Transcript Document

The Maternal Drinking
History Guide
Presented by Moumita Sarkar, PhD
Alcohol and Substance Use Helpline
The Motherisk Program, Hospital for Sick
Children
Based on a consensus report developed by the FASD Advisory Workgroup in
collaboration with SOGC and PHAC
Case #1


Infant born at 35 weeks of gestation with
severe IUGR and APGAR score of 5
Poor tonus, poor suckling
Case #1 cont….

Medical history does not reflect any maternal
exposure related to baby’s symptoms

Patient denies the use of alcohol and substances

Meconium test for Fatty Acid Ethyl Ester
(combination of alcohol and fatty acids): 52nM/g
(N=<2)

Mother is a problem drinker, unknown to the GP or
gynecologist
Alcohol and Pregnancy

9-12% of women reported drinking throughout
their pregnancies (Health Canada 2000)

1.4% of pregnant women reported binge drinking
(CDC 2011)

Health care providers do not systematically
screen all pregnant women on their consumption
of alcohol

19% of women reported not being ask about their
alcohol use (Chang, 2011)

25% of pregnant women were not asked
Prenatal Alcohol Use:
widespread

Problem drinking:



refers to the amount of maternal drinking
associated with harm to the fetus
Exceeds 3 drinks at one sitting or 7 drinks
per week (NIAAA, 2005)
Pregnant or planning:

Any amount of drinking is risky for women
who are pregnant or trying to become
pregnant (USDHHS, 2005)
Routine Screening

Ask all women of childbearing age about
alcohol/drug use (especially pregnant women)

Advise all women planning/pregnant that no
alcohol is the safest choice; women who consumed
alcohol during their pregnancy to contact Motherisk

Assist all women to stop drinking through
information, counselling, care and referral to
appropriate programs and services
SCREEN TO PREVENT FASD
The Maternal Drinking Guide:
Purpose
 Determine if the mother drinks /has drank at a
problem drinking level in pregnancy.
 A Positive screen on TWEAK
 Meets the NIAAA guidelines for problem drinker
 Obtain accurate maternal alcohol use report
 Knowledge of prenatal alcohol use is essential for
 1) subsequent FASD diagnosis in the future and
 2) harm reduction strategies
Benefits

Validated methodology


as effective means of eliciting maternal alcohol use
Provides practitioner with options

appropriate for different groups and circumstances

No training/ expertise required to screen

Integrate screening questions into standardized
health questionnaires

among innocuous questions related to lifestyle
When to ask?

Key times to assess alcohol use:
Initial visit (to any new provider)
 Annual gynecological visit
 Preconception visit
 Visits for confirmation of pregnancy
 Mid-pregnancy (24-28 weeks)
 Exit visit (32-36 weeks)

Level I
Practice-based
screening
Single-question
method
Motivational
Supportive
interviewing
dialogue
Sarkar et al., CJCP 2009;
16 (1): e242-63
Level II
Structured
questionnaire
Direct
questioning
Indirect/masked
screening
Time Line
Follow Back Tool
CRAFFT
T-ACE
TWEAK
Sarkar et al., CJCP 2009; 16 (1): e242-63
Level III
Laboratory-based
screening tool
Liver enzymes
Alcohol measures
in blood/breath
Hair and Meconium
for FAEE
Sarkar et al., CJCP 2009; 16 (1): e242-63
Case #1: Introduction

Explain that you will be asking a standard series
of health questions that are directed to all
patients in order to improve health

Intro #1: “I want to ask you a series of questions
today about your lifestyle. I ask all my patients
these questions because it helps me to get to know
you better and provide better care.”
Level I: Practice-based

When did you find out/suspect you were pregnant?

Single-question method of screening

Embed at least one question to identify prenatal alcohol use among
other innocuous questions related to lifestyle
e.g. Do you take any prenatal vitamins? Do you
smoke any cigarettes? If so, how many?



Do you ever enjoy a drink or two? When was the last time?
Do you sometimes drink beer, wine or other alcoholic beverages?
In the past month or so, have you enjoyed a drink or two?
What about taking medications? Did you
exercise?
Case #1: Brief questionnaires

Most effective method of screening (Stratton, 1996)
 Quick, practical, efficient and cost effective

Direct questioning
 Timeline Follow Back Tool (TLFB)

Indirect/masked screening
 Overcome issues of possible underreporting
 T-ACE, TWEAK


