1. MRFASTC Alcohol Screening and Brief Interventions of Women Competency #2 Midwest Regional Fetal Alcohol Syndrome Training Center

2. MRFASTC Competency 2: Screening and Brief Interventions This competency addresses preventing alcohol-exposed pregnancies (AEP) in women of childbearing age through screening and brief interventions for alcohol use.

3. MRFASTC Learning Goals Appropriately screen women of childbearing age for alcohol use Use demographic and other risk factors appropriately in prevention and screening activities Appropriately use alcohol screening methods/instruments Conduct brief interventions with women

4. MRFASTC Why Screen? Alcohol use during pregnancy is one of the leading preventable causes of birth defects and developmental disabilities in the United States! Even low levels of alcohol during pregnancy can have negative developmental consequences Recommended by the US Preventive Services Task Force and the CDC

5. MRFASTC Who Should We Screen? All women of child-bearing age Pregnant women Nursing mothers

6. MRFASTC Why Screen Women of Child-Bearing Age? Women who drink prior to pregnancy more likely to drink during pregnancy 53% of non-pregnant women drink, 12% binge drink Women may not volunteer information on alcohol intake Half of childbearing age women do not use birth control Many women do not realize they are pregnant until after the 4th – 6th week of gestation

7. MRFASTC Alcohol Consumption by Women – Primary Care Data Alcohol use among women ages 18-30

8. MRFASTC Alcohol Consumption Among Women Categories of Alcohol Consumption Percent Women

9. MRFASTC Why Screen Pregnant Women? 12% of women continue to drink while pregnant despite efforts to educate on its dangers Alcohol use during pregnancy, even at low intake levels, has been associated with significant negative consequences, including FASD

10. MRFASTC Why Screen Nursing Mothers? Infants consume less milk when mothers consume alcohol before breastfeeding Exposure to alcohol in mother’s milk results in infant motor development delay Exposure to alcohol in mother’s milk shown to interrupt an infant’s sleep/wake pattern Early alcohol exposure may increase a child’s risk of addiction to alcohol

11. MRFASTC Are Women Being Screened? Despite potential risks and established clinical guidelines, some individuals are not screened for problem drinking Physicians are less likely to detect alcohol problems in patients that they do not expect to have alcohol problems

12. MRFASTC Risk Factors Who is Likely to Drink ? Those who are alcohol dependent or previously abused alcohol while pregnant Previous biological child with FASD Partner/Family member heavy drinker Associated depression Other drug or tobacco use

13. MRFASTC Risk Factors Who is Likely to Drink ? Low socioeconomic status Unmarried African-American and American- Indian/Alaska-Native ethnicity Younger maternal age

14. MRFASTC What Tools are Available for Screening? National Institute on Alcohol Abuse and Alcoholism (NIAAA) Quantity and Frequency Screen Standardized screening instruments No one gold standard exists Most are less accurate when used in women Laboratory evaluation Not very sensitive

15. MRFASTC What is a Drink? Before screening, women should be taught what constitutes a typical drink A standard drink is defined as one 12-ounce bottle of beer one 5-ounce glass of wine 1.5 ounces of distilled spirits

16. MRFASTC NIAAA Quantity/Frequency Screen 1.Do you drink alcohol? 2.On average, how many days a week do you drink? 3.On a day when you drink alcohol, how many drinks do you have? 4.What is the maximum number of drinks you consumed on any given occasion in the past month?

17. MRFASTC Recommended Alcohol Screening Instruments Best instruments should be: Brief Easy to administer and score Reliable/accurate in target population To be effective they must be: Used routinely with EVERY patient With pregnant patients, must be administered multiple times

18. MRFASTC Recommended Alcohol Screening Instruments WomenTWEAK, T-ACE Pregnant WomenTWEAK, T-ACE AdolescentsCRAFFT

19. MRFASTC TWEAK 1.How many drinks does it take to feel effects of alcohol? [Tolerance] ( 3 or more drinks = 2 points) 2.Have friends/relatives Worried about your drinking in the past year? [Worried] (yes = 2 points) 3.Ever drank first thing in the morning? [Eye-opener] (yes = 1 point) 4.Ever drank but can't remember what you said or did? [Amnesia] (yes = 1 point) 5.Ever feel the need to cut down on your drinking? [K(C)ut down] (yes = 1 point)

