Prevention Tools and Techniques: Alcohol Screening and Brief Intervention

1. Prevention Tools and Techniques:  Alcohol Screening and Brief Intervention Samuel MacMaster, Ph.D. University of Tennessee smacmast@utk.edu

2. Objectives • How to teach-train: • Awareness of Students’ Lens • SBIRT Method • Alcohol Screening • Screening Tools • Brief Intervention • Resources • Developing Empathy • Role Play

3. The lens your students are using • Anyone who drinks less/more than me • Creates a definition of “normal drinking” • Some students may actually have substance abuse issues • Uncle Buzzy Effect • Family history of substance abuse • Higher prevalence • Cultural-Media Assumptions • What does an alcoholic look like? • Who has an alcohol problem? • Brown paper bag, etc.

4. Important to Address Lens First • What does a substance user look like? • Gender plays an effect • What are their assumptions? • Family history? • Experiences with media images, cultural bias? • If not addressed, remain an elephant in the room

5. SBIRT: Screening, Brief Intervention and Referral to Treatment

6. SBIRT-Early Intervention • SBIRT represents a paradigm shift in the provision of treatment for substance use and abuse. • Services are different from, but designed to work in concert with, specialized or traditional treatment. • Dirty secret of specialized substance abuse treatment is that it is primarily designed for individuals who are dependent---individuals with less severe issues fit less well with treatment models.

7. Basics • Incorporates screening into medical and other health service providers • After screening comes a decision to move towards—no further services, brief intervention, brief treatment, or a referral to specialized treatment • Serves as a background for working with women at risk for FASD

9. Need to Understand Screening • Screening in the Medical Field • Tuberculosis • Pregnancy • HIV/AIDS • Must highlight that a Positive Screen is not a Diagnosis! • A Positive Screen simply indicates that more information needs to be gathered. • It also creates an opportunity to begin a dialogue

10. The Diagnostic Process • Ongoing Clinical Process • Begins with Screening • All Diagnoses are Preliminary Screening Assessment Diagnosis

11. Importance of Universal Screening • Most substance users experiencing problems do not access treatment • Stages of Change Concept • Change is a gradual process • Five stage model: precontemplation, contemplation, preparation, action and maintenance • 85%-90% of substance abusers have no interest and/or awareness that substance use is a problem

12. Importance for Women who are Pregnant or Potentially Pregnant • Women of Child Bearing Age • Approximately 53% of women report some alcohol use and Approximately 12% report binge drinking • More than half of women who do not use birth control report alcohol use • 13% are sexually active and drink alcohol frequently or binge drink • Prenatal drinking status is predictive of alcohol use during pregnancy • Many women continue to drink into the third semester before knowing they are pregnant • Pregnant women: • Data from pregnant women indicate 10% report drinking alcohol • 2% to 4% reported binge drinking • High-risk drinking among women has not declined in the past decade • Sample of WIC study participants • Rate of post-conception drinking was 24% and 62% reported drinking before they knew they were pregnant

13. Recommended Alcohol Limit During Pregnancy and Preconception?

15. Conceptualizing Risk vs. Disorder • Women’s Alcohol Risk Categories • Abstinence • Low Risk: ≤7 drinks/week and ≤3 drinks/occasion • At-Risk: 8-21 drinks/week or >3 drinks/ occasion, or in high-risk situations • Problem Drinker: >21 drinks/week, may experience negative consequences, may correlate with DSM abuse category • Alcohol-Dependent: may correlate with DSM dependence category, usually associated with heavy drinking--with or without physical dependence, and negative consequences

16. At-Risk Drinking Per Week Per Occasion Men > 14 drinks > 4 drinks Women > 7 drinks > 3 drinks Seniors > 7 drinks > 1 drink Pregnant > 0 drinks > 0 drinks Women

17. Alcohol Assessment: Frequency and Quantity Always remember to first ask: Do you drink alcohol of any kind? If the answer is yes…….. Begin Screening Process

18. Issues in Screening False Positives & False Negatives Everyone Screened Screen Negative Screen Positive False Negatives False Positives

19. Issues in Selecting Instruments • Sensitivity • Does the screen detect all cases • Measure of true positives • the probability that a risk drinker is positive on the test (0 to 1) • Specificity • Does the screen not pick up non-cases • Measure of true negatives • the probability that a non-risk drinker is negative on the test (0 to 1)

20. TWEAK Alcohol Assessment • Developed originally to screen for at-risk drinking during pregnancy • Five-item scale • Shown to be appropriate and effective with pregnant women and African-American women with low SES

21. “TWEAK” • T-Tolerance: "How many drinks does it take you to feel the first effects of the alcohol?" • W-Worry: "Have close friends or relatives Worried or complained about your drinking in the past year?" • E-Eye-openers: "Do you sometimes take a drink in the morning when you first get up?" • A-Amnesia (blackouts); "Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?" • K(C)-Cut Down: "Do you sometimes feel the need to Cut Down on your drinking?"

