MANAGEMENT OF AN MANAGEMENT OF AN ALCOHOLIC.pptx

MANAGEMENT OF AN ALCOHOLIC.pptx

1. MANAGEMENT OF AN ALCOHOLIC PRESENTER: DR. P. PRAGNYA MODERATOR: DR. P. VISHNU PRASAD TOTAL NO. OF SLIDES: 65 APPROX. DURATION: 45minutes 1

2. SCHEMA OF PRESENTATION INTRODUCTION TREATMENT GOALS IN ALCOHOLICS ASSESSMENT OF ALCOHOL USE DISORDERS MANAGEMENT OF ALCOHOL WITHDRAWAL AND DETOXIFICATION STATE (SIMPLE AND COMPLICATED) MANAGEMENT OF ALCOHOL DEPENDENCE PSYCHOSOCIAL INTERVENTIONS 2

3. INTRODUCTION Alcohol use disorders show an increased trend in developing countries like India National Household survey : Alcohol (21.4% ) was the primary substance use apart from tobacco. Among them 17-26% of alcohol users qualified to ICD-10 diagnosis of dependence translating into an average prevalence of about 4% In India currently the most important and significant changes seen in alcohol use is Decrease in age of initiation into alcohol, Increase in female alcohol use and Signature pattern of alcohol intake - take alcohol regularly (mostly solitarily) and heavily to the point of intoxication. 3

4. Q. What is a unit of alcohol? One unit = 10mL of ethanol or 1L of 1% alcohol. For example, 250mL of wine that is 10% alcohol contains 2.5 units. Q. How much alcohol is too much? The UK Department of Health in 2016 gave the following advice and recommendations to minimise the health risks from alcohol consumption: No more than 14 units should be consumed per week on a regular basis. This applies to both men and women. Harm is minimised when these units are spread across 3 or more days. Heavy single‐occasion drinking is associated with risk of harm, injury and accidents. The consumption of any volume of alcohol is still associated with a number of illnesses such as cancers of the throat, mouth and breast. 4

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6. MAJOR CONCERNS FOR CURRENT MANAGEMENT OF ALCOHOL USE DISORDERS IN INDIA Low awareness level Beliefs about alcoholism Lack of trained personnel Lack of community resources Inadequate access to health care 6

7. TREATMENT AIMS/GOALS Main goal of treatment is to maintain abstinence and if not possible decrease the frequency and severity of relapses and maximize functioning in between. Promote complete abstinence Stabilize acute medical and psychiatric conditions as needed Increase motivation for recovery Initiate treatment for chronic medical and psychiatric conditions as needed Enhance coping and relapse prevention skills Improve occupational functioning, social support and assist in integrating to society as needed Promote maintenance of recovery through ongoing participation in structured treatment or self-help groups 7

8. SHORT TERM GOALS 1. Manage Intoxication 2. Manage withdrawal 3. Motivation Enhancement 4. Treat acute medical sequel 5. Crisis Intervention 8

9. LONG TERM GOALS 1. Relapse Prevention 2. Maintain Abstinence 3. Occupational rehabilitation 4. Social reintegration 5. Improve Quality of Life 9

10. ASSESSMENT OF ALCOHOL USE DISORDERS Assessment will help in diagnosing, establishing rapport, motivating the person and in formulating the plan of the management. During the first contact it is to establish rapport, diagnosis and plan of management. During intervention it is monitoring the progress and assessing abstinence. If the client is uncooperative the aim of assessment is to retain the client in the treatment. During this time the information can be collected in pieces and information can be added when patient is co-operative. 10

11. 1. CLINICAL HISTORY Substance related factors - age of initiation, frequency, amount, tolerance, craving, withdrawal symptoms, salience, last dose, motivation, consequences of substance use etc., History of other substance use, Physical and psychiatric comorbidity if any, Abstinent related factors - past abstinence, duration, reasons for relapse, past treatment/s, methods used for controlling craving etc., High risk behaviours , Presence of any externalizing disorders, Family history of substance abuse, and psychiatric illness, Assessing social support , current living arrangements and reasons for current visit 11

12. 2. PHYSICAL EXAMINATION Look for signs of intoxication withdrawal signs, evidence of physical damage, assess for psychopathology 12

