1. Competency II:Screening and Intervention of Women
© NORTHEAST REGIONAL FAS EDUCATION AND TRAINING CENTER. 2006

2. “This is the face of the woman you did not screen” Said during an interview with a professional upper middle class caucasian woman in recovery

3. Commonly Abused Substances
Alcohol
Tobacco
Heroin
Methadone
Cocaine
Marijuana
Prescription Drugs
Inhalants

4. Alcohol Comparison-The Standard Drink
It is essential in screening that you are clear about the definition of a standard drink. If the person you are screening cannot tell you how many standard drinks, ask them to pour water in a glass to show you how much alcohol goes in a drink they would mix.
2. “Beer Consumption in Hazardous Drinkers”
For the unborn child it is the alcohol in the drink that harms.

5. Categories of Alcohol use in Women
Abstainers
Low Risk Drinkers
At Risk Drinkers
Problem Drinkers
Alcohol Abuse
Alcohol Dependence
Binge Drinkers

6. Universal Screening Alcoholism as a chronic disease
Multiple areas of life, people, and bodily systems affected
FAS the most common cause of preventable mental retardation
High risk lifestyle
Billions of dollars yearly in treatment and consequences
These are the reasons to screen every patient. People who have no concerns about their alcohol use are generally not offended by routine questions.
Adverse events are not confined to alcohol abuse and dependence.

7. Why Screen? Women are under-represented in treatment
Addictive and psychiatric disorders may be under or misdiagnosed in women
Screening at every encounter improves the chances of making a diagnosis and obtaining a good outcome
Pregnant women and women with children need special attention and consideration

8. Alcohol Crosses the Placenta
Alcohol passes freely from the mother to the fetus.
The fetal liver cannot metabolize alcohol efficiently.
Blood alcohol concentrations (BAC) are approximately equivalent within the mother and fetus.
Fetus is more susceptible to alcohol than mother.
(Cohen-Kareem, 2002)

9. Why Screen-Epidemiology
Birth Mother’s Profile (Astley)
80% had at least one DSM-IV diagnosis
with a maximum10 and median 4
10% had custody of their child
Birth Mother’s Profile (Streissguth)
A high proportion (69% in one study) of the biological
mothers of children with FAS are dead before their children
grow up

10. Why Screen: Alcohol Induced Damage to Women and Fetuses
Female Reproductive Tract
Other Systems
High Risk Lifestyle
Legal Issues
Interrupt Multigenerational FASD
Prevent Secondary Disabilities
1.Damage to preconceptual oocytes, hormone imbalances, decreased milk letdown, increased cancer risk of breast and GI tract, multiple other GI effects, decreased bone density, domestic violence, STD’s, MVA’s and other traumas.

11. Why Screen: Possible Nutritional Effects of Alcohol Consumption
Decreased dietary intake
Impaired metabolism and absorption of nutrients- folate, B6, B1, B3, A
Altered nutrient activation and utilization- K, Mg, Ca, Zn, PO4, Glucose
Any pregnant woman using alcohol must be assessed for nutritional risk

12. Specific Indications for Screening
Any patient with signs of an emerging problem
Any patient who:
-is pregnant, trying to conceive, or not contracepting
-is likely to drink or binge heavily-smokers, adolescents, college students
-is having a health problem that may be alcohol induced (arrhythmia, dyspepsia, depression, trauma, insomnia)
-is having a chronic illness that is not responding to treatment

13. Opportunities for Screening
Routine part of any medical exam
Before prescribing any medication that interacts with alcohol
In the emergency department or urgent care center
Any licensing, athletics, or prison physical
Adolescent school physicals or counselling
. The clinical dx of alcohol abuse / dependence ultimately rests on the documentation of of a pattern of difficulties associated with alcohol use, not the quantity or frequency of use. Probe for life problems, then tie in alcohol/drug use.

14. Asking About Alcohol Use
Helping Patients Who Drink Too Much-NIAAA 2005 Publication
Prescreen-Do you sometimes drink alcoholic beverages? If yes, ask-
How many times in the past year have you had 4 or more drinks in a day (for women)
If one or more heavy drinking days or AUDIT score > 4 for women,
Assess for alcohol abuse or dependence
This NIAAA publication reviews screening, brief intervention, statistics, meds-useful as a guide.

