Presentation on theme: "Samuel MacMaster, Ph.D. University of Tennessee"— Presentation transcript:
1 Samuel MacMaster, Ph.D. University of Tennessee firstname.lastname@example.org Prevention Tools and Techniques: Alcohol Screening and Brief InterventionSamuel MacMaster, Ph.D.University of TennesseeCarey Szetela, Ph.D.
2 Objectives How to teach-train: Developing Empathy Awareness of Students’ LensSBIRT MethodAlcohol ScreeningScreening ToolsBrief InterventionResourcesDeveloping EmpathyRole PlayCarey Szetela, Ph.D.
3 The lens your students are using Anyone who drinks less/more than meCreates a definition of “normal drinking”Some students may actually have substance abuse issuesUncle Buzzy EffectFamily history of substance abuseHigher prevalenceCultural-Media AssumptionsWhat does an alcoholic look like?Who has an alcohol problem?Brown paper bag, etc.Carey Szetela, Ph.D.
4 Important to Address Lens First What does a substance user look like?Gender plays an effectWhat are their assumptions?Family history?Experiences with media images, cultural bias?If not addressed, remain an elephant in the roomCarey Szetela, Ph.D.
5 SBIRT: Screening, Brief Intervention and Referral to Treatment Carey Szetela, Ph.D.
6 SBIRT-Early Intervention SBIRT represents a paradigm shift in the provision of treatment for substance use and abuse.Services are different from, but designed to work in concert with, specialized or traditional treatment.Dirty secret of specialized substance abuse treatment is that it is primarily designed for individuals who are dependent---individuals with less severe issues fit less well with treatment models.Carey Szetela, Ph.D.
7 BasicsIncorporates screening into medical and other health service providersAfter screening comes a decision to move towards—no further services, brief intervention, brief treatment, or a referral to specialized treatmentServes as a background for working with women at risk for FASDCarey Szetela, Ph.D.
9 Need to Understand Screening Screening in the Medical FieldTuberculosisPregnancyHIV/AIDSMust highlight that a Positive Screen is not a Diagnosis!A Positive Screen simply indicates that more information needs to be gathered.It also creates an opportunity to begin a dialogueCarey Szetela, Ph.D.
10 The Diagnostic Process Ongoing Clinical ProcessBegins with ScreeningAll Diagnoses are PreliminaryScreeningAssessmentDiagnosisCarey Szetela, Ph.D.
11 Importance of Universal Screening Most substance users experiencing problems do not access treatmentStages of Change ConceptChange is a gradual processFive stage model: precontemplation, contemplation, preparation, action and maintenance85%-90% of substance abusers have no interest and/or awareness that substance use is a problemCarey Szetela, Ph.D.
12 Importance for Women who are Pregnant or Potentially Pregnant Women of Child Bearing AgeApproximately 53% of women report some alcohol use and Approximately 12% report binge drinkingMore than half of women who do not use birth control report alcohol use13% are sexually active and drink alcohol frequently or binge drinkPrenatal drinking status is predictive of alcohol use during pregnancyMany women continue to drink into the third semester before knowing they are pregnantPregnant women:Data from pregnant women indicate 10% report drinking alcohol2% to 4% reported binge drinkingHigh-risk drinking among women has not declined in the past decadeSample of WIC study participantsRate of post-conception drinking was 24% and 62% reported drinking before they knew they were pregnantCarey Szetela, Ph.D.
13 Recommended Alcohol Limit During Pregnancy and Preconception? Carey Szetela, Ph.D.
15 Conceptualizing Risk vs. Disorder Women’s Alcohol Risk CategoriesAbstinenceLow Risk: ≤7 drinks/week and ≤3 drinks/occasionAt-Risk: drinks/week or >3 drinks/ occasion, or in high-risk situationsProblem Drinker: >21 drinks/week, may experience negative consequences, may correlate with DSM abuse categoryAlcohol-Dependent: may correlate with DSM dependence category, usually associated with heavy drinking--with or without physical dependence, and negative consequencesCarey Szetela, Ph.D.
19 Issues in Selecting Instruments SensitivityDoes the screen detect all casesMeasure of true positivesthe probability that a risk drinker is positive on the test (0 to 1)SpecificityDoes the screen not pick up non-casesMeasure of true negativesthe probability that a non-risk drinker is negative on the test (0 to 1)Carey Szetela, Ph.D.
20 TWEAK Alcohol Assessment Developed originally to screen for at-risk drinking during pregnancyFive-item scaleShown to be appropriate and effective with pregnant women and African-American women with low SESCarey Szetela, Ph.D.
21 “TWEAK”T-Tolerance: "How many drinks does it take you to feel the first effects of the alcohol?"W-Worry: "Have close friends or relatives Worried or complained about your drinking in the past year?"E-Eye-openers: "Do you sometimes take a drink in the morning when you first get up?"A-Amnesia (blackouts); "Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?"K(C)-Cut Down: "Do you sometimes feel the need to Cut Down on your drinking?"Carey Szetela, Ph.D.
22 Tweak Scoring Tolerance: 3 or more drinks to feel effect = 2 points Worry: Yes = 2 pointsEye Opener: Yes = 1 pointAmnesia: Yes = 1 pointCut Down: Yes = 1 pointA score of >0 indicates at-risk during pregnancyFor others, a score of 2 indicates likelihood of at-risk drinking;A score of 3-4 or more is a positive screenSensitivity- .91, Specificity- .77Chang G. Alcohol Screening Instruments for Pregant Women. Alcohol Research and Health. 2001;25(3): (at NOFAS website).Carey Szetela, Ph.D.
