Georgiana Wilton, PhD University of Wisconsin Department of Family Medicine

1. Brief Alcohol Interventions to Reduce the Risk of an Alcohol-Exposed Pregnancy: Lessons from the Field Georgiana Wilton, PhD University of Wisconsin Department of Family Medicine CityMatCH Practice Collaborative October 17-19, 2011

2. Examples for Illustration The Healthy Moms Study Healthy Choices NOTE: Variations on a Theme

3. Healthy Moms Study: Overview • Goal: To reduce alcohol use in postpartum women • Recruitment and Follow-up: July 2002 – April 2005 • Recruitment Methods: • Brief Prescreen (6-week postpartum visit) • Baseline Assessment Interview (BAI) • Eligible women were randomized Tx/Control

4. Healthy Moms Study, cont. • Brief Intervention • 2 face-to-face visits • 2 follow-up phone calls (1 after each visit) • Follow-up interviews at 6- and 12-months post intervention

5. Healthy Moms Intervention

6. Education Component: The Harmful Effects of Alcohol Use

7. Define Risky Drinking

8. Compare Client use…

9. Make a Plan

10. Homework

11. Self-HelpAction Plan

12. Study Results • Significant reduction in alcohol use at 6-month follow-up • 19% reduction in daily alcohol use • 21% reduction in number of drinking days • 36% reduction in heavy drinking days • Support clinical findings i.e., Floyd et al., 2007, Chang et al., 2005, O’Connor and Whaley, 2007) Significant reduction in mean depression score compared to baseline in women who received the intervention

13. But what's really interesting...

14. Success Story Claudia* is a professional woman with a high-level job in sales. She participated in two intervention sessions and one brief check-in. She successfully reduced her drinking—below her goal of 2-3 drinks per week. On her last check-in with her interventionist she reported, “My husband feels like he has the ‘old me’ back. I don’t sleep ‘till noon on the weekends. I spend more time with him and my children. I feel like I wasted so much time drinking—and so much energy was lost.” *Not her real name

15. Success Story Karla* was completing her first intervention session when it became clear that she was depressed. The interventionist provided a brief ‘screen’ per study protocol, and followed the clinic’s protocol in seeking immediate help when it was determined that the woman was suicidal. A hospital social worker was called, and Karla received immediate clinical intervention. Upon notification of her physician (per hospital protocol), he indicated, “I provided prenatal care for her for 9 months and never guessed she drank.” *Not her real name

16. The Healthy Choices Study

17. The Study in Context… • Centers for Disease Control and Prevention Cooperative Agreement • #U84-CCU524082 • One level of a four-tiered ‘dream’ project • Fetal Alcohol Spectrum Disorders Prevention and Intervention Project (PIP) • Awareness campaign • Surveillance • Multidisciplinary clinic • Randomized clinical trial

18. The Healthy Choices Study • Randomized trial to test the efficacy of a BI in reducing the risk of an alcohol-exposed pregnancy • Testing difference between in-person administration and telephone administration • 2-4 session adapted from previous models within the dept. of family medicine and CDC • Healthy Moms; CHIPs, Project Choices • Combination of motivational interviewing/cognitive behavior therapy

19. Screening/Intake Protocol • Target Population: • Sexually active, fertile women ages 18-44 • Not using effective contraception • Start Date: August 2006 • Recruitment End Date: January 2009 • Recruitment Sites: • Health Clinics (HMO, Public Health) • Institutions of Higher Learning • Community Events • Callers to Healthy Choices Information Line

20. Content • Health review • Targeted health information • Alcohol use comparison • Assessment of “readiness to change” • Identification of life goals • Making a plan • Tools for tracking

21. Key Components Likes/Don’t Likes Health Risks

22. Key Components Comparison of Drinking Readiness to Change

23. Key Components Goals Goals

24. Prescreen ResultsN = 3,051

25. Baseline ResultsN = 131

26. Baseline ResultsN = 131

27. Follow-Up Results

28. In a nutshell… • No significant difference between groups • In-person vs. telephone • This is our BIG BANG • Significantly reduced risk of an alcohol-exposed pregnancy

29. In a nutshell, cont. • Significant increase in effective use of contraception • Significant reductions in levels of alcohol use from baseline to 6-month follow-up • Total drinks in past 30 days • Total drinks in past 90 days • Total number of drinking days (prev. 30 & 90) • Number of binges in past 30 and 90 days • Lowered risk ≠ No risk

