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Prevention Tools and Prevention Tools and Techniques: Techniques:
Alcohol Screening and Alcohol Screening and Brief InterventionBrief Intervention
Samuel MacMaster, Ph.D.Samuel MacMaster, Ph.D.University of TennesseeUniversity of Tennessee
[email protected]@utk.edu
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ObjectivesObjectives• How to teach-train:How to teach-train:
– Awareness of Students’ LensAwareness of Students’ Lens– SBIRT MethodSBIRT Method– Alcohol Screening Alcohol Screening – Screening ToolsScreening Tools– Brief InterventionBrief Intervention– ResourcesResources
• Developing EmpathyDeveloping Empathy– Role PlayRole Play
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The lens your students are using The lens your students are using
Anyone who drinks less/more than meAnyone who drinks less/more than me
– Creates a definition of “normal drinking”Creates a definition of “normal drinking”
– Some students may actually have substance abuse issuesSome students may actually have substance abuse issues
Uncle Buzzy EffectUncle Buzzy Effect
– Family history of substance abuseFamily history of substance abuse
– Higher prevalence Higher prevalence
Cultural-Media AssumptionsCultural-Media Assumptions
– What does an alcoholic look like?What does an alcoholic look like?
– Who has an alcohol problem? Who has an alcohol problem?
– Brown paper bag, etc.Brown paper bag, etc.
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Important to Address Lens Important to Address Lens FirstFirst• What does a substance user look like?What does a substance user look like?• Gender plays an effectGender plays an effect• What are their assumptions?What are their assumptions?• Family history?Family history?• Experiences with media images, Experiences with media images,
cultural bias?cultural bias?• If not addressed, remain an elephant If not addressed, remain an elephant
in the roomin the room
SBIRT: Screening, Brief SBIRT: Screening, Brief Intervention and Referral Intervention and Referral
to Treatmentto Treatment
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SBIRT-Early InterventionSBIRT-Early Intervention• SBIRT represents a paradigm shift in the SBIRT represents a paradigm shift in the
provision of treatment for substance use provision of treatment for substance use and abuseand abuse. .
• Services are different from, but designed Services are different from, but designed to work in concert with, specialized or to work in concert with, specialized or traditional treatment. traditional treatment.
• Dirty secret of specialized substance Dirty secret of specialized substance abuse treatment is that it is primarily abuse treatment is that it is primarily designed for individuals who are designed for individuals who are dependent---individuals with less severe dependent---individuals with less severe issues fit less well with treatment models.issues fit less well with treatment models.
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BasicsBasics• Incorporates screening into medical Incorporates screening into medical
and other health service providersand other health service providers
• After screening comes a decision to After screening comes a decision to move towards—no further services, move towards—no further services, brief intervention, brief treatment, or brief intervention, brief treatment, or a referral to specialized treatmenta referral to specialized treatment
• Serves as a background for working Serves as a background for working with women at risk for FASDwith women at risk for FASD
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Need to Understand Need to Understand ScreeningScreening
• Screening in the Medical FieldScreening in the Medical Field– Tuberculosis Tuberculosis – PregnancyPregnancy– HIV/AIDSHIV/AIDS
• Must highlight that a Positive Screen is not Must highlight that a Positive Screen is not a Diagnosis!a Diagnosis!– A Positive Screen simply indicates that more A Positive Screen simply indicates that more
information needs to be gathered.information needs to be gathered.– It also creates an opportunity to begin a It also creates an opportunity to begin a
dialoguedialogue
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The Diagnostic ProcessThe Diagnostic Process
• Ongoing Clinical ProcessOngoing Clinical Process