15. Screening Tools for Alcohol Use During Pregnancy
Combination of self-report questionnaires, variety of biomarkers and ultrasound results may best identify alcohol use in pregnant women and risk of prenatal effects
Future lab studies-ADH-phenotypes, DNA-ethanol adducts (genetic studies)
Goal for screening is therapeutic intervention as indicated for mom/child

16. Screening Tools Alcohol Exposure Screening Forms
CAGE, MAST, TWEAK, 4P’s Plus, 5 P’s, AUDIT
Adolescent Alcohol Involvement Scale
Adolescent Drinking Scale
Drug and Alcohol Problem Quick Screen
CRAFFT screen for adolescents
Perceived Benefits of Drinking Scale

17. Screens: CAGE C…..Cut down or control use A…..Anger or annoyance
G…..Guilt regarding use
E…..Eye opener (or signs of withdrawal)

18. Screens: T-ACE T…..Tolerance. How many to get “high”
A…..Annoyance with criticism
C…..Cut Down
E…..Eye Opener

19. Screens: TWEAK T…Tolerance 2 pts W…Worry (are friends concerned) 1pt
E…Eye opener 1pt
A…Amnesia (describe blackout, not
passing out) 1 pt
K…Cut down attempts 1 pt
3 pts = problem

20. Screens: 4 P’s Plus Parents-problem with alcohol or drugs?
Partner-problem with alcohol or drugs? Temper problems?
Past-have you ever used alcohol?
Pregnancy-in the month before you knew, how many cigarettes did you smoke? How much alcohol did you drink?
Used for pregnant women

21. AUDIT and AUDIT-C
AUDIT is 10 items and needs to be scored, length may preclude use in primary care
AUDIT may be self-administered
AUDIT-C uses only the three consumption questions and performs well in screening for AUD’s and risk drinking (Dawson et.al. 2005)

22. Associated Family and Social History
Consider possibility of prenatal alcohol exposure in persons who have experienced:
-premature maternal death related to alcohol use
-living with alcoholic parent
-current or previous abuse/neglect
-current or previous involvement with CPS
-history of foster/adoptive placements
(MMWR October 28, 2005)
If your screening is not clear but the person seems to be cooperative, consider that the patient may have alcohol related damage also. FASDs can be multigenerational. If the client has also been exposed to alcohol, treatment may need to be more intensive.

23. Laboratory Diagnosis of Alcohol- Using Pregnancy
Accurate biomarkers of alcohol use would be invaluable in identifying and intervening with pregnant women who drink
-multiple barriers to accurate verbal screening-both patient and health care professional.
-profound, persistent, pervasive nature of damage
(AAP 2000)
-biochemical markers are direct or indirect
Remember the legal implications of having this labwork on a patient’s chart.

24. Alcohol Biomarkers Breath Alcohol
Alcohol Concentrations peak within minutes of consumption ( varies depending on multiple factors)
The half life of blood alcohol is approximately 4 hours
Within 8-10 hours of ingestion, blood alcohol is metabolized and excreted

25. Alcohol Biochemistry
Alcohol—acetaldehyde—acetate—CO2+H2O. The primary enzymes are alcohol dehydrogenase and acetaldehyde dehydrogenase.
Acetaldehyde is extremely reactive
-Forms reversible and irreversible compounds with proteins, lipids, DNA
-These compounds (adducts) may be used as markers of alcohol use

26. Laboratory Markers of Alcohol Biochemistry
Hemoglobin-associated acetaldehyde (HAA) and Whole blood associated acetaldehyde
Adducts between acetaldehyde and erythrocyte or whole blood hemoglobin
The irreversible HAA adduct is detectable for 28 days after formation

27. Laboratory Markers of Alcohol Biochemistry
Carbohydrate-deficient transferrin (CDT)
Alcohol interferes with the production of carbohydrate bonds with transferrin
with chronic alcohol ingestion, these transferrins accumulate
detectable after heavy drinking and for two weeks after cessation
Transferrin is the protein molecule that combines with, and transfers, iron in the body.

28. Laboratory Diagnosis of Chronic Alcohol Use
Liver function tests-ALT, AST, bilirubin
Gamma glutamyl transferase (GGT)
-elevations caused by increased enzyme production, liver damage, decreased stability of liver cell membranes
-patterns of elevations can persist for months
Patterns are in direct and indirect bilirubin, ratios of ALT and AST.

29. Laboratory Markers of Chronic Alcohol Use
Mean Corpuscular Volume (red blood cells)
direct effect on stem cell precursors
abnormal with continuous, heavy use of alcohol
lasts for life of RBC, months to normalize
consider B12, folate, iron deficiency
Look at the differential section of the patients Complete Blood Count (CBC). RBC’s will be larger with the B12 and folate deficiency and smaller with iron deficiency (decreased absorption because of alcohol effects on gastric mucosa). If all three are deficient, cell size may average out as normal, but you will see a mixed population of cells.

