DRUG ADDICTION IS A CHRONIC, RELAPSING DISEASE OF THE BRAIN AND NEEDS BEHAVIORAL INTERVENTION ALONG WITH PHARMACOTHERAPY. HERE IS WHAT A DOCTOR CAN DO IN BUSY OPD TO HELP PATIENTS QUIT DRUGS

1. HELPING PEOPLE CHANGE
BEHAVIOUR
DR MADHU NIMESH THAKKAR
BHMS
1

2. IS CHANGING BEHAVIOUR THAT
DIFFICULT THAT IT NEEDS HELP?
2

3. HOW MANY OF US HAVE DECIDED TO
EXERCISE AND REGULARLY DO
EXERCISE?
3

4. WHAT IS OUR PRESENT STYLE OF
COUNSELLING?
4

5. Doctor as Counselor
• Daru sodum dya
• Tambacco band kara
• “Kashala ghetos”
• “Sodun ka det nahis”
• Nahi sodlis tar liver kharab hoil
• Tambaco ne cancer hoto, mahit ahe na?
• Nahi sodlis tar maron jashil
• Gharchyancha vichar kar
5

6. DOCTORS ARE TRIANED TO BE BAD
COUNSELORS
Directive
Prescriptive
Authoritative
Advice giving
Expert
Pill for every ill mentality
Don't like being questioned, esp Google
patients!!!
6

7. ASK ABOUT ADDICTION
• Ask each and every patient about drug
abuse
• Sometimes you do not even have to ask—
PPT on “Could it be Addiction?”
7

8. ASSESS
• How Much, How Long?
• How Severe? Social, Excesssive, Abuse Or
Dependence
• Cage, Audit, Dast, Fagestorm Scores-
Download App
• Previous Quit Attempts And The Experience
Of That Attempt
• Stage Of Change
• Ability To Change? Will-readiness-ability
8

9. GIVE FEEDBACK
• The provision of personally relevant
feedback (as opposed to general feedback)
• Give it in a very objective way- do not over
exaggerate or undermine
• Do not use moralistic words
9

10. GIVE FEEDBACK
• Providing feedback is particularly effective
during oral examination.
• Keep a mirror handy, and show the patient
evidence of the effects of tobacco.
• Even in the absence of demonstrable
disease, measures to suggest that the
patient is compromising on his/her health
are useful. Eg: Peak flow meter, carbon
monooxide meter
10

11. ADVICE
• Clients may be unaware that their current
pattern of substance use
• Providing clear advice HELPS in cutting
down or stopping substance use
• Advice should be CLEAR, STRONG AND
PERSONALISED
• “The best way you can reduce GI is to cut
down or stop using alcohol”
11

12. DOES ADVICE HELP????????
• Advice Is Most Important But Just The First
Step.
• Drug Addiction Is Physical, Psychological
And Behavioural Addiction.
• We Need To Go Beyond Advice……….
12

13. WE NEED TO UNDERSTAND…….
• Addiction and recovery cycle
• Stages of Change
• Motivational Interviewing technique
• Brief Intervention technique
• Application of all above in day to day cases
13

14. UNDERSTADING ADDICTION CYCLE
14

15. ADDICTIVE THINKING
• Denial - “I don’t have a problem”
• Projection: “I am not the problem, you are the
one with the problem”
• Rationalization : “I have a problem because of
my wife keeps on nagging all the time”.
*Addictive thinking by Abraham Twerski, MD.
15

16. ADDICTIVE THINKING
• Low self esteem
• Distorted thinking
• Self deception
• Difficulty in dealing with conflict
• Emotional Hypersensitivity
• Manipulation
*Addictive thinking by Abraham Twerski, MD.
16

17. ADDICTIVE THINKING
• Guilt and Shame
• Omnipotence
• Spiritual Emptiness
• Hard time admitting that they are wrong
• Feel constantly victimized by and are angry at
everyone.
• “The Confining Wall”
17

18. STAGES OF ADDICTION AND RECOVERY
18

19. EARLY PHASE OF ADDICTION
• Relief using/drinking
• Increase in tolerance
• Preoccupation
• Denial
• Loss of control in amount
• Continued use despite negative consequences
• Sneaking, hiding
Ideal stage for intervening, but difficult to
diagnose because both the patient and the
relatives are in denial
19

20. MIDDLE / CRUCIAL PHASE OF ADDICTION
• Family problems
• Social problems
• Financial problems
• Legal problems
• Emotional problems
• Occupational problems
Crucial stage to intervene, or it will be too
late
20

21. LATE/ CHRONIC PHASE OF ADDICTION
• Physical problems
• Withdrawal symptoms
• Drinking/using to feel normal
• Obsession replaces pre-occuaption
• Loss of support
• Hopelessness and despair
Needs to undergo 12 step program,
admission in rehab, beyond scope of OPD
management
21

