1 Alcohol Screening and Brief Interventions of Women Competency #2 Midwest Regional Fetal Alcohol Syndrome Training Center
2 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.
3 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
4 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
5 Who Should We Screen? All women of child-bearing age Pregnant women Nursing mothers
6 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
7 Alcohol Consumption by Women Primary Care Data 17% 33% 7% 4% Abstainers Low-Risk At-Risk Problem Dependent 39% Alcohol use among women ages 18-30
8 Percent Women Alcohol Consumption Among Women Might become pregnant Pregnant Any Frequent Binge Categories of Alcohol Consumption
9 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
10 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
11 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
12 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
13 Risk Factors Who is Likely to Drink? Low socioeconomic status Unmarried African-American and American- Indian/Alaska-Native ethnicity Younger maternal age
14 What Tools are Available for Screening? 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 Not very sensitive
15 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 beer one 5-ounce glass of wine 1.5 ounces of distilled spirits
16 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?
17 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
18 Recommended Alcohol Screening Instruments Women TWEAK, T-ACE Pregnant Women TWEAK, T-ACE Adolescents CRAFFT
19 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)
20 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)
21 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)
22 Laboratory Screening None are of much clinical use Alcohol is metabolized too quickly to use blood levels to determine use Most of the others indicate only longterm use problems High cost make these less feasible for universal screening
23 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
24 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 payers These strategies have worked for smoking cessation, breast cancer screening, diabetes education, etc.
25 If Screen is Positive Determine Drinking Pattern 1. Abstainers 2. Low-risk 3. At-risk 4. Problem 5. Alcohol dependent
26 Five Drinking Patterns 1. Abstainers No alcohol or fewer than 12 drinks per year
27 Five Drinking Patterns 2. Low-risk drinking 7 or fewer drinks per week No more than 1 standard drink per day No alcohol use before driving, when pregnant or breast feeding, or with certain medications
28 Five Drinking Patterns 3. At-risk drinking more than 7 standard drinks per week more than 3 standard drinks on any occasion drink while pregnant, breast feeding absence of negative consequences from drinking
29 Five Drinking Patterns 4. Problem drinking more than 7 standard drinks per week more than 3 standard drinks on any occasion drink while pregnant, breast feeding experience negative consequences from drinking (DUIs, MVAs, divorce, loss of employment, etc.)
30 Five Drinking Patterns 5. Alcohol dependent drinking can t 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)
31 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
32 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
33 Brief Interventions Referral to alcohol treatment specialist: For women with dependent drinking patterns Performing a brief intervention prior to referral has been shown to increase the patient s motivation to enter counseling, even if the brief intervention fails
34 Steps in a Brief Intervention: FRAMES Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Feedback of personal risk Responsibility of the patient for personal control Advice to change Menu of ways to reduce or stop drinking Empathetic counseling style Self efficacy or optimism of the patient to cut down or stop drinking
35 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.
36 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?
37 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.
38 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.
39 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?
40 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.
41 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
42 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 experimental control Follow-up: 174 subjects completed 48-month interview (85%) 97% of subjects completed at least one follow-up interview
43 Number of Binge Drinking Episodes: Past 30 Days (more than 4 drinks per occasion) p<.05 Control Treatment 0 Baseline 6 months 12 months 24 months 36 months 48 months Repeated measures overall p < 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% TrEAT Subsample: Women of Childbearing Age
44 Percent Drinking Excessively in Past Week 60% 50% (more than 13 drinks per week) 40% 30% 20% p<.10 p<.05 p<.01 p<.05 Control Treatment 10% 0% Baseline 6 months 12 months 24 months 36 months 48 months Treatment Control % reduction from: base to 6 months 57.4% 40.7% Repeated measures base to 12 months overall p < % 42.6% base to 24 months TrEAT Subsample: 61.7% Women of Childbearing 38.9% Age base to 36 months
45 Useful Websites for Providers ml p_7_pg2.htm
46 Useful Websites for Providers 5.htm (screening) 66.htm (brief interventions) mimh200.mimh.edu/fas/.../mrfastic Atlanta Presentation July 2003.ppt
47 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
48 Conclusions 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.