30. Meconium in the Alcohol Exposed Pregnancy
Meconium is formed in the fetal GI tract from a variety of secretions
Fatty acid ethyl esters (FAEEs) are formed in tissues that have little or no alcohol dehydrogenase i.e. brain and placenta
Send as much of first meconium passed to lab for FAEE analysis

31. Combination of Markers
None of the markers alone has adequate sensitivity
Enhance detection using markers with different mechanisms
Combination CDT, MCV, GGT, AST/ALT-(Stoler)
Check hospital/ lab for profiles available

32. Brief Intervention

33. Brief Intervention
Utilized by general medical and mental health practitioners
For patients not needing, wanting or ready for specialty care
Intended for less severe, nondependent, early stage drinker
Brief, structured, time-limited, goal-specific
Patient goal may be abstinence, moderation, or harm reduction
Goal for pregnant patient is abstinence

34. Goals of Brief Intervention
Reduce risk of harm from continued substance use
Abstinence provides the greatest degree of harm reduction and safety, especially in the pregnant patient
Only the client can choose the goal, no matter what you recommend and think is best

35. General Recommendations for Brief Intervention
Be friendly and non-threatening
Convey an attitude of curiosity and concern
Avoid being authoritarian, judgmental, or confrontational
Reassure that all information is confidential

36. Inform Patients About:
Safe Consumption limits for alcohol
Definitions of substance abuse and dependence
Added risks from family, social, medical history, or other drug use
Your confidence in their ability to change
Your willingness to help

37. Advise Patients to Abstain If:
Pregnant or trying to conceive
Evidence of substance abuse or dependence
Contraindicated medical/psychiatric condition or medication
Significant family history of alcohol/drug problems
Reproductive age and not using contraception

38. Brief Interventions-Summary
Screen all patients
Assess problem severity
Provide objective feedback and advise
Assess patient readiness to change
Negotiate goals/strategies to change
Monitor patient progress and reassess
This is really no different than the approach to any chronic disease in the general medical office. You as a health care provider may feel more urgency when there is a fetus also being exposed to the alcohol. Abstinence from bullying or shaming is not generally long-lasting and may result in avoidance of prenatal care. A mutual agreement is much more likely to be effective through this and future pregnancies.

39. Results of Brief Intervention
Decreases alcohol use in women and men
Decreases health care utilization
Decreases costs
1 to 4 sessions are effective
Physicians can be trained to conduct brief intervention
Pharmacologic and Nonpharmacologic Treatment of Alcohol Dependence, program sponsored by ASAM
SAMHSA TIP34, Brief Interventions and Brief Therapies for Substance Abuse

40. Barriers to Screening and Referral
Patient
Healthcare Providers
Picture from NOFAS website, from an article by Janet Golden ( author of “Message in a Bottle”), regarding the needs of pregnant, alcohol-using women for treatment. Consider what the picture suggests-these women can be manipulated, they are depressed, they are deliberately giving their fetus alcohol, etc. We as health care providers have a responsibility to be aware of our own attitudes- if we can’t provide compassionate treatment we have to get them to someone who can.

41. Barriers To Screening-Patient
Pregnant women deny or misrepresent their drinking for multiple reasons:
-shame and stigma
-legal and custody ramifications
-other illegal activities
-fear of labelling, treatment, change
-alcohol is a legal drug and is advertised as having beneficial health effects

42. Barriers to Screening-Patient
Depression
Hopelessness
Opposition of partner/family members
Lack of social support-child care, jobs, skills, housing, insurance
Codependency with addicted partner

43. Barriers to Screening-Health Care Professional
Inadequate education/training/role models
Fear of loss of patients/ income
Time pressure
Lack of known referral resources
Confidentiality dilemmas
Personal substance use pattern

44. Specific Medical Concerns
Domestic Violence
HIV/AIDS
Anxiety Disorders
PTSD- significant abuse history
Mood Disorders
Eating Disorders
Borderline Personality-confusion with drug behavior
If you are not making progress in the intervention, make sure you have screened for these common complicating factors.

45. Stages of Change
People with alcohol/drug problems generally fall into one of 5 stages along a continuum of readiness to change
This provides a useful framework for determining how to approach patients in each stage of change and what types of interventions are most likely to be effective
Patient stage can vary between visits both forward and backward

46. Stages of Change Precontemplation- “no problem”, no desire to change
Contemplation- patient is beginning to recognize a problem, still wavering
Preparation- patient is considering options for change
Action- patient is taking specific steps to change
Maintenance- patient is preventing relapse
Consider brain changes with chronic alcohol use

47. Substance Abuse Treatment Options
Medical Detoxification- inpatient or outpatient
Residential Treatment
Outpatient Treatment
Office-Based Treatment- Addiction Medicine Psychologist, Psychiatrist, or Specialist
AA or other self-help program

48. Management: Person Centered Care
Education
Mental Health
Health Care
Child Welfare and Family Support Services
Criminal and Juvenile Justice
Chemical Dependency
Developmental Disabilities
Note the need for multidisciplinary case management.