MRFASTC Alcohol Screening and Brief Interventions of Women Competency #2 Midwest Regional Fetal Alcohol Syndrome Training Center

MRFASTC

Alcohol Screening and Brief Interventions of Women

Competency #2Midwest Regional Fetal Alcohol Syndrome Training Center

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Competency 2: Screening and Brief Interventions

• This competency addresses preventing alcohol-exposed pregnancies (AEP) in women of childbearing age through screening and brief interventions for alcohol use.

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Learning Goals

• Appropriately screen women of childbearing age for alcohol use

• Use demographic and other risk factors appropriately in prevention and screening activities

• Appropriately use alcohol screening methods/instruments

• 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 developmental disabilities in the United States!

• Even low levels of alcohol during pregnancy can have negative developmental consequences

• Recommended by the US Preventive Services Task Force and the CDC

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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 more likely to drink during pregnancy

• 53% of non-pregnant women drink, 12% binge drink

• Women may not volunteer information on alcohol intake

• Half of childbearing age women do not use birth control

• Many women do not realize they are pregnant until after the 4th – 6th week of gestation

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Alcohol Consumption by Women – Primary Care Data

Alcohol use among women ages 18-30

33%

39%

17%

7% 4%

Abstainers

Low-Risk

At-Risk

Problem

Dependent

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Alcohol Consumption Among Women

10.112.412.0

1.9 1.9

54.9

0

10

20

30

40

50

60

Any Frequent Binge

Might becomepregnant

Pregnant

Categories of Alcohol Consumption

Per

cen

t W

om

en

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Why Screen Pregnant Women?

• 12% 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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Why Screen Nursing Mothers?

• Infants consume less milk when mothers consume alcohol before breastfeeding

• Exposure to alcohol in mother’s milk results in infant motor development delay

• Exposure to alcohol in mother’s milk shown to interrupt an infant’s sleep/wake pattern

• Early alcohol exposure may increase a child’s risk of addiction to alcohol

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Are Women Being Screened?

• Despite potential risks and established clinical guidelines, 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 ?

• Those who are alcohol dependent or previously abused alcohol while pregnant

• Previous biological child with FASD

• Partner/Family member heavy drinker

• Associated depression

• Other drug or tobacco use

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Risk Factors Who is Likely to Drink ?

• Low socioeconomic status

• Unmarried

• African-American and American-Indian/Alaska-Native ethnicity

• Younger maternal age

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What Tools are Available for Screening?

• National Institute on Alcohol Abuse and Alcoholism (NIAAA) Quantity and Frequency Screen

• Standardized screening instrumentsNo one gold standard existsMost are less accurate when used in women

• Laboratory evaluationNot very sensitive

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What is a Drink?

• Before screening, women should be taught what constitutes a typical drink

• A standard drink is defined as one 12-ounce bottle of beerone 5-ounce glass of wine1.5 ounces of distilled spirits

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NIAAA Quantity/Frequency Screen

1.Do you drink alcohol?

2.On average, how many days a week do you drink?

3.On a day when you drink alcohol, how many drinks do you have?

4.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

• 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 With pregnant patients, must be

administered multiple times

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Recommended Alcohol Screening Instruments

Women TWEAK, T-ACE

Pregnant Women TWEAK, T-ACE

Adolescents CRAFFT

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TWEAK

1. 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? [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 morning? [Eye opener] (yes = 1 point)

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CRAFFT1. 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 Screening

• None are of much clinical useAlcohol is metabolized too quickly to

use blood levels to determine useMost of the others indicate only long-

term use problemsHigh cost make these less feasible

for universal screening

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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 and in conjunction with broader health behavior assessment screening

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Strategies for Overcoming Barriers to Effective Screening

• Using clinic-based system protocols (e.g. patient questionnaires) to prompt provider

• Research alcohol treatment programs prior to need

• Educate payersThese strategies have worked for smoking

cessation, breast cancer screening, diabetes education, etc.

