Brief Alcohol Interventions to Reduce the Risk of an Alcohol-Exposed Pregnancy: Lessons from the Field
Georgiana Wilton, PhDUniversity of Wisconsin
Department of Family Medicine
CityMatCH Practice CollaborativeOctober 17-19, 2011
Examples for Illustration
The Healthy Moms StudyHealthy Choices
NOTE: Variations on a Theme
Healthy Moms Study: Overview
Goal: To reduce alcohol use in postpartum womenRecruitment and Follow-up: July 2002 – April 2005Recruitment Methods:– Brief Prescreen (6-week postpartum visit)– Baseline Assessment Interview (BAI)– Eligible women were randomized Tx/Control
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
Healthy Moms Intervention
Education Component: The Harmful
Effects of Alcohol Use
Define Risky Drinking
Compare Client use…
Make a Plan
Homework
Self-HelpAction Plan
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
Success StoryClaudia* 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
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
Success Story
The Healthy Choices Study
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 campaignSurveillanceMultidisciplinary clinicRandomized clinical trial
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 CDCHealthy Moms; CHIPs, Project ChoicesCombination of motivational interviewing/cognitive behavior therapy
Screening/Intake ProtocolTarget Population:– Sexually active, fertile women ages 18-44– Not using effective contraception
Start Date: August 2006Recruitment End Date: January 2009Recruitment Sites:– Health Clinics (HMO, Public Health)– Institutions of Higher Learning– Community Events– Callers to Healthy Choices Information Line
Health reviewTargeted health informationAlcohol use comparisonAssessment of “readiness to change” Identification of life goalsMaking a planTools for tracking
Content
Key ComponentsLikes/Don’t Likes Health Risks
Key ComponentsComparison of Drinking Readiness to Change
Key ComponentsGoals Goals
Prescreen ResultsN = 3,051
EligibleConsent
EligibleNo Consent
NotEligible
N = 3,051 899 296 1856Average Age 24 24 26*Drank in Past 90 Days 100% 100% 64%Binged in Past 90 Days 98% 99% 25%Binged in Past 90 Days AND Intercourse in Past 90 Days
98% 99% 6%
Smoked in Past 90 Days 43% 42% 24%
Baseline ResultsN = 131
In-Person Telephone
N=131 63 68
Average Age 25 26
Average Education 13 yrs 14 yrs
Race White Black Hispanic Other
65%26%* 6% 3%
62%15% 4% 19%*
Baseline ResultsN = 131
In-Person Telephone
Illegal Drug Use in Past 12 months 71% 65%
Average Total # Drinks in Past 30 Days
34 43
Average Total # Binges in Past 90 Days
14 13
Current Smoker 37% 46%
Follow-Up Results
6-Month Follow-Up 90 Day TLFB
Risk for Alcohol-Exposed Pregnancy 29%
Risk Based on Drinking Criteria 84%
Risk Based on Contraception Criteria 36%
Baseline 90 Day TLFB
Risk for Alcohol-Exposed Pregnancy 100%
Risk Based on Drinking Criteria 100%
Risk Based on Contraception Criteria 100%
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
In a nutshell, cont.Significant increase in effective use of contraceptionSignificant 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
Success StorySarah* 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
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
Success Story
Participant Satisfaction Summary (n=30)
Please rate your feelings for each of the statements below Strongly
AgreeAgree Disagree Strongly
Disagree
Overall, participating in Healthy Choices was helpful to me
27% 63% 10% 0
The printed materials I received were useful to me
23% 54% 23% 0
I felt that the information in Healthy Choices was appropriate to my culture
40% 53% 7% 0
The sessions gave me information about alcohol use I did not know before
23% 44% 33% 0
The sessions gave me information about contraception use I did not know before
13% 50% 34% 3%
I would recommend participating in Healthy Choices to a friend
47% 43% 7% 3%
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.”
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.”
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
Samples and Lessons Learned…
Part II
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
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
Designing Your InterventionCost– What is it costing them
$$, Time (or time away from something), EnergyReality 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!
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?
What other components should be included?
Traps to Avoid
Question/AnswerConfrontation/DenialExpert vs. StudentLabeling– What do we need to call ‘it’ anything
Premature Focus– Can’t rush the process
Blaming
AVOID: Question/Answer
Tends to elicit passivity in clientClients not encouraged to explore in depth
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…
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…”
Or.…
“Long Island ice tea doesn’t really count, right?”
