NIAAA Recommended - PDF Document

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  1. NIAAA Recommended Drinking Limits and SBIRT: A Review of the Scientific Evidence

  2. Presentation Overview The purpose of this presentation is to inform participants about NIAAA’s drinking guidelines and to briefly illustrate the usefulness of SBIRT. This presentation consists of 7 sections: 1. The Basis for the NIAAA Guidelines 2. The Recommended Drinking Limits in NIAAA Guidelines 3. Medical Consequences of Risky Alcohol Use 4. NIAAA and SBIRT 5. SBIRT and Efficacy 6. Incorporating SBIRT into Practice 7. References 3 8/16/2013

  3. The Basis for the NIAAA Guidelines

  4. Evidence Behind the Numbers* • Studies demonstrate that the 5+/4+ limits accurately reflect the amount of alcohol consumed at which psychomotor and cognitive impairment is notably increased in both men and women. Epidemiologic risk curve analyses reveal significant and rapid increases in the risks of: ─ Unintentional injuries ─ Deaths resulting from external causes ─ Being a target of aggression or taking part in an aggression-related event ─ Alcohol use disorders ─ Unfavorable medical, work-related, legal, and social consequences related to drinking • • As the frequency of exceeding NIAAA’S guidelines increases, the likelihood of developing these problems increases. *Full references provided at the end of the presentation: 4, 5, 7-10, 13, 19, 20, 21, 24, 34, 36-38, 56 5 8/16/2013

  5. Evidence Behind the Numbers* • Men and women over 65 are generally advised to have no more than 3 drinks on any day and 7 per week. • Heavy drinking during pregnancy can cause brain damage and other serious problems in the baby. Because it is not yet known whether any amount of alcohol is safe for a developing baby, women who are pregnant or may become pregnant should not drink. *Full references provided at the end of the presentation: 32 6 8/16/2013

  6. Significance of the Numbers Studies have consistently shown that when individuals exceed NIAAA’s daily or weekly drinking guidelines, their risk for alcohol-related problems increases significantly. 7 8/16/2013

  7. Background on the Recommended Limits* • The measurement of 5 or more drinks to determine alcohol risks has been used for decades, predating NIAAA. • In the 1960s, studies conducted by Virginia Technical College and later by the University of North Carolina Highway Research Center/National Transportation Safety Board assessed the impact of alcohol use and safety. • At blood alcohol levels (BAL) of .06 to .09 (approximately 5 drinks for a male), there is measurable impairment in reasoning, depth perception, peripheral vision, and nighttime glare recovery, as well as increased risks for accident and injury. *Full references provided at the end of the presentation: 2, 12, 35, 56 8 8/16/2013

  8. NIAAA Epidemiologic Studies* • NIAAA conducted extensive, nationally representative, epidemiologic surveys including: – National Longitudinal Alcohol Epidemiologic Survey—NLAES (1992) – National Epidemiologic Survey on Alcohol and Related Conditions—NESARC (2001–2002) – NESARC 3-year followup (2004–2005) • The surveys included questions regarding the frequency with which people drank more than 5 drinks in a given day. • Findings indicated that exceeding these drinking limits can significantly increase alcohol-related health problems. *Full references provided at the end of the presentation: 9, 15, 28, 29 9 8/16/2013

  9. Binge Drinking Defined* Based on consensus recommendations from a task force chaired by NIAAA Associate Director Dr. Mark Goldman in 2004, the NIAAA National Advisory Council approved the following definition for binge drinking: *Full references provided at the end of the presentation: 30 10 8/16/2013

  10. The Recommended Drinking Limits in NIAAA Guidelines

  11. How Much is Too Much?* • For healthy adults age 65 and under: • For people over 65, exceeding 3 drinks a day or 7 drinks a week is not recommended. • Women who are pregnant or may become pregnant should not drink. *Full references provided at the end of the presentation: 32 12 8/16/2013

  12. How Much is 1 Drink?* 0.6 fluid ounces or 14 grams of "pure" alcohol is the standard measurement used to define a typical drink *Full references provided at the end of the presentation: 31 13 8/16/2013

  13. Medical Consequences of Risky Alcohol Use

  14. Physiological Consequences of Risky Drinking* Excessive alcohol use is associated with many negative health and societal-related outcomes, including: • Certain types of cancer, including breast cancer • Obesity • High blood pressure • Stroke • Injury • Type 2 diabetes • Accident and death resulting from drunk driving • Violence, including homicide and sexual assault • Suicide • Cirrhosis of the liver *Full references provided at the end of the presentation: 14,18,22,23,27,33,41,42,45,47,50,52 15 8/16/2013