13. 3. INSTRUMENTS The Alcohol Use Disorders Identification Test (AUDIT) questionnaire, This is a 10‐item questionnaire which is useful as a screening tool in those identified as being at increasing risk. Questions 1–3 address the quantity of alcohol consumed , 4–6 the signs and symptoms of dependence and 7–10 the behaviours and symptoms associated with harmful alcohol use. Each question is scored 0–4, giving a maximum total score of 40. A score of 8 or more is suggestive of hazardous or harmful alcohol use. Hazardous drinking = consumption of alcohol likely to cause harm. Harmful drinking = consumption already causing mental or physical health problems. The Severity of Alcohol Dependence Questionnaire (SADQ) is a more detailed 20‐item questionnaire with the score on each item ranging from 0 to 3, giving a maximum total score of 60 13

14. CAGE Questionnaire: widely used brief and straightforward instrument for screening alcohol abuse. It includes 4 questions pertaining to: ‘C’ (cut down) : feeling the need to cut down on one’s drinking, ‘A’ (annoyance): being annoyed by people’s criticizing one’s drinking behaviour, ‘G’ (guilt ): ever having felt bad or guilty about one’s drinking, and ‘E’ (eye opener): ever having had a drink first thing in the morning to steady one’s nerves or to get rid of a hangover. It was considered by the developer of the instrument that if 2 or more apply in an individual’s case, it suggests alcohol abuse. MAST (Michigan Alcoholism Screening Test) : screening instrument to identify alcohol use disorders and alcohol-related disabilities. 14

15. ASSIST (the Alcohol, Smoking and Substance Involvement Screening Test) developed by the WHO to identify persons with hazardous or harmful use of a range of psychoactive substances. It consists of 8 questions and provides information on the individual’s use of substance(s) during lifetime and over the last 3 months, substance use related problems, risk of current or future harm, dependence and injecting drug use. The specific substance involvement scores (low/moderate/high risk in relation to alcohol and all other substances) can then be linked to an appropriate intervention for each patient. 15

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17. 4. INVESTIGATIONS Confirmation of alcohol, LFT, Hemogram, GGT, Serum B12, USG Abdomen, HIV, VDRL (high risk cases) ECG (> 40yrs) Neuropsychologic Tests 17

18. MANAGEMENT OF ALCOHOL WITHDRAWAL AND DETOXIFICATION WITHDRAWAL STATE The factors which predict the severity of a withdrawal syndrome Time elapsed since last use Concomitant use of other substance use The presence or absence of concurrent general medical or psychiatric disorders, Past complicated withdrawal syndromes 18

19. SIMPLE V/S COMPLICATED WITHDRAWAL 19

20. MILD ALCOHOL WITHDRAWAL 20

21. TREATMENT REGIMENS FOR ALCOHOL WITHDRAWAL Pharmacological agents are treatment of choice in alcohol withdrawal Pharmacological agents are directed towards reducing CNS hyper excitability and restore homeostasis The ideal pharmacological agent should be effective in relieving the symptoms of alcohol withdrawal and also should prevent alcohol withdrawal seizures and delirium. It should be safe in overdose with benign side effect profile, less drug-drug interaction, tolerability and suppress drinking during and after alcohol withdrawal. 21

22. PHARMACOLOGICALLY ASSISTED WITHDRAWAL Pharmacologically assisted withdrawal is likely to be needed when: Regular consumption of >15 units/day. AUDIT score >20. There is a history of significant withdrawal symptoms. A CIWA‐ Ar score >10 or a SAWS score >12 should prompt assisted withdrawal. 22

23. INPATIENT DETOXIFICATION Inpatient detoxification is likely to be required if: Regular consumption of >30 units/day. SADQ >30 (severe dependence). There is a history of seizures or delirium tremens. The patient is very young or old. There is current benzodiazepine use in combination with alcohol. Substances other than alcohol are also being misused/abused. There is co‐morbid mental or physical illness, learning disability or cognitive impairment. 23

24. COMMUNITY DETOXIFICATION Community detoxification is usually possible when: There is a supervising carer, ideally 24 hours a day throughout the duration of the detoxification process. The treatment plan has been agreed with the patient, their carer and their GP. A contingency plan has been agreed with the patient, their carer and their GP. The patient is able to pick up medication daily and be reviewed by professionals regularly throughout the process. Outpatient/community-based programmes including psychosocial support are available. Community detoxification should be stopped if the patient resumes drinking or fails to engage with the agreed treatment plan. 24

