Screening Clinician Intervention to address HighRisk Alcohol Use

Screening & Clinician Intervention to address High-Risk Alcohol Use at Cornell University Nianne Van Fleet, M. S. R. N. , Director of Operations Stephen Hughes, M. D. , Medical Director

Why screening for high risk alcohol use in college students • Alcohol use can affect physical well-being and treatment recommendations. • The World Health Organization (2001) and U. S. Department of Health and Human Services (2005) recommend that screening for alcohol problems be a routine part of primary health care visits. • Level of substance abuse among college students 4 x higher than general adult population (Knight et. al. 2002, Grant et. al. 1992) • Research has found that when primary care providers talk with college students about drinking, these students have reduced how much they drink and the associated harms that come from heavy drinking (Schaus et. al. 2009, Flemming et. al. 2010).

Barriers • Clinicians’ time, particularly because of depression screening already in place • Clinicians’ comfort with topic • Nurses (L. P. N. s) unsure about if consistent with their role • Students’ attitudes towards drinking

Could we develop a screening & intervention that. . . • Adequately identified high risk students? • Provide brief interventions consistent with motivational interviewing? • Not take up too much of the clinician's time? • Not piss off the students?

Process • PDSA (Plan, Do, Study, Act) process of pilot (in short time frame) and tweak • 1 clinician piloted various forms of screening and interventions (8/11 to 1/12) • Once screening and intervention finalized, implemented for all primary care visits (began 2/12) • Provided staff training on motivational interviewing (1/12) • Expanded screening & intervention into sexual health nurses visits (9/12)

Screening process • Pre-appointment questionnaire: student completes initial screening question: In the past two weeks: • For a male: Have you had more than 5 alcoholic drinks in one sitting in the past 2 weeks? • For a female: Have you had more than 4 alcoholic drinks in one sitting in the past 2 weeks? • If positive to initial screening: LPN administers AUDIT (Alcohol Use Disorders Identification Test), scores and gives immediate feedback to student. • RN sends all students an electronic message to follow up on AUDIT score. • Clinician or RN for nurse visits speaks to student in appointment if score is at least a 16 or higher • Clinician or RN for nurse visits records AUDIT score in EHR.

About the AUDIT • 10 questions • Easily-scored, score from 0 -40 • Developed by World Health Organization • Valid and reliable measure of risk across gender, age, and culture (WHO, 2001) • Free!

Domains and Item Content on the AUDIT Domains Question Item Content Numbers Hazardous 1 Frequency of drinking Alcohol Use 2 Typical quantity 3 Frequency of heavy drinking Dependency 4 Impaired control over Symptoms 5 drinking 6 Increased salience of drinking Morning drinking Harmful Alcohol 7 Guilt after drinking Use 8 Blackouts 9 Alcohol-related injuries 10 Others concerned about drinking From WHO, 2001, p. 11

AUDIT score-based interventions as recommended by WHO (2001, p 22) AUDIT Score Recommended intervention 0 to 7 Alcohol education 8 to 15 Simple advice 16 to 19 Simple advice plus brief counseling and continued monitoring 20 – 40 Referral to specialist for diagnostic evaluation and treatment

Cornell’s AUDIT score-based interventions AUDIT Score % of Cornell patients Intervention Key content from secure message 0– 7 63% • • Returned AUDIT Secure message • • 3 facts about alcohol Link to Health Service website page about alcohol 8– 15 34% • • Returned AUDIT Secure message • Recommendation to cut back or quit • Male: no more than 4 /day, no more than 14/wk • Female: no more than 3/day, no more than 7/ week. Link to Rethinking Drinking • 16 – 19 20 – 40 2% 1% • • • Returned AUDIT Secure message Clinician conversation w/advice • • Returned AUDIT with written ed Secure message Clinician conversation w/ referral Strongly worded recommendation to cut back or quit Referral to CAPS • • • Strongly worded recommendation to cut back or quit Link to BASICS or CAPS (depending on if done BASICS)

Training in Motivational Interviewing • Built on previous MI training • Dr. Paul Grossberg for all staff • Intersection of training and doing/ use it or loose it • Reminder on the brevity of MI