• Begins with ScreeningBegins with Screening
• All Diagnoses are PreliminaryAll Diagnoses are Preliminary
Screening Assessment Diagnosis
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Importance of Universal Importance of Universal ScreeningScreening• Most substance users experiencing Most substance users experiencing
problems do not access treatmentproblems do not access treatment
• Stages of Change ConceptStages of Change Concept– Change is a gradual processChange is a gradual process– Five stage model: Five stage model:
precontemplation, contemplation, precontemplation, contemplation, preparation, action and preparation, action and maintenancemaintenance
• 85%-90% of substance abusers have 85%-90% of substance abusers have no interest and/or no interest and/or awarenessawareness that that substance use is a problemsubstance use is a problem
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Importance for Women who Importance for Women who are Pregnant or Potentially are Pregnant or Potentially PregnantPregnant• Women of Child Bearing AgeWomen of Child Bearing Age
– Approximately 53% of women report some alcohol use and Approximately 53% of women report some alcohol use and Approximately 12% report binge drinkingApproximately 12% report binge drinking
– More than half of women who do not use birth control report More than half of women who do not use birth control report alcohol usealcohol use
– 13% are sexually active and drink alcohol frequently or binge 13% are sexually active and drink alcohol frequently or binge drinkdrink
– Prenatal drinking status is predictive of alcohol use during Prenatal drinking status is predictive of alcohol use during pregnancypregnancy
– Many women continue to drink into the third semester before Many women continue to drink into the third semester before knowing they are pregnantknowing they are pregnant
• Pregnant women:Pregnant women:– Data from pregnant women indicate 10% report drinking alcoholData from pregnant women indicate 10% report drinking alcohol– 2% to 4% reported binge drinking2% to 4% reported binge drinking– High-risk drinking among women has not declined in the past High-risk drinking among women has not declined in the past
decadedecade– Sample of WIC study participantsSample of WIC study participants– Rate of post-conception drinking was 24% and 62% reported Rate of post-conception drinking was 24% and 62% reported
drinking before they knew they were pregnantdrinking before they knew they were pregnant
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Recommended Alcohol Limit Recommended Alcohol Limit During Pregnancy During Pregnancy andand Preconception?Preconception?
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Conceptualizing Risk vs. Conceptualizing Risk vs. DisorderDisorder• Women’s Alcohol Risk CategoriesWomen’s Alcohol Risk Categories
– AbstinenceAbstinence– Low Risk: Low Risk: ≤≤7 drinks/week and 7 drinks/week and ≤≤3 3
drinks/occasiondrinks/occasion– At-Risk: 8-21 drinks/week or >3 drinks/ At-Risk: 8-21 drinks/week or >3 drinks/
occasion, or in high-risk situationsoccasion, or in high-risk situations– Problem Drinker: >21 drinks/week, may Problem Drinker: >21 drinks/week, may
experience negative consequences, may experience negative consequences, may correlate with DSM abuse categorycorrelate with DSM abuse category
– Alcohol-Dependent: may correlate with DSM Alcohol-Dependent: may correlate with DSM dependence category, usually associated with dependence category, usually associated with heavy drinking--with or without physical heavy drinking--with or without physical dependence, and negative consequencesdependence, and negative consequences
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At-Risk DrinkingAt-Risk Drinking
Per WeekPer Week Per Per OccasionOccasion
MenMen > 14 drinks> 14 drinks > 4 drinks> 4 drinks
WomenWomen > 7 drinks> 7 drinks > 3 drinks> 3 drinks
Seniors Seniors > 7 drinks> 7 drinks > 1 drink> 1 drink
Pregnant Pregnant > > 00 drinks drinks > > 00 drinks drinks
WomenWomen
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Alcohol Assessment: Alcohol Assessment: Frequency and QuantityFrequency and Quantity
Always remember to first ask: Do Always remember to first ask: Do you drink alcohol of any kind?you drink alcohol of any kind?
If the answer is yesIf the answer is yes…………....