Developed and validated for use among pregnant women
TWEAK - Optimal for racially diverse groups, highly sensitive
test
TWEAK
TWEAK
QUESTIONS
POINTS
Tolerance
How many drinks does it take to make you feel the first effect (before
pregnancy)? _________
(3 or more = 2 points)
Worry
Have close friends worried or complained about your drinking in the
past year?
(yes = 2 points)
Eyeopener
Do you sometimes take a drink in the morning when you first get up?
(yes = 1 point)
Amnesia
Has a friend or family member ever told you about things you said or
did while you were drinking that you could not remember?
(yes = 1 point)
Cut down
Do you sometimes feel the need to cut down on your drinking?
(yes = 1 point)
Russell M. New assessment tools for risk drinking during pregnancy: T-ACE,
TWEAK and Others. Alcohol Health and Research World (1994) 18 (1): 55-61
Case #1: Level III Screening
(with consent)

Postpartum case (index of suspicion but
deny use)

If Level I and/or level II (TWEAK) screening is
not successful
Level III screening (with consent)

Why is this knowledge valuable?
FASD assessment referral

Referral by a doctor required

Assessment involves physical, neurological,
psychiatric, genetic examination

Confirmation of prenatal alcohol
exposure required
Screening and
Intervention
What can be done?
Early Dx = Early Intervention
• Early diagnosis - evidence based
• Stimulation in early ages - important
• Parenting support materials
LEV EL O NE
I n trodu cto ry s tate me n t (refer to s e cti o n II b):
“I w ill begin yb asking a standard seriesof health questions I ask all m y patients in
order to improve your health and the health of your child”
Practi cebase dqu e sti on (refer
s
to s e cti onII c):
General “Do you ever enjoy a drink or tw o?”
“Do you sometimes drinkbeer, w ine or o
ther alcoholic beverages?”
LEV EL TW O
“Do you ever u se alcohol?”
Ifor
retw
s pon
To as sess“In
problem
nki ngorbe
h avi
ou
ryou ever enjoyed a drink
the pastdri
month
two
have
o?” sei s n e gati ve
(i .e. n o alcoh ol/dru gs ):
 Apply“Do
TWEAK
test any
(refe
r to s e cti
on III)
you have
concerns
abou
t you r drinking?”
Educate / advise on effects of
“In a typical w eek, how many occasionsdid you usu allyhave
somalcohol/
ething todrug use
prenatal
drink?”
Problem Dri nker
If TWEAK is 2 or more
Not a Proble m Dri nker
If TWEAK is less than 2 AND/ OR
response is 0 times in a week or in a sit ting
Brief intervention (harm reduction)
Advise and Refer
Follow- up at every subsequent visit
Advise
Follow- up at every subsequent visit
Brief intervention
Advise and Refer
LEV EL THREE
Laboratory An alys i s(refer to s e cti onIII c)
(e.g. Hair FAEE) in relevant cases, with FULL
INFORMED CONSENT
Advise
Case #2

BJ has been your patient for a year. She is very private
and can be both defensive and combative by nature

She has a 5 yr old child with both developmental and
behavioural issues

She is now pregnant and has previously never been asked
about her alcohol use

During her prenatal screening, her provider asks:


“I’m sure you know alcohol and pregnancy don’t go well together.
You don’t drink, do you?” She responds: “No”
Few weeks later, her partner mentions his concern for her
continued drinking
Case #2: Introduction

Explain that you will be asking a standard
series of health questions that are directed
to all patients in order to improve health

Intro example: “I want to ask you a series of
questions today about your lifestyle. I ask all
my patients these questions because it
helps me to get to know you better and
provide better care of your pregnancy.”
Level I: Practice-based

Begin Innocuous questions:


When did you find out/suspect you were pregnant?
Single-question method of screening
e.g. Do you take any prenatal vitamins? Do you
smoke any cigarettes? How is your diet?



Do you ever enjoy a drink or two? When was the last time?
Do you sometimes drink beer, wine or other alcoholic
beverages?
In the past month or so, have you enjoyed a drink or two?
What about taking medications? Did you exercise?
Case #2

BJ has been your patient for a year. She is very private
and can be both defensive and combative by nature

She has a 5 yr old child with both developmental and
behavioural issues

She is now pregnant and has previously never been asked
about her alcohol use

During her prenatal screening, her provider asks:


“I’m sure you know alcohol and pregnancy don’t go well together.
You don’t drink, do you?” She responds: “No”
Few weeks later, her partner mentions his concern for her
continued drinking
Case #2: Motivational
Interviewing Techniques

Avoid questions that suggest that you want a negative
response:
 Negative: You don’t drink, do you?
 Positive: Many women wind down the day with a glass of wine
or a few drinks on a night out…..do you sometimes enjoy a drink
or two?”
 Avoid many closed or dead-ended questions:
 Negative: Do you drink since you found out? Yes or No
 How has your alcohol consumption evolved since finding out your
pregnancy?
a) I continue my usual habit
b) I have cut down
c) I am trying to abstain but find it difficult
Case #2: Supportive Dialogue

Supportive dialogue (Without any moral
connotation & empathetic listening)

Can you tell me a bit about your drinking pattern before you
knew you were pregnant?

