Alcohol Intake Revised (3.3)

Transcription

1 Revised: December 11, 2000 National Institute on Alcohol Abuse and Alcoholism COMBINE Form 90 - AIR/ED Alcohol Intake Revised (3.3) COMBINE

2 Introduction This manual introduces the Form 90 Alcohol Intake Revised (AIR/ED) for use in Project COMBINE. The manual first provides an overview to the general instructions and content of the Form 90 interview. The second part of the manual reviews each of the four major components of the Form 90 interview: (1) Economic Development Questions (ED), (2) Alcohol Use, (3) Hours of Drinking, and (4) Other Drug Use. Interviewers new to the Form 90 will find the first section of the manual helpful in conducting efficient Form 90-AIR/ED interviews. Techniques described in this section include bracketing of alcohol consumption and calendar preparation and coding. Once understood, these procedures will facilitate rapid and valid data collection. Interviewers experienced in the administration of the Form 90 will find that significant changes have been made in the Form 90-AIR/ED, changes that both simplify and shorten the assessment interview. As examples, the recent experiences section has been reduced in length by half, time-to-consume alcohol is not collected in the alcohol grid and calendar section, and measurement of lifetime weeks of illicit drug use has been deleted. It is important to note that the Form 90-AIR/ED is a work in progress. This structured interview is the product of the joint efforts of the Project COMBINE assessment committee, principal investigators, and research assistants to tailor the original Form 90 interview to meet the specific needs of this study. Given the unique aspects of this study, we anticipate that some further procedural refinements will be required. We welcome your input and appreciate your flexibility during this refinement phase of the Form 90-AIR/ED. You may encounter some difficulties when administering your first few Form 90- AIR/ED interviews. Many such difficulties can be resolved by reference to this manual or with continued practice. In some cases, however, you may want to contact designated Form 90 trainers who can assist you. Page 1 of 31

3 Table of Contents I. An Overview Calendar Individual day boxes Institutional codes Standard drink units Bracketing Conducting the interview: Step 1: Introduce the Form 90-AIR/ED Step 2: Identify memory aids Step 3: Note abstinent days Step 4: Steady pattern grid Step 5: Daily alcohol consumption II. Instructions for the Form 90-AIR/ED Tables Preparation for the interview Conducting the interview Health care/ incarceration experiences Recent activities (motor vehicle accidents, labor market) Alcohol use Steady pattern grids Idiosyncratic drinking Coding alcohol information Hours of drinking form Other drug use Completing the interview 1. Items needed for conducting Form 90-AIR/ED interviews 2. Estimating frequency from verbal descriptions 3. Criteria for qualifying drug use (yes) 4. Drug categories 5. Some common errors made by less experienced Form 90-AIR/ED interviewers Page 2 of 31

4 I. An Overview The Form 90 interviews were first developed for Project MATCH, and have been adapted and abbreviated for use in Project COMBINE. The Form 90 interview method builds on the important work of Linda and Mark Sobell in developing the calendar-based timeline followback method for reconstructing drinking behavior. The weekly grid method originally developed by Alan Marlatt has been integrated in order to facilitate reconstruction of drinking patterns that were reasonably consistent over a period of weeks. This can be particularly useful when filling in several months of drinking. Other important outcome information is also collected during the structured Form 90 interview, using the calendar to assist the client's recall. Calendar This chapter provides a general orientation to the Form 90-AIR/ED interview and includes some charts and definitions. More detailed instructions are provided in the next chapter. The calendar is a key component of the Form 90 interview and should be carefully managed while completing the interview. The ultimate goal of using the calendar is to gather continuous, detailed and accurate data about selfreported drinking behavior over a specified time period. This involves gathering information about the quantity and potency of the beverages consumed as well as the actual dates on which drinking occurred. The particular dates on which drinking occurred are especially important when time-to-event statistical approaches are used to analyze followup data. When conducting a Form 90 client interview, it is necessary to have a calendar form for recording data. This could be a regular blank calendar page (with holidays marked), but in COMBINE computer-generated calendars will be used. Note that only more memorable events should be entered in order to avoid a confusing amount of detail on the calendar. The purpose is to aid, not confuse the client. An efficient approach is to make multiple copies of the calendar grid for each month and keep them in stock. Interviewers can then easily assemble a Form 90 calendar by taking copies of the needed months. Page 3 of 31