“No, just one drink, and I hardly ever finish the entire pint.”
AVOID: Expert
Counselor falls into ‘Expert’ role and provides direction before client can explore their own goals
AVOID: Labeling
Client as ‘addict’ ‘alcoholic’ – Accompanied by stigma
Client does not need to have a label to work towards behavior change
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…”
Or…
“you report drinking about 12 drinks each week—mainly on weekends. Did you know that health risks increase for women who drink more than 7 drinks weekly, or more than 3 drinks on any one day. These risks include things like breast cancer…”
AVOID: Premature Focus
Caution against focusing on a problem too quickly–May raise resistance –May focus on unimportant ‘problem’
AVOID: Blaming
Establish ‘no fault’ policy–Don’t play the blame game!–Re-focus
“I’m not interested in who’s to blame, I’m interested in what’s troubling you and what you may be able to do about it”
Change can’t happen in a vacuum!
What’s going on at home?What’s going on in her community?What’s going on in her family?What barriers exist?– We don’t know unless we ask…– Is this the goal of SBI?
Everybody Loves RaymondRay is a pessimist– Wins “Sportswriter of the Year”
Fear of ‘now what’– Gets promotion at work
Fear of added stress, ulcers, etc.
Deborah as counselor– Works to change his thinking
Ray worked to change his thinking– Even when NOBODY around him changed
Could he maintain his new optimism?
What other ‘Traps’ should be avoided?
Tools for the Toolkit
Understanding the difference between the sexes – ‘Gender-responsive’– Understanding relationships– Increased risk during menstrual cycle– Trauma-informed
These issues will come up during the intervention
Tools for the Toolkit
Homework assignments– Journaling assignments, Reading, Checklists,
PracticeResources– Tracking cards
Readiness ruler
Cautions…
Much of MI relies on individual’s ability to draw abstract conclusions and project into the futureTools can be abstractMay be less effective with – Individuals with cognitive limitations– Children and adolescents
Can be adapted to increase usefulness
Cautions, cont…
Because of the non-directive, non-judgmental approach we may not be as happy with our options:– Is it okay for a pregnant woman to not be
ready to cut down or quit drinking?– Is it okay for an individual with one OWI to not
want to change her habits?– Are we comfortable with certain levels of
illegal drug use?
Lessons Learned…
Use the tools in your tool kit!
Meeting ‘site’ -- where they’re atDetermining readiness for adoption of BI into practice– On a scale of 1-10– What would have to happen for you to…
Plan for all contingenciesKnow about time needed, costs involved, level of education/training…
– HAVE A PLAN, but make sure its flexible
Use the tools in your tool kit!
Everything I needed to know about implementing BI I learned from the IRB– …okay, so not really– Similar processes
Minimize riskMaximize outcomeMinimize expenditures (time, energy, money)Maximize outcome
Be prepared to have it take time
The ‘Columbo’ Principle– Staff meetings
Staffing meetings“wouldn’t it be great if we had someone…”
– Policy meetings‘Hmmm…we lost 28 patients last year because of their alcohol…’
– Budget meetingsBilling for SBI services
Be prepared to do the leg work
Determine how to bill insurance providersKnow treatment referral sources– Gender-responsive– Age-responsive– ADA-responsive
Practice the ‘yeah-but’ responses
What has worked in YOUR community?
For More Information on Brief Intervention
US Dept. of Health and Human ServicesSubstance Abuse and Mental Health
Services Administration (SAMHSA)Center for Substance Abuse Treatment
www.samhsa.gov
TIP Series
References
Herman, A. I. & Sofuoglu, M. (2010). Comparison of available treatment for tobacco addiction. Current Psychiatry Reports, 12, 433-440.
Klein, G., et al., Effects of practitioner-delivered brief counseling and computer-tailored letters on cigarettes per day among smokers who did not quit—A quasi-randomized controlled trial. Drug Alcohol Depend. (2010), doi:10.1016/j.drugalcdep.2010.05.016
References
Marcus et al., 2001. Preventive Medicine 33, 204–216 (2001) doi:10.1006/pmed.2001.0873, available online at http://www.idealibrary.com on IDEAL
Miller, W.R., & Sanchez, V. C. (1993). Motivating young adults for treatment and lifestyle change. In G. Howard (Ed.), Issues in alcohol use and misuse in young adults. Notre Dame, IN: University of Notre Dame Press.