1. General guidelines about Alcohol Use Disorder

A chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking. If a person has 3 or more of the following characteristics for a period of 1 year, then he/she has Alcohol Use Disorder

1. Strong desire or compulsion to take the substance.

2. Difficulties in controlling substance – taking behaviour in terms of onset, termination, or levels of use.

3. Physiological withdrawal state when substance use has ceased or been reduced (Anxiety, tremors, headache, nausea, vomiting, insomnia, sweating).

4. Evidence of tolerance - need to increase alcohol dosage to gain the desired effect

5. A lot of time is spent on drinking alcohol; Recreational, social activities are given up because of alcohol use

6. Alcohol used despite knowledge that it created physical and psychological problems.

History Taking and Mental Status Examination Annexure1

Special emphasis -

· Daily dosage

· length of use and last dosage

· multiple substance use

2. a. Investigations required

1. Psychometric assessment: AUDIT, CAGE, MMSE

2. Laboratory: (if physical complications are present)

• - Routine CBC

• - Peptic ulcer

• - Liver disease

• - Kidney

• - Others

• - LFT

• - KFT

• - Urine

• - Blood sugar

• - Lipid profile

• - S. Electrolytes

2. 2. b. Co-morbidity

1.  Anxiety Disorder

2.  Mood Disorder

3.  Somatoform disorder

4.  Other substances

2. 2. c. Differential Diagnosis

Consider acute head injury and hypoglycaemia. Consider also the possibility of intoxication as the result of substance use. The following five-character codes may be used to indicate whether the acute intoxication was associated with any complications.

· Uncomplicated (Symptoms of varying severity, usually dose- dependent, particularly at high dose levels.

· With trauma or other bodily injury

· With other medical complications, such as haematemesis, inhalation of vomitus.

· With Delerium

· With convulsions

· Intoxication of/with other substance

3. Treatment

a) Psychopharmacology

· Immediate detoxification with Benzodiazepine (preferably long acting)

· Symptomatic and supportive

· Long term use of Disulfiram (if patient desire and is motivated)

Treatment for substance disorder

1. This guideline should be used for substance addiction only.

2. Drug addiction should be diagnosed by MBBS doctors based on ICD 10 and DSM 5 criteria. (E.g. drug addiction, alcohol abuse, withdrawal symptoms, prioritizing drugs over anything else, using substance to the point of incontinence and to the point of physical harm etc)

3. The diagnosis should be made by taking history from a reliable source or informant (personal interviews, telephone interviews, medications and doses, and other important information are important for self-care)

4.  Patients history should include: a) What type of drugs, b) Last dose of substance intake, c) Daily dose of drug used, d) Whether the patient take OST or not, e) Does the patient has any other illness?

5.  Drug use should be stopped immediately upon entry into the Centre

6. Qualified nurses under the guidance of MBBS doctor should treat the patient. MBBS Doctor should treat the patient with understanding while taking into consideration the mental, physical and characteristics of the patient.

7. The following are ways to tell if the patient needs to be referred to a more advanced facility:

8. The patient is physically tired and weak

9. The patient is confused and dangerous to others and himself

I. PHARMACOLOGICAL DETOXIFICATION

1. Treatment for alcoholics

After entering the centre, the alcoholic must stop drinking alcohol. If he does not need alcohol anymore, he must take his medicine from his daily intake. For example, if the daily dose is 500 ml, the following medicines should be given considering the effects on the body:

i. Lorazepam 2 mg/ Chlordiazepoxide 10 mg/ Clonazepam 0.5 ng tablets should be given twice a day, i.e. Two (2) tablets in the morning, two (2) tablets in the afternoon and three (3) tablets in the evening. The dose should be gradually reduced daily or weekly over a period of seven to ten days (7-10 days)

ii. Thiamine 100 mg (Bl -e.g. Beplex Forte) should be given for three days. Thiamine should be reduced to 10 mg for one month.

iii. If the drug addict is not able to control himself or if he is not able to control his mother, Inj. Diazepam 1 tablet IV or Inj. Lorazepam 1 ampoule each IV/IM.

iv. If the patient is mentally ill or has a mental illness, Inj. Haloperidol and Inj. Promethazine 1 ampoule each IM.

v. Treatment should be given according to the patient's illness and severity

II. FOLLOW UP

1. Patient should be advised to revisit Psychiatry OPDs/ DMHP OPDs- district towns after discharge from Centres

2. Patients and their caregivers can call Psychiatrists, Clinical Psychologists and DMHP Mental Health Professionals on State helpline 102 (toll free) if necessary.

a) Combined treatment

b) Psychosocial Intervention

Psychoeducation – nature of illness, etiology, progression, consequences, prognosis, treatment.

i. Relapse Prevention Therapy -

a) Identifying the triggers

b) Strategies for coping with triggers (5 D’s) delayed, drink, divert, discuss, deep breath

ii. Motivation Enhancement Therapy - Motivational enhancement therapy (MET) is a directive, person-centered approach to therapy that focuses on improving an individual's motivation to change.

- Pre contemplation- not interested/not even thinking about behaviour change

- Contemplation- ambivalent/ considering change

- Preparation- ready for action/change is necessary and possible

- Action- initiating action/actively working toward behaviour change

- Maintenance/recovery- already acting/sustaining new behaviour

iii. Family counselling

iv. Physical Activity / Activity Scheduling-Activity scheduling (AS), also called behavioral activation (BA), is a therapeutic technique based on the premise that regularly engaging in pleasant activities may help alleviate depression and elevate mood.

- Exercising: Physical Exercises, calisthenics exercises, stretching, brisk walking Playing basketball, going to the gym, or getting out for a hike.

- Nurturing relationships: Going out to dinner, seeing a movie, or attending a play with friends or family

- Self-education: Taking a class, going to the library, reading more

- Participating in hobbies: Taking a cooking class, learning how to knit or paint, learning to play an instrument, learning new languages, new game, carpentry or clay modelling etc

- Expanding self-care: Learning mindfulness techniques, practicing relaxation therapy, visualizing, or doing yoga

4. Follow-up

a.  Psychiatry opd/ DMHP

b.  Physical check-up at OPD

c.  Through telephonic conversation TeleManas14416/18008914416

5. Referrals

Depending upon the severity and complications of the patient, he/she may need to be referred to Psychiatry department.

a) To TeleManas

b) To the nearest DMHP

c) To psychiatry OPD at Kulikawn Hospital or ZMC

d) To higher centers outside Mizoram through Referral Board.