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If Screen is Positive

Determine Drinking Pattern1. Abstainers

2. Low-risk

3. At-risk

4. Problem

5. Alcohol dependent

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Five Drinking Patterns

1. Abstainers No alcohol or fewer than 12

drinks per year

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2. Low-risk drinking7 or fewer drinks per weekNo more than 1 standard drink

per dayNo alcohol use before driving,

when pregnant or breast feeding, or with certain medications

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3. At-risk drinkingmore than 7 standard drinks per

weekmore than 3 standard drinks on any

occasiondrink while pregnant, breast feedingabsence of negative consequences

from drinking


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4. Problem drinkingmore than 7 standard drinks per weekmore than 3 standard drinks on any

occasiondrink while pregnant, breast feedingexperience negative consequences

from drinking (DUIs, MVAs, divorce, loss of employment, etc.)


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5. Alcohol dependent drinkingcan’t stop drinking once started (loss

of control)repeated negative consequences

from drinkingheavy drinking has led to a physical

need for alcohol (e.g. tolerance, withdrawal)


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What We Know About Brief Interventions?

• Decrease alcohol use in both women and men

• Decrease health care utilization and cost

• 1 to 4 sessions at 10 to 15 minutes, scheduled at 2 to 4 week intervals are effective

• Primary care providers can be trained to conduct brief interventions

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Brief Interventions

• 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

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• Referral to alcohol treatment specialist: For women with dependent drinking

patternsPerforming a brief intervention prior to

referral has been shown to increase the patient’s motivation to enter counseling, even if the brief intervention fails

Brief Interventions

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Steps in a Brief Intervention: FRAMES

Step 1 Feedback of personal risk

Step 2 Responsibility of the patient for personal control

Step 3 Advice to change

Step 4 Menu of ways to reduce or stop drinking

Step 5 Empathetic counseling style

Step 6 Self efficacy or optimism of the patient to cut down or stop drinking

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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 current recommendations for you would be to drink less than one drink per day.

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Menu of Ways to Reduce or 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 or 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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• 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?

Empathetic Counseling Style

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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.

• Review progress, drinking diary, revise drinking agreements

• Review goals or set new ones

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Project TrEAT: Subsample of Women 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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Number of Binge Drinking Episodes: Past 30 Days

0

1

2

3

4

5

6

Baseline 6 months 12 months 24 months 36 months 48 months

ControlTreatment

Treatment Control % reduction from: base to 6 months 56.3% 35.5%

base to 12 months 55.5% 32.8%base to 24 months 40.4% 7.1%base to 36 months 41.6% 23.9%base to 48 months 42.2% 17.9%

(more than 4 drinks per occasion)

Repeated measures overall p < 0.001

p<.05

TrEAT Subsample: Women of Childbearing Age

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Percent Drinking Excessively in Past Week

0%

10%

20%

30%

40%

50%

60%

Baseline 6 months 12 months 24 months 36 months 48 months

TreatmentControl% reduction from: base to 6 months 57.4%40.7%

base to 12 months 57.4%42.6%




ControlTreatment

p<.10

p<.05

p<.01

Repeated measures overall p < 0.001

(more than 13 drinks per week)

p<.05

TrEAT Subsample: Women of Childbearing Age

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Useful Websites for Providers

• http://www.cdc.gov/ncbddd/fasd/acog_toolkit.html

• http://www.projectcork.org/clinical_tools/

• http://pathwayscourses.samhsa.gov/vawp/vawp_7_pg2.htm

• http://alcoholism.about.com/library/blnaa56.htm

• http://www.cdc.gov/ncbddd/fasd/hcp.html

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• http://pubs.niaaa.nih.gov/publications/aa65/AA65.htm (screening)

• http://pubs.niaaa.nih.gov/publications/AA66/AA66.htm (brief interventions)

• mimh200.mimh.edu/fas/.../MRFASTIC Atlanta Presentation July 2003.ppt

• http://nofas.org/healthcare/

• http://www.mimhcetv.com/catalog/clin.html

Useful Websites for Providers

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Conclusions

• 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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• Brief Intervention 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 drinkers, whether pregnant or not, should be referred to specialized alcohol treatment programs. A prior brief Intervention can facilitate this referral.

Conclusions

Documents

MRFASTC Alcohol Screening and Brief Interventions of Women Competency #2 Midwest Regional Fetal Alcohol Syndrome Training Center