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Screening and Brief Intervention for Risky Alcohol Use Roger Zoorob, MD, MPH,a Heather Snell, MSPH,a Courtney Kihlberg, MD, MSPH,a and Yasmin Senturias, MD, FAAPb
Alcohol Use, Abuse, and Addiction lcohol use is common among many populations in the United States (U.S.). The 2011 Behavioral Risk Factor Surveillance System (BRFSS) found that among adult Americans surveyed, 57.1% (63.3% of males and 51.3% of females) reported that they had consumed at least one alcoholic beverage in the preceding month. The highest prevalence, 59.9%, was found among whites (blacks: 50.0%, Hispanics: 49.1%, other: 48.4%, and multiracial: 52.6%).1 Of those adults surveyed, 18.3% (24.2% of males and 12.6% of females) reported binge drinking, which is defined as the consumption of five or more drinks for males and four or more drinks for females on one occasion.2 For most individuals, this level of consumption causes the blood alcohol concentration (BAC) to rise to at least 0.08%.3 Alcohol abuse is a diagnostic term for excessive alcohol use. The Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) states that alcohol use that is harmful to an individual's health or impairs his/her ability to function at home, school, work, or in social settings is defined as abusive. Indications that alcohol use may have reached the level of abuse include an inability to fulfill personal or professional responsibilities, legal repercussions, and drinking in dangerous situations (i.e., while driving) or despite on-going problems that have resulted from drinking.4
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For some, at-risk drinking can progress into dependency or addiction. Alcohol addiction is a chronic condition resulting from physiologic changes that are often more difficult to treat than alcohol abuse alone. Alcohol addiction is diagnosed when an individual meets three out of seven criteria described in Table 1 in a given year. Whether diagnostically classified as use, abuse, or addiction, excessive alcohol consumption contributes to significant morbidity and mortality. Alcohol produces chronic diseases of the liver and the digestive system, hypertension, poor pregnancy outcomes (including FASDs and SIDS), mental health disorders, and unintentional injuries (e.g., motor vehicle crashes and firearm misuse).5 These are just a few of the devastating consequences experienced as the result of excessive alcohol use. Through the inclusion of 54 acute and chronic causes of alcohol-related mortality in the Centers for Disease Control and Prevention's (CDC) Alcohol-Related Disease Impact (ARDI) software, calculations indicate there were over 80,000 alcohol-attributable deaths in the US from 2001 to 2005, with a slight majority due to acute causes.6 These premature deaths are estimated to have caused almost 2.4 million years of productive life lost (YPLL). With a price tag of $223.5 billion in 2006 alone, screening for alcohol use in the U.S. should be of paramount concern for health care professionals.7,8
Screening for Alcohol Use in Primary Care From the aDepartment of Family and Community Medicine, Meharry Medical College, Nashville, TN; and bCarolinas Healthcare System and University of North Carolinas, Chapel Hill, NC. Curr Probl Pediatr Adolesc Health Care 2014;44:82-87 1538-5442/$ - see front matter & 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.cppeds.2013.12.011
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Most contact with health care professionals occurs in primary care, which makes it the best setting to provide prevention of FASD.9 The U.S. Preventive Services Task Force (USPSTF) recommends screening and brief counseling intervention (SBI) in primary care
Curr Probl Pediatr Adolesc Health Care, April 2014
TABLE 1. The DSM-IV diagnostic criteria for alcohol dependence require three or more of the following criteria in a year
1. 2. 3. 4. 5. 6.