25. BENZODIAZEPINES (BZD) Used in withdrawal syndrome due to cross tolerance with alcohol All BZD (short and long acting) are equally effective in management of the simple u alcohol withdrawal state, Both short acting and long acting Benzodiazepines are effective in primary and secondary seizure prevention Long acting BZD are better in prevention of seizures and delirium tremens Short acting BZD (Oxazepam and Lorazepam) are preferred in liver damage, elderly u and in cognitive impairment Dosing pattern - fixed dose regimens for BZD are recommended for routine use with symptom-triggered dosing reserved for use only with adequate monitoring 25

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27. FIXED DOSE REGIMENS 27

28. SYMPTOM‐TRIGGERED REGIME This should be reserved for managing assisted withdrawal in specialist alcohol inpatient or residential settings. Regular monitoring is required, for example pulse, blood pressure, temperature and level of consciousness. Medication is only given when withdrawal symptoms are observed as determined using CIWA‐ Ar , SAWS or an alternative validated measure. Symptom‐triggered therapy is generally used in patients without a history of complications. A typical symptom‐triggered regime would be chlordiazepoxide 20–30mg hourly as needed. FOR EG. Day 1–5 : 20–30mg chlordiazepoxide as needed, up to hourly, based on symptoms 28

29. PROPHYLACTIC THIAMINE Low‐risk drinkers without neuropsychiatric complications and with an adequate diet should be offered oral thiamine: A minimum of 300mg daily during assisted alcohol withdrawal and periods of continued alcohol intake. Thiamine is required to utilise glucose . A glucose load in a thiamine‐deficient patient can precipitate Wernicke’s encephalopathy. Parenteral B complex ( Pabrinex ) must be administered before glucose is administered in all patients presenting with altered mental status. 29

30. It is generally advised that patients undergoing in‐patient detoxification should be given parenteral thiamine as prophylaxis although there is insufficient evidence from randomised controlled trials (RCTs) as to the best dose, frequency or duration of use. Guidance is based on ‘expert opinion’ and the standard advice is one pair of Pabrinex IMHP daily (containing thiamine 250mg/dose) for 5 days, followed by oral thiamine and/or vitamin B compound for as long as needed (where diet is inadequate or alcohol consumption is resumed). All inpatients should receive this regime as an absolute minimum. 30

31. OTHER DRUGS USED IN SIMPLE WITHDRAWAL BACLOFEN Selective GABA-B agonist Evidence is insufficient for its use in alcohol withdrawal ACAMPROSATE NMDA antagonist and GABA-A agonist The evidence for the use of acamprosate in alcohol withdrawal is confusing. Some trials have shown that when given along with Benzodiazepines during withdrawal they improved outcome, whereas some trials have shown that they indeed worsen the outcome when given during the beginning of detoxification Propranolol – beta-blocker, Clonidine - a2 agonist, Supplementation on D-Phenyl-alanine, L glutamine, L-5 hydroxytryptophan (Limited evidence in withdrawal stage) 31

32. MANAGEMENT OF COMPLICATED WITHDRAWAL-SEIZURES 32

33. MANAGEMENT OF COMPLICATED WITHDRAWAL- DELIRIUM TREMENS 33

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36. MANAGEMENT OF ALCOHOL DEPENDENCE GOALS Maintain complete abstinence, If not possible: Decrease the frequency and severity of relapses Maximize functioning in between Improve the quality of life 36

37. DISULFIRAM First pharmacological agent to be approved by FDA in 1951 as an Aversive agent. Only drug used for complete abstinence from alcohol dependence Irreversible inhibitor of Aldehyde De-Hydrogenase Causes increase in the level of dopamine and decrease in the level of nor adrenaline u in brain by blocking dopamine b hydroxylase Patients who are motivated, have less impulsivity, intelligent, and whose craving is dependent on internal and external cues are better candidates for disulfiram 37

38. Dose: 250 mg/day for 1 year. Started when the body is alcohol free for at least 24 hrs. Monitoring is recommended every 2 weeks for the first 2 months, then monthly for the following 4 months . Medical monitoring should be continued at 6‐monthly intervals after the first 6 months. Patients must not consume any alcohol while taking disulfiram. 38

39. DISULFIRAM REACTIONS WITH ALCOHOL Mild alcohol–disulfiram reaction: Facial flushing Sweating Nausea Hyperventilation Dyspnoea Tachycardia Hypotension 39