22. Tweak Scoring • Tolerance: 3 or more drinks to feel effect = 2 points • Worry: Yes = 2 points • Eye Opener: Yes = 1 point • Amnesia: Yes = 1 point • Cut Down: Yes = 1 point • A score of >0 indicates at-risk during pregnancy • For others, a score of 2 indicates likelihood of at-risk drinking; • A score of 3-4 or more is a positive screen • Sensitivity- .91, Specificity- .77 Chang G. Alcohol Screening Instruments for Pregant Women. Alcohol Research and Health. 2001;25(3):204-209 (at NOFAS website).

23. “T-ACE” • T-Tolerance: "How many drinks can you hold?" • A-Annoyance: "Have people annoyed you by criticizing your drinking?" • K(C)-Cut Down: “Have you ever felt the need to Cut Down on your drinking?" • E-Eye-openers: “Have you ever had a drink the first thing in the morning to steady your nerves?"

24. T-ACE Scoring • Tolerance-two points if a woman reports she needs more than two drinks to get high • All other questions are worth one point • Cut-off is two • Sensitivity- .76 • Specificity- .79

25. Non-Empirical Tools • Four Ps • Have you drank or used drugs during this pregnancy, in the past, has your partner or parents had drinking or drug use problems? • Global Question • “Are you experiencing problems related to your drug and alcohol use?” Richard Brown-University of Wisconsin

26. For Patient Discomfort with Screening • Must be comfortable • Change topic and revisit later • Ask more about social context and establish more rapport • Ask about discomfort and request cooperation • Explain need for questions

27. What about a positive screen….. • Discuss results in a non-confrontational, relaxed manner • You are not indicting your client, you are helping to facilitate their transition to tx. • Shame can be part of the problem---avoid it • Explain what a positive screen is and what it is not

28. Brief Intervention • Found to be effective with female problem drinkers in primary-care clinics • 5-10 minute counseling session has been found to reduce alcohol use in women by 20-30% • … is not difficult Wallace P, Cutler S, Hains A. Randomized controlled trial of general practitioner in patients with excessive alcohol consumption. British Medical Journal. 1988;297(6649):663-668. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers: A randomized controlled trial in community-based primary-care practices. JAMA. 1997;277(13):1039-1045.

29. Brief Intervention: Ask and Assess Risk Level • Raise the subject: “I like to ask all my patients about their drinking patterns” • Does the patient have alcohol-related problems? (Medical, behavioral, social, familial) • Provide feedback about alcohol risk level: Relate health concerns / pregnancy risks to alcohol use “Are you concerned about how your drinking may affect your health” “There is no known safe limit for drinking during pregnancy. You need to stop drinking completely b/c when you drink, your baby drinks.”

30. Brief Intervention: Advise and Assist • Engage the patient in the process: Assess, enhance motivation and patient responsibility “How do you feel about your drinking?” • For alcohol-risk, establish drinking goals: Advise and negotiate “Are you ready to set a drinking goal? What do you think will work best for you?” (give brochure materials) • Not appropriate for alcohol dependence, advise abstinence and refer to specialized treatment. National Institute on Alcohol Abuse and Alcoholism and Office of Research on Minority Health, Identification of At-Risk Drinking and Intervention with Women of Childbearing Age. NIH Publication No. 99-4368 (Printed 1999)

31. Brief Intervention • Always follow up: • review progress, • commend effort, • reinforce positive change, • reassess motivation

32. Optional Brief Motivational Interview • Motivational Interviewing—developed by William Miller to assist problem drinkers resolve ambivalence around behavior change • Ambivalence is seen as a normal natural process • Ultimately relationship-based style---empathy is the key

33. FRAMES Approach • Quick Motivational Interviewing Technique. • Feedback • Responsibility • Advice • Menu of Options • Empathy • Self-Efficacy

34. Hints and Traps to Avoid • Joint Denial • Johnny (Jenny) you don’t do drug do you? • Triangulation • For many problem drinkers their primary relationship is with alcohol • Taking Responsibility • Roll with Resistance

35. You don’t have a substance abuse problem, right? Great

36. Triangulation

37. Responsibility • Voice for change must come from client • Can’t be imposed or forced

38. Roll with Resistance Normal for client/patient to resist change, become annoyed or angry when criticized---must be avoided. Roll with resistance and avoid argumentation at all costs. Otherwise you are reinforcing the status quo.

39. Improving Health Provider Practices It may seem difficult to talk with patients about FASD, but you can do it.

40. Information and Treatment Resources • NOFAS (National Organization on FAS) Phone: 202-785-4585 Web: www.nofas.org • University of Washington FAS Prevention Network Web: http://depts.washington.edu/fasdpn/ • Alcoholics Anonymous Phone: 212-686-1100 Web: www.alcoholics-anonymous.org • Local Alcohol and Drug Treatment Resources: Web: http://findtreatment.samhsa.gov/facilitylocatordoc.htm

41. FASD Role Play • 22 year old college student, name: ______ • Pregnant, 10 weeks • Do alcohol assessment • Describe risks of FAS/D – facial/size/CNS • Excited about becoming a mom • Going to marry boyfriend • Likes to party and drink socially • Beer, wine, liquor (whatever is around) • Have cut down due to pregnancy (get tipsy faster) • 1-3 drinks per occasion (previously 1-6)