20. MRFASTC T-ACE 1.Does it take more than it used to for you to get high? [Tolerance] (yes = 2 points) 2.Have you become Angry or Annoyed when others express concern about your use? (yes = 1 point) 3.Have you tried to Cut down or quit? (yes = 1 point) 4.Have you ever had a drink first thing in the morning? [Eye opener] (yes = 1 point)

21. MRFASTC CRAFFT 1.Have you ever ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs? (Yes = 1 point) 2.Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in? (Yes = 1 point) 3.Do you ever use alcohol or drugs while you are by yourself (Alone)? (Yes = 1 point) 4.Do you ever Forget things you did while using alcohol or drugs? (Yes = 1 point) 5.Do your Family or Friends ever tell you that you should cut down on your drinking or drug use? (Yes = 1 point) 6.Have you ever gotten into Trouble while you were using alcohol or drugs? (Yes = 1 point)

22. MRFASTC Laboratory Screening None are of much clinical use Alcohol is metabolized too quickly to use blood levels to determine use Most of the others indicate only long- term use problems High cost make these less feasible for universal screening

23. MRFASTC Strategies for Overcoming Barriers to Effective Screening Increase provider knowledge Increase provider comfort Designate support staff to assist with screening Screen EVERY patient and in conjunction with broader health behavior assessment screening

24. MRFASTC Strategies for Overcoming Barriers to Effective Screening Using clinic-based system protocols (e.g. patient questionnaires) to prompt provider Research alcohol treatment programs prior to need Educate payers These strategies have worked for smoking cessation, breast cancer screening, diabetes education, etc.

25. MRFASTC If Screen is Positive Determine Drinking Pattern 1.Abstainers 2.Low-risk 3.At-risk 4.Problem 5.Alcohol dependent

26. MRFASTC Five Drinking Patterns 1. Abstainers No alcohol or fewer than 12 drinks per year

27. MRFASTC Five Drinking Patterns 2. Low-risk drinking 7 or fewer drinks per week No more than 1 standard drink per day No alcohol use before driving, when pregnant or breast feeding, or with certain medications

28. MRFASTC 3. At-risk drinking more than 7 standard drinks per week more than 3 standard drinks on any occasion drink while pregnant, breast feeding absence of negative consequences from drinking Five Drinking Patterns

29. MRFASTC 4. Problem drinking more than 7 standard drinks per week more than 3 standard drinks on any occasion drink while pregnant, breast feeding experience negative consequences from drinking (DUIs, MVAs, divorce, loss of employment, etc.) Five Drinking Patterns

30. MRFASTC 5. Alcohol dependent drinking can’t stop drinking once started (loss of control) repeated negative consequences from drinking heavy drinking has led to a physical need for alcohol (e.g. tolerance, withdrawal) Five Drinking Patterns

31. MRFASTC What We Know About Brief Interventions? Decrease alcohol use in both women and men Decrease health care utilization and cost 1 to 4 sessions at 10 to 15 minutes, scheduled at 2 to 4 week intervals are effective Primary care providers can be trained to conduct brief interventions

32. MRFASTC Brief Interventions In the office setting: For women with at-risk or problem drinking patterns -Non-pregnant woman with intake above low risk drinking -Sexually active, non-pregnant woman NOT using effective contraception -Trying to conceive or pregnant drinking at any level

33. MRFASTC Referral to alcohol treatment specialist: For women with dependent drinking patterns Performing a brief intervention prior to referral has been shown to increase the patient’s motivation to enter counseling, even if the brief intervention fails Brief Interventions

34. MRFASTC Steps in a Brief Intervention: FRAMES Step 1 F eedback of personal risk Step 2 R esponsibility of the patient for personal control Step 3 A dvice to change Step 4 M enu of ways to reduce or stop drinking Step 5 E mpathetic counseling style Step 6 S elf efficacy or optimism of the patient to cut down or stop drinking

35. MRFASTC Feedback I am very concerned about how your drinking is affecting your health (e.g. sleeping, social issues, increased BP, headaches, elevated LFTs). I am concerned about your risk for developing liver disease. There is no known safe limit for drinking during pregnancy. You may be causing harm to your baby.

