4Alcohol 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.
5Categories of Alcohol use in Women AbstainersLow Risk DrinkersAt Risk DrinkersProblem DrinkersAlcohol AbuseAlcohol DependenceBinge Drinkers
6Universal Screening Alcoholism as a chronic disease Multiple areas of life, people, and bodily systems affectedFAS the most common cause of preventable mental retardationHigh risk lifestyleBillions of dollars yearly in treatment and consequencesThese 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.
7Why Screen? Women are under-represented in treatment Addictive and psychiatric disorders may be under or misdiagnosed in womenScreening at every encounter improves the chances of making a diagnosis and obtaining a good outcomePregnant women and women with children need special attention and consideration
8Alcohol 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)
9Why Screen-Epidemiology Birth Mother’s Profile (Astley)80% had at least one DSM-IV diagnosiswith a maximum10 and median 410% had custody of their childBirth Mother’s Profile (Streissguth)A high proportion (69% in one study) of the biologicalmothers of children with FAS are dead before their childrengrow up
10Why Screen: Alcohol Induced Damage to Women and Fetuses Female Reproductive TractOther SystemsHigh Risk LifestyleLegal IssuesInterrupt Multigenerational FASDPrevent Secondary Disabilities1.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.
11Why Screen: Possible Nutritional Effects of Alcohol Consumption Decreased dietary intakeImpaired metabolism and absorption of nutrients- folate, B6, B1, B3, AAltered nutrient activation and utilization- K, Mg, Ca, Zn, PO4, GlucoseAny pregnant woman using alcohol must be assessed for nutritional risk
12Specific Indications for Screening Any patient with signs of an emerging problemAny 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
13Opportunities for Screening Routine part of any medical examBefore prescribing any medication that interacts with alcoholIn the emergency department or urgent care centerAny licensing, athletics, or prison physicalAdolescent 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.
14Asking About Alcohol Use Helping Patients Who Drink Too Much-NIAAA 2005 PublicationPrescreen-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 dependenceThis NIAAA publication reviews screening, brief intervention, statistics, meds-useful as a guide.
15Screening 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 effectsFuture lab studies-ADH-phenotypes, DNA-ethanol adducts (genetic studies)Goal for screening is therapeutic intervention as indicated for mom/child
16Screening Tools Alcohol Exposure Screening Forms CAGE, MAST, TWEAK, 4P’s Plus, 5 P’s, AUDITAdolescent Alcohol Involvement ScaleAdolescent Drinking ScaleDrug and Alcohol Problem Quick ScreenCRAFFT screen for adolescentsPerceived Benefits of Drinking Scale
17Screens: CAGE C…..Cut down or control use A…..Anger or annoyance G…..Guilt regarding useE…..Eye opener (or signs of withdrawal)
18Screens: T-ACE T…..Tolerance. How many to get “high” A…..Annoyance with criticismC…..Cut DownE…..Eye Opener
20Screens: 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
21AUDIT and AUDIT-CAUDIT is 10 items and needs to be scored, length may preclude use in primary careAUDIT may be self-administeredAUDIT-C uses only the three consumption questions and performs well in screening for AUD’s and risk drinking (Dawson et.al. 2005)
22Associated 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.
23Laboratory 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 indirectRemember the legal implications of having this labwork on a patient’s chart.
24Alcohol Biomarkers Breath Alcohol Alcohol Concentrations peak within minutes of consumption ( varies depending on multiple factors)The half life of blood alcohol is approximately 4 hoursWithin 8-10 hours of ingestion, blood alcohol is metabolized and excreted
25Alcohol BiochemistryAlcohol—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
26Laboratory Markers of Alcohol Biochemistry Hemoglobin-associated acetaldehyde (HAA) and Whole blood associated acetaldehydeAdducts between acetaldehyde and erythrocyte or whole blood hemoglobinThe irreversible HAA adduct is detectable for 28 days after formation
27Laboratory Markers of Alcohol Biochemistry Carbohydrate-deficient transferrin (CDT)Alcohol interferes with the production of carbohydrate bonds with transferrinwith chronic alcohol ingestion, these transferrins accumulatedetectable after heavy drinking and for two weeks after cessationTransferrin is the protein molecule that combines with, and transfers, iron in the body.
