Clinical Approaches to addressing alcohol use during pregnancy

1. Clinical Approaches to addressing alcohol use during pregnancy Peter Selby MBBS,CCFP,MHSc,ASAM Asst. Professor, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences, University of Toronto Clinical Director Addictions Program CAMH

2. Learning objectives • Introduce the Alcohol Risk Assessment Project • Discuss the role of health care professionals in assessing alcohol risk in women of childbearing years & pregnant women • How to Ask, Advise, and Assist women regarding alcohol use during pregnancy • Overview of the standardized T-ACE alcohol screening tool • Identify brief motivational strategies when advising women about alcohol use in the perinatal & preconception periods • Build awareness of provincial resources developed by the Alcohol Risk Assessment Project

3. Brief interventions • have been shown to have an impact on alcohol use in some pregnant women • Interventions should include a review of: • The general health of the woman • The course of the pregnancy • The lifestyle changes the woman has made since pregnancy • Interest in changing drinking behaviour • Goal setting • Situations when the woman is most likely to drink

4. Key clinical practices • Ask • ask all women of childbearing age about alcohol use • ask all pregnant women about alcohol use • Advise • advise all women planning a pregnancy that no alcohol is the safest choice • advise all pregnant women that no alcohol is the safest choice • advise women who consumed alcohol during their pregnancy to contact Motherisk • Assist • assist women to stop drinking through information, counselling, care and referral to appropriate programs and services

5. Physician concerns • Lack knowledge • Are uncomfortable asking about alcohol use • Have concerns about patient response • Have personal issues about alcohol use • Lack time • Are unsure how to ask women • Are unaware of effective screening tools • Are unsure how to advise women • Are unaware of services for women who are having difficulty changing drinking behaviour

6. Common drinking patterns • Abstainers: do not consume alcohol • Low-risk drinkers: consume 1-2 drinks per day, no more than 9 per week • Problem drinkers: consume more than 21 drinks per week • Alcohol-dependant drinkers: cannot stop drinking once they start • Binge drinkers: consume 5 or more drinks per occasion

7. Standard drinks = 0.5 oz alcohol

8. At risk drinking • There are no known benefits to alcohol use during pregnancy • The level of harm is dose related • Adverse effects to the fetus are related to the peak blood alcohol levels • Damage to the fetus is most likely to occur with higher levels of alcohol use including: • Average of 2 or more drinks a day (heavy drinking) • 5-6 drinks on some occasions (binge drinking)

9. Safe limits • No known safe limit for alcohol use in pregnancy • FAS is most strongly associated with heavy or binge drinking • Moderate levels of drinking may be associated with low birth weight, IUGR, miscarriage, stillbirth, developmental and neuro-behavioral problems, however, more research is needed in this area • Physicians should advise patients that the safest choice is not to consume alcohol during pregnancy

10. CASE • 28 year old office manager presenting for 1st prenatal visit • How will you screen for • Drinking? • Drinking problems?

12. T-ACE • Tolerance - How many drinks does it take to make you high? • Score 2 for more than 2 drinks • Score 0 for 1 or 2 drinks • Annoyance - Have people Annoyed you by criticizing your drinking? • Score 1 for yes • Cut Down - Have you ever felt you ought to Cut down your drinking? • Score 1 for yes • Eye Opener - Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hang over? • Score 1 for yes • High Risk Score=2 or more points • At Risk= 0 or 1 points

13. When screening • A positive response is likely to be accurate, however a negative response may not be accurate • Continue to ask about alcohol use on subsequent visits and watch for signs and symptoms of alcohol use • Screening will assist in identifying higher risk drinking and can help you link patients to needed resources and services • The goal, however, is to reduce all forms of maternal alcohol use

14. HIGH RISK ASSESS patient’s readiness and ability to stop drinking ASSESS level of alcohol dependence, and arrange for medical detoxification ADVISE patients unable to stop drinking, to reduce drinking ASSIST through continued follow-up and support AT RISK ADVISE the patient that it is safest to stop drinking ADVISE patients unable to stop drinking, to reduce drinking ADVISE by providing personalized feedback and information ASSIST through referral to appropriate resources ASSIST through continued follow-up and support

16. When to ASK • Ask everyone as alcohol use is widespread and most show no symptoms of alcohol use • Ask at the initial visit and during several follow-up visits • Key times to assess alcohol use are: • Initial visit • Annual gynecological visit • Preconception visit • Visits for confirmation of pregnancy • Mid pregnancy (24-28 weeks) • Exit visit (32-36 weeks gestation)

17. Office environment • Consider: • Putting up posters about alcohol and pregnancy • Ordering patient handouts such as brochures • Using a chart reminder system to remind you to ask about alcohol use

18. How to ASK • Explain that you will be asking a standard series of health questions that are directed to all patients in order to improve health • Avoid questions that suggest that you want a negative response. Once the patient responds negatively, it is difficult to explore the issue further: • Negative: You don’t drink, do you? • Positive: How much alcohol do you drink?

19. When asking: • Be non-judgmental • Listen attentively to her concerns • Refrain from negative comments or reactions • Focus on the mother as well as the baby • Be sensitive to broader issues such as poverty and abuse • Make positive statements about the fact that the woman is seeking prenatal care • Make positive statements about progress at each prenatal visit

20. CASE • MS is drinking 3 standard drinks every weekend. 1 on Friday, 1 on Saturday and 1 on Sunday. She is at 13 weeks gestation. Her T-ACE score is 1 ( T=0, A=1, C=0, E=0). She has never met criteria for alcohol dependence. • How will you advise her in a 5 minute interview?

21. ADVISE to stop drinking • Recommend that patients stop drinking if they are planning a pregnancy or if they are pregnant • Use a clear straight forward statement such as: • When planning a pregnancy, it is safest to stop drinking prior to conception or • The safest choice is not to drink during pregnancy or • Now that you know you are pregnant, it is safest to stop drinking • If a patient is unable to stop drinking, advise them to cut back as much as possible

22. ADVISE about the risks • Use positive statements to provide an accurate assessment of risks. • Positive: If you stop drinking you have a better chance of having a healthy baby. • Negative: Your drinking has already damaged your baby. • Positive: Your concern for your baby will help you be a good mother. • Negative: If you really loved your baby, you would not drink so much.

23. CASE • MJ is 24 and working hard in a waitressing job. She usually has a drink at work at the end of her 12 hour shift. At times she has 2 to 3 to relax. Her TACE score is 2 ( T=2, ACE= 0). • How will you assess her motivation to stop in 3 minutes or less?

24. How to ASSIST • Discuss alcohol use in a comfortable non-threatening manner • Strategies that are effective in engaging substance-using patients in care: • Are non-judgmental • Use motivational enhancement • Are honest and open • Are women-centred • Build on strengths • Are culturally sensitive • Are supportive

25. Levels of motivation • To assess readiness and ability to change drinking behaviour ask: • How important it is to the woman • How confident she is of making the change

26. FRAMES • Feedback: provide clients with personal feedback regarding their individual status • Responsibility: emphasize personal responsibility for change and the individual’s freedom of choice • Advice: include a clear recommendation on the need for change, in a supportive rather than an authoritarian manner • Menu: offer a menu of strategies for change, providing options from which the client may choose • Empathy: be empathetic, reflective, warm and supportive • Self-efficacy: reinforce clients expectation that she can change

27. 5 Rs • Relevance • Rewards • Risks • Roadblocks • Repetition

28. Summary • Brief Interventions are effective • Use in at risk drinkers • Use in problem drinkers • Refer Alcohol Dependent Drinkers • We can make a difference!