36. MRFASTC Responsibility What you do about your drinking is up to you. No one else can make you decide to change. Are you willing to work with me on reducing/stopping your alcohol use?

37. MRFASTC Advice I am worried about the level at which you are currently drinking. The current recommendations for you would be to drink less than one drink per day.

38. MRFASTC Menu of Ways to Reduce or Stop Drinking I would like for you to read this pamphlet that discusses the use of alcohol and suggest ways to help you cut down or stop drinking. I would like you to sign a “Drinking Reduction Agreement”. I would like for you to keep a log of every drink you take and what you were doing at the time.

39. MRFASTC I see from your drinking diary that you drank 5 beers last Saturday. It is important that we begin to identify what situations are proving to be risky for you so can you share with me what you were doing when you had those 5 drinks? NOT – Why did you drink 5 beers last Saturday? Empathetic Counseling Style

40. MRFASTC Self Efficacy Can you share with me some ways that you think you could cope with going to that party where all of your friends will be drinking? I want you to remind yourself daily that you can reduce your drinking.

41. MRFASTC Follow-up Schedule follow-up visit or phone call every 2 weeks or so during the early part of a brief intervention. Review progress, drinking diary, revise drinking agreements Review goals or set new ones

42. MRFASTC Project TrEAT: Subsample of Women of Childbearing Age 64 physicians, 17 clinics in 10 Wisconsin counties 5,979 female subjects screened with the health screening survey 205 subjects enrolled - 103 experimental - 102 control Follow-up: 174 subjects completed 48-month interview (85%) 97% of subjects completed at least one follow-up interview

43. MRFASTC Control Treatment TreatmentControl % reduction from: base to 6 months56.3% 35.5% base to 12 months55.5% 32.8% base to 24 months40.4% 7.1% base to 36 months41.6% 23.9% base to 48 months42.2% 17.9% (more than 4 drinks per occasion) Repeated measures overall p < 0.001 p<.05 TrEAT Subsample: Women of Childbearing Age

44. MRFASTC TreatmentControl % reduction from: base to 6 months57.4% 40.7% base to 12 months 57.4%42.6% base to 24 months 61.7%38.9% base to 36 months 68.1%38.9% base to 48 months 68.1%57.4% Control Treatment p<.10 p<.05 p<.01 Repeated measures overall p < 0.001 (more than 13 drinks per week) p<.05 TrEAT Subsample: Women of Childbearing Age

45. MRFASTC Useful Websites for Providers http://www.cdc.gov/ncbddd/fasd/acog_toolkit.ht ml http://www.projectcork.org/clinical_tools/ http://pathwayscourses.samhsa.gov/vawp/vaw p_7_pg2.htm http://alcoholism.about.com/library/blnaa56.htm http://www.cdc.gov/ncbddd/fasd/hcp.html

46. MRFASTC http://pubs.niaaa.nih.gov/publications/aa65/AA6 5.htm (screening) http://pubs.niaaa.nih.gov/publications/AA66/AA 66.htm (brief interventions) mimh200.mimh.edu/fas/.../MRFASTIC Atlanta Presentation July 2003.ppt http://nofas.org/healthcare/ http://www.mimhcetv.com/catalog/clin.html Useful Websites for Providers

47. MRFASTC Conclusions Identifying at-risk women involves assessment of maternal high-risk behavior and appropriate screening Screens should be brief, reliable, and ethnic/gender sensitive Positive screens should initiate more complete assessment of alcohol use and appropriate intervention

48. MRFASTC Brief Intervention shown to be a low-cost, effective treatment alternative for alcohol problems Brief intervention can fit into the context of busy, high-volume practice settings Dependent drinkers, whether pregnant or not, should be referred to specialized alcohol treatment programs. A prior brief Intervention can facilitate this referral. Conclusions