40. Severe alcohol–disulfiram reaction: Acute heart failure Myocardial infarction Arrhythmias Bradycardia Respiratory depression Severe hypotension Contraindications: Ingestion of alcohol within the previous 24 hours Cardiac failure , Coronary artery disease , Hypertension Cerebrovascular disease Pregnancy Breastfeeding Liver disease Peripheral neuropathy Severe mental illness 40

41. NALTREXONE Naltrexone is one of the most widely studied medications with a strong efficacy base Opiate receptor antagonist. Reduces return to heavy drinking by reducing lapse to relapse, but does not improve the abstinence rate. Useful in people with family history of alcohol dependence and type A alcoholism ( Babor classification) Oral dose: 50 mg/day ( can be given also while using alcohol), Injectable (not yet formally approved for use in India): 190 mg and 380 mg/month in people with poor adherence. Mild and transient side effects – Most common adverse effect is nausea and sedation CNS: headache, dysphoria, fatigue; GI: nausea, abdominal pain, vomiting, and liver toxicity. Longer duration of use (6 months) had better outcomes compared to shorter duration (3 months) - benefits also observed to last for 3-12 months after stopping 41

42. ACAMPROSATE ACAMPROSATE: Synthetic molecule which is hypothesized as a functional glutaminergic NMDA antagonist and reduces hyper-glutamatergic state and reestablishes the homeostasis. Acamprosate reduces heavy drinking in patients who have relapsed. Dosage: Available in 333 mg pill & dose of 999 mg to 1998 mg/day based of weight u of the patient The dose is 1998mg daily (666mg three times per day) for individuals over 60kg. For those under 60kg, the dose is 1332mg daily. Adverse effects : GI disturbance most common, Not metabolized in the liver and excreted unchanged in kidney – contraindicated in severe liver and renal impairment To be used for a year - benefits also observed to last for 3-12 months after stopping. 42

43. BACLOFEN BACLOFEN Stereo selective gamma aminobutyric acid B receptor (GABA) agonist. Inhibits the release of neurotransmitters such as Dopamine, 5HT, NA, Glutamate. Baclofen has a higher rate of abstinence and decreases anxiety. Baclofen holds promise and should be first line of management in patients with moderate to severe u cirrhotic liver disease. Dose: 30-60 mg/day First line of management in the presence of moderate to severe cirrhosis 43

44. TOPIRAMATE Reduces mesolimbic activity of dopamine by Facilitates GABA transmission, decrease in AMPA (Glutamate excitation) Reduces the percentage of heavy drinking days, maintain abstinence, harmful drinking consequences, physical health and quality of life. Dose: 150-300 mg/day Adverse effects: Paraesthesia, Anorexia, Insomnia, difficulty in concentration SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRI) SSRIs are generally used for patients with comorbid depression, effectiveness is less consistent in non depressed patients SSRIs worsen outcome in early onset, family history of alcoholism. ONDANSETRON 5-HT3 antagonist May be effective in early onset users ANTIPSYCHOTICS Aripiprazole, Quetiapine, Olananzapine , Amisulpride , Flupenthixol , Haloperidol and Clozapine – only case reports which state that they improve drinking outcome. Not recommended for general use 44

45. Nalmefene is also an opioid antagonist, recommended by NICE as an option for reducing alcohol consumption for people with alcohol dependence. It has been shown in one indirect meta‐analysis to be superior to naltrexone in reducing heavy drinking. However use of Nalmefene remains controversial, with another meta‐analysis suggesting that Nalmefene had only limited efficacy in reducing alcohol consumption and that its value in treating alcohol addiction and relapse prevention was not fully established. 45

46. PSYCHOSOCIAL INTERVENTIONS 1. MOTIVATION ENHANCEMENT THERAPY Maximize patient's intrinsic desire to change substance use using motivational interviewing techniques Empathic, non-judgemental and supportive approach to examine patient's ambivalence about changing substance use behaviours 46

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48. 5 Rs The 5 Rs represent the following: Relevance: What is the personal relevance of quitting substance for the client? Risks: What are the potential negative consequences of using substance for the client? Rewards: What are the potential benefits of stopping the substance for the client? Roadblocks: What are the barriers in quitting the substance and elements in treatment that may help in handling the barriers. Repetition: The motivational intervention should be repeated every time the unmotivated client visits you. 48