5 Individual Day Boxes Each portion of a calendar day box is used for a particular kind of information. These are explained in more detail later in this manual. Upper top center: Center: SECs Special day information (e.g., holiday, memorable event, which also may be automatically inserted by calendar software) Drinking information (A, P 1, P 2 or idiosyncratic drinking information). Bottom Right (Standard Ethanol Contents), or SEC s, should be calculated on BACCUS and then entered in the lower right corner of each appropriate day box on the calendar. Institutional Codes When clients are institutionalized for any of the following reasons, the proper code should be entered in the lower left corner of each appropriate day box: Hm: Rt: In: Medical hospitalization Residential treatment Incarcerated in jail or prison Standard Drink Units Drinking information obtained through the Form 90 AIR/ED interview is converted into standard drink units. The conventional drink unit used in all applications to date is the standard ethanol content (SEC) units defined by Miller, Heather, and Hall (1991; cf. Miller 1978), which is 0.5 oz (15 ml) of absolute alcohol. A simple way of calculating SEC units is the formula: (ounces of beverage) X (percent alcohol in beverage) X 2 Examples: Beer: (48 oz)(.05)(2) = 4.8 standard drinks Wine: (16 oz)(.12)(2) = 3.8 standard drinks 80 proof spirits: (6 oz)(.40)(2) = 4.8 standard drinks 86 proof spirits: (6 oz)(.43)(2) = 5.2 standard drinks 100 proof spirits: (6 oz)(.50)(2) = 6.0 standard drinks Page 4 of 31

6 Most alcoholic beverages are labeled as to their alcohol content. A significant exception is beer, which can range from under 2 percent to over 11 percent alcohol. The average content of normal U.S. beers has remained fairly constant over the years at just under 5 percent (Leake and Silverman, 1971). Even most light beers are between 4 and 5 percent alcohol, except for those explicitly labeled LA (low alcohol), which average between 2 and 3 percent. Malt liquors average around 6 percent, and ice beers and imported beers tend to be over 5 percent as well. Bracketing The Form 90 interview specifies actual numbers of standard drinks for each day, rather than using ranges or categories (e.g., light days, heavy days). It is necessary to arrive at the most reasonable estimate of the number of drinks on each drinking day. A behavioral assessment procedure known as bracketing is often quite useful in conducting the interview. This can be used, for example, when a client is having difficulty providing a precise number of drinks for a specific occasion. The basic approach is to ascertain a range within which the actual value falls, starting with values that are too high and too low. Did you have more than two beers? Was it more than 50? What is the least you would have had? And what is the most you would have had? These outer bounds are then tightened until a narrow range is obtained. When the range cannot be constricted further, the midpoint of the range is used as the estimated value. When a smaller range is offered by the client (e.g., I had 3 or 4 beers ), use a closer to question to decide on the actual value to be entered ( Was it probably closer to 3 or 4? ). Conducting the Interview The most challenging aspect of the interview is filling in drinking information for each of the days in the calendar form. The recommended progression for accomplishing this follows five general steps. Page 5 of 31

7 Step 1 Introduce Form 90 Explain to clients that the interview involves mainly reconstructing their drinking history during a specified time period and that you need their help to do this well. Also explain how you will use the calendar as a memory aid to recall drinking during this time. Step 2 Identify Memory Aids To facilitate clients recall about their drinking, it is important to gather other information before turning to the drinking questions on the Form 90-AIR/ED. Notations about what was occurring in the clients lives are entered on the calendar to invoke the clients retrospective recall of daily consumption of alcohol beverages. In order to establish these memorable anchor points, it is important to give clients a variety of probes, ideas, or suggestions and then allow them enough time to search their memory. The regularities in the client s life (e.g., work schedule, payday) can and should be used to provide a context for filling in the calendar with memory aids. Anchor points common to most clients would include holidays, birthdays, major news or sporting events, paydays, and weekends. Negative events that may have occurred in the client s life are as important as the positive or festive occasions. More idiosyncratic events would include dates of hospitalizations, illness or accidents, arrests or incarcerations, court appearances, beginning or termination of employment, vacations, marital arguments, separations and reconciliations, anniversaries, and birthdays of family members or friends. Reports of such events also make it possible to estimate how much alcohol has been consumed during periods of alcohol availability (e.g., excluding days in jail or treatment). Record all periods of hospitalization, residential treatment, and incarceration on the calendar. Attending therapy, other activities, use of medication, outpatient treatment and 12-step group experiences are also queried but are recorded on the calendar only if they may be helpful memory aids for later reconstruction of drinking. Questions regarding treatment are addressed in greater detail following the drinking portion of the Form 90, and treatment codes are used to indicate days of hospital, residential treatment, or incarceration. Use of prescription medications is determined as well as status with regard to work and education. Page 6 of 31

8 Step 3 Note Abstinent Days Next proceed to quantify the client s drinking. At intake Form 90-AIR/ED, spans of abstinence are usually queried first and recorded on the calendar. Ask about drinking even on days that the client reported hospitalization or incarceration because clients may do some drinking on such days. Although it is usually easier to start by asking about abstinent days first, there are also cases in which it makes most sense to fill in drinking days first (e.g., only a few drinking days in a follow-up period). Step 4 Steady Pattern Grids Next, determine whether the client has any predictable patterning for periods of drinking. For those who have a reasonably consistent pattern of drinking over several weeks, a steady pattern grid may be used to specify that pattern. This pattern can then be used to fill in blocks of the calendar. If no pattern is reasonably consistent across weeks, skip the steady pattern grid and work directly on the calendar. A second steady pattern grid is available in Form 90-AIR/ED for cases where it is useful to define two different but consistent weekly patterns that occurred during the same assessment window. For example, one steady pattern may characterize the first portion of a followup window, whereas a different steady pattern predominates during the latter portion (e.g., summer versus school months or employed versus unemployed periods). If appropriate, complete one or more steady pattern grids and fill in periods accounted for by these patterns. Note on the calendar those periods when the drinking pattern applied. Step 5 Daily Alcohol Consumption Drinking days that cannot be accounted for by steady patterns are reconstructed individually using a modified timeline approach. On completion of this step, there should be drinking data entries in every day of the entire assessment window. Always obtain sufficient information so that SECs may be calculated. The cardinal rule is to always obtain the kind and amount of alcohol consumed. Page 7 of 31

