1. Module 2 Screening and Assessment

2. ADVISE APPROPRIATE ACTION FOLLOW UP - Supportive Care ASSESS Academic Social Behavioral Medical ASK Quantity/Frequency Binge CAGE AUDIT Brief Intervention Motivational Interview Referral Step 1 Step 2 Step 3 Step 4

3. 2-3 Screening - What We know... 1. Quantity, frequency, and binge drinking questions seem to have the best psychometric properties to detect high- risk college drinking. 2. Asking about alcohol use in the context of other behaviors such as smoking, exercise, nutrition, and sexual activities results in more accurate alcohol use information. 3. Just asking the question may change alcohol use and norms.

4. 2-4 Screening - What We know... (continued) 4. Context! Method of administration! Skills of the provider! All are critical factors! 5. No current biological or laboratory markers are sufficiently sensitive for routine screening in college students. 6. Denial is much less common than previously thought! From a public health perspective, it is unimportant; part of the noise.

5. 2-5 College Students Clinical Opportunities: Screening... Health maintenance visits School and sports physicals Foreign travel consultation Possible alcohol-related symptoms Headaches Depression Anxiety Acute care visits for trauma  Fatigue  Heartburn  Palpitations

6. 2-6 College Students Approach  Be sincere  Be respectful  Emphasize confidentiality  Establish trust

7. 2-7 Alcohol Screening: Consumption Questions To Detect At-Risk and Problem Drinkers Frequency: “On average, how many days per week do you drink alcohol?” Quantity: “On a typical day when you drink, how many drinks do you have?” Binge drinking:“How many times did you have more than four drinks on a single occasion in the last 30 days?”

8. 2-8 Alcohol Screening: To Detect At-Risk or Problem Drinkers Single questions developed by Cherpital, Vinson, Brown and others. “Do you have five or more drinks one or more times per week?” “Have you felt the need to cut down on your alcohol use?” “How many drinks does it take to get high?” “How many six packs did you drink last weekend?”

9. 2-9 “Have you ever felt that you should Cut down on your drinking?” “Have people Annoyed you by criticizing your drinking? “ “Have you ever felt bad or Guilty about your drinking? “ “Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?” (Eye opener) Alcohol Screening: To Detect Dependent Drinkers - CAGE

10. 2-10 Additional Screening Questions: RAFFT (Cherpital) Relax - Use to relax? Alone - Use alone? Family - Use with family? Friends - Use with friends? Trouble - Had any problems related to alcohol use?

11. 2-11 Additional Screening Questions Used to Predict Risk Family history Has anyone in your family, such as as your parents or siblings, had any problems with alcohol? Do you think they drink too much? Did their drinking affect you when you were growing up?

12. 2-12 Additional Screening Questions Used to Predict Risk Age at first drink? Age first time you became drunk? How many times did you drink in high school? How many times a week did you drink alcohol in high school?

13. 2-13 Self Administered Pencil and Paper Questionnaire Alcohol Use Disorder Inventory Test (AUDIT) (10 questions) 3 quantity/frequency questions 3 CAGE questions 4 consequence (blackouts, injuries, DUI, physician advice)

14. 2-14 Alcohol Use Disorders Identification Test (AUDIT) The following questions are about the past year.(Score) 1. How often do you have a drink containing alcohol? q Never (0) q Monthly or less (1) q 2 to 4 times a month (2) q 2 to 3 times a week (3) q 4 or more times a week (4) ____________________________________________________________________________________ 2. How many drinks containing alcohol do you have on a typical day when you are drinking? q None (0) q 1 or 2 (1) q 3 or 4 (2) q 5 or 6 (3) q 7 to 9 (4) q 10 or more (5) ____________________________________________________________________________________ 3. How often do you have six or more drinks on one occasion? q Never (0) q Less than monthly (1) q Monthly (2) q Weekly (3) q Daily or almost daily (4) ____________________________________________________________________________________

