Mary Kate Weber, MPHCityMatCH Practice Collaborative Meeting

October 17, 2011

Preventing Alcohol and Other Substance-Exposed Pregnancies: A National Perspective

Office of the DirectorNational Center on Birth Defects and Developmental Disabilities

Today’s Presentation Public health burden of risky alcohol and

other substance use among women of reproductive age

Strategies to reduce alcohol-exposed pregnancy and unhealthy alcohol use

Examples of national prevention efforts

What is the Problem?

At-Risk Alcohol and Other Substance Use

Pose significant health risks to women of reproductive age, and for those who become pregnant, to their children

One of the strongest predictors of substance use during pregnancy is substance use before pregnancy

Early identification of substance use in the preconception period offers an opportunity to help women reduce major health risks, including risks to their children

Evidence-based methods for screening and intervening on harmful use of alcohol, tobacco and illicit drugs have been developed and are recommended for use in primary care settings for women of reproductive age

At-Risk Alcohol and Other Substance Use (continued)

Adverse Outcomes Associated with Substance Use During Pregnancy

Alcohol use Spontaneous abortion, prenatal and postnatal growth

restrictions, fetal alcohol spectrum disorders Maternal smoking

Intrauterine growth retardation, prematurity, low birth weight, sudden infant death syndrome, orofacial clefts

Illicit drug use Cocaine: increased risk for low birth weight,

prematurity, perinatal death, abruptio placenta, and small for gestational age births

Marijuana: linked to effects on intellectual development in young children

Women who use illicit drugs often have higher rates of STDs, HIV, hepatitis, domestic violence and depression

Alcohol Use during Pregnancy

Fetal Alcohol Spectrum Disorders (FASD) Describes a range of effects that can occur in an

individual whose mother consumed alcohol during pregnancy

Physical, mental, behavioral, and/or learning disabilities with lifelong implications

Not intended as a clinical diagnosis Fetal Alcohol Syndrome (FAS)

Characterized by specific facial features, growth deficits, and central nervous system abnormalities

Prevalence Rates FAS - range from 0.2 to 1.5 cases per 1,000 live births FASD - estimated to be at least three times as many

cases as FAS The lifetime cost of care for an individual

with FAS in 2002 was estimated to be $2 million

The Story of Iyal

Prevalence of Any Alcohol Use among Women Aged 18-44 Years – United

States, 1991-2005

0

10

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Not pregnant Pregnant

Behavioral Risk Factor Surveillance System, 1991-2005, United States

Prevalence of Binge Drinking among Women Aged 18-44 Years – United

States, 1991-2005

02468

10121416

1991

1992

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Behavioral Risk Factor Surveillance System, 1991-2005, United States

Risks of Binge Drinking to Women’s Health

Contributes to over 11,500 deaths among women in the U.S. each year—approximately 32 deaths per day

Increases the risk for breast cancer, heart disease, and stroke, all of which are leading causes of death in women

Risk factor for sexual assault, especially among young women in college settings

Increases the risk for unintended pregnancy

Risks of Binge Drinking to Women’s Health (continued)

Women who binge drink are more likely to have unprotected sex and multiple sex partners, which can increase their risk of acquiring HIV and other sexually transmitted diseases

Women who drink alcohol while pregnant increase their risk of having a baby with an FASD If a woman does not recognize that she is pregnant and

she continues drinking, she can expose her developing fetus to alcohol without realizing it.

Long term effects of binge drinking increases risk for certain types of cancer, alcohol-related liver disease, and heart problems

Percentage of Women Aged 15-44 YearsUsing Substances

Sources: SAMHSA, Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011. *Colliver, J. D., Kroutil, L. A., Dai, L., & Gfroerer, J. C. (2006). Misuse of prescription drugs: Data from the 2002, 2003, and 2004 National Surveys on Drug Use and Health (DHHS Publication No. SMA 06-4192, Analytic Series A-28). Rockville, MD: SAMHSAn, Office of Applied Studies.

Past Month Substance Use among American Indians or Alaska Native Women Aged 18 or Older Compared with the National Average,

2004-2008

*Differences are significant at .05 levelSource: 2004-2008 SAMHSA National Surveys on Drug Use and Health

Discussion Do these findings reflect what is going on in

your city/state/community? How are they similar or different?

