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

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

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.
Carey Szetela, Ph.D.

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
Carey Szetela, Ph.D.

5. SBIRT: Screening, Brief Intervention and Referral to Treatment
Carey Szetela, Ph.D.

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.
Carey Szetela, Ph.D.

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
Carey Szetela, Ph.D.

8. Carey Szetela, Ph.D.

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
Carey Szetela, Ph.D.

10. The Diagnostic Process
Ongoing Clinical Process
Begins with Screening
All Diagnoses are Preliminary
Screening
Assessment
Diagnosis
Carey Szetela, Ph.D.

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
Carey Szetela, Ph.D.

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
Carey Szetela, Ph.D.

13. Recommended Alcohol Limit During Pregnancy and Preconception?
Carey Szetela, Ph.D.

14. Carey Szetela, Ph.D.

15. Conceptualizing Risk vs. Disorder
Women’s Alcohol Risk Categories
Abstinence
Low Risk: ≤7 drinks/week and ≤3 drinks/occasion
At-Risk: 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
Carey Szetela, Ph.D.

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
Carey Szetela, Ph.D.

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
Carey Szetela, Ph.D.

18. False Positives & False Negatives
Issues in Screening
False Positives & False Negatives
Everyone Screened
Screen Negative
Screen Positive
False
Negatives
False
Positives
Carey Szetela, Ph.D.

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)
Carey Szetela, Ph.D.

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
Carey Szetela, Ph.D.

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?"
Carey Szetela, Ph.D.

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): (at NOFAS website).
Carey Szetela, Ph.D.

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?"
Carey Szetela, Ph.D.

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
Carey Szetela, Ph.D.

25. Non-Empirical Tools Four Ps Global Question
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
Carey Szetela, Ph.D.

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
Carey Szetela, Ph.D.

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
Carey Szetela, Ph.D.

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 ;297(6649):
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 ;277(13):
Carey Szetela, Ph.D.

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.”
Carey Szetela, Ph.D.

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 (Printed 1999)
Carey Szetela, Ph.D.

31. Brief Intervention Always follow up: review progress, commend effort,
reinforce positive change,
reassess motivation
Carey Szetela, Ph.D.

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
Carey Szetela, Ph.D.

33. FRAMES Approach Quick Motivational Interviewing Technique. Feedback
Responsibility
Advice
Menu of Options
Empathy
Self-Efficacy
Carey Szetela, Ph.D.

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
Carey Szetela, Ph.D.

35. You don’t have a substance abuse problem, right? Great
Carey Szetela, Ph.D.

36. Triangulation
Carey Szetela, Ph.D.

37. Responsibility Voice for change must come from client
Can’t be imposed or forced
Carey Szetela, Ph.D.

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.
Carey Szetela, Ph.D.

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

40. Information and Treatment Resources
NOFAS (National Organization on FAS)
Phone: Web:
University of Washington FAS Prevention Network
Web:
Alcoholics Anonymous
Phone: Web:
Local Alcohol and Drug Treatment Resources: Web:
Carey Szetela, Ph.D.

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)
Carey Szetela, Ph.D.

42. Role Play: Alcohol Assessment and FASD Prevention
FP in a rural town; you have seen your pt since 10 weeks PG but have not done an alcohol assessment
Pt: 21yo female goes to community college
- 4 months PG, generally optimistic a/b PG, likes to party, likes being 21
- If asked, reports drinking a lot, including binge (avg 5 drinks per occasion, 4 days per week)
Carey Szetela, Ph.D.

43. If you know what to look for, you can help minimize
the difficulties for
a child affected by
FAS/D and family.
Photo courtesy of Teresa Kellerman
Carey Szetela, Ph.D.