Begin Screening ProcessBegin Screening Process
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Everyone Screened
Issues in ScreeningIssues in Screening
False Positives & False NegativesFalse Positives & False Negatives
False Positives
FalseNegatives
Screen Positive Screen Negative
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Issues in Selecting Issues in Selecting InstrumentsInstruments
• SensitivitySensitivity– Does the screen detect all casesDoes the screen detect all cases– Measure of true positivesMeasure of true positives– the probability that a risk drinker is positive the probability that a risk drinker is positive
on the test (0 to 1)on the test (0 to 1)
• SpecificitySpecificity– Does the screen not pick up non-casesDoes the screen not pick up non-cases– Measure of true negativesMeasure of true negatives– the probability that a non-risk drinker is the probability that a non-risk drinker is
negative on the test (0 to 1)negative on the test (0 to 1)
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TWEAK Alcohol TWEAK Alcohol AssessmentAssessment
• Developed originally to screen for at-Developed originally to screen for at-risk drinking during pregnancyrisk drinking during pregnancy
• Five-item scale Five-item scale
• Shown to be appropriate and effective Shown to be appropriate and effective with pregnant women and African-with pregnant women and African-American women with low SESAmerican women with low SES
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““TWEAKTWEAK””• T-ToleranceT-Tolerance: "How many drinks does it take you to : "How many drinks does it take you to
feel the first effects of the alcohol?" feel the first effects of the alcohol?" • W-WorryW-Worry: "Have close friends or relatives Worried or : "Have close friends or relatives Worried or
complained about your drinking in the past year?" complained about your drinking in the past year?" • E-Eye-openersE-Eye-openers: "Do you sometimes take a drink in the : "Do you sometimes take a drink in the
morning when you first get up?" morning when you first get up?" • A-AmnesiaA-Amnesia (blackouts); "Has a friend or family (blackouts); "Has a friend or family
member ever told you about things you said or did member ever told you about things you said or did while you were drinking that you could not while you were drinking that you could not remember?" remember?"
• K(C)-Cut Down:K(C)-Cut Down: "Do you sometimes feel the need to "Do you sometimes feel the need to Cut Down on your drinking?"Cut Down on your drinking?"
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Tweak ScoringTweak Scoring• Tolerance: 3 or more drinks to feel effect Tolerance: 3 or more drinks to feel effect
= 2 points= 2 points• Worry: Yes = 2 pointsWorry: Yes = 2 points• Eye Opener: Yes = 1 pointEye Opener: Yes = 1 point• Amnesia: Yes = 1 pointAmnesia: Yes = 1 point• Cut Down: Yes = 1 pointCut Down: Yes = 1 point
• A score of >0 indicates at-risk during pregnancyA score of >0 indicates at-risk during pregnancy• For others, a score of 2 indicates likelihood of at-For others, a score of 2 indicates likelihood of at-
risk drinking; risk drinking; • A score of 3-4 or more is a positive screenA score of 3-4 or more is a positive screen• Sensitivity- .91, Specificity- .77Sensitivity- .91, Specificity- .77
Chang G. Alcohol Screening Instruments for Pregant Women. Alcohol Chang G. Alcohol Screening Instruments for Pregant Women. Alcohol Research and Health. 2001;25(3):204-209 (at NOFAS website). Research and Health. 2001;25(3):204-209 (at NOFAS website).
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““T-ACET-ACE””• T-ToleranceT-Tolerance: "How many drinks can you : "How many drinks can you
hold?" hold?"
• A-Annoyance:A-Annoyance: "Have people annoyed you "Have people annoyed you by criticizing your drinking?" by criticizing your drinking?"
• K(C)-Cut DownK(C)-Cut Down: : ““Have you ever felt the Have you ever felt the need to Cut Down on your drinking?"need to Cut Down on your drinking?"
• E-Eye-openersE-Eye-openers: : ““Have you ever had a drink Have you ever had a drink the first thing in the morning to steady the first thing in the morning to steady your nerves?"your nerves?"
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T-ACE ScoringT-ACE Scoring
• Tolerance-two points if a woman Tolerance-two points if a woman reports she needs more than two reports she needs more than two drinks to get high drinks to get high
• All other questions are worth one pointAll other questions are worth one point
• Cut-off is twoCut-off is two
• Sensitivity- .76Sensitivity- .76
• Specificity- .79Specificity- .79
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Non-Empirical ToolsNon-Empirical Tools• Four PsFour Ps
– Have you drank or used drugs during Have you drank or used drugs during this pregnancy, in the past, has your this pregnancy, in the past, has your partner or parents had drinking or partner or parents had drinking or drug use problems? drug use problems?
