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 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 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 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 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 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) 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 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 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 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 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 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 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 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