9 Throughout the interview, continually focus the client s attention on the calendar and the events depicted on the calendar. It is useful to break the calendar into months or weeks to facilitate recall of patterns. Even for clients with very consistent patterns, probe regarding any special events on the calendar that may have triggered an idiosyncratic episode. Add special events to the calendar that emerge after the actual drinking history interview begins. Pay close attention to any inconsistencies in the client s description of drinking and ask questions to resolve these differences and to make sure that accurate information is collected. Probe in cases where the amount of drinking seems unreasonably high, especially if clients report drinking likely-lethal amounts of alcohol for extended periods of time (e.g., a gallon of spirits a day for a period of a month). Page 8 of 31

10 II. Specific Instructions for Form 90- AIR/ED Preparing for the Interview To conduct an in-person Drinking Assessment Interview Intake (Form 90-AIR/ED) or Followup Interview Assessment of Drinking and Related Behaviors (90-AF/ED), you will need a table to work on and the items listed below in Table 1. Table 1. Items needed for conducting Form 90 interviews The proper blank Form 90-AIR/ED interview form Calendar to cover the assessment window Breathalyzer The Form 90 Drug Card Sort Scale A set of glasses, a pitcher of water, and a measuring cup (optional) Pencils with erasers (for the interviewer and the client) Define the Assessment Window Generate calendar forms to cover the assessment window to be constructed. A calendar software program should automatically insert holidays and allow for insertion of other memorable local events (e.g., state fair, school holidays, or elections). Someone at your site should be appointed to fill in memorable local events at least once weekly - particularly those events likely to be linked to drinking. The period for drinking inquiry on Form 90-AIR/ED will always be the 90 days before the client's last drink prior to the day of the intake interview. This will almost always require at least 4 monthly grids. Days not included in the assessment window should be crossed out on the calendar with X s to avoid confusion. Print "Today" on the date of interview and place an X over subsequent dates. At intake, the assessment window begins 89 days before the client s last drink, with the last day of drinking being the 90 th day. An easy way to locate the point 89 days before the last drink is to place your finger on the day of the last Page 9 of 31

11 drink, then count back 13 weeks, staying on the same day of the week as the day of the last drink. When you go back 13 weeks, cross out (X) that day and the next day (13 weeks minus 2 days). The following day is your starting point for the 90-day period. Often the entire assessment period is longer than 90 days. If, for example, the client's last drink was 8 days before the intake interview, you would mark A (abstinent) in the days between day of last drink and yesterday and then you would be asking for specific drinking information for the 90- day period between 98 and 8 days prior to interview. For other questions, however (such as work, incarceration, and other drug use), you are asking about the entire 98 day period. Before the interview begins, be sure to fill in the client ID, interviewer ID and the date of the interview. At Item 1, obtain a Blood Alcohol Level (BAC) using standard procedures and the Breathalyzer provided. At Item 2, specify the starting and ending dates of the period being queried. At Item 3, indicate if the client is male or female. At Item 4, indicate the number of days in this period. At Item 5, indicate the client s current body weight in pounds. For Item 6, indicate whether the interview is being done in person on site, by telephone, in person during a home visit, or at another location. Item 7 indicates how long it took the client to arrive to the interview [door to door, in minutes]. Conducting the Interview Style The style of interviewing is important. A warm empathic tone will encourage more honest reporting. Use reflective listening to respond to client statements. Maintain eye contact and memorize instructions in order to avoid excessive reliance on the form. Patience and positive reinforcement are also vital, given the amount of detail the client is being asked to provide. When a client voices frustration, it is often helpful to offer an empathic reflection of the feeling and then to reassure or refocus the interviewee [e.g., It really is difficult to say, and I m sure that your drinking does vary from week to week, but were there some periods here when your drinking was fairly consistent from week to week? ] It is also wise to thank and reinforce the client for persisting with a sometimes difficult process. Page 10 of 31