Tool 1: Mapping the Problem & Context

Strategies to address alcohol-exposed

pregnancy

Preventing Alcohol-Exposed Pregnancies (AEP)

Alcohol use during pregnancy continues to be a serious public health problem

Women who are sexually active and drinking alcohol are at risk of having an AEP since they may be drinking and not know they are pregnant for several weeks or more

Almost half of pregnancies in U.S. are unplanned

FASDs are 100% preventable

Reducing Alcohol-Exposed Pregnancies: A Report of the National Task Force on

Fetal Alcohol Syndrome and Fetal Alcohol Effect, 2009

Goal: to review evidence-based prevention strategies to reduce AEPs and provide recommendations for prevention of AEPs

Utilized Institute of Medicine Prevention Framework strategies: Universal Selective Indicated

Strategies that have been used to reduce alcohol use and alcohol-exposed

pregnancies Surgeon General’s advisories Alcoholic beverage warning labels Point of purchase signage Health communication campaigns Population-based strategies to reduce

alcohol use Alcohol screening and brief intervention

(SBI) Project CHOICES Case management with highest risk

women

Surgeon General Advisories on Alcohol Use in Pregnancy

1981 Surgeon General’s Advisory on Alcohol and Pregnancy

2005 Surgeon General’s Advisory on Alcohol Use in Pregnancy

Alcoholic Beverage Warning Labels

Alcoholic Beverage Warning Label Act 1988

Studies on the impact of the warning label on alcohol use: A significant number of people

reported seeing the warning labels; some effects on alcohol use on light drinkers but not heavy drinkers

Overall, exposure to the label does not reduce alcohol use but has increased awareness in some groups

Point-of-Purchase Warning Posters

Typically posted in bars, liquor stores and restaurants

While posters alone have not been shown to change alcohol-related behaviors, they Can raise awareness of health

and safety risks associated with drinking and pregnancy

Reinforce the beverage warning label

Use this strategy in combination with others

Resource: Mandatory Point-of-Purchase Messaging on Alcohol and Pregnancy (2008)

NIAAA Alcohol Policy Information System, 2011http://www.alcoholpolicy.niaaa.nih.gov

Alcohol and Pregnancy: Mandatory Warning Signsas of January 1, 2011

Communication Campaigns

Increase knowledge and awareness about a health issue

Can complement or promote FASD prevention efforts

Rarely result in behavior change Can be costly; however, new

mediaoffers opportunities for creativity

Careful planning is needed Evaluation is critical but is often

not done

Are these strategies effective at reducing AEPs?

There is insufficient evidence to indicate that these strategies are effective in reducing AEPs; however, they Are important strategies for increasing

public awareness and political will Help raise the visibility of fetal alcohol

spectrum disorders as a public health concern

Complement a comprehensive approach to FASD prevention

More research is needed to explore the effects of these kinds of strategies

Population-based Interventions to Reduce Excessive Alcohol Use

Population-based interventions WHO report No Ordinary Commodity Community Guide reviews

Effective population-based alcohol interventions could ultimately impact alcohol consumption rates among women of reproductive age

What is the Community Guide? Resource of evidence-based

recommendations for public health policy and practice

Assessed effectiveness of over 210 public health interventions in 18 topic areas and settings, including excessive alcohol use

CDC provides scientific and administrative support to the Task Force on Community Preventive Services

Community Guide – Alcohol ReviewsInterventions Directed Toward the General Population

Regulation of alcohol outlet density

Recommended based on sufficient evidence

Maintaining limits on days of sale Recommended based on strong evidence

Maintaining limits on hours of sale

Recommended

Increasing alcohol taxes Recommended based on strong evidence

Enhanced enforcement of overservice laws

Recommended

Dram shop liability RecommendedPrivatization of retail sales Insufficient EvidenceResponsible beverage service training

Insufficient EvidenceInterventions Directed Toward Underage Drinkers

Enhanced enforcement of laws prohibiting sales to minors

Recommended based on sufficient evidence

www.thecommunityguide.org/alcohol/index.html

Has been shown to reduce risky alcohol consumption in a variety of settings and among various population groups

Recommended by the U.S. Preventive Services Task Force for people 18 and older, including pregnant women

National Task Force on FAS identified brief alcohol interventions as the most promising approach to reduce alcohol use among women of reproductive age

Alcohol Screening and Brief Intervention (SBI)

Project CHOICES Intervention

Four counseling sessions based on standard brief intervention components

Dual focus: reducing alcohol use, improving contraceptive use

Use of motivational interviewing approach One family planning consultation & services

visit

Project CHOICESEfficacy Study Results

Those in intervention group 2x more likely to be NOT at risk for AEP at 3, 6, 9 months than those in control group

71% in study at 9-month follow-up Both groups had reduced AEP More intervention women changed both

behaviors Effective approach to reducing AEP

Not at risk by: Intervention Control

• Reducing alcohol use 49%40%

• Improved contraception 56% 39%

Parent-Child Assistance Program (PCAP)

Intensive case-management intervention serving high-risk alcohol and/or drug abusing mothers and their families To prevent future substance-exposed births To intervene with women with FASDs and children who

might be affected Assist women in obtaining treatment,

staying in recovery, and addressing other life challenges

Results of original studies were positive for participation, abstinence, use of reliable birth control and decreases in subsequent pregnancies

Discussion What kinds of strategies have you used in

your city/state/community to address substance-exposed pregnancy? What has worked? What hasn’t?

