Title: Alcohol Screening and Brief Interventions of Women
1Alcohol Screening and Brief Interventions of
Women
- Competency 2
- Midwest Regional Fetal Alcohol
- Syndrome Training Center
- 2006
1
2Learning 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
2
3Why Screen?
- Alcohol use during pregnancy is one of the
leading preventable causes of birth defects and
childhood disabilities in the United States!
3
4Who Should We Screen?
- All women of child-bearing age
- Pregnant women
- Nursing mothers
4
5Why 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
5
6More 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
6
7Why 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
7
8Alcohol Consumption Among Women
52.6
Percent Women
10.1
12.3
13.1
1.9
1.9
Categories of Alcohol Consumption
8
9Why 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
9
10Are 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
10
11Risk 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
11
12What 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
12
13NIAAA 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?
13
14Recommended 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
14
15TWEAK
- 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)
15
16T-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)
16
17CRAFFT
- 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)
17
18Laboratory 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
18
19Strategies 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.
19
20If Screen is Positive
- Determine Drinking Pattern
-
- Drinking Patterns
- 1 Abstainers
- 2 Low-risk
- 3 At-risk
- 4 Problem
- 5 Alcohol dependent
20
21A 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
21
225 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
22
235 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
23
245 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
24
255 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)
25
26Brief 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
26
27What 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 -
27
28Steps in a Brief Intervention - FRAMES
28
29Feedback
- 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
29
30Responsibility
- 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?
30
31Advice
- 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
31
32Menu 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
32
33Empathetic 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?
33
34Project 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
34
35Self 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.
35
36Follow-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
36
37TrEAT Subsample Women of Childbearing Age
plt.05
37
38TrEAT 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
38
39Useful 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
39
40Useful 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
40
41Conclusions 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
41
42Conclusions 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.
42