Use of AUDIT as mini-BASICS Your score on the AUDIT (Alcohol Use Disorders Identification Test) is . • A score of 0 -7 suggests that, on occasion, you may be drinking too much, with the potential for negative consequences. • A score of 8 - 15 suggests that you are at risk for experiencing an alcohol problem. • A score of 16 - 20 suggests that you are at significant risk for experiencing alcohol abuse or dependency. • A score of 20 or higher suggests a very high likelihood of alcohol abuse or dependency. A personalized message with more information will soon be sent to you via the my. Gannett messaging system

Also on back of AUDIT Signs of alcohol dependency: Many people think that only someone who “needs to drink every day” is alcoholic. While this may be a sign of alcohol dependency, a person can meet the criteria for dependency even if they do not drink all that regularly. The criteria for alcohol dependency are as follows: In the past 12 months, have you experienced: q Not being able to stick to drinking limits q Not being able to cut down or stop q Increased tolerance (needing more alcohol to feel the same effect) q Signs of withdrawal (tremors, sweating, nausea or insomnia when trying to quit or cut down) q Drinking despite the fact that it has caused problems for you (e. g. problems with school work, relationships, or health) q Spending a lot of time drinking (or anticipating drinking or recovering from drinking) q Spending less time on other activities (e. g. cutting back on activities like sports, hobbies, academics or relationships that used to be important to you) If you answer yes to three or more items above, please speak with your medical provider at today’s appointment.

Real life challenges. . • Negative article in the student newspaper in March 2012 • Screening question appears at pre-appointment questionnaire (except sexual assault) for every primary care visit– even follow-ups • Students can decline the screening question and/or to do the AUDIT • Not knowing if the student makes any changes as a result of the clinician’s conversation

Screening at Health Service a part of many internal improvements/interventions • Coordinated with local hospital to improve flow of communication regarding students seen for etoh intox • Coordinated with local tx agency to provide brief intervention in ER after etoh intox • Health service after-hours on-call provides consultation to anonymous callers regarding concern for others in alcoholrelated emergencies • Improved health service’s ability to track alcohol issues/use of services • All alcohol-related concerns added to health record problem list

Interventions external to Health Service • Improved communication sharing with local police • Joint IPD/CUPD patrols in off-campus areas • Coordinated response to AOD incidents among university administrators • Consequences that are swift, certain and meaningful for individual and group violations of policies • Parental notification for 2 nd AOD violations • Alternative late night programs • Bear’s Den • Cayuga’s Watchers • Implementing wellness chairs in some Greek-letter organizations • Policy change on first year student ability to attend events in Greek system • Social norms media messages campaigns

How are we doing big picture? Based on random sample surveys of undergraduates conducted Fall 2012 and Spring 2013 semesters: Ø decreased incidence of high risk drinking (5+ drinks for male/4 + drinks for females) ØIncreased number of students not drinking and drinking moderately

References • Barber, T. F. , Higgens-Biddle, J. C. , Saunders, J. B. , Monterio, M. G. , (2001). The Alcohol Use Disorders Identification Test: Guidelines for use in primary care. World Health Organization • Fleming, M. F. , Balousek, S. L. , Grossberg, P. M. , Mundt, M. P. , Brown, D. , Wiegel, J. R. , . . . & Saewyc, E. M. (2010). Brief physician advice for heavy drinking college students: a randomized controlled trial in college health clinics. J Stud on alcohol and drugs, 71(1), 23 -31. • Grant, B. F. , Harford, T. C. , Dawson, D. A. , Chou, S. P. , Dufour, M. , Pickering, R. P. (1992). Prevalence of DSM-IV alcohol abuse and dependence: United States, 1992. Alcohol Health Res. World, 18, 243– 248 • Knight JR, Wechsler H, Kuo M, Seibring M, Weitzman E, Schuckit M. (2002). Alcohol abuse and dependence among US college students. J Stud Alcohol, 63, 263– 270 • Schaus, J. F. , Sole, M. L. , Mc. Coy, T. P. , Mullett, N. , & O'Brien, M. C. (2009). Alcohol screening and brief intervention in a college student health center: a randomized controlled trial. Journal of studies on alcohol and drugs. Supplement, (Supplement no. 16), 131 -141. • U. S. Department of Health and Human Services. (2005). Helping patients who drink too much: A clinician’s guide.