30. But what's really interesting...

31. Success Story Sarah* is a college student who lives with chronic pain. She used alcohol to relax and help “deal with the pain.” She tended to binge on weekends, and was inconsistent in her use of birth control. Sarah participated in two intervention sessions and one brief check-in. She successfully reduced her drinking—below her goal of 2-3 drinks per week. By her exit interview (12-months), she had eliminated alcohol entirely and had completed six months of contraceptive compliance (she never missed her pill!). In her 12-month follow-up interview, she commented, “See, I actually learned something from your study” upon completing the contraception usage table. She particularly appreciated the educational section of the workbook and was not aware of the link between alcohol use and an increased risk of breast cancer. *Not her real name

32. Success Story Karla* is a woman over the age of 40 who was drinking well above recommended levels. She was also in an abusive relationship that often led to inconsistent use of contraception. She had been in AODA treatment in the past and was trying to “manage” on her own. Karla participated in four sessions (two intervention sessions, and two check-in sessions). In her final interview, she admitted needing more support upon completion of the study and accepted a referral into treatment. She also terminated her unhealthy relationship. *Not her real name

33. Participant Satisfaction Summary(n=30)

34. Participant Satisfaction, cont. • Did Participating in Healthy Choices change your behavior in any way? • “I am more aware of how much I drink and have since always used contraception. I didn’t realize how important these things are and how they played into my life.” • “I think more about the amount I drink when I go out.” • “It has moved me to pursue some things that I already knew and needed to pursue.”

35. Participant Satisfaction, cont. • What was your favorite part about Healthy Choices? • “Facts about drinking averages and effects and unknown facts about correct usage of contraception.” • “How the counselors talk to you and try and understand you as a person, not as a person with a problem.” • “Calculating how much money I spend on alcohol in a year’s time helps me realize how much money I waste by going out so often.” • “Taking the time to reflect on my personal decisions.”

36. Is BI for Everybody? • NO! • Alcohol Dependence • Conditions requiring medical management • Individuals with cognitive limitations • Whether developmental in nature, or due to mental health or chronic drinking problems • Can act as a “screening” tool for referral

37. Part II What should I include in my intervention? Samples and Lessons Learned…

38. Designing Your Intervention • Feedback from whatever screen you use • Otherwise—the screen is a waste of time • Allows for buy-in from individual you are concerned about • “But, I didn’t mean…” • Asking ‘WHY’ • What are some of the good things • What are some of the bad things

39. Designing Your Intervention • Providing Education • Allows for the discussion of why you are concerned about their behavior • Provides support to your argument • Showing Comparisons • Their behavior vs. their peers

40. Designing Your Intervention • Cost • What is it costing them • $$, Time (or time away from something), Energy • Reality check • Cost of drink vs. Cost of day-fee at health club • Readiness to Change • Where most of the work is • Must be able to ‘step away from the intervention’ • Research pressure vs. clinic reality • You want them to come back!

41. Designing Your Intervention • Developing a Plan • Can be as simple as, “Can I bring this up again next time you visit” • Plans can fail • Can people?

42. What other components should be included?

43. Traps to Avoid Question/Answer Confrontation/Denial Expert vs. Student Labeling What do we need to call ‘it’ anything Premature Focus Can’t rush the process Blaming

44. AVOID: Question/Answer Tends to elicit passivity in client Clients not encouraged to explore in depth

45. AVOID: Confrontation/Denial If client not ‘ready to change’ sessions may become argumentative T: What about… C: Yes, but… T: But what about… C: Yes, but…

46. What you might hear… • “But I dilute my shots by adding orange juice, so the alcohol isn’t as bad for me…” • “No, I don’t drink alcohol, only beer…”

47. Or.… • “Long Island ice tea doesn’t really count, right?” • “No, just one drink, and I hardly ever finish the entire pint.”

48. AVOID: Expert Counselor falls into ‘Expert’ role and provides direction before client can explore their own goals

49. AVOID: Labeling Client as ‘addict’ ‘alcoholic’ Accompanied by stigma Client does not need to have a label to work towards behavior change

50. For Example “Are you saying that I’m an alcoholic?” “What I’m saying is that based on what you’ve told me, I’m concerned about your health and safety. I’d like to talk with you more about this…”