Preventing an Alcohol-Exposed Pregnancy: Results from the Healthy Choices Study

1. Preventing an Alcohol-Exposed Pregnancy: Results from the Healthy Choices Study Georgiana Wilton, PhD University of Wisconsin Department of Family Medicine October 4, 2011

2. Overview • Women and alcohol • Definitions of ‘risky drinking’ • Screening and treatment options • Results of the Healthy Choices Study

3. Scope of the Issues • Women and Alcohol • On average: • 50% of U.S. women age 18–44 use alcohol • 8-24% binge drink (BRFSS, 2008) • Women who binge drink are at increased risk of an unintended pregnancy and an alcohol exposed-pregnancy • About 10% of pregnant women report using alcohol, and 2% drink excessively— heavy drinking, binge drinking, or both (Tsai, 2004)

5. Risks for Women Drinkers Alcohol can have a dramatic, negative effect on women, including: Health Risks Liver Disease Increased Risk of Cancer Weight/Nutrition Mood Disorders Safety Risks Increased Risk of Sexual Assault Reproductive Risks Decreased fertility Risk of an Alcohol-Exposed Pregnancy

6. Clinical Perspective • How much alcohol is too much?

7. “Sensible” Drinking Guidelines • Drinking no more than 7 drinks per week • Drinking no more than 1-2 drinks on any day, and no more than three days per week • No drinking if pregnant, breastfeeding, planning to become pregnant, or sexually active and not using contraception • No drinking if planning to drive, if taking certain medications, with certain medical conditions, or have history of alcohol or drug abuse/dependence • LOW RISK ≠ NO RISK

8. Factors Associated with Risky Drinking in Women • Ethnicity and acculturation • Lower socioeconomic status • Age at first drink • First drink before age 14 • Depression • Depression contributes to increased drinking levels • Increased drinking leads to depression

9. Risk Factors, cont. • Marital status • Divorced, separated, or never married women at greater risk for having a child with FASD • Heavy alcohol use in partner and/or family member • Use of other substances (incl. tobacco) • Abuse • Multiple sex partners

10. Guidelines for Screening Women • Define Standard Drink • Assess Quantity and Frequency of health risk • Average or typical patterns • Timeline Follow Back (TLFB) • Note patterns of excessive risk

11. Defining the Standard Drink Source: National Institute on Alcohol Abuse and Alcoholism. (2005a). Helping patients who drink too much: A clinician’s guide, Updated 2005 Edition. NIH Pub. No. 07-3769. Bethesda, MD: U.S. Department of Health and Human Services. 

12. Assessing Quantity and Frequency • Score from Screening Tool • If screening tools used • Assess “Adverse Events” • What health/social/physical concerns may be associated with the unhealthy behavior • CAUTION:Will screener interpret scores (risks) correctly (appropriately) • and then provide appropriate action

13. Short Questionnaires T-ACE TWEAK AUDIT CAGE NOTE: Variations on a theme… Timeline Follow Back (TLFB) Etc… Screening Tools

14. Clinical Perspective • What are my options to address alcohol use with my patient?

15. Treatment/Support Options • Residential/In-Patient Treatment • Outpatient Treatment • Counseling/Therapy • Pharmacotherapy • Self-Help/Support Groups • AA • Brief Intervention

16. Brief Intervention (BI) • Effective, low-cost treatment alternative for alcohol problems • Time-limited, typically < 4 sessions • Self-help • For use in non-dependent individuals (or for referral of dependent individuals) • Can be conducted in non-treatment clinical setting by non-AODA professionals • Combines techniques of Motivational Interviewing, Cognitive Behavior Therapy

17. Brief Alcohol Intervention (BAI) • Meta analyses of BAI found significant reductions in: • Alcohol use • Alcohol-related harms • Alcohol-related costs • Bertholet et al., 2005; Whitlock et al., 2004 • Reduction in aggression in adolescents • Walton et al., 2010 • Reduced risk of alcohol-exposed pregnancy • Floyd et al., 2007

18. BAI in Pregnant Women • Significant reductions in alcohol use • Chang et al., 2005; O’Connor and Whaley, 2007 • Higher birth weights • Lower fetal mortality rates • O’Connor and Whaley, 2007

19. BAI in Postpartum Women • Significant reductions in alcohol use • Mean # of drinking days • Mean # of total drinks • Mean # of ‘heavy’ drinking days • Fleming et al., 2008 • Decrease in postpartum depressive symptomatology • Wilton et al., 2009

20. The Healthy Choices Study

21. UW Population Health Institute D. Paul Moberg, PhD Kit Van Stelle, MA Janae Goodrich, BS Project Team UW Department of Family Medicine Georgiana Wilton, PhD Lyric Dold, MS, LPC Kristi Obmascher, BS

22. 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

23. Wisconsin FASD Prevention and Intervention Project Education Entry into Project Screening Intervention Outcome 1. Increased reported use of contraception in women at-risk of giving birth to a child with FASD 2. Decrease in reported alcohol consumption in women at-risk Education of Child and Family Service Providers Screen and ID Women at Risk: 1. Clinical and community settings 2. Self-Referrals Method of Entry: 1. Clinical and community participants 2. Self-Referral from Media Campaign Brief Alcohol and Contraceptive Intervention Consumer Education: Child and Family Service Consumers Increased access to services for children identified with FASD and their families Diagnostic Evaluation through UW Medical School Screening of Children at-risk for FASD Mass Media Campaign  In reported at-risk drinking through State surveillance FAS Surveillance

24. 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

25. 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 • Institutions of Higher Learning • Community Events • Callers to Healthy Choices Information Line

26. Recruitment Pre-Screen Not Eligible Eligible/Enroll: Conduct Baseline Int. Not Eligible/Non Consent: Resource Guide Self-Help Guide Eligible/Consent: Randomize (Telephone or In-Person)

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

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

29. Key Components Comparison of Drinking Readiness to Change

30. Key Components Goals Goals

31. Study Flow Total Prescreens N= 3,051 PS Eligible N/C N = 296 PS Eligible YES/C N = 899 PS NOT eligible N = 1,856 Ref. or W/D Prior to Baseline N = 465 Completed Baselines N = 434 Intervention Eligible N = 132 Intervention Ineligible N = 302 Refused N = 1 Telephone N = 68 In-Person N = 63

32. Prescreen ResultsN = 3,051

33. Baseline ResultsN = 131

34. Baseline ResultsN = 131

35. Follow-Up Results

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

37. 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

38. But what's really interesting...

39. 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

40. 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

41. Participant Satisfaction Summary(n=30)

42. 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.”

43. 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.”

44. Limitations… • Not as large of a sample as we’d have liked • As with most BI—based on self-report of alcohol use • IRB mandates re: exclusion of pregnant women • More women who did not consent reported history of domestic violence and/or partner use/abuse

45. Where we’re going now… • Healthy Choices has taught us • No difference in effectiveness of method of intervention…so no excuses… • Screen all women, provide intervention services • Scripted or not scripted…talk to women!! • Surveillance taught us… • Need to educate medical and allied health providers • Funding by CDC to develop implementation plan for Wisconsin…

46. 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

47. THANK YOU !