28Laboratory Diagnosis of Chronic Alcohol Use Liver function tests-ALT, AST, bilirubinGamma glutamyl transferase (GGT)-elevations caused by increased enzyme production, liver damage, decreased stability of liver cell membranes-patterns of elevations can persist for monthsPatterns are in direct and indirect bilirubin, ratios of ALT and AST.
29Laboratory Markers of Chronic Alcohol Use Mean Corpuscular Volume (red blood cells)direct effect on stem cell precursorsabnormal with continuous, heavy use of alcohollasts for life of RBC, months to normalizeconsider B12, folate, iron deficiencyLook 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.
30Meconium in the Alcohol Exposed Pregnancy Meconium is formed in the fetal GI tract from a variety of secretionsFatty acid ethyl esters (FAEEs) are formed in tissues that have little or no alcohol dehydrogenase i.e. brain and placentaSend as much of first meconium passed to lab for FAEE analysis
31Combination of Markers None of the markers alone has adequate sensitivityEnhance detection using markers with different mechanismsCombination CDT, MCV, GGT, AST/ALT-(Stoler)Check hospital/ lab for profiles available
33Brief InterventionUtilized by general medical and mental health practitionersFor patients not needing, wanting or ready for specialty careIntended for less severe, nondependent, early stage drinkerBrief, structured, time-limited, goal-specificPatient goal may be abstinence, moderation, or harm reductionGoal for pregnant patient is abstinence
34Goals of Brief Intervention Reduce risk of harm from continued substance useAbstinence provides the greatest degree of harm reduction and safety, especially in the pregnant patientOnly the client can choose the goal, no matter what you recommend and think is best
35General Recommendations for Brief Intervention Be friendly and non-threateningConvey an attitude of curiosity and concernAvoid being authoritarian, judgmental, or confrontationalReassure that all information is confidential
36Inform Patients About: Safe Consumption limits for alcoholDefinitions of substance abuse and dependenceAdded risks from family, social, medical history, or other drug useYour confidence in their ability to changeYour willingness to help
37Advise Patients to Abstain If: Pregnant or trying to conceiveEvidence of substance abuse or dependenceContraindicated medical/psychiatric condition or medicationSignificant family history of alcohol/drug problemsReproductive age and not using contraception
38Brief Interventions-Summary Screen all patientsAssess problem severityProvide objective feedback and adviseAssess patient readiness to changeNegotiate goals/strategies to changeMonitor patient progress and reassessThis 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.
39Results of Brief Intervention Decreases alcohol use in women and menDecreases health care utilizationDecreases costs1 to 4 sessions are effectivePhysicians can be trained to conduct brief interventionPharmacologic and Nonpharmacologic Treatment of Alcohol Dependence, program sponsored by ASAMSAMHSA TIP34, Brief Interventions and Brief Therapies for Substance Abuse
40Barriers to Screening and Referral PatientHealthcare ProvidersPicture 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.
41Barriers 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
42Barriers to Screening-Patient DepressionHopelessnessOpposition of partner/family membersLack of social support-child care, jobs, skills, housing, insuranceCodependency with addicted partner
43Barriers to Screening-Health Care Professional Inadequate education/training/role modelsFear of loss of patients/ incomeTime pressureLack of known referral resourcesConfidentiality dilemmasPersonal substance use pattern
44Specific Medical Concerns Domestic ViolenceHIV/AIDSAnxiety DisordersPTSD- significant abuse historyMood DisordersEating DisordersBorderline Personality-confusion with drug behaviorIf you are not making progress in the intervention, make sure you have screened for these common complicating factors.
45Stages of ChangePeople with alcohol/drug problems generally fall into one of 5 stages along a continuum of readiness to changeThis 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 effectivePatient stage can vary between visits both forward and backward
46Stages of Change Precontemplation- “no problem”, no desire to change Contemplation- patient is beginning to recognize a problem, still waveringPreparation- patient is considering options for changeAction- patient is taking specific steps to changeMaintenance- patient is preventing relapseConsider brain changes with chronic alcohol use
47Substance Abuse Treatment Options Medical Detoxification- inpatient or outpatientResidential TreatmentOutpatient TreatmentOffice-Based Treatment- Addiction Medicine Psychologist, Psychiatrist, or SpecialistAA or other self-help program
48Management: Person Centered Care EducationMental HealthHealth CareChild Welfare and Family Support ServicesCriminal and Juvenile JusticeChemical DependencyDevelopmental DisabilitiesNote the need for multidisciplinary case management.