Tolerance Withdrawal symptoms Drinking more than intended Unsuccessful attempts to decrease consumption Excessive time related to alcohol (obtaining it or hangover) Forfeiture of professional and recreational activities as a result of alcohol use 7. Use despite physical or psychological consequences Adapted with permission from American Psychiatric Association.4
settings to reduce alcohol misuse.8 The CDC, American Academy of Family Physicians (AAFP), and American Congress of Obstetrics and Gynecology (ACOG) recommend that all women of childbearing age be screened for alcohol use in order to prevent alcohol-related birth defects.10–12 The USPSTF defines risky or hazardous drinking as more than 7 drinks per week or 3 per day for women and men over 65, and 14 drinks per week or 4 per day for men.8 There are several resources available to assist physicians in addressing alcohol misuse. In 2005, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) released an updated clinician's guide for helping patients with alcohol use problems.13 ACOG also released “Drinking and Reproductive Health: A Fetal Alcohol Spectrum Disorders Prevention Tool Kit” for clinicians.14 Screening tools for alcohol consumption use a series of questions to identify a patient's drinking habits. There are several alcohol-screening tools available, depending upon what is appropriate for the clinic's population and setting. Screening for alcohol consumption can be easily integrated as a standard of care by making it a part of the patient's annual health assessment. The Tolerance, Worried, Eye opener, Amnesia, and K/cut down (TWEAK) and Tolerance, Annoyance, Cut down, and Eye opener (T-ACE) are screening tools specifically designed to identify risky drinking in pregnant women.14–17 The Cut down, Annoyed, Guilty, and Eye opener (CAGE) is effective in identifying those who abuse alcohol or have dependence, rather than risky drinking.18 The CAGE tool was designed for use among men and has not been shown to be effective among women of childbearing age or among pregnant women.14,15 The Alcohol Use Disorders Identification Test (AUDIT) was designed by the World Health Organization (WHO) for identifying risky drinking and alcohol dependence in primary care settings19 and is
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the most universal tool with high validity and reliability (Table 2).20–22 It consists of 10 multiple choice questions measuring hazardous alcohol use, dependence symptoms, and harmful alcohol use, and it can be completed and scored in 2–4 min.20 Each choice has a number in parentheses, which is added up to give a total score ranging from 0 to 40. The scores are divided into categories, or in this case “Zones,” based on the level of risk. Those who score 7 and below (Zone 1) are considered “abstainers or low-risk drinkers.” Those who score between 8 and 15 (Zone 2) are considered “mild-to moderate-risk drinkers” and should receive simple advice on the daily recommendations for alcohol consumption. Those who score between 16 and 19 (Zone 3) are “moderate- to high-risk drinkers” and should receive brief counseling and continued monitoring. Those in Zone 3 are the target population for SBI since they are the group that may benefit the most from brief intervention.23 Scores of 20 and above (Zone 4) have “probable alcohol dependence” and should be referred to specialized care.
Brief Intervention in Primary Care Brief intervention is a face-to-face counseling technique that can be done in 1–4 sessions that last between 5 and 15 min and include feedback, advice, resources, and goal-setting. Several randomized controlled trials have found brief intervention to be an effective method for primary care settings in reducing alcohol consumption.24–26 A review of studies reported a reduction in alcohol consumption from 13% to 34% among those who received brief intervention.27 A randomized controlled trial revealed that brief intervention reduced the amount of alcohol consumed, and the frequency and the percentage of heavy drinking days 6 months after the initial intervention were given.28 A meta-analysis included studies with follow-up periods from 6 months to 48 months after brief intervention was given. The analysis concluded that brief intervention showed benefits at 6 and 12 months of follow-up.29 Brief intervention has been shown to be most effective among risky drinkers compared to those who are alcohol dependent.23,30 Brief intervention is both time efficient and a cost-effective approach for treating patients identified as risky drinkers.31 Brief interventions use motivational interviewing approaches to facilitate change in the patient's drinking habits. One method for executing brief intervention is the 5 A's
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TABLE 2. Alcohol use disorders identification test (AUDIT)
1. How often do you have a drink containing alcohol? a. (0) Never (Skip to Question 9) b. (1) Monthly or less c. (2) 2–4 times a month d. (3) 2–3 times a week e. (4) 4 or more times a week
6. How often during the last year have you been unable to remember what happened the night before because you had been drinking? a. (0) Never b. (1) Less than monthly c. (2) Monthly d. (3) Weekly e. (4) Daily or almost daily
2. How many drinks containing alcohol do you have on a typical day when you are drinking? a. (0) 1 or 2 b. (1) 3 or 4 c. (2) 5 or 6 d. (3) 7, 8, or 9 e. (4) 10 or more
7. How often during the last year have you needed an alcoholic drink first thing in the morning to get yourself going after a night of heavy drinking? a. (0) Never b. (1) Less than monthly c. (2) Monthly d. (3) Weekly e. (4) Daily or almost daily
3. How often do you have six or more drinks on one occasion? a. (0) Never b. (1) Less than monthly c. (2) Monthly d. (3) Weekly e. (4) Daily or almost daily
8. How often during the last year have you had a feeling of guilt or remorse after drinking? a. (0) Never b. (1) Less than monthly c. (2) Monthly d. (3) Weekly e. (4) Daily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you had started? a. (0) Never b. (1) Less than monthly c. (2) Monthly d. (3) Weekly e. (4) Daily or almost daily