  15. Physiological Consequences of Risky Drinking 16 8/16/2013

  16. Progressive Effects of Alcohol Based on Blood Alcohol Concentration 17 8/16/2013 Full references provided at the end of the presentation: 51

  17. Incidence of Alcohol Use Disorders Increases in Relationship to Exceeding NIAAA Guidelines* Data analyzed extensively from NIAAA’s 2001 and 2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) • When daily drinking limits were exceeded: – Prevalence of possessing either alcohol abuse or dependence rose linearly as the frequency of exceeding the limits increased. – Exceeding weekly limits, in addition to daily limits, increased the incidence of having both disorders. *Full references provided at the end of the presentation: 9 18 8/16/2013

  18. Weekly Alcohol Consumption Limits: USDA and NIAAA Consistency U.S. Department of Agriculture (USDA) definition of moderate drinking: NIAAA definition of heavy drinking: Full references provided at the end of the presentation: 11, 25, 45, 46 19 8/16/2013

  19. NIAAA and SBIRT

  20. What is SBIRT? An intervention that includes the following: • Screening: Universal screening for quickly assessing use and severity of alcohol, illicit drugs, and prescription drug abuse • Brief Intervention: A brief motivational and awareness- raising intervention given to risky or problematic substance users • Referral to Treatment: Referrals to specialty care for patients with substance use disorders • Treatment can be brief treatment or specialty AOD treatment 21 8/16/2013

  21. NIAAA and SBIRT • The essential approach to alcohol screening and intervention remains unchanged. • In the 2005 NIAAA Clinician Guidelines, new directions for alcohol screening included a simplified, single-question screening question. • This guide recommends that this validated single- question screener be used in conjunction with the AUDIT. Full references provided at the end of the presentation: 47 22 8/16/2013

  22. NIAAA Single Question Alcohol Screen • Men: How many times in the past year have you had 5 or more drinks in a day? • Women: How many times in the past year have you had 4 or more drinks in a day? (a response of ≥ 1 is considered positive) 23 8/16/2013

  23. Impact of SBIRT on Public Health • SBIRT provides an opportunity for primary care, emergency service providers, and other community health providers to take proactive measures for patients who may be engaged in risky use of substances, but are not currently seeking treatment and are not in need of specialty treatment. • SBIRT demonstrates that a rapid and simple set of procedures has the potential for impacting the public health burden of substance abuse. 24 8/16/2013

  24. Using Both Daily and Weekly NIAAA Limits* The consensus is that NIAAA’s daily and weekly limits are considered the best option for balancing both sensitivity and specificity in predicting alcohol-related outcomes. *Full references provided at the end of the presentation: 6 25 8/16/2013

  25. SBIRT and Efficacy Over 200 Published Studies Demonstrating Effectiveness

  26. SBIRT Benefits: Primary Care Settings* Arrests Hospitalizations Nonfatal Injuries ER Visits BingeDrinking Drinks Per Week 0% 20% 40% 60% *Full references provided at the end of the presentation: 3 27 8/16/2013

  27. SBIRT Impact on Individuals and Communities* At the 6-month GPRA† followup, people who received SBIRT services reported: • 41% reduction in alcohol use • 68% reduction in illicit drug use • Fewer arrests, more stable housing, improved employment status, fewer emotional problems, and improved overall health † Government Performance Results Act of 1993 (GPRA) findings are based on self reported data and do not include a control group. *Full references provided at the end of the presentation: 43 28 8/16/2013

  28. Changes in Substance Use and Other Outcomes* State Cohorts I-IV Count of Intakes: 1,474,659 Count of Matched Six Month Follow-up: 21,035 *Full references provided at the end of the presentation: 45 29 8/16/2013

  29. Mental Health Related Outcomes* State Cohorts I–IV Count of Intakes: 1,474,659 Count of Matched Six Month Follow-up: 21,035 *Full references provided at the end of the presentation: 45 30 8/16/2013

  30. SBIRT Benefits ED and Trauma Centers Studies have repeatedly demonstrated SBIRT’s value, especially pertaining to alcohol problems (see reference section for full citation) Bernstein, E. and Bernstein, J. (2008). Effectiveness of alcohol screening and brief motivational intervention in the emergency department setting. Washington State Department of Social and Health Services, Research and Data Analysis Division. (2007). Medicaid costs declined among emergency department patients who received brief interventions for substance use disorders through WASBIRT. Vaca, F. and Winn, D. (2007). The basics of alcohol screening, brief intervention and referral to treatment in the emergency department. Schermer, C., Moyers, T., Miller, W., and Bloomfield, L. (2006). Trauma center brief interventions for alcohol disorders decrease subsequent driving under the influence arrests. D'Onofrio, G. and Degutis, L. (2002). Preventive care in the emergency department: Screening and brief intervention for alcohol problems in the emergency department: A systematic review. Gentilello, L., et al. (1999). Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. 8/16/2013 31 • • • • • •

