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

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Presentation on theme: "Competency II:Screening and Intervention of Women © NORTHEAST REGIONAL FAS EDUCATION AND TRAINING CENTER. 2006."— Presentation transcript:

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 Alcohol Comparison-The Standard Drink 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

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

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

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

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 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)

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

24 Alcohol Biomarkers Breath Alcohol Alcohol Concentrations peak within 30-45 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

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

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

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 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

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

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

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

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