Transcript Women of Childbearing Age - NOFAS

Alcohol Screening and
Brief Interventions of
Women
Competency #2
Midwest Regional Fetal Alcohol
Syndrome Training Center
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.
MRFASTC
Learning Goals
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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
MRFASTC
Why Screen?
• Alcohol use during pregnancy is one of the
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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
MRFASTC
Who Should We Screen?
• All women of child-bearing age
• Pregnant women
• Nursing mothers
MRFASTC
Why Screen Women of
Child-Bearing Age?
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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
MRFASTC
Alcohol Consumption by
Women – Primary Care Data
7% 4%
33%
17%
Abstainers
Low-Risk
At-Risk
Problem
Dependent
39%
Alcohol use among women ages 18-30
MRFASTC
Alcohol Consumption
Among Women
Percent Women
60
54.9
50
Might become
pregnant
40
Pregnant
30
20
12.0
12.4
10.1
10
1.9
1.9
0
Any
Frequent
Binge
Categories of Alcohol Consumption
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
MRFASTC
Why Screen Nursing
Mothers?
• Infants consume less milk when mothers
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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
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
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
MRFASTC
Risk Factors
Who is Likely to Drink ?
• Low socioeconomic status
• Unmarried
• African-American and AmericanIndian/Alaska-Native ethnicity
• Younger maternal age
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
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• Laboratory evaluation
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Not very sensitive
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
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?
MRFASTC
Recommended Alcohol
Screening Instruments
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Best instruments should be:
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Brief
Easy to administer and score
Reliable/accurate in target population
To be effective they must be:
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Used routinely with EVERY patient
With pregnant patients, must be
administered multiple times
MRFASTC
Recommended Alcohol
Screening Instruments
Women
TWEAK, T-ACE
Pregnant Women TWEAK, T-ACE
Adolescents
CRAFFT
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)
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)
MRFASTC
CRAFFT
1.
2.
3.
4.
5.
6.
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)
Do you ever use alcohol or drugs to Relax, feel better about
yourself, or fit in? (Yes = 1 point)
Do you ever use alcohol or drugs while you are by yourself
(Alone)? (Yes = 1 point)
Do you ever Forget things you did while using alcohol or drugs?
(Yes = 1 point)
Do your Family or Friends ever tell you that you should cut down
on your drinking or drug use? (Yes = 1 point)
Have you ever gotten into Trouble while you were using alcohol
or drugs? (Yes = 1 point)
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 longterm use problems
 High cost make these less feasible
for universal screening
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
MRFASTC
Strategies for Overcoming
Barriers to Effective Screening
• Using clinic-based system protocols (e.g.
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patient questionnaires) to prompt provider
Research alcohol treatment programs prior
to need
Educate payers
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These strategies have worked for smoking
cessation, breast cancer screening,
diabetes education, etc.
MRFASTC
If Screen is Positive
Determine Drinking Pattern
1.
2.
3.
4.
5.
Abstainers
Low-risk
At-risk
Problem
Alcohol dependent
MRFASTC
Five Drinking Patterns
1. Abstainers
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No alcohol or fewer than 12
drinks per year
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
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MRFASTC
Five Drinking Patterns
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
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MRFASTC
Five Drinking Patterns
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.)
MRFASTC
Five Drinking Patterns
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)
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MRFASTC
What We Know About
Brief Interventions?
• Decrease alcohol use in both women and
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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
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
MRFASTC
Brief Interventions
• 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
MRFASTC
Steps in a Brief
Intervention: FRAMES
Step 1
Step 2
Feedback of personal risk
Responsibility of the patient for personal
control
Step 3
Advice to change
Step 4
Menu of ways to reduce or stop drinking
Empathetic counseling style
Self efficacy or optimism of the patient to cut
Step 5
Step 6
down or stop drinking
MRFASTC
Feedback
• I am very concerned about how your
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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.
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?
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.
MRFASTC
Menu of Ways to Reduce
or Stop Drinking
• I would like for you to read this pamphlet that
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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.
MRFASTC
Empathetic Counseling Style
• I see from your drinking diary that you
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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?
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.
MRFASTC
Follow-up
• Schedule follow-up visit or phone call
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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
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
MRFASTC
Number of Binge Drinking Episodes: Past 30 Days
(more than 4 drinks per occasion)
6
5
Control
Treatment
p<.05
4
3
2
1
0
Baseline
6 months
12 months
24 months
36 months
48 months
Treatment
% reduction from: base to 6 months 56.3%
base to 12 months 55.5%
base to 24 months 40.4%
base to 36 months 41.6%
Repeated measures
base to 48 months 42.2%
overall p < 0.001
TrEAT Subsample: Women of Childbearing Age
Control
35.5%
32.8%
7.1%
23.9%
17.9%
MRFASTC
Percent Drinking Excessively in Past Week
60%
(more than 13 drinks per week)
50%
40%
p<.05
p<.10
p<.01
30%
p<.05
Control
Treatment
20%
10%
0%
Baseline
6 months
12 months
24 months
36 months
48 months
Treatment
% reduction from: base to 6 months
57.4%
base to 12 months 57.4%
base to 24 months 61.7%
Repeated measures
base to 36 months 68.1%
overall p < 0.001
base to 48 months 68.1%
TrEAT Subsample: Women of Childbearing Age
Control
40.7%
42.6%
38.9%
38.9%
57.4%
MRFASTC
Useful Websites for
Providers
• http://www.cdc.gov/ncbddd/fasd/acog_toolkit.ht
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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
MRFASTC
Useful Websites for
Providers
• http://pubs.niaaa.nih.gov/publications/aa65/AA6
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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
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
MRFASTC
Conclusions
• 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.
MRFASTC