9. Have you or someone else been injured as a result of your drinking? a. (0) No b. (2) Yes, but not in the last year c. (4) Yes, during the last year
5. How often during the last year have you failed to do what was normally expected from you because of drinking? a. (0) Never b. (1) Less than monthly c. (2) Monthly d. (3) Weekly e. (4) Daily or almost daily
10. Has a relative, friend, doctor, or another health professional expressed concern about your drinking or suggested you cut down? a. (0) No b. (2) Yes, but not in the last year c. (4) Yes, during the last year
Adapted with permission from Babor and Higgins-Biddle.19
model (ask, assess, advise, assist, and arrange). This model is consistent with the components of brief intervention and has been shown to be effective in behavioral change in primary care settings.26,32,33 The five-step process includes the following: (1) ask about their drinking habits; (2) assess risk level; (3) advise patients about the personal health risks and benefits; (4) agree on an appropriate drinking goal; and (5) arrange a follow-up visit to assess progress. Patients who are identified as alcohol dependent may not benefit from brief intervention and will need to be referred to specialized treatment.23,30
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Referral for Further Assessment and Intervention Referral to treatment aids in facilitating resources for those with alcohol dependence (Zone 4) or those who receive brief intervention and relapse (Zone 3). This step requires primary care facilities to establish linkages with local alcohol abuse treatment centers. Treatment centers can be identified by using the Substance Abuse and Mental Health Services Administration's (SAMHSA) toll-free telephone number or the online locator for treatment referral assistance. Substance
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abuse specialists utilize support groups (self-help), behavioral therapies (cognitive and motivational), and medications for treatment. Cognitive behavioral therapy helps identify high-risk situations, teaches strategies to cope with those situations, and deals with alcohol cravings.34 Motivational enhancement uses the patient's own resources to change behavior.34 The 12step (self-help) support groups are typically used in conjunction with a formal treatment program.34 A National Institute on Alcohol Abuse and Alcoholism (NIAAA) study, Project MATCH, studied the efficacy of the three therapies and found significant improvement in the percentage of abstinent days in all therapies with no significant difference between them.35 There are also several medications available to assist those with alcohol dependence.34,36 Naltrexone helps suppress alcohol cravings and acamprosate reduces symptoms during abstinence.34,36 The COMBINE study evaluated the efficacy of naltrexone and acamprostate medications for alcohol dependence with and without brief intervention.36 All groups showed a reduction in alcohol consumption; however, those receiving naltrexone, brief intervention, or both had better outcomes than those taking acamprostate.36 Additional drugs that assist with withdrawal symptoms are beyond the scope of this article.
Support for Birth Mothers In addition to the aforementioned screening and intervention options, special consideration must be given to birth mothers of children with an FASD. While many of these women share similar challenges to others who have used or continue to use alcohol, women who have given birth to a child with an FASD have unique needs as well. The Birth Mother's Network states that intervention and treatment must focus both on the women's alcohol and substance use and on addressing the myriad of needs that arise from raising a child with an FASD.37 Screening and Brief Intervention serve a three-fold purpose in this population: they can improve overall health, prevent future alcohol-exposed pregnancies, and empower birth mothers to be better prepared to care for their children with FASDs. Current research, such as that funded by the NIAAA through The Center of Alcohol Studies at Rutgers University, seeks to improve outpatient treatment programs for women by addressing needs specific to this population that have
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not been fully explored in prior research and intervention studies.38 Additional interventions, such as Project CHOICES, have shown positive outcomes when pairing contraception consultation with motivational counseling to assist women with at-risk drinking behaviors. Sessions over 12–14 weeks lead to a twofold risk reduction in alcohol-exposed pregnancies compared to the control group.39 Though the loss to follow-up rate was 29%, in the intent to treat analysis, where participants lost to follow-up were considered failures, results still showed significance in spite of lower odds ratios.39 The National Organization on Fetal Alcohol Syndrome (NOFAS) provides support for birth mothers as well. Founded in 2004 by the vice president of NOFAS, the Circle of Hope, also known as the Birth Mother's Network, provides a forum for mothers who have given birth to a child with an FASD to share personal stories, resources, and opportunities to advocate and educate for reducing alcohol misuse among women of childbearing age. The network includes women with current alcohol addiction, those in recovery, and those who have not suffered from addiction but who drank alcohol during pregnancy.37 Resources suggested by the Circle of Hope include a series of easy-to-access YouTube videos produced by the US Department of Health and Human Services SAMHSA entitled, “Recovering Hope, Mothers speak out about Fetal Alcohol Spectrum Disorders.” These videos highlight topics such as self-forgiveness, resources for caring for a child with an FASD, and finding support from family, friends, and the community to overcome alcohol misuse.