15. 2-15 Alcohol Use Disorders Identification Test (AUDIT ) __________________________________________________________________________ 4. How often during the last year have you found that you were unable to stop drinking once you had started? q Never (0) q Less than monthly (1) q Monthly (2) q Weekly (3) q Daily or almost daily (4) _________________________________________________________________ 5. How often during the last year have you failed to do what was normally expected from you because of drinking? q Never (0) q Less than monthly (1) q Monthly (2) q Weekly (3) q Daily or almost daily (4) ___________________________________________________________________________ 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? q Never (0) q Less than monthly (1) q Monthly (2) q Weekly (3) q Daily or almost daily (4) __________________________________________________________________

16. 2-16 Alcohol Use Disorders Identification Test (AUDIT) ____________________________________________________________________ 7. How often during the last year have you had a feeling of guilt or remorse after drinking? q Never (0) q Less than monthly (1) q Monthly (2) q Weekly (3) q Daily or almost daily (4) ___________________________________________________________ 8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? q Never (0) q Less than monthly (1) q Monthly (2) q Weekly (3) q Daily or almost daily (4) ____________________________________________________________________

17. 2-17 Alcohol Use Disorders Identification Test (AUDIT) ______________________________________________________________________ 9. Have you or someone else been injured as the result of your drinking? q No (0) q Yes, but not in the last year (2) q Yes, during the last year (4) ______________________________________________________________________ 10. Has a relative, friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? q No (0) q Yes, but not in the last year (2) q Yes, during the last year (4) **A score of 8 or more is suggestive of high-risk drinking. People who score positive on the AUDIT should be assessed for potential alcohol-related problems. Babor TF, de la Fuente JR, Saunders J, Grant M. AUDIT: The Alcohol Use Disorders Identification Tests: Guidelines for use in Primary Health Care. Geneva, Switzerland: World Health Organization, 1992.

18. 2-18 Biological Measures Blood Alcohol Level/Breathalyzer MCV (Mean Corpuscular Volume) GGT (Gamma-Glutamyl Transferase) CDT (Carbohydrate-Deficient Transferrin) Urine Toxicology Screens

19. 2-19 A “Standard Drink”

20. 2-20 Biological Measures Blood Alcohol Level (BAL) 0.015 mg% = 1 drink (14 grams in US) a standard drink is metabolized in 60-90 minutes in an average person 3-4 standard drinks over 1-2 hours to get to 0.08 mg% (women) 5-6 standard drinks to get to 0.08 mg% (men)

21. 2-21 Assessment Assess for alcohol-related medical concerns Assess for alcohol dependence Assess for mental health conditions Assess for alcohol-related behavioral problems Assess for readiness to change

22. 2-22 Assess for Alcohol-Related Medical Concerns Accidents/falls Cognitive GI tract Diabetes High blood pressure Blackouts Driving Under Influence Headaches Injuries Suicide ideation

23. 2-23 Assess for Alcohol Dependence Loss of control Preoccupation with use Repeated alcohol-related problems Tolerance or morning withdrawal Making rules to control drinking Compulsive use

24. 2-24 Assess for Mental Health Conditions Anxiety Panic attacks Depression Physical or sexual abuse Bipolar disorders Axis II disorder (DSM – IV)

25. 2-25 Assess for Alcohol-Related Behavioral Problems Academic performance below ability Receives incompletes for failing to turn in course assignments Dropping courses Getting into fights with roommates and friends Involvement with campus police

26. 2-26 Readiness to Change Paradigm XXX resistanceambivalence Not considering change Thinking about change Ready to change Taking action Maintaining change Is the student considering reducing or stopping alcohol use?

27. 2-27 How to Implement Routine Screening and Assessment in a College Population Student Health Administer alcohol use questions on AUDIT as part of new patient process. Have nurse ask alcohol question on every visit as part of vital signs check and document in record. Have all freshman complete a health history questionnaire that contains the AUDIT as part of routine admissions process.

28. 2-28 How to Implement (continued) Urgent Care and Emergency Departments Routine screening by nurse Routine BAL on all patients seen for trauma Availability of counselor to conduct brief intervention in Emergency Department