4% 19%*

Baseline ResultsN = 131

In-Person Telephone

Illegal Drug Use in Past 12 months 71% 65%

Average Total # Drinks in Past 30 Days

34 43

Average Total # Binges in Past 90 Days

14 13

Current Smoker 37% 46%

Follow-Up Results

6-Month Follow-Up 90 Day TLFB

Risk for Alcohol-Exposed Pregnancy 29%

Risk Based on Drinking Criteria 84%

Risk Based on Contraception Criteria 36%

Baseline 90 Day TLFB

Risk for Alcohol-Exposed Pregnancy 100%

Risk Based on Drinking Criteria 100%

Risk Based on Contraception Criteria 100%

In a nutshell…No significant difference between groups–In-person vs. telephone

This is our BIG BANG

Significantly reduced risk of an alcohol-exposed pregnancy

In a nutshell, cont.Significant increase in effective use of contraceptionSignificant reductions in levels of alcohol use from baseline to 6-month follow-up– Total drinks in past 30 days– Total drinks in past 90 days– Total number of drinking days (prev. 30 & 90)– Number of binges in past 30 and 90 days

Lowered risk ≠ No risk

Success StorySarah* is a college student who lives with chronic pain. She used alcohol to relax and help “deal with the pain.” She tended to binge on weekends, and was inconsistent in her use of birth control. Sarah participated in two intervention sessions and one brief check-in. She successfully reduced her drinking—below her goal of 2-3 drinks per week. By her exit interview (12-months), she had eliminated alcohol entirely and had completed six months of contraceptive compliance (she never missed her pill!).

In her 12-month follow-up interview, she commented, “See, I actually learned something from your study” upon completing the contraception usage table. She particularly appreciated the educational section of the workbook and was not aware of the link between alcohol use and an increased risk of breast cancer.

*Not her real name

Karla* is a woman over the age of 40 who was drinking well above recommended levels. She was also in an abusive relationship that often led to inconsistent use of contraception. She had been in AODA treatment in the past and was trying to “manage” on her own. Karla participated in four sessions (two intervention sessions, and two check-in sessions). In her final interview, she admitted needing more support upon completion of the study and accepted a referral into treatment.

She also terminated her unhealthy relationship.

*Not her real name

Success Story

Participant Satisfaction Summary (n=30)

Please rate your feelings for each of the statements below Strongly

AgreeAgree Disagree Strongly

Disagree

Overall, participating in Healthy Choices was helpful to me

27% 63% 10% 0

The printed materials I received were useful to me

23% 54% 23% 0

I felt that the information in Healthy Choices was appropriate to my culture

40% 53% 7% 0

The sessions gave me information about alcohol use I did not know before

23% 44% 33% 0

The sessions gave me information about contraception use I did not know before

13% 50% 34% 3%

I would recommend participating in Healthy Choices to a friend

47% 43% 7% 3%

Participant Satisfaction, cont.Did Participating in Healthy Choices change your behavior in any way?– “I am more aware of how much I drink and have

since always used contraception. I didn’t realize how important these things are and how they played into my life.”

– “I think more about the amount I drink when I go out.”

– “It has moved me to pursue some things that I already knew and needed to pursue.”

Participant Satisfaction, cont.

What was your favorite part about Healthy Choices?– “Facts about drinking averages and effects and unknown

facts about correct usage of contraception.”– “How the counselors talk to you and try and understand you

as a person, not as a person with a problem.”– “Calculating how much money I spend on alcohol in a year’s

time helps me realize how much money I waste by going out so often.”

– “Taking the time to reflect on my personal decisions.”

Is BI for Everybody?

NO!– Alcohol Dependence– Conditions requiring medical management– Individuals with cognitive limitations

Whether developmental in nature, or due to mental health or chronic drinking problems

Can act as a “screening” tool for referral

Samples and Lessons Learned…

Part II

Designing Your Intervention

Feedback from whatever screen you use– Otherwise—the screen is a waste of time– Allows for buy-in from individual you are

concerned about“But, I didn’t mean…”

Asking ‘WHY’– What are some of the good things– What are some of the bad things

Designing Your Intervention

Providing Education– Allows for the discussion of why you are

concerned about their behavior– Provides support to your argument

Showing Comparisons– Their behavior vs. their peers

Designing Your InterventionCost– What is it costing them

$$, Time (or time away from something), EnergyReality check

– Cost of drink vs. Cost of day-fee at health club

Readiness to Change– Where most of the work is– Must be able to ‘step away from the

intervention’Research pressure vs. clinic reality

– You want them to come back!

Designing Your Intervention

Developing a Plan– Can be as simple as, “Can I bring this up

again next time you visit”– Plans can fail

Can people?

What other components should be included?