Summary Alcohol screening and brief intervention are effective evidence-based methods recommended by multiple major medical societies. Primary care providers are uniquely positioned to recognize patients with alcohol use problems when they utilize screening in their practices. SBI has the potential to improve patients' overall health, reduce the risk of alcohol dependence, and prevent future alcohol-exposed pregnancies.
References 1. Centers for Disease Control and Prevention (CDC). Behavioral risk factor surveillance system survey data. Atlanta, Georgia: U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. http://apps.nccd.
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cdc.gov/brfss/ Accessed 03.03.13. Published 2011. Updated 2011. Kanny D, Liu Y, Brewer RD. Centers for Disease Control and Prevention (CDC). Binge drinking–United States, 2009. MMWR Surveill Summ 2011;60(suppl):101–4. National Institute on Alcohol Abuse and Alcoholism (NIAAA). NIAAA council approves definition of binge drinking. NIAAA Newslett 2004;3(3). American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994. Centers for Disease Control and Prevention (CDC). Alcohol and public health. http://www.cdc.gov/alcohol/faqs.htm Accessed 03.03.13. Updated July 31, 2013. Centers for Disease Control and Prevention (CDC). Alcoholrelated disease impact (ARDI). http://apps.nccd.cdc.gov/DACH_ ARDI/Default/Default.aspx Accessed 03.03.13. Centers for Disease Control and Prevention (CDC). Preventing excessive alcohol use: what public health can do. www. cdc.gov/about/grand-rounds/archives/2012/March2012.htm Accessed 03.03.13. Updated 2012. Moyer VA. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. preventive services task force recommendation statement. Ann Intern Med 2013;159(3):210–8. Wyatt SA, Dekker MA. Improving physician and medical student education in substance use disorders. J Am Osteopath Assoc 2007;107(9 suppl 5):ES27–38. American Academy of Family Physicians. Alcohol misuse. http:// www.aafp.org/online/en/home/clinical/exam/alcoholmisuse.html Accessed 20.02.13. Updated 2004. American College of Obstetricians and Gynecologists. Committee on health care for underserved women. Committee opinion no. 496: at-risk drinking and alcohol dependence: obstetric and gynecologic implications. Obstet Gynecol 2011;118(2 Pt 1):383–8. Centers for Disease Control and Prevention (CDC). Fetal alcohol spectrum disorders: training and education. http:// www.cdc.gov/ncbddd/fasd/training.html Accessed 01.03.13. Updated April 15, 2013. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Helping patients with alcohol problems: a clinician's guide. Bethesda, MD: Vol NIH Pub No. 05-3769, 2005. Barry KL, Caetano R, Chang G, et al. Reducing Alcohol Exposed Pregnancies: A Report of the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect. Atlanta, GA: Centers for Disease Control and Prevention, 2009. Burns E, Gray R, Smith LA. Brief screening questionnaires to identify problem drinking during pregnancy: a systematic review. Addiction 2010;105(4):601–14. Dawson DA, Das A, Faden VB, Bhaskar B, Krulewitch CJ, Wesley B. Screening for high- and moderate-risk drinking during pregnancy: a comparison of several TWEAK-based screeners. Alcohol Clin Exp Res 2001;25(9):1342–9. Flynn HA, Marcus SM, Barry KL, Blow FC. Rates and correlates of alcohol use among pregnant women in obstetrics clinics. Alcohol Clin Exp Res 2003;27(1):81–7.