• Global QuestionGlobal Question– ““Are you experiencing problems related to Are you experiencing problems related to
your drug and alcohol use?” your drug and alcohol use?” Richard Brown-Richard Brown-University of Wisconsin University of Wisconsin
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For Patient Discomfort with For Patient Discomfort with ScreeningScreening
• Must be comfortableMust be comfortable
• Change topic and revisit laterChange topic and revisit later
• Ask more about social context and Ask more about social context and establish more rapportestablish more rapport
• Ask about discomfort and request Ask about discomfort and request cooperationcooperation
• Explain need for questionsExplain need for questions
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What about a positive What about a positive screen…..screen…..• Discuss results in a non-Discuss results in a non-
confrontational, relaxed mannerconfrontational, relaxed manner• You are not indicting your client, you You are not indicting your client, you
are helping to facilitate their transition are helping to facilitate their transition to tx.to tx.
• Shame can be part of the problem---Shame can be part of the problem---avoid itavoid it
• Explain what a positive screen is and Explain what a positive screen is and what it is notwhat it is not
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Brief InterventionBrief Intervention
• Found to be effective with female problem Found to be effective with female problem drinkers in primary-care clinicsdrinkers in primary-care clinics
• 5-10 minute counseling session has been found 5-10 minute counseling session has been found to reduce alcohol use in women by 20-30%to reduce alcohol use in women by 20-30%
• … … is not difficultis not difficult
Wallace P, Cutler S, Hains A. Randomized controlled trial of general Wallace P, Cutler S, Hains A. Randomized controlled trial of general practitioner in patients with excessive alcohol consumption. British practitioner in patients with excessive alcohol consumption. British Medical Journal. 1988;297(6649):663-668.Medical Journal. 1988;297(6649):663-668.Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers: A randomized controlled trial in advice for problem alcohol drinkers: A randomized controlled trial in community-based primary-care practices. JAMA. 1997;277(13):1039-community-based primary-care practices. JAMA. 1997;277(13):1039-1045.1045.
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Brief Intervention: Brief Intervention: Ask and Assess Risk LevelAsk and Assess Risk Level• Raise the subject:Raise the subject:
““I like to ask all my patients about their drinking patterns”I like to ask all my patients about their drinking patterns”
• Does the patient have alcohol-related Does the patient have alcohol-related problems? problems? (Medical, behavioral, social, familial)(Medical, behavioral, social, familial)
• Provide feedback about alcohol risk level: Provide feedback about alcohol risk level: Relate health concerns / pregnancy risks to Relate health concerns / pregnancy risks to alcohol usealcohol use
““Are you concerned about how your drinking may affect Are you concerned about how your drinking may affect your health” your health”
““There is no known safe limit for drinking during There is no known safe limit for drinking during pregnancy. You need to stop drinking completely b/c pregnancy. You need to stop drinking completely b/c when you drink, your baby drinks.”when you drink, your baby drinks.”
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Brief Intervention: Advise and Brief Intervention: Advise and AssistAssist• Engage the patient in the process: Engage the patient in the process:
Assess, enhance motivation and patient responsibilityAssess, enhance motivation and patient responsibility““How do you feel about your drinking?”How do you feel about your drinking?”
• For alcohol-risk, establish drinking goals: For alcohol-risk, establish drinking goals: Advise and negotiateAdvise and negotiate““Are you ready to set a drinking goal? Are you ready to set a drinking goal? What do you think will work best for you?” (give brochure What do you think will work best for you?” (give brochure materials)materials)
• Not appropriate for alcohol dependence, advise Not appropriate for alcohol dependence, advise abstinence and refer to specialized treatment. abstinence and refer to specialized treatment.