12 Starting the Interview Below is a script that can be used or paraphrased before beginning the Form 90-AIR/ED to help you obtain more useful and accurate information. This script may be worked into the opening introduction provided on the Form 90- AIR/ED interview form. I d like to begin by reminding you that whatever you say here is confidential. I am going to be asking you some specific questions concerning the period of time from three months prior to your last drink up through yesterday. [At follow-up interviews, the period to be reconstructed extends from the last interview up to the day before the present interview.] Place calendar in front of client. Continue using the script of the Form 90-AIR/ED interview form. Carefully follow the instructions as printed on the interview form. When asking for memorable events to serve as calendar prompts, read the list of possible events slowly and allow clients time to search their memory. Write any mentioned memorable events on the calendar in the upper top center of the day boxes. Clients often volunteer information here about abstinent or drinking days. Note these briefly and then proceed with the instructions printed on the interview form. Health Care This section of the Form 90 AIR/ED taps information regarding different types of health care received during the Form 90 calendar period. The following instructions are used to introduce this section: Now I d like to ask you a few questions about your use of various health care services. Please refer to the calendar to help you remember. For the following questions, please exclude visits made for Project COMBINE. The results of the questions in this section are recorded on the Form 90 AIR/ED protocol in the boxes next to the items. To be counted as a hospital or residential day, the client must have been admitted to the hospital or other residential facility for an overnight stay. To count as an admission this stay must include at least 3 hours between midnight and 6 am. Visits to the emergency room, for example, do not count as hospital days if they did not result in an admission. The number of days is the number of overnight stays. Page 11 of 31

13 Health Care Part I (Items 8-11) Item 8 Ascertain whether the client has spent the night in a hospital in order to receive care. If the client has received care, then the number of hospital nights is recorded in section a. In section b, denote how many of these nights were alcohol, drug abuse or mental health related. Any overnight stay (in which the client arrives at the hospital during the day and sleeps there overnight) is counted as a night in the hospital. In addition, if the client arrives at the hospital during off hours or in the emergency room, an overnight is counted if the stay includes 3 hours between midnight and 6 am. Recall that all residential codes (Hm, Rt, In) are recorded in the lower left-hand corner of the appropriate day boxes on the calendar. Halfway house stays do not count as hospital days. If the client reports no hospitalization, then proceed to Item 9. Record nights in the hospital on the calendar as Hm. Item 9 Report any type of residential care for alcohol, substance abuse, or mental health difficulties. To count as an admission this stay must include at least 3 hours between midnight and 6 am. Record residential overnight stays on the calendar as Rt. Item 10 Item 11 Indicate whether the client visited an emergency room or urgent care facility for treatment. Also fill in the specific information about these visits on items a, b, c, and d (number of visits, visits that were alcohol, drug abuse or mental health related, how long it took [from door to door] to get to the emergency or urgent care facililty, and how much time was spent in the E.R or urgent care facility). Emergency room visits that can be counted as hospital overnight stays are not counted here they are counted under nights spent in the hospital. Report whether the client has received any outpatient health care, including outpatient treatment and counseling, during the Form 90 period. If there were no outpatient visits, proceed to Item 12. If there were outpatient visits reported, begin at item a and determine how many visits were made. For medical care visits, record only those visits that address primary medical care. DO COUNT x-rays, ultrasounds, blood draws, day surgery and outpatient detox. Partial hospitalization services (e.g., day treatment) are counted here as outpatient days. Family counseling and psychiatry Page 12 of 31

14 Medications (Items 12-15) visits also count here. DO NOT COUNT medical care given while receiving institutional treatment (hospital, inpatient detox, or incarcerated days). Do not count dental visits, eye care (e.g., ophthalmologist or optometrist), chiropractic treatment, acupuncture, homeopathy, physical or occupational therapy visits. In addition, do not count any health care received as part of the COMBINE study. At item b determine how many outpatient visits were alcohol, drug abuse, or mental health related.. Record how long it typically took from door to door to get to the health care provider for each visit (item c) and how long the client typically spent at the health care facility, including waiting room time (item d). During this period, on how many days did you take any medications that were prescribed by a physician? Item 12 Item 13 Item 14 Item 15 Indicate here medications and number of days taken for a medical (including dental) problem. Record number of days a medication was taken to help the client keep from drinking. Specify the medication on the line provided. Record days that medications were used to help the client detoxify or come off of alcohol or other drugs. Again, specify the medications on the line provided. Indicate the number of days medications were taken for psychological or emotional problems. Indicate the types of medications taken and dosages, if possible. Inquire separately for each group of medications. For each, record the estimated number of days on which the client took medication by prescription and specify the medications used. DO NOT COUNT vitamins or birth control pills. DO NOT COUNT nonprescription drugs (e.g., aspirin, over-the-counter medications) recommended by a physician but not requiring a prescription. DO NOT COUNT STUDY MEDICATIONS! When in doubt about the type of medication, record medication information and consult with medical staff. While it is important to include all medications taken from each category, do not double count days of medication use from the same type of category. For example, if both Zoloft and Trazodone are taken every day over a full 90 day period (both are drugs from the Page 13 of 31