23 “T-ACE” T-Tolerance: "How many drinks can you hold?" A-Annoyance: "Have people annoyed you by criticizing your drinking?"K(C)-Cut Down: “Have you ever felt the need to Cut Down on your drinking?"E-Eye-openers: “Have you ever had a drink the first thing in the morning to steady your nerves?"Carey Szetela, Ph.D.
24 T-ACE ScoringTolerance-two points if a woman reports she needs more than two drinks to get highAll other questions are worth one pointCut-off is twoSensitivity- .76Specificity- .79Carey Szetela, Ph.D.
25 Non-Empirical Tools Four Ps Global Question Have you drank or used drugs during this pregnancy, in the past, has your partner or parents had drinking or drug use problems?Global Question“Are you experiencing problems related to your drug and alcohol use?” Richard Brown-University of WisconsinCarey Szetela, Ph.D.
26 For Patient Discomfort with Screening Must be comfortableChange topic and revisit laterAsk more about social context and establish more rapportAsk about discomfort and request cooperationExplain need for questionsCarey Szetela, Ph.D.
27 What about a positive screen….. Discuss results in a non-confrontational, relaxed mannerYou are not indicting your client, you are helping to facilitate their transition to tx.Shame can be part of the problem---avoid itExplain what a positive screen is and what it is notCarey Szetela, Ph.D.
28 Brief InterventionFound to be effective with female problem drinkers in primary-care clinics5-10 minute counseling session has been found to reduce alcohol use in women by 20-30%… is not difficultWallace P, Cutler S, Hains A. Randomized controlled trial of general practitioner in patients with excessive alcohol consumption. British Medical Journal ;297(6649):Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers: A randomized controlled trial in community-based primary-care practices. JAMA ;277(13):Carey Szetela, Ph.D.
29 Brief Intervention: Ask and Assess Risk Level Raise the subject:“I like to ask all my patients about their drinking patterns”Does the patient have alcohol-related problems? (Medical, behavioral, social, familial)Provide feedback about alcohol risk level:Relate health concerns / pregnancy risks to alcohol use“Are you concerned about how your drinking may affect your health”“There is no known safe limit for drinking during pregnancy. You need to stop drinking completely b/c when you drink, your baby drinks.”Carey Szetela, Ph.D.
30 Brief Intervention: Advise and Assist Engage the patient in the process:Assess, enhance motivation and patient responsibility“How do you feel about your drinking?”For alcohol-risk, establish drinking goals:Advise and negotiate“Are you ready to set a drinking goal?What do you think will work best for you?” (give brochure materials)Not appropriate for alcohol dependence, advise abstinence and refer to specialized treatment.National Institute on Alcohol Abuse and Alcoholism and Office of Research on Minority Health, Identification of At-Risk Drinking and Intervention with Women of Childbearing Age. NIH Publication No (Printed 1999)Carey Szetela, Ph.D.
32 Optional Brief Motivational Interview Motivational Interviewing—developed by William Miller to assist problem drinkers resolve ambivalence around behavior changeAmbivalence is seen as a normal natural processUltimately relationship-based style---empathy is the keyCarey Szetela, Ph.D.
34 Hints and Traps to Avoid Joint DenialJohnny (Jenny) you don’t do drug do you?TriangulationFor many problem drinkers their primary relationship is with alcoholTaking ResponsibilityRoll with ResistanceCarey Szetela, Ph.D.
35 You don’t have a substance abuse problem, right? Great Carey Szetela, Ph.D.
37 Responsibility Voice for change must come from client Can’t be imposed or forcedCarey Szetela, Ph.D.
38 Roll with ResistanceNormal for client/patient to resist change, become annoyed or angry when criticized---must be avoided.Roll with resistance and avoid argumentation at all costs.Otherwise you are reinforcing the status quo.Carey Szetela, Ph.D.
39 Improving Health Provider Practices It may seem difficultto talk with patientsabout FASD,but you can do it.Carey Szetela, Ph.D.
40 Information and Treatment Resources NOFAS (National Organization on FAS)Phone: Web:University of Washington FAS Prevention NetworkWeb:Alcoholics AnonymousPhone: Web:Local Alcohol and Drug Treatment Resources: Web:Carey Szetela, Ph.D.
41 FASD Role Play 22 year old college student, name: ______ Pregnant, 10 weeksDo alcohol assessmentDescribe risks of FAS/D – facial/size/CNSExcited about becoming a momGoing to marry boyfriendLikes to party and drink sociallyBeer, wine, liquor (whatever is around)Have cut down due to pregnancy (get tipsy faster)1-3 drinks per occasion (previously 1-6)Carey Szetela, Ph.D.
42 Role Play: Alcohol Assessment and FASD Prevention FP in a rural town; you have seen your pt since 10 weeks PG but have not done an alcohol assessmentPt: 21yo female goes to community college- 4 months PG, generally optimistic a/b PG, likes to party, likes being 21- If asked, reports drinking a lot, including binge (avg 5 drinks per occasion, 4 days per week)Carey Szetela, Ph.D.
43 If you know what to look for, you can help minimize the difficulties fora child affected byFAS/D and family.Photo courtesy of Teresa KellermanCarey Szetela, Ph.D.