National Institute on Alcohol Abuse and Alcoholism and Office of Research on Minority Health, Identification of At-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 Risk Drinking and Intervention with Women of Childbearing Age. NIH Publication No. 99-4368 (Printed 1999)1999)
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Brief InterventionBrief Intervention
•Always follow up: Always follow up: – review progress, review progress, – commend effort, commend effort, – reinforce positive change, reinforce positive change, – reassess motivationreassess motivation
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Optional Brief Motivational Optional Brief Motivational InterviewInterview
• Motivational Interviewing—developed Motivational Interviewing—developed by William Miller to assist problem by William Miller to assist problem drinkers resolve ambivalence around drinkers resolve ambivalence around behavior changebehavior change
• Ambivalence is seen as a normal Ambivalence is seen as a normal natural processnatural process
• Ultimately relationship-based style---Ultimately relationship-based style---empathy is the keyempathy is the key
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FRAMES ApproachFRAMES Approach
• Quick Motivational Interviewing Quick Motivational Interviewing Technique.Technique.
• FFeedbackeedback• RResponsibilityesponsibility• AAdvicedvice• MMenu of Optionsenu of Options• EEmpathympathy• SSelf-Efficacyelf-Efficacy
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Hints and Traps to AvoidHints and Traps to Avoid
• Joint DenialJoint Denial– Johnny (Jenny) you don’t do drug do Johnny (Jenny) you don’t do drug do
you?you?
• TriangulationTriangulation– For many problem drinkers their primary For many problem drinkers their primary
relationship is with alcoholrelationship is with alcohol
• Taking ResponsibilityTaking Responsibility
• Roll with ResistanceRoll with Resistance
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You don’t have a substance abuse problem, right? Great
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TriangulationTriangulation
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ResponsibilityResponsibility
• Voice for change must come from Voice for change must come from clientclient
• Can’t be imposed or forcedCan’t be imposed or forced
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Roll with Resistance Roll with Resistance
Normal for client/patient to resist change, Normal for client/patient to resist change, become annoyed or angry when become annoyed or angry when criticized---must be avoided. criticized---must be avoided.
Roll with resistance and avoid Roll with resistance and avoid argumentation at all costs. argumentation at all costs.
Otherwise you are reinforcing the status Otherwise you are reinforcing the status quo.quo.
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Improving Improving Health Provider PracticesHealth Provider Practices
It may seem It may seem difficult difficult
to talk with to talk with patients patients
about FASD, about FASD,
but but you can do ityou can do it..
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Information and Information and Treatment ResourcesTreatment Resources• NOFAS (National Organization on FAS)NOFAS (National Organization on FAS)
Phone: 202-785-4585 Web: Phone: 202-785-4585 Web: www.nofas.org• University of Washington FAS Prevention University of Washington FAS Prevention
NetworkNetworkWeb: Web: http://depts.washington.edu/fasdpn/
• Alcoholics Anonymous Alcoholics Anonymous Phone: 212-686-1100 Web: Phone: 212-686-1100 Web: www.alcoholics-anonymous.org
• Local Alcohol and Drug Treatment Resources:Local Alcohol and Drug Treatment Resources: Web: Web: http://findtreatment.samhsa.gov/facilitylocatordoc.htm
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FASD Role PlayFASD Role Play• 22 year old college student, name: ______22 year old college student, name: ______
• Pregnant, 10 weeksPregnant, 10 weeks
• Do alcohol assessmentDo alcohol assessment
• Describe risks of FAS/D – facial/size/CNSDescribe risks of FAS/D – facial/size/CNS– Excited about becoming a momExcited about becoming a mom– Going to marry boyfriendGoing to marry boyfriend– Likes to party and drink sociallyLikes to party and drink socially
•Beer, wine, liquor (whatever is around)Beer, wine, liquor (whatever is around)
•Have cut down due to pregnancy (get tipsy faster)Have cut down due to pregnancy (get tipsy faster)
•1-3 drinks per occasion (previously 1-6)1-3 drinks per occasion (previously 1-6)