15 psychological/emotional problem category), only 90 days are counted for this category, not 180 days. If Zoloft is taken for a full 90 day period and Trazodone is taken for 20 of those days, the number of drug days for psychological/emotional problems is still 90 days. However, if Zoloft were taken for one month (30 days) of the time period and Trazodone was taken for 20 other days (not in that month), the total number of drug days for emotional problems would be 50. Health Care Part II (Items 16-18) Item 16 Item 17 Item 18 Indicate here whether the client has participated in an AA or other 12-step program. At item a, report the number of meetings attended. Items b and c address the amount of time it took to get to the meetings (from door to door) and how much time was typically spent at the meetings, respectively. Do count any meetings attended while in hospital, residential treatment, jail, etc. At this item, determine whether the client has attended or participated in other self-help alcohol recovery programs, other than those that are 12-step based (e.g., RR, SMART Recovery, SOS, Women for Sobriety). Again, items a, b, and c are used to report number of meetings, how long it took to get to the meetings, and how long the client typically spent at the meetings. During this period, how many days have you experienced significant emotional problems? If asked for clarification, state that these were days when emotional difficulties affected your normal daily functioning. Crime/Incarceration (Items 19-22) This section of the Form 90 AIR/ED taps involvement with the criminal justice system it is introduced with the following statement: Now I d like to ask you some questions about your involvement with the police. Please refer to the calendar if it will help you remember. Item 19 Indicate whether the client reports being arrested during the Form 90 period. If the client has been arrested, indicate the number of times and for Page 14 of 31

16 what violations in the appropiate boxes on the Form 90 protocol. If the client reports no arrests, proceed to Item 20. Item 20 Item 21 Record whether the client had any court appearances and how many. Determine if the client was on probation or parole. At item a record the number of times the client visited his/her parole/probation officer, and at item b, record the amount of time in minutes it typically took to get to the parole/probation officer (from door to door). Item 22 Record whether the client was incarcerated overnight. To count as an overnight stay, the stay must include 3 hours between midnight and 6 am. If the client was incarcerated overnight, record the number of nights at item a. Record the days corresponding to the nights spent in jail on the calendar as In. Motor Vehicle Accidents (Item 23) Item 23 The section is introduced with the following statement: Now I d like to ask you a question about your driving record during this period. Please refer to the calendar to help you remember. Then record whether the client has had an automobile accident (only if the the client was driving) during the Form 90 period at Item 23 and record the number of accidents at item a. Labor Market (Items 24-32) The section is introduced: Now I d like to ask you some questions about your employment activity during this period. Please refer to the calendar if it will help you remember. Item 24 At this item, check the appropriate box which best describes the client s current work situation (i.e., working, retired, etc.). Page 15 of 31

17 Item 25 Item 26 Item 27 Item 28 Item 29 Item 30 Item 31 Item 32 Indicate here whether the client was employed at any point during the Form 90 period. If the client was not employed at all, skip to question 30. Otherwise, continue to Item 26. Determine the client s wage or salary on their primary job, before taxes and deductions, and indicate the amount at item a. At item b, indicate the time period for which the client is paid (e.g., monthly, yearly, every two weeks, etc.). At this item record the number of weeks that the client was employed at any job in the appropriate box. Weeks spent on paid leave such as vacation or paid maternity leave are counted here. Indicate to the client the number of weeks in the time period to facilitate their memory. The number of weeks should be calculated as the number of Sundays that occurred in the period. Record the number of hours per week that the client usually worked here. Record here the number of workdays missed, if any, due to alcohol. Indicate whether the client has received any other income from any public or government source, such as social security, VA, welfare, unemployment compensation or food stamps. It the client did receive income from a public or government source, indicate the amount at item a. Record whether the client has received income from any other source not already reported, such as pension, alimony or child support, or interest income. Illegal income would also be counted here. At item a indicate the amount of income from these sources. The approximate income for the last twelve months of all household members who live with the client, including the client themselves, before taxes and deductions, is recorded here. Ask about income from all sources. The household income can include income from family members but can also include income from others who live with the client and contribute to the overall household income. The overall household income can include groceries, bills, a portion of the rent, etc. (any money that contributes to the maintenance of the house or its members). Alcohol Use The goal of this section is to record drinking information for EACH calendar day. The grid section of the alcohol use section was designed to Page 16 of 31

18 efficiently gather daily drinking information. Several grids may be required to accurately portray distinct drinking patterns. When grids are not appropriate, day-by-day reconstruction of drinking is required. If the client has not already provided this information, ask: Now I d like to ask you about your drinking during this same period. The things already recorded on the calendar here may help you to remember better. First of all, were there any periods of days when you had nothing to drink at all? At follow-up points, a client may have been continuously and completely abstinent throughout the assessment window. In this case you complete items 1-32, leave items blank and go to Other Drug Use (items 37-47). It is not necessary in this case to add further details to the calendar. If there were periods of abstinent days but not complete abstinence for the entire assessment window, proceed to record drinking and abstinent days on the calendar according to the sequence outlined earlier. Make full use of the information already recorded on the calendar to help the client recall dates and periods of abstinence and drinking. The first step is simply to distinguish days of complete abstinence from those in which any alcohol was consumed. Print an A in the center of every day box for days of non-drinking. (For prolonged periods of abstinence, an A in the first day of each week and an arrow through the rest of the week will suffice.) Be sure to inquire about drinking during reported periods of hospitalization, residential treatment, and incarceration as well. Do not assume abstinence on these days. Items For all clients who drank, ascertain the date of the first drink during the assessment window (Item 33) and the date of the most recent drink during the window (item 34). For clients drinking throughout the period, these will be the first and last days of the assessment window respectively. Page 17 of 31