18. Ewing JA. Detecting alcoholism. The CAGE questionnaire. J Am Med Assoc 1984;252(14):1905–7. 19. Babor TF, Higgins-Biddle JC. Brief Intervention for Hazardous and Harmful Drinking: A Manual for Use in Primary Care. Geneva: World Health Organization, 2001. 20. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption—II. Addiction 1993;88(6):791–804. 21. Reinert DF, Allen JP. The alcohol use disorders identification test (AUDIT): a review of recent research. Alcohol Clin Exp Res 2002;26(2):272–9. 22. Coulton S, Drummond C, James D, et al. Opportunistic screening for alcohol use disorders in primary care: comparative study. Br Med J 2006;332(7540):511–7. 23. Jonas DE, Garbutt JC, Amick HR, et al. Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. preventive services task force. Ann Intern Med 2012;157(9):645–54. 24. Floyd RL, O'Connor MJ, Bertrand J, Sokol R. Reducing adverse outcomes from prenatal alcohol exposure: a clinical plan of action. Alcohol Clin Exp Res 2006;30(8):1271–5. 25. O'Connor MJ, Whaley SE. Brief intervention for alcohol use by pregnant women. Am J Public Health 2007;97(2):252–8. 26. Whitlock EP, Polen MR, Green CA, Orleans T, Klein J. U.S. Preventive Services Task Force. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. preventive services task force. Ann Intern Med 2004;140(7):557–68. 27. U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse. Ann Intern Med 2004;140(7):554–6. 28. Ramsey SE, Engler PA, Harrington M, et al. Brief alcohol intervention among at-risk drinkers with diabetes. Subst Abuse 2010;4:1–8. 29. Bertholet N, Daeppen JB, Wietlisbach V, Fleming M, Burnand B. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Arch Intern Med 2005;165(9):986–95. 30. Saitz R. Alcohol screening and brief intervention in primary care: absence of evidence for efficacy in people with dependence or very heavy drinking. Drug Alcohol Rev 2010;29(6):631–40. 31. Saitz R, Svikis D, D'Onofrio G, Kraemer KL, Perl H. Challenges applying alcohol brief intervention in diverse practice settings: populations, outcomes, and costs. Alcohol Clin Exp Res 2006;30(2):332–8. 32. Fiore MC. Treating tobacco use and dependence: an introduction to the US public health service clinical practice guideline. Respir Care 2000;45(10):1196–9. 33. Goldstein MG, Whitlock EP, DePue J. Multiple behavioral risk factor interventions in primary care: summary of research evidence. Am J Prev Med 2004;27(2 suppl):61–79. 34. Center for Substance Abuse Treatment. Treating alcohol problems. Subst Abuse 2004;3(1). 35. Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: project MATCH posttreatment drinking outcomes. J Stud Alcohol 1997;58(1):7–29.
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36. Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. J Am Med Assoc 2006;295(17):2003–17. 37. The National Organization on Fetal Alcohol Syndrome (NOFAS). Join the circle of hope/the birth mother's network. http://www. nofas.org/join-the-circle-of-hope/ Accessed 03.03.13.
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38. The Center of Alcohol Studies at Rutgers University. Center of alcohol studies women's treatment project. http://womenandal cohol.rutgers.edu/ Accessed 03.03.13. 39. Floyd RL, Sobell M, Velasquez MM, et al. Preventing alcoholexposed pregnancies: a randomized controlled trial. Am J Prev Med 2007;32(1):1–10.