49. 2. BRIEF INTERVENTIONS 1. FRAMES F: Feedback : Following an appropriate assessment and is provided to the subject on his/her pattern/level of substance use, existing or potential harmful effects, awareness of these issues along with certain laboratory parameters (e.g. Blood test for liver enzymes including GGT for alcohol users, urine screen for opiates), keeping in mind his/ her motivation to change. Feedback may also include a comparison between the patient’s substance use patterns/problems and the prevailing patterns and problems experienced by other similar people in the population. R: Responsibility: An emphasis is laid upon the person that to think and decide about the need for change in substance use is solely the individual’s personal responsibility. A: Advice: Based on the assessment, the physician or the therapist gives a direct professional opinion or clear advice to the person regarding the harms associated with continued substance use to make changes in substance use in the direction of a specified goal e.g., ‘moderation’ or ‘quitting’. 49

50. M: Menu : The subject is provided information regarding an array of options or a menu of the various alternative ways/strategies to reduce/stop substance use. Providing choices reinforces the sense of personal control and responsibility for making the change and can thereby help in strengthening the motivation to change. For example, keeping a diary for substance use (mentioning details viz., where, when, amount, with whom, why); helping patients to prepare substance use guidelines for themselves; identifying relapse precipitants-high risk situations and strategies to avoid them; providing information on self help resources and written information, reading pamphlets; attending counseling session(s) and follow up; Identifying healthy enjoyable activities and life style changes that could replace drug use viz., hobbies, exercises, sports, spending time with family and visiting sober friends; providing information on specialized treatment centres or professionals; Putting aside the money they would usually spend on drug use for something which is constructive, healthy and satisfying. 50

51. E: Empathy : The therapeutic style of warm, reflective listening and an understanding approach is an important component of effective brief intervention. The therapist communicates respect to the client, encourages exploration, reinforces the adaptive statements made by the client and avoids confrontation to prevent resistance. S: Self-efficacy : The therapist endeavours to boost the client’s sense of self-efficacy or optimism or perceived control and confidence. It is considered particularly helpful to elicit self efficacy statements from patients as they are likely to believe what they hear themselves say 51

52. DARES There are five principles which guide the practice of motivational interviewing (acronym DARES). These include D: Develop discrepancy A: Avoid argumentation R: Roll with resistance E: Express empathy S: Support Self-efficacy 52

53. 3. CBT COGNITIVE BEHAVIOUR THERAPY Based on social learning theories aimed at improving self control and social skills Along with medications they have found to be effective in relapse prevention & decrease in alcohol use 53

54. FUNCTIONAL ANALYSIS 54

55. DECISION MAKING MATRIX 55

56. REFRAMING Reframing is a strategy by which therapists invite clients to examine their perceptions in a new light or a reorganized form. New meaning is given to what is said. Client’s admissions of being able to hold their liquor - to be able to drink more than other people without looking or feeling as intoxicated can be reframed as being a risk factor. The absence of a built in warning system that tells people when they’ve had enough. Thus good news becomes bad news. Other reframes are: “Drinking as a reward - You may have the need to reward yourself on the weekends for successfully handling a stressful and difficult job during the week. The implication is that there are other ways to handle issues without going on a binge. 56

57. “ Drinking as an adaptive function - Your drinking can be viewed as a means of avoiding tension or conflict in your marriage. It tends to keep things as they are. It seems like you have been drinking to keep your marriage intact. Yet both of you are uncomfortable with this arrangement”. The implication here is that the client cares about his marriage and has been trying to keep it together but needs to find more effective ways to do it The general idea of reframing is to place the problem behaviour in a more positive light , which can itself have a paradoxical effect (prescribing the symptom), but to do so in a way that causes the person to take action to change the problem. 57

58. 4. PREVENTING RELAPSE Common Relapse Precipitants Positive mood (excessive happiness) Negative mood (sadness, frustration) BEHAVIORAL Impulsivity, Poor coping skills COGNITIVE Overconfidence (self-perception of ability to cope with high-risk situations) ENVIRONMENTAL Peer pressure Loneliness / no engagement Lack of social support/ constant criticism by family PHYSIOLOGICAL Craving, Long lasting withdrawal symptoms (sleep disturbance after stopping alcohol, pain after stopping opioids),Chronic physical pain PSYCHIATRIC CONDITIONS Anxiety disorder Mood disorder Psychoses Unrecognized depression/anxiety disorders 58