19 Steady Pattern Grids To determine whether to use the steady pattern grid, first examine the calendar. If the pattern is mostly abstinence, with only sporadic days of drinking, the steady pattern grid may not be appropriate. If, on the other hand, there are at least several weeks of drinking, inquire: During this period of time, when you were drinking, was your pattern at all similar from one week to the next, at least for some of these weeks? I realize that drinking varies from day to day and from week to week, but I want to know if there was any similarity among weeks. Was there any consistency to your drinking from week to week? Allow enough time for the client to study the memorable events on the calendar to assist in recall. It is also helpful to allow the client to see a steady pattern grid in relation to the calendar so that he or she may assist you with the task. If the client has had a reasonably consistent pattern of consumption from week to week when drinking, at least for part of the assessment window, complete the first steady pattern grid. Note that this grid divides a regular drinking week into 21 parts: morning, afternoon, and evening for each of the seven days. These grid divisions are to be used as guides to help the client recall drinking information. Fill in each of the 21 boxes by recording the type and amount of alcohol typically consumed (including the proof or percentage strength of alcohol content whenever possible). Begin with weekdays, working through mornings, then afternoons, then evenings. Use these instructions to start: Could you describe for me a usual or typical week of drinking. In a typical week, let s start with weekdays Monday through Friday, what did you normally drink in the morning, from the time you got up until about lunch time? Focus client s attention on the grid. The latter phrasing is intended to provide permission for reporting morning drinking. Alternative phrasing such as Did you ever drink in the morning? may encourage falsification or minimization of morning drinking information. Use past tense to inquire about drinking (e.g., What did you drink, not What would you drink? or What do you drink? ). Page 18 of 31

20 You can help the client to be more specific by first asking which beverages were consumed and then how much of each. It helps to know ordinary drink sizes (e.g., standard bar draft of beer = 10 oz; ordinary wine glass = 4 oz). To clarify actual drink size, use a set of glasses of different sizes, a pitcher of water, and a measuring cup. Often clients have no idea what volume they are consuming. In this case, ask the client to select a glass that is about the size of the glass usually used. The client may pour water into the glass, to the level normally poured with the preferred beverage. You can then measure this volume. We have found that clients estimates of the amount poured can be off by a factor of 3 or more, usually in the direction of under-estimation. Be careful not to assume drink size. One drink of whiskey may mean an 8-oz tumbler for one client but a 1-oz shot for another. Ask for details. Also inquire about the brand of liquor, the size of a bottle, can, and so forth. After each reported type of drink for a given time block, ask:... and what else? Another precaution is to clarify whether the client, when drinking with others, drank the full quantity being described or shared it with drinking companions. Seek clear estimates for the amount consumed by the client alone. Because drinking is often consistent from day to day, do not begin by asking about days one at a time. The weekdays approach described above often works well. If drinking varies from day to day (e.g., Two mornings a week I may have a glass of beer before lunch), this can be specified. For example, if there are particular days when this occurs (e.g., Tuesdays and Thursdays), record those days on the grid. If particular days cannot be specified, ask for the client s best guess and record those days on the grid. After constructing morning drinking, proceed to the afternoons: Now how about weekday afternoons, including what you drank with lunch up through the afternoon until dinner time what did you normally drink on weekday afternoons, Monday through Friday? Again, if the pattern varies from one afternoon to the next, record this variation. Use probing questions. Would that be on the same days when you had a beer in the morning? Page 19 of 31

21 Again it is important to use the calendar to assist with identifying the actual days drinking occurred rather than arbitrarily picking days to fill up the grid. (This is important for future time-to-event statistical analyses.) The grid is then continued by inquiring about evenings: And how about weekday evenings? What did you normally drink with dinner, up through the rest of the evening, until the time you went to sleep? Inquire about Friday evenings separately from other weekday evenings, as they are likely to be heavier drinking times. The grid is completed by repeating the entire weekday process for weekend days. Separate inquiries are recommended for weekdays and weekends because drinking patterns on these days often differ widely. Repeat the query regarding morning drinking even if the client, when asked about morning drinking on weekdays, reported never drinking in the morning. These procedures must be modified to accommodate clients with certain lifestyles or schedules (e.g., working night shifts, different meal patterns). Remember that the purpose of this grid is to obtain a well-specified estimate of consumption during a repetitive drinking week. If the client indicates two distinct drinking periods during the assessment window and there seems to be a second steady pattern grid, for each steady pattern ask: Now which are the weeks on this calendar when your drinking was like this? Remember to fill in the calendar as you go with the steady pattern. The steady pattern grid and the calendar should be completed hand in hand, not independently of each other. Keep the steady pattern grid(s) in plain view of the client so that he/she can remember what pattern is being matched to the calendar (especially when two steady pattern grids are being used). For weeks or portions of weeks described by pattern 1, write P1" on the first day of the week and draw an arrow through the remainder of that week. Do the same for P2", if there is a second steady pattern. Use of the steady pattern grids is at your discretion. If it appears that the client s drinking pattern does not lend itself to quantification via pattern charts, these may be bypassed, and the entire assessment window reconstructed day by day. Page 20 of 31

