Screening for At-Risk Drinking and Alcohol Dependence

How I Practice Video Series
Erin E. Tracy, MD, MPH, FACOG

HIP: Screening for At-Risk Drinking and Alcohol Dependence from ACOG on Vimeo.


I first became interested in Fetal Alcohol Syndrome, which unfortunately is incredibly prevalent in today’s society, because my beautiful niece and nephew were diagnosed with it and I got a personal interest after that. I really started reviewing the literature and realized that we as obstetricians need to do a better job of counseling our patients and screening for this preventable condition, namely Fetal Alcohol Syndrome Spectrum Disorders. The true prevalence of this is not known. The literature says anywhere from 1 to 2 in a 1000, but in reality a lot of these children aren’t diagnosed until their school years so I think there’s a lot of underreporting. And it’s also difficult for biological mothers to admit to alcohol consumption when faced with these diagnoses. Unfortunately, Fetal Alcohol Syndrome, which is largely preventable is the number one cause of mental retardation in this country and others. So I think as obstetricians and gynecologists we can do a much better job trying to prevent this preventable tragedy. One of the screening kits that’s used, and this is available on ACOG’s website and the CDC and many departments of public health have this and there are many different tools, but what I find helpful is the TACE, with the mnemonic being for Tolerance, Annoyance, Cut Down, and Eye Opener. It’s a very quick test to administer, it takes one to two minutes and very briefly you can ask a patient “How many drinks, for tolerance, does it take for you to feel the effects of alcohol? Or to feel high?” If the patient answers more than two drinks, that is worth two points. The second question, annoyance. “Have you ever been annoyed when someone criticized your drinking?” If the answer is yes, that’s worth one point. The third question, cut down. “Have you yourself ever felt the need to cut down on your drinking?” And if the answer is yes, that’s worth one point. And the last question, eye opener. “Have you ever had the need to have a drink first thing in the morning either to calm your nerves or to self-treat what is a hangover from the night before?” If the answer’s yes, that’s worth one point. And doing that simple math, a score of more than two is a positive screen. And that patient should have a longer discussion about how to identify at-risk behavior and potentially meet with a substance abuse expert or social worker. There are studies showing that very brief intervention programs cut down up to 70% of at-risk drinking. So these strategies work, we just have to identify the patients. If the TACE tool or other tools like the CRAFT tool or other ones out in literature are too cumbersome, there’s also another way to quickly screen for at-risk drinking by asking how much alcohol a patient drinks. More than seven drinks a week or more than three drinks at one time is considered by most experts as at-risk drinking. If we identify pregnant women who are engaging in at-risk behavior, first of all I reassure them that often they didn’t know they were pregnant or weren’t aware of the risks, that hopefully there’s been no harm done to their child but I do also tell them that it’s not too late to help their baby by quitting drinking. And I also help them avail themselves of available online resources. The ACOG/CDC toolkit is a really helpful tool that you can find on the ACOG website. I think it’s important to screen our pregnant women but I think it’s equally important to screen women of reproductive age who may become pregnant. We have a very vigorous education program on long term acting reversible contraception and many of these methods from IUDs to implants to injectables are excellent methods to try to prevent pregnancy. Unfortunately about 50% of pregnancies in this country are unplanned so a lot of patients who are engaging in at-risk drinking may have a child affected simply because they weren’t counseled regarding their at-risk drinking behavior and the availability of effective contraception. There are a handful of items that we know for sure cause birth defects. Alcohol is, sadly, on that list. It is a known teratogen. And while alcohol is certainly part of our culture and the media often portrays poorly done studies saying there is some safe minimal dose of alcohol, when you really critically look at the literature it’s my position and the CDC’s and ACOG’s that no dose of alcohol is safe in pregnancy. So I advise against patients drinking any alcohol once they identify the pregnancy or if they’re potentially able to become pregnant. This is how I practice.


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