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Screening and Brief Intervention for Risky Alcohol Use Roger Zoorob, MD, MPH,a Heather Snell, MSPH,a Courtney Kihlberg, MD, MSPH,a and Yasmin Senturias, MD, FAAPb
Alcohol Use, Abuse, and Addiction lcohol use is common among many populations in the United States (U.S.). The 2011 Behavioral Risk Factor Surveillance System (BRFSS) found that among adult Americans surveyed, 57.1% (63.3% of males and 51.3% of females) reported that they had consumed at least one alcoholic beverage in the preceding month. The highest prevalence, 59.9%, was found among whites (blacks: 50.0%, Hispanics: 49.1%, other: 48.4%, and multiracial: 52.6%).1 Of those adults surveyed, 18.3% (24.2% of males and 12.6% of females) reported binge drinking, which is defined as the consumption of five or more drinks for males and four or more drinks for females on one occasion.2 For most individuals, this level of consumption causes the blood alcohol concentration (BAC) to rise to at least 0.08%.3 Alcohol abuse is a diagnostic term for excessive alcohol use. The Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) states that alcohol use that is harmful to an individual's health or impairs his/her ability to function at home, school, work, or in social settings is defined as abusive. Indications that alcohol use may have reached the level of abuse include an inability to fulfill personal or professional responsibilities, legal repercussions, and drinking in dangerous situations (i.e., while driving) or despite on-going problems that have resulted from drinking.4
A
For some, at-risk drinking can progress into dependency or addiction. Alcohol addiction is a chronic condition resulting from physiologic changes that are often more difficult to treat than alcohol abuse alone. Alcohol addiction is diagnosed when an individual meets three out of seven criteria described in Table 1 in a given year. Whether diagnostically classified as use, abuse, or addiction, excessive alcohol consumption contributes to significant morbidity and mortality. Alcohol produces chronic diseases of the liver and the digestive system, hypertension, poor pregnancy outcomes (including FASDs and SIDS), mental health disorders, and unintentional injuries (e.g., motor vehicle crashes and firearm misuse).5 These are just a few of the devastating consequences experienced as the result of excessive alcohol use. Through the inclusion of 54 acute and chronic causes of alcohol-related mortality in the Centers for Disease Control and Prevention's (CDC) Alcohol-Related Disease Impact (ARDI) software, calculations indicate there were over 80,000 alcohol-attributable deaths in the US from 2001 to 2005, with a slight majority due to acute causes.6 These premature deaths are estimated to have caused almost 2.4 million years of productive life lost (YPLL). With a price tag of $223.5 billion in 2006 alone, screening for alcohol use in the U.S. should be of paramount concern for health care professionals.7,8
Screening for Alcohol Use in Primary Care From the aDepartment of Family and Community Medicine, Meharry Medical College, Nashville, TN; and bCarolinas Healthcare System and University of North Carolinas, Chapel Hill, NC. Curr Probl Pediatr Adolesc Health Care 2014;44:82-87 1538-5442/$ - see front matter & 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.cppeds.2013.12.011
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Most contact with health care professionals occurs in primary care, which makes it the best setting to provide prevention of FASD.9 The U.S. Preventive Services Task Force (USPSTF) recommends screening and brief counseling intervention (SBI) in primary care
Curr Probl Pediatr Adolesc Health Care, April 2014
TABLE 1. The DSM-IV diagnostic criteria for alcohol dependence require three or more of the following criteria in a year
1. 2. 3. 4. 5. 6.
Tolerance Withdrawal symptoms Drinking more than intended Unsuccessful attempts to decrease consumption Excessive time related to alcohol (obtaining it or hangover) Forfeiture of professional and recreational activities as a result of alcohol use 7. Use despite physical or psychological consequences Adapted with permission from American Psychiatric Association.4
settings to reduce alcohol misuse.8 The CDC, American Academy of Family Physicians (AAFP), and American Congress of Obstetrics and Gynecology (ACOG) recommend that all women of childbearing age be screened for alcohol use in order to prevent alcohol-related birth defects.10–12 The USPSTF defines risky or hazardous drinking as more than 7 drinks per week or 3 per day for women and men over 65, and 14 drinks per week or 4 per day for men.8 There are several resources available to assist physicians in addressing alcohol misuse. In 2005, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) released an updated clinician's guide for helping patients with alcohol use problems.13 ACOG also released “Drinking and Reproductive Health: A Fetal Alcohol Spectrum Disorders Prevention Tool Kit” for clinicians.14 Screening tools for alcohol consumption use a series of questions to identify a patient's drinking habits. There are several alcohol-screening tools available, depending upon what is appropriate for the clinic's population and setting. Screening for alcohol consumption can be easily integrated as a standard of care by making it a part of the patient's annual health assessment. The Tolerance, Worried, Eye opener, Amnesia, and K/cut down (TWEAK) and Tolerance, Annoyance, Cut down, and Eye opener (T-ACE) are screening tools specifically designed to identify risky drinking in pregnant women.14–17 The Cut down, Annoyed, Guilty, and Eye opener (CAGE) is effective in identifying those who abuse alcohol or have dependence, rather than risky drinking.18 The CAGE tool was designed for use among men and has not been shown to be effective among women of childbearing age or among pregnant women.14,15 The Alcohol Use Disorders Identification Test (AUDIT) was designed by the World Health Organization (WHO) for identifying risky drinking and alcohol dependence in primary care settings19 and is
Curr Probl PediatrAdolesc Health Care, April 2014
the most universal tool with high validity and reliability (Table 2).20–22 It consists of 10 multiple choice questions measuring hazardous alcohol use, dependence symptoms, and harmful alcohol use, and it can be completed and scored in 2–4 min.20 Each choice has a number in parentheses, which is added up to give a total score ranging from 0 to 40. The scores are divided into categories, or in this case “Zones,” based on the level of risk. Those who score 7 and below (Zone 1) are considered “abstainers or low-risk drinkers.” Those who score between 8 and 15 (Zone 2) are considered “mild-to moderate-risk drinkers” and should receive simple advice on the daily recommendations for alcohol consumption. Those who score between 16 and 19 (Zone 3) are “moderate- to high-risk drinkers” and should receive brief counseling and continued monitoring. Those in Zone 3 are the target population for SBI since they are the group that may benefit the most from brief intervention.23 Scores of 20 and above (Zone 4) have “probable alcohol dependence” and should be referred to specialized care.