22 Idiosyncratic Drinking The combination of A and P should in many cases account for the majority of days during the assessment window. What remains is to reconstruct, day by day, the client s drinking on days not covered by the procedures above. It is conceivable, however, that a given client would report no consistent steady (P) patterns, in which case the entire assessment window would be constructed one day at a time. You may also elect to use a day-by-day approach rather than P grids. Sometimes a day by day approach is more efficient and less frustrating for both interviewer and client than the process of constructing steady pattern grids. These situations particularly occur when a client is unable to generalize about steady patterns or typical weeks of drinking. Before this frustration occurs, abandon this line of questioning and direct the client s attention back to the calendar. Again, the client should be clear about the task at hand. You might say, We are going to work on filling in the calendar with your drinking information. Each calendar day will be filled in with your best estimate of the amount you drank that day. Although it sounds like a difficult task, it really can be done. We will do this task by focusing on what you were doing in your life during this 90-day period. Begin by focusing on the longest spans of invariant behavior, such as abstinence and/or heavy daily drinking. For example you might say, Looking at the calendar and thinking about these events in your life that are written on the calendar, what is the longest number of days you went without drinking anything at all, not even one (favorite drink)? When did that occur? Fill in the calendar days as indicated, and then focus on the days immediately following this salient period by asking: What happened then? How did your drinking pattern change? Page 21 of 31

23 Continue by focusing on the days immediately preceding the invariant period, using any anchor points that are in close proximity to these days. Then ask about other times during the window when the client remembers an extended number of days in a regular pattern. Throughout the interview, make use of the anchor points provided by the client, especially those of regularities in the client s life (work schedule, payday) to prompt the client in detailing his/her drinking pattern. For every idiosyncratic day which is neither abstinent nor included in a pattern, be sure to record (in the middle of the day box) the specific beverage(s) consumed and the amount of each beverage consumed. In certain situations, it is more difficult to obtain a good estimate of the amount of alcohol consumed. This is so, for example, when the client had drinks mixed by others or of unknown quantity (e.g., a party punch), or when the client suffered a memory blackout. Nevertheless, an estimate is better than no data, and there are often clues to help in arriving at a reasonable guess (e.g., amount of money spent, empty bottles and cans, friends reports, apparent strength of drinks from their effects). Coding Alcohol Information When you have finished, there should be a drinking entry in each and every one of the calendar boxes for the assessment window. The entry can be an A (for abstinent days), a P code for steady drinking pattern days, or a specific amount of consumption for all other days. In the latter case (idiosyncratic days), record the specific beverage(s) and the specific amount(s) of each beverage consumed throughout the day. The information should be recorded clearly and neatly in such a way that another staff member can easily understand and enter or verify the record. At times, clients will report quantities of consumption that seem logically simpossible. Whenever the volume of consumption that the client reports seems unrealistically high, probe to be sure you have the correct information. Is there possible confusion about bottle size (e.g., quarts versus pints) or case size (12 versus 24 bottles)? Did the client share the reported amount with others? Do not passively accept drinking information that seems implausible. Page 22 of 31

24 Hours of Drinking Form Begin this section by instructing the client: "Now I would like to ask you about the two days during this period when you drank the most. The two days don't have to be together-they can be separate days-but they should be the two days when you drank the most. Which days do you think those might be?" Other Drug Use Items Look over the calendar with the client, and together identify the two days likely to yield the highest BAC. Note that these are not necessarily the days with the largest number of standard drinks. For example, if there is a day with 12 drinks spread over 12 hours, and another with 10 drinks spread over 3 hours, the latter will yield a much higher BAC. In the Hours of Drinking grid, fill in one row for each of the two days. Record the date, the total amount of alcohol consumed (giving enough detail to compute the standard drink units), and the time to consume (the time from the beginning of the first drink to the completion of the last drink). If the peak days occur during P1 or P2, use the two days of the week with highest BAC. Record date by indicating the pattern and the day (e.g., P1 Monday ). Record the information on the Hours of Drinking form (page 12 of Form 90 AIR/ED). If the client s body weight was not available from the medical record, also ask for this information and record it at Item 5 (page 1 of the Form 90-AIR/ED. After the interview has been completed, use the BACCUS software (with appropriate drinking information and client s weight) to compute the total number of standard drinks, and then to calculate peak BAC using the total number of drinks, and the total hours of consumption. Estimated peak BACs for the two heaviest drinking days are recorded at Items 35 and 36 on page 12. Page 23 of 31