59. A. Identifying and Handling High Risk Situations Common Situations where a Person can Develop Craving The sight of a bar, especially the one the person used to frequent before Meeting friends with whom one was using drugs, passing by usual hangouts Peer pressure Parties Saturday nights/ weekends z Some environmental cues like eating non-vegetarian food Being home alone Family conflicts Job stress, other stresses, fatigue Having a lot of unscheduled time Negative emotions like frustration, sadness, depression Positive emotions such as happiness, excitement, a feeling of accomplishment (desire to celebrate). 59

60. B. Handling Craving 60

61. C. Drink Refusal Skills and Assertiveness Beware of Pressure Tactics Pleading: “Please give me company just for a few minutes.” Reassuring: “It’s ok, I’ll talk to your family so they won’t be angry with you.” Anger: “Look, I’m drinking, but nothing has happened to me.” “So you mean to say I’m bad and you are a reformed person.” “So you want to avoid me.” Ridicule: “Are you planning to build an estate with all the money you have saved.” Challenging: “Are you a slave to your wife?” “Aren’t you the earning member? Don’t you have the right to spend your own money the way you want to?” Threatening: “So you don’t want our friendship.” “We will expel you from our group if you don’t drink with us anymore.” 61

62. Some Common Drink Refusal Statements “No thanks, I have stopped drinking.” “Let us have tea of coffee instead.” “I am taking medicine and I can’t drink on it.” “I have an important engagement.” “I have to get up early.” “I have to work a double shift tomorrow.” “I have a headache.” “I was just leaving.” 62

63. D. Dealing with faulty cognitions Dealing with faulty cognitions like overconfidence, helplessness, etc. A person’s faulty thought very often becomes a problem for him/her and leads to a relapse. A simple example is: “I can stay away from alcohol. Nothing can tempt me.” The consequence is - going to parties where alcohol may be available, telling myself “I will go, but I’ll not drink.” 63

64. 5. BEHAVIOURAL THERAPIES Based on learning theories and positive reinforcements for target behaviours Community reinforcement approach is effective 6. GROUP THERAPIES Helps in making efficient use of therapist time Encourage people to discuss problems and reduction in stigma Group therapies involving assertive techniques, social skill training, family focussed therapy and motivation enhancement has been shown to be effective 64

65. 7. FAMILY THERAPY To address dysfunctional families and those with high expressed emotions that leads to substance abuse and plays an important role in Indian context Family therapies along with medication have found to be better in reduction of alcohol, relapses and this has also been found effective in Indian setup. 65

66. 8. SELF HELP GROUP APPROACH 12 steps approach – steps used in Alcoholics Anonymous (AA) Offers emotional support and a model of abstinence for people recovering from alcohol dependence AA or other 12 step approaches have been found to be effective method for management but was not found to better than other treatments in reducing alcohol use and achieving abstinence. 66

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69. Q1. IF A PATIENT HAS CONSUMED 500ML OF BEER, HOW MANY UNITS OF ALCOHOL IT CORROSPONDS TO? 1. 1 UNIT 2. 2 UNITS 3. 3 UNITS 4. 5 UNITS 69

70. Q2. AUDIT STAND FOR? 70

71. Q3. FIXED DOSE REGIMEN FOR MODERATE WITHDRAWAL USUALLY STARTS AT WHAT DOSE OF CHLORDIAZEPOXIDE? 1. 40MG 2. 60 MG 3. 80MG 4. 100 MG 71

72. Q4. DISULFIRAM IS ? 1. REVERSIBLE INHIBITOR OF ALCOHOL DE-HYDROGENASE 2. REVERSIBLE INHIBITOR OF ALDEHYDE DE-HYDROGENASE 3. IRREVERSIBLE INHIBITOR OF ACOHOL-DEHYDROGENASE 4. IRREVERSIBLE INHIBITOR OF ALDEHYDE DEHYDROGENASE 72

73. Q5. WHAT DOES A IN “FRAMES”BRIEF INTERVENTION STAND FOR? 1. ALTERNATIVE STRATERGIES 2. ASSESS 3. ASK 4. ADVICE 73

74. REFERENCES… 1. MAUDSLEY’S PRESCRIBING GUIDELINES. 14 TH EDITION 2. COMPREHENSIVE TEXTBOOK OF PSYCHIATRY, 11 TH EDITION 3. IPS CPG SUD SYNOPSIS BOOK. 4. SUD MANUAL FOR PHYSICIANS. 74

75. TOMORROW’S ACADEMIC EVENT CASE PRESENTATION BY DR. M. KAVITHA MODERATOR: DR. V. HARSHAVARDHAN 75

76. THANK YOU… 76