Brief Intervention in Primary Care Brief intervention is a face-to-face counseling technique that can be done in 1–4 sessions that last between 5 and 15 min and include feedback, advice, resources, and goal-setting. Several randomized controlled trials have found brief intervention to be an effective method for primary care settings in reducing alcohol consumption.24–26 A review of studies reported a reduction in alcohol consumption from 13% to 34% among those who received brief intervention.27 A randomized controlled trial revealed that brief intervention reduced the amount of alcohol consumed, and the frequency and the percentage of heavy drinking days 6 months after the initial intervention were given.28 A meta-analysis included studies with follow-up periods from 6 months to 48 months after brief intervention was given. The analysis concluded that brief intervention showed benefits at 6 and 12 months of follow-up.29 Brief intervention has been shown to be most effective among risky drinkers compared to those who are alcohol dependent.23,30 Brief intervention is both time efficient and a cost-effective approach for treating patients identified as risky drinkers.31 Brief interventions use motivational interviewing approaches to facilitate change in the patient's drinking habits. One method for executing brief intervention is the 5 A's
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TABLE 2. Alcohol use disorders identification test (AUDIT)
1. How often do you have a drink containing alcohol? a. (0) Never (Skip to Question 9) b. (1) Monthly or less c. (2) 2–4 times a month d. (3) 2–3 times a week e. (4) 4 or more times a week
6. How often during the last year have you been unable to remember what happened the night before because you had been drinking? a. (0) Never b. (1) Less than monthly c. (2) Monthly d. (3) Weekly e. (4) Daily or almost daily
2. How many drinks containing alcohol do you have on a typical day when you are drinking? a. (0) 1 or 2 b. (1) 3 or 4 c. (2) 5 or 6 d. (3) 7, 8, or 9 e. (4) 10 or more
7. How often during the last year have you needed an alcoholic drink first thing in the morning to get yourself going after a night of heavy drinking? a. (0) Never b. (1) Less than monthly c. (2) Monthly d. (3) Weekly e. (4) Daily or almost daily
3. How often do you have six or more drinks on one occasion? a. (0) Never b. (1) Less than monthly c. (2) Monthly d. (3) Weekly e. (4) Daily or almost daily
8. How often during the last year have you had a feeling of guilt or remorse after drinking? a. (0) Never b. (1) Less than monthly c. (2) Monthly d. (3) Weekly e. (4) Daily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you had started? a. (0) Never b. (1) Less than monthly c. (2) Monthly d. (3) Weekly e. (4) Daily or almost daily
9. Have you or someone else been injured as a result of your drinking? a. (0) No b. (2) Yes, but not in the last year c. (4) Yes, during the last year
5. How often during the last year have you failed to do what was normally expected from you because of drinking? a. (0) Never b. (1) Less than monthly c. (2) Monthly d. (3) Weekly e. (4) Daily or almost daily
10. Has a relative, friend, doctor, or another health professional expressed concern about your drinking or suggested you cut down? a. (0) No b. (2) Yes, but not in the last year c. (4) Yes, during the last year
Adapted with permission from Babor and Higgins-Biddle.19
model (ask, assess, advise, assist, and arrange). This model is consistent with the components of brief intervention and has been shown to be effective in behavioral change in primary care settings.26,32,33 The five-step process includes the following: (1) ask about their drinking habits; (2) assess risk level; (3) advise patients about the personal health risks and benefits; (4) agree on an appropriate drinking goal; and (5) arrange a follow-up visit to assess progress. Patients who are identified as alcohol dependent may not benefit from brief intervention and will need to be referred to specialized treatment.23,30
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Referral for Further Assessment and Intervention Referral to treatment aids in facilitating resources for those with alcohol dependence (Zone 4) or those who receive brief intervention and relapse (Zone 3). This step requires primary care facilities to establish linkages with local alcohol abuse treatment centers. Treatment centers can be identified by using the Substance Abuse and Mental Health Services Administration's (SAMHSA) toll-free telephone number or the online locator for treatment referral assistance. Substance