25 The Form 90-AIR/ED interview includes an assessment of other drug use during the assessment window. To facilitate this, a set of cards has been prepared, describing 9 major drug classes (see appendix). For in-person interviews, the client is given this set of cards, always arranged in numerical order, and asked to sort them into two piles. At intake (90-AIR/ED), both recent use and lifetime use are reconstructed. Refer to Table 3 for assistance in determining what ought to be counted in the illicit drug use section. Recent Use To inquire about recent drug use, hand the set of cards to the client. "Now I'm going to show you this set of cards. Each card names a kind of drug that people sometimes use. I'd like you to sort them into two piles for me. In a pile on the left [indicate position]. I d like you to place those cards that name a kind of drug that you have tried at least once during the period we ve been talking about on this calendar, from up through yesterday. In a pile on the right [indicate position], place the cards that name types of drugs that you did not use at all during this period. For each of the YES cards, specify the specific drugs(s) during this recent period, and ask: During this period, on how many days would you say you used? [Record days of use under Current Period on the drug chart. Repeat for all YES cards.] Nicotine-specific questions: If the client has used nicotine, record number of days of use (i.e., 45 days of smoking cigarettes = 45 days; 90 days of nicotine patch use = 90 days) and follow-up (if appropriate) with the two nicotine-specific questions. For tobacco cigarette users, ask about the number of cigarettes used per day and record this number in the appropriate space on Item 37. During this period of time, how many cigarettes would you say you smoked per day, on average (on days when you did smoke)? [Record only cigarette use.] Page 24 of 31

26 And For nicotine users (tobacco, cigarettes, cigars, snuff [dip], chewing tobacco, nicotine [patch, gum, inhaler]), be sure to ask about the typical time between waking and first nicotine use. From the time you woke up, how long was it before you had your first cigarette or other nicotine? [Record for all nicotine use.] [For 24 hour nicotine patch use, enter 0.] Lifetime Use [If a drug was used during Current Period, record by checking YES on the drug chart under Lifetime Use.] To inquire about additional lifetime drug use, hand the NO cards back to the client to resort. [Give cards to client IN NUMERICAL ORDER.] Now, these are the drugs that you say you have not used during the current period. I d like you to sort them into two piles for me. If you have tried the drug at least once during your lifetime, put it in a pile here [indicate position], and if you have never tried the drug, put it in a pile here [indicate position]. [Record on drug chart under Lifetime Use.] Completing the Interview Use the header cards that are provided ( Drugs I have used at least once and Drugs I have not used ) to mark where the two piles are to be placed. Emphasize that you are asking about drug use ever in the client s lifetime. Give the cards to the client in numerical order with nicotine on top, cannabis next, and so on. Review the calendar and other drinking information before the client leaves the interview setting in order to ensure that the information is accurate and Page 25 of 31

27 codable. This may be done while the client is completing other questionnaires. Be sure that P1 (and P2) days are clearly marked on the calendar and that the data entered on the steady pattern grids are clear and easily readable for computer entry. This includes the number of ounces and percent alcohol or brand name of alcohol. For idiosyncratic days, check the calendar for readability, amount, and percentage alcohol. No days may be omitted. Page 26 of 31

28 Table 2 Estimating Frequency from Verbal Descriptions At various points in the Form 90-AIR interview, clients are asked about the frequency with which specific things have happened during the assessment window. Table 1 may be helpful in recording event frequency during a 90-day period. Be aware, however, that the assessment window for Form 90-AIR is rarely exactly 90 days, so that these should be used only as examples of how to convert verbal descriptions of occurrence into actual frequencies for an assessment window. Remember that the purpose of these questions is to determine how often specific events have occurred within the assessment window bring reconstructed on the calendar. TABLE 2. Conversion of verbal descriptions to 90-day scale (number of occurrences/90days) Once a month 3 Twice a month 6 Three days a month 9 Four days a month 12 Once a week 13 Twice a week 26 Three days a week 39 Four days a week 51 Five days a week 64 Six days a week 77 Every day 90 Page 27 of 31

29 Table 3 TABLE 3. Criteria for qualifying drug use (YES) DO NOT COUNT: Over - the - counter medications taken to treat circumscribed illness (e.g., colds, allergies) Illegal remedies taken for nonpsychoactive hoped-for curative properties (e.g., for cancer) Medications prescribed and taken for 30 days or less if taken as directed for prescribed purposes (e.g., Seconal prescribed and taken for 5 days for post-surgical pain; benzodiazepines prescribed during alcohol withdrawal) Nonpsychoactive controlled medications that are not included in the card sort drug categories (e.g., antibiotics), even if not taken as prescribed Psychoactive drugs unlikely to be abused and not falling into one of the card sort drug categories (e.g., anticonvulsants, lithium, antidepressants) DO COUNT: All nicotine use Any use of controlled psychoactive drugs without prescription Any use of illegal psychoactive drugs Any use of prescribed psychoactive drugs above prescribed doses Any use of psychoactive drugs specifically to get high Any regular (e.g., daily or almost daily) use of prescribed psychoactive drugs for more than 30 consecutive days, even if within prescribed limits and for prescribed purposes. This includes psychoactive medication prescribed for pain relief, muscle relaxation, weight loss, insomnia, attention deficit disorder, etc.. Any use of multiple prescriptions from different physicians for the same psychoactive medication in order to exceed prescribed limits Any psychoactive drug prescribed or otherwise used as a maintenance or substitution medication to treat alcohol or other drug abuse (e.g., methadone but not disulfiram) Page 28 of 31