Examples of national prevention activities

FASD Regional Training Centers (RTCs) Purpose: to educate medical and allied health students

and practitioners in the prevention, identification, and treatment of FASDs

Previous Cycle of RTCs (2008-11) In 2008, awarded 5 cooperative agreements Conducted 542 trainings/events Reached 5,535 students/residents and 7,875

health care professionals New funding cycle (2011-2014)

In 2011, awarded 4 cooperative agreements Emphasis on SBI implementation in addition to traditional

core training competencies

Washington

Montana

Oregon

Nevada

California

Utah

ArizonaNew Mexico

Colorado

Idaho

Wyoming

North Dakota

South Dakota

Minnesota

IowaNebraska

Kansas

TexasFlorida

Mississippi

Louisiana

Alabama

Georgia

South Carolina

North Carolina

Virginia

Maine

New York

Michigan

Wisconsin

Oklahoma

Missouri

ArkansasTennessee

Kentucky

IllinoisIndiana

Michigan

Ohio

West Virginia

DC

MarylandDelaware

New Jersey

Vermont

Rhode IslandConnecticut

New Hampshire

Massachusetts

Alaska

Hawaii

Pennsylvania

FASD Regional Training Centers, 2011-2014

Arctic RTC, Univ of Alaska AnchorageMidwestern RTC, Saint Louis UnivGreat Lakes RTC, Univ of WisconsinSoutheastern RTC, Meharry Medical CollegeFrontier RTC, Univ of Nevada Reno

American College of Obstetricians and Gynecologists

(ACOG) In 2005, CDC partnered with ACOG to

develop a tool kit for women’s health providers Focused on screening, educating, and intervening with

women at risk for an alcohol-exposed pregnancy Over 17,000 copies distributed to ACOG membership

and others Recent ACOG survey found most ob/gyns were unaware

of the toolkit In 2010, CDC awarded a contract to ACOG

to: Re-assess the FASD Prevention Tool Kit Integrate FASD prevention information and materials

into ACOG activities and disseminate to ACOG membership

Establish a relationship with CDC’s FASD RTCs to integrate primary prevention materials and the tool kit into RTC trainings

CHOICES Plus: A Preconception Approach to Reducing Alcohol and

Tobacco-exposed Pregnancies

Clinical trial aimed at testing the efficacy of combining a facilitated referral for smoking cessation with the CHOICES intervention to reduce risks for alcohol and tobacco-exposed pregnancies

Awarded to University of Texas at Austin (2008-2012)

Translation of the CHOICES Intervention Two sites funded in 2009 to implement

CHOICES in STD clinics Colorado Dept of Public Health and Environment/Denver

Metro Health Clinic Baltimore City Health Department/Johns Hopkins

University Two sites funded in 2010 to implement

CHOICES in CHCs and Family Planning Clinics Alta Med Corporation, Los Angeles CA New York City Health and Hospitals

Inter-Agency Agreement in 2010 with Indian Health Service Oglala Sioux Tribe in South Dakota

CHOICES Dissemination

Developed intervention and training materials, based on the original CHOICES protocol & related resources, for public health providers serving women of childbearing age: Counselor Manual Client Workbook Assessment Tools Training Curriculum Resources-training videos, on-line tutorials, etc.

Enhanced Resources for FASD Prevention and Intervention through National Networking, Education, &

Dissemination In 2010, CDC’s FAS Prevention Team

awarded a four-year cooperative agreement to NOFAS to: Enhance/expand the NOFAS National & State Resource

Directory Engage/enhance existing network affiliate members and

increase the number of affiliate organizations and build capacity among network members

Enhance/expand the NOFAS Information Clearinghouse and disseminate resources/materials

Conduct media outreach

CityMatCH Practice Collaborative Project

Project Purpose Pilot a multi-city urban practice collaborative focused on

addressing alcohol and other substance misuse among women of reproductive age

• Increase awareness and education about the risks of substance use during pregnancy & their associated adverse effects, and

• Enhance capacity of providers to deliver screening, brief intervention, and referral services for women of reproductive age

Practice Collaborative Teams 6 local teams selected through an application process Develop and implement local action plans to address

this issue

SAMHSA’s FASD Center for Excellence Provides training and technical assistance Maintain FASD Information Resource Center

& FASD Center Website Developing FASD Treatment Improvement

Protocol (TIP) Fund 23 local, state and juvenile court to

implement evidence-based interventions National Association of FASD State

Coordinators

www.fasdcenter.samhsa.gov

National Institute on Alcohol Abuse and Alcoholism

Conducts both basic science and prevention research on a wide range of topics related to alcohol

Manages a large FASD research portfolio Coordinates the Interagency Coordinating

Committee on FASD SBI-related materials include:

Helping Patients Who Drink Too Much: A Clinician’s Guide Rethinking your Drinking – rethinkingdrinking.niaaa.com New “Alcohol and Brief Intervention for Youth”

practitioner guide

www.niaaa.nih.gov

For more information on “10 Years of Service”http://www.cdc.gov/ncbddd/tenyears/

Questions?

Contact Information:Mary Kate Webermuw1@cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.