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

“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

Commonly Abused Substances Alcohol Tobacco Heroin Methadone Cocaine Marijuana Prescription Drugs Inhalants

Alcohol 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.

Categories of Alcohol use in Women Abstainers Low Risk Drinkers At Risk Drinkers Problem Drinkers Alcohol Abuse Alcohol Dependence Binge Drinkers

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 These 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.

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

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)

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

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 1.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.

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

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

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 . 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.

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 This NIAAA publication reviews screening, brief intervention, statistics, meds-useful as a guide.

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

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

Screens: CAGE C…..Cut down or control use A…..Anger or annoyance G…..Guilt regarding use E…..Eye opener (or signs of withdrawal)

Screens: T-ACE T…..Tolerance. How many to get “high” A…..Annoyance with criticism C…..Cut Down E…..Eye Opener

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

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

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 et.al. 2005)

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) 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.

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 Remember the legal implications of having this labwork on a patient’s chart.

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

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

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

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 Transferrin is the protein molecule that combines with, and transfers, iron in the body.

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 Patterns are in direct and indirect bilirubin, ratios of ALT and AST.

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 Look 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.

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

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

Brief Intervention

Brief Intervention 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

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

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

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

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

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 This 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.

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

Barriers to Screening and Referral Patient Healthcare Providers Picture 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.

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

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

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

Specific Medical Concerns Domestic Violence HIV/AIDS Anxiety Disorders PTSD- significant abuse history Mood Disorders Eating Disorders Borderline Personality-confusion with drug behavior If you are not making progress in the intervention, make sure you have screened for these common complicating factors.

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

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

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

Management: Person Centered Care Education Mental Health Health Care Child Welfare and Family Support Services Criminal and Juvenile Justice Chemical Dependency Developmental Disabilities Note the need for multidisciplinary case management.