Have you been able to stop or cut down since you found
out?
Case #2: Supportive Dialogue

If alcohol problem suspected, but denied,


Important to engage women to improve trust
Use empathy

"it is recommended to abstain from alcohol during
pregnancy, if you are having hard time stopping, or
even if you drink occasionally, do not hesitate to
discuss it with me"
Advise/ Feedback

If screen positive as problem drinker, or report continued prenatal
alcohol use, begin the process by:
 Here is some information that has been learned through
research; I’d like to share it with you, if I may.
 What is your understanding about alcohol use in pregnancy?
 Do you have any questions about your alcohol use?
 Provide feedback that allows clients to compare their behavior to
others so they know how their behavior relates to national norms


“Many women drink on a regular basis, and since half of all
pregnancies are unplanned, many women are exposed to
alcohol prior to pregnancy knowledge.”
Do you mind if we spend a few minutes talking about…..?
Are you interested in learning more about……..?
LEV EL O NE
I n trodu cto ry s tate me n t (refer to s e cti o n II b):
“I w ill begin yb asking a standard seriesof health questions I ask all m y patients in
order to improve your health and the health of your child”
Practi cebase dqu e sti on (refer
s
to s e cti onII c):
Pregnant w omen: “Can you tell me a bit abou t your drinking
patterns before you knew
you w ere pregnant?”
“Do you sometimes drinkbeer, w ine or o
ther alcoholic beverages?”
LEV EL TW O
“Do you ever u se alcohol?”
If re s pon sei s n e gati ve
To as sess problem dri nki ng be h avi ou
r - 3 option s :
pastmany
month
or two
have
ever
enjoyed a drink
(ior
.e. tw
n oo?”
alcoh ol/dru gs ):
 In the“In
pastthe
, how
times
have
youyou
had
more
than 7 drinks in a week?
anytimes
concerns
t youmore
r drinking?”
Educate / advise on effects of
 In the “Do
past ,you
howhave
many
have abou
you had
prenatal alcohol/ drug use
than 3 drinks at one sit ting?
“In a typical w eek, how
ORmany occasionsdid you usu allyhave som ething to
 Apply TWEAK test (refe r to s e cti on III)
drink?”
Problem Dri nker
Not a Proble m Dri nker
If TWEAK is 2 or more
If TWEAK is less than 2
Brief intervention (harm reduction)
Advise and Refer
Educate / advise on effects of prenatal
alcohol/ drug use
Follow- up at every subsequent visit
Level 1 questions re alcohol/drugs
Advise
Follow- up at every subsequent visit
Level 1 questions re alcohol (IIIb)
Brief intervention
Advise and Refer
N/A
LEV EL THREE
Recommendations: Screening

During regular health exams, health care
providers should use standardized questions that
should include at least Level I screening


Early identification and reduction of maternal drinking
No known safe limit for alcohol use in pregnancy

Level II should be adopted as standard screening
process to identify alcohol use in all women of
childbearing age and pregnant women

Upon screening, women need to be linked to
services if required by their providers
Take Home Message




Health care provider role in harm reduction is vital
 advise patients that the safest choice is not to
consume alcohol during pregnancy
Adequate resources should be made available to
women requiring interventions beyond primary
interaction
Recording of maternal alcohol use in newborn’s birth
record and child’s health record
Early identification and subsequently early FASD Dx
= intervention can occur
FASD programs/resources
Best Start (www.beststart.org)
Provides online training tools for screening alcohol
Motherisk Alcohol and Substance Abuse Helpline
(www.motherisk.org) National toll-free helpline 1 877 FAS-INFO
providing evidence-based info and referrals on alcohol/drugs
Canadian Centre on Substance Abuse (www.ccsa.ca)
PRIMA (www.addictionpregnancy.ca)
Alberta Health Services (www.albertahealthservices.ca)
Healthy Choices in Pregnancy in BC (www.hcip-bc.org)
Acknowledgments

Dr. Gideon Koren

Motherisk Alcohol and Substance Use
Helpline Counselors

The National Taskforce for FASD Screening

Canadian Association for Paediatric Health
Science Centre

Public Health Agency of Canada
The Maternal Drinking
History Guide
Thank You!
Thank you for listening!