1. How would you classify Pam’s drinking habits?

Based on the detailed information provided, Pam’s drinking habits can be classified as severe Alcohol Use Disorder (AUD), as defined by the DSM-5 criteria.

Here’s why:

• Impaired Control:
  • Craving: “Only alcohol would make me feel better” when sick from withdrawal.
  • Unsuccessful efforts to cut down or control use: “She had made attempts to cut down but found that she would begin drinking more within a few days.”
  • Larger amounts or longer period than intended: She started with one glass of wine, which escalated to 3-4 glasses, and later admits to drinking “more than twice as much as she had initially told you.”
• Social Impairment:
  • Failure to fulfill major role obligations: “She has received several citations at work because of her behavior” due to her morning drinking affecting her work.
• Risky Use:
  • Recurrent use in physically hazardous situations: Arrested for drunk driving.
  • Continued use despite knowledge of physical/psychological problem: She thinks her drinking makes her depression worse, knows it affects her work, and uses it despite negative consequences (arrest, fall, aspiration, seizure).
• Pharmacological Criteria:
  • Tolerance: “One glass has not been sufficient, and even when she drinks three or four glasses of wine, that might not be enough.” She needs increasing amounts to achieve the desired effect.
  • Withdrawal: “Each time would feel ‘sick’ to the point where ‘only alcohol would make me feel better.'” She experiences anxiety and shakiness in the morning, which she self-medicates with alcohol (a classic sign of withdrawal and subsequent drinking to alleviate symptoms).

Her AUDIT-C score of 8 (which is very high, a score of 4 or more for women indicates positive screening for hazardous drinking or active AUD) further supports this classification. The severity is indicated by the number of criteria met. Pam meets multiple criteria, including significant impairment and dangerous behaviors.

2. How does alcohol affect sleep?

Alcohol has a complex and detrimental effect on sleep, especially with chronic use:

• Initial Sedative Effect: Alcohol is a central nervous system depressant. Initially, it can make a person feel drowsy and facilitate falling asleep more quickly. This is why Pam used it as a sleep aid.
• Disruption of Sleep Architecture: This initial sedative effect is short-lived. As alcohol is metabolized, it disrupts the natural sleep cycle throughout the night.
  • Reduced REM Sleep: Alcohol suppresses Rapid Eye Movement (REM) sleep, which is crucial for cognitive function, memory consolidation, and emotional regulation. This often leads to less restorative sleep.
  • Increased Wakefulness and Fragmented Sleep: As the alcohol wears off, often in the latter half of the night, its stimulating effects can rebound. This leads to frequent awakenings, early morning waking, and highly fragmented sleep. This explains why Pam “wakes up multiple times every night” and feels “groggy for several hours in the morning.”
• Exacerbation of Sleep Disorders: Alcohol can worsen existing sleep disorders, such as:
  • Insomnia: It perpetuates a cycle where individuals rely on alcohol to fall asleep, only to experience worse sleep quality, leading to increased anxiety about sleep and further alcohol use.
  • Sleep Apnea: Alcohol relaxes the muscles in the throat, which can worsen obstructive sleep apnea, leading to more frequent and severe breathing interruptions during sleep.
• Withdrawal-Related Sleep Disturbances: For individuals with AUD, withdrawal (even mild morning withdrawal) often includes severe sleep disturbances like insomnia, nightmares, and night sweats, perpetuating the cycle of dependence and poor sleep. Pam’s morning anxiety and shakiness followed by drinking to calm herself illustrate this cycle.

3. What is SBIRT? How is it effective in helping clients?

SBIRT stands for Screening, Brief Intervention, and Referral to Treatment. It’s a comprehensive, integrated public health approach to the delivery of early intervention and treatment services for persons with substance use disorders and those at risk of developing these disorders.

• Screening (S): Quickly assesses the severity of substance use and identifies appropriate levels of treatment. This is done through validated tools like the AUDIT-C, DAST-10, or ASSIST. In Pam’s case, an AUDIT-C score of 8 clearly indicated high risk.
• Brief Intervention (BI): A short, conversational, and motivational conversation (typically 5-15 minutes) with a patient who screens positive for substance use. It focuses on raising awareness of risks, increasing motivation to change, and developing a plan. Key elements often include:
  • Expressing Empathy
  • Developing Discrepancy (between current behavior and goals)
  • Rolling