Traps to Avoid

Question/AnswerConfrontation/DenialExpert vs. StudentLabeling– What do we need to call ‘it’ anything

Premature Focus– Can’t rush the process

Blaming

AVOID: Question/Answer

Tends to elicit passivity in clientClients not encouraged to explore in depth

AVOID: Confrontation/Denial

If client not ‘ready to change’ sessions may become argumentative– T: What about…– C: Yes, but…– T: But what about…– C: Yes, but…

What you might hear…

“But I dilute my shots by adding orange juice, so the alcohol isn’t as bad for me…”

“No, I don’t drink alcohol, only beer…”

Or.…

“Long Island ice tea doesn’t really count, right?”

“No, just one drink, and I hardly ever finish the entire pint.”

AVOID: Expert

Counselor falls into ‘Expert’ role and provides direction before client can explore their own goals

AVOID: Labeling

Client as ‘addict’ ‘alcoholic’ – Accompanied by stigma

Client does not need to have a label to work towards behavior change

For Example

“Are you saying that I’m an alcoholic?”

“What I’m saying is that based on what you’ve told me, I’m concerned about your health and safety. I’d like to talk with you more about this…”

Or…

“you report drinking about 12 drinks each week—mainly on weekends. Did you know that health risks increase for women who drink more than 7 drinks weekly, or more than 3 drinks on any one day. These risks include things like breast cancer…”

AVOID: Premature Focus

Caution against focusing on a problem too quickly–May raise resistance –May focus on unimportant ‘problem’

AVOID: Blaming

Establish ‘no fault’ policy–Don’t play the blame game!–Re-focus

“I’m not interested in who’s to blame, I’m interested in what’s troubling you and what you may be able to do about it”

Change can’t happen in a vacuum!

What’s going on at home?What’s going on in her community?What’s going on in her family?What barriers exist?– We don’t know unless we ask…– Is this the goal of SBI?

Everybody Loves RaymondRay is a pessimist– Wins “Sportswriter of the Year”

Fear of ‘now what’– Gets promotion at work

Fear of added stress, ulcers, etc.

Deborah as counselor– Works to change his thinking

Ray worked to change his thinking– Even when NOBODY around him changed

Could he maintain his new optimism?

What other ‘Traps’ should be avoided?

Tools for the Toolkit

Understanding the difference between the sexes – ‘Gender-responsive’– Understanding relationships– Increased risk during menstrual cycle– Trauma-informed

These issues will come up during the intervention

Tools for the Toolkit

Homework assignments– Journaling assignments, Reading, Checklists,

PracticeResources– Tracking cards

Readiness ruler

Cautions…

Much of MI relies on individual’s ability to draw abstract conclusions and project into the futureTools can be abstractMay be less effective with – Individuals with cognitive limitations– Children and adolescents

Can be adapted to increase usefulness

Cautions, cont…

Because of the non-directive, non-judgmental approach we may not be as happy with our options:– Is it okay for a pregnant woman to not be

ready to cut down or quit drinking?– Is it okay for an individual with one OWI to not

want to change her habits?– Are we comfortable with certain levels of

illegal drug use?

Lessons Learned…

Use the tools in your tool kit!

Meeting ‘site’ -- where they’re atDetermining readiness for adoption of BI into practice– On a scale of 1-10– What would have to happen for you to…

Plan for all contingenciesKnow about time needed, costs involved, level of education/training…

– HAVE A PLAN, but make sure its flexible

Use the tools in your tool kit!

Everything I needed to know about implementing BI I learned from the IRB– …okay, so not really– Similar processes

Minimize riskMaximize outcomeMinimize expenditures (time, energy, money)Maximize outcome

Be prepared to have it take time

The ‘Columbo’ Principle– Staff meetings

Staffing meetings“wouldn’t it be great if we had someone…”

– Policy meetings‘Hmmm…we lost 28 patients last year because of their alcohol…’

– Budget meetingsBilling for SBI services

Be prepared to do the leg work

Determine how to bill insurance providersKnow treatment referral sources– Gender-responsive– Age-responsive– ADA-responsive

Practice the ‘yeah-but’ responses

What has worked in YOUR community?

For More Information on Brief Intervention

US Dept. of Health and Human ServicesSubstance Abuse and Mental Health

Services Administration (SAMHSA)Center for Substance Abuse Treatment

www.samhsa.gov

TIP Series

References

Herman, A. I. & Sofuoglu, M. (2010). Comparison of available treatment for tobacco addiction. Current Psychiatry Reports, 12, 433-440.

Klein, G., et al., Effects of practitioner-delivered brief counseling and computer-tailored letters on cigarettes per day among smokers who did not quit—A quasi-randomized controlled trial. Drug Alcohol Depend. (2010), doi:10.1016/j.drugalcdep.2010.05.016

References

Marcus et al., 2001. Preventive Medicine 33, 204–216 (2001) doi:10.1006/pmed.2001.0873, available online at http://www.idealibrary.com on IDEAL

Miller, W.R., & Sanchez, V. C. (1993). Motivating young adults for treatment and lifestyle change. In G. Howard (Ed.), Issues in alcohol use and misuse in young adults. Notre Dame, IN: University of Notre Dame Press.