  31. SBIRT: Consensus Among Medicine and Government Organizations recommending SBIRT: • NIAAA • SAMHSA • American College of Surgeons Committee on Trauma (ACS-COT) • American Medical Association • American Public Health Association • American Society of Addiction Medicine (ASAM) • Centers for Medicaid and Medicare Services (CMS) • American Academy of Family Medicine • Centers for Disease Control and Prevention 32 8/16/2013

  32. American College of Surgeons Committee on Trauma (ACS-COT)* ACS-COT mandates that Level I and II trauma centers have SBIRT capabilities and recommends the integration of SBIRT into all trauma centers. *Full references provided at the end of the presentation: 49, 50 33 8/16/2013

  33. A Closer Look at SBIRT’s Generation of Cost Savings* Findings in a 2010 study of Washington State’s SBIRT program: The program reduced monthly Medicaid costs by approximately $366 per member (compared with those who did not receive brief interventions). *Full references provided at the end of the presentation: 17 34 8/16/2013

  34. Incorporating SBIRT Into Practice

  35. Rationale for Universal Screening • Drinking and drug use are common. • Drinking and drug use can increase risk for health problems, safety risks, and a host of other issues. • Drinking and drug use often go undetected. • People are more open to change than you might expect. 36 8/16/2013

  36. Benefits of Universal Screening • Provides an opportunity for education, early intervention • Alerts provider to risks for interactions with medications or other aspects of treatment • Offers an opportunity to engage the patient further • Has proved beneficial in reducing high-risk activities for people who are not dependent 37 8/16/2013

  37. What is Screening? • A range of evaluation procedures and techniques to capture indicators of risk • A preliminary assessment that indicates probability that a specific condition is present • A single event that informs subsequent diagnosis and treatment 38 8/16/2013

  38. Screening Tools Currently Used in Practice* • The National Institute on Alcohol Abuse and Alcoholism (NIAAA) validated single-question screener • The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) • The Alcohol Use Disorder Identification Test (AUDIT and AUDIT-C) • The Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) • The Comprehensive Adolescent Severity Inventory (CASI) • The Cut down, Annoyed, Guilty, and Eye Opener (CAGE) test or the CAGE-AID, which includes questions about alcohol and illicit drugs *Information obtained from the SBIRT Medical Residency and State Aggregate Report FY 2011 39 8/16/2013

  39. Key Points for Screening • Screen everyone. • Screen for both alcohol and drug use, including Rx abuse and tobacco. • Explore each substance; many patients use more than one. • Follow up positives or "red flags" by assessing details and consequences of use. • Show nonjudgmental, empathic verbal and non-verbal behaviors during screening. 40 8/16/2013

  40. Screening Strategy Use a brief yet valid screening question: The NIAAA Single- Question Screener 41 8/16/2013

  41. Prescreening Sensitivity/Specificity: 82%/79% *Full references provided at the end of the presentation: 42 42 8/16/2013

  42. Drinking Limits Recommended Low-Risk Limits Men = 4 per day / 14 per week Women/anyone 65+ = 3 per day / 7 per week 43 8/16/2013

  43. A Positive Alcohol Screen = At-Risk Drinker *Full references provided at the end of the presentation: 55 44 8/16/2013

  44. AUDIT Alcohol Use Disorders Identification Test What is It? • Ten questions, self-administered or through an interview, address recent alcohol use, alcohol dependence symptoms, and alcohol-related problems. • Developed by the World Health Organization (WHO). What are the strengths? • Public domain—the test and manual are free. • Validated in multiple settings, including primary care. • Test is brief and flexible. • Focuses on recent alcohol use. • Consistent with ICD-10 and DSM IV definitions of alcohol dependence, abuse, and harmful alcohol use. Limitations? • Does not screen for drug use or abuse, only alcohol. 45 8/16/2013

  45. AUDIT Questionnaire 46 8/16/2013 Full references provided at the end of the presentation: 46

  46. AUDIT Domain Full references provided at the end of the presentation: 46 47 8/16/2013

  47. Scoring the AUDIT 48 8/16/2013

  48. Conclusion

  49. In Conclusion • NIAAA Guidelines were informed by years of research. • Exceeding the recommended drinking limits can increase the likelihood of negative health consequences. • SBIRT can assist with identifying drinking behaviors that may be risky or harmful to patients. • Screening questions have proven valid for identifying persons at risk. • Multiple screening tools are available that have been tested for sensitivity and specificity. 50 8/16/2013