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abuse specialists utilize support groups (self-help), behavioral therapies (cognitive and motivational), and medications for treatment. Cognitive behavioral therapy helps identify high-risk situations, teaches strategies to cope with those situations, and deals with alcohol cravings.34 Motivational enhancement uses the patient's own resources to change behavior.34 The 12step (self-help) support groups are typically used in conjunction with a formal treatment program.34 A National Institute on Alcohol Abuse and Alcoholism (NIAAA) study, Project MATCH, studied the efficacy of the three therapies and found significant improvement in the percentage of abstinent days in all therapies with no significant difference between them.35 There are also several medications available to assist those with alcohol dependence.34,36 Naltrexone helps suppress alcohol cravings and acamprosate reduces symptoms during abstinence.34,36 The COMBINE study evaluated the efficacy of naltrexone and acamprostate medications for alcohol dependence with and without brief intervention.36 All groups showed a reduction in alcohol consumption; however, those receiving naltrexone, brief intervention, or both had better outcomes than those taking acamprostate.36 Additional drugs that assist with withdrawal symptoms are beyond the scope of this article.
Support for Birth Mothers In addition to the aforementioned screening and intervention options, special consideration must be given to birth mothers of children with an FASD. While many of these women share similar challenges to others who have used or continue to use alcohol, women who have given birth to a child with an FASD have unique needs as well. The Birth Mother's Network states that intervention and treatment must focus both on the women's alcohol and substance use and on addressing the myriad of needs that arise from raising a child with an FASD.37 Screening and Brief Intervention serve a three-fold purpose in this population: they can improve overall health, prevent future alcohol-exposed pregnancies, and empower birth mothers to be better prepared to care for their children with FASDs. Current research, such as that funded by the NIAAA through The Center of Alcohol Studies at Rutgers University, seeks to improve outpatient treatment programs for women by addressing needs specific to this population that have
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not been fully explored in prior research and intervention studies.38 Additional interventions, such as Project CHOICES, have shown positive outcomes when pairing contraception consultation with motivational counseling to assist women with at-risk drinking behaviors. Sessions over 12–14 weeks lead to a twofold risk reduction in alcohol-exposed pregnancies compared to the control group.39 Though the loss to follow-up rate was 29%, in the intent to treat analysis, where participants lost to follow-up were considered failures, results still showed significance in spite of lower odds ratios.39 The National Organization on Fetal Alcohol Syndrome (NOFAS) provides support for birth mothers as well. Founded in 2004 by the vice president of NOFAS, the Circle of Hope, also known as the Birth Mother's Network, provides a forum for mothers who have given birth to a child with an FASD to share personal stories, resources, and opportunities to advocate and educate for reducing alcohol misuse among women of childbearing age. The network includes women with current alcohol addiction, those in recovery, and those who have not suffered from addiction but who drank alcohol during pregnancy.37 Resources suggested by the Circle of Hope include a series of easy-to-access YouTube videos produced by the US Department of Health and Human Services SAMHSA entitled, “Recovering Hope, Mothers speak out about Fetal Alcohol Spectrum Disorders.” These videos highlight topics such as self-forgiveness, resources for caring for a child with an FASD, and finding support from family, friends, and the community to overcome alcohol misuse.
Summary Alcohol screening and brief intervention are effective evidence-based methods recommended by multiple major medical societies. Primary care providers are uniquely positioned to recognize patients with alcohol use problems when they utilize screening in their practices. SBI has the potential to improve patients' overall health, reduce the risk of alcohol dependence, and prevent future alcohol-exposed pregnancies.
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