22. • Addiction to hard drugs like meow meow,
meth, bath salts, LSD, synthetic cannabis,
etc do not pass through these stages.
• Few doses can be enough to take the patient
from “use” to 3rd stage of addiction
• They are so so addictive
22

23. STAGES OF RECOVERY
23

24. TRANSITION FACE OF RECOVERY
• Enters transition phase after reaching rock
bottom or family/friends forces him into
treatment
• Accepts that he/she have a problem
• Take supports to change the addictive
behaviour
24

25. STABILISATION PHASE OF RECOVERY
(30 TO 90 DAYS)
• ACHIEVE ABSTINENCE
• RECOVER FROM WITHDRAWALS
• NO PREOCCUPATION/ OBSESSION
• HOPE AND MOTIVATION
• Rehab programs are minimum of 30 days and
usually of 90 days –for stabilisation.
25

26. Treatment/counselling in transition
and stabilisation phase is acting
“externally”
26

27. EARLY RECOVERY
(6 MONTHS TO 1 YEAR)
• Physical healing (drinking problem)
• Psychological healing(thinking problem)
• AA steps: 1, 2 ,3
27

28. MIDDLE RECOVERY
(2 TO 3 YEARS)
• Emotional healing (Feeling Disease)
• Inter-personal healing( healing
relationships)
• Actual housecleaning happens here
• AA steps: 4 to 9
28

29. LATE RECOVERY
(3 YEARS AND UP)
• Spiritual healing
• Self actualization
• Rediscover true self
• AA STEPS: 10 TO 12
29

30. IT TAKES MANY YEARS TO TRULY
RECOVER AND FIND TRUE SELF
30

31. WHAT IS ADDICTION?
Addiction is a complex brain
disease significant behavioural
characteristics
31

32. 9/4/2016
MUKTAA CHARITABLE OUNDATION-
SAMVAD HELPLINE-020-26381234
Addiction is a disease of Brain
And we need to lay new networks for “de-addiction”

33. IT’S ABOUT BEHAVIOUR CHANGE
33
“PILL FOR EVERY ILL”
MENTALITY WILL NOT DO

34. IF WE HAVE TO CHANGE BEHAVIOUR ,
WE NEED TO UNDERSTAND HOW
CHANGE OCCURS NATURALLY?
Stages of Change
Prochaska and DiClemente (1982)
34

35. Stages of Change
Prochaska and DiClemente (1982)
People often go through a series of “stages”
from the point they begin to realize that they have a
problem and consider to do anything about it.
35

36. 36
CYCLICAL, NOT LINEAR

37. • Happy users
• Unaware a problem exists or
underestimate
• Denial
PRECONTEMPLETION
37

38. • Beginning to acknowledge there is a
problem
• Begin thinking of solutions
• But have not yet made a decision to change
• Ambivalent
• Want to be in this stage and change at the
same time
• Procrastination as “indecision” is a painful
feeling
• Perceived as “RESISTANT”
COMTEMPLATION 38

39. • Have made the decision to change
• Ready to change in next 30 days
• Trying to find out alternatives and solutions
• Some anxiety about change may still persist
• “ Let’s go”--motivated for change
PREPARATION STAGE
39

40. • “Doing it” for few months( less than 6)
ACTION STAGE
40

41. • Has been abstinent for few months
• Is not “preoccupied” about the object of
addictions
• Has found new “re-inforcers”
Maintenance Stage
41

42. Something happened and patient has slipped
back to previous pattern of drug abuse
RELAPSE
42

44. Pre-
Contemplation
Contemplation
PreparationAction
How many patient’s are ready for treatment?

45. What if we wait for patient to go
through this changes on his own ,
without any intervention?
Wait for he/she
Reaching the Rock bottom
45

46. “Reaching the rock bottom”
• When an addict realises that stopping drugs
is less painful than taking drugs, it is called
“Reaching the rock bottom”
• Physical, mental, emotional and spiritual
damage already might have occurred
46

47. STAGES OF ADDICTION AND RECOVERY
47ROCK BOTTOM

48. SO CAN WE SPEED UP THE
CHANGE PROCESS?
• BY INFORMATION?
• BY EDUCATION??
• BY ADVICE???
MOTIVATION
48

49. Change and motivation
• Motivation is a key to Change.
• Patients may not have to hit “rock bottom” to become
aware of the need to change.
• Intrinsic motivation is the basis for change, extrinsic
motivation provide suitable conditions for change.
• Motivation to change can be influenced by doctors, family,
friends, emotions and community support. 49

50. DOCTOR AS MOTIVATOR
• Doctors still enjoy a privileged position in our
“commercial” health sector.
• “After God, its Doctor’
• Good interpersonal skills is more important
than professional training or experience
50

51. DOCTOR AS MOTIVATOR
• Change is the responsibility of the patient,
our role is assist and encourage patients to
recognize problem behaviour.
• We can help the patient feel competent to
change, to begin treatment and prevent
relapse
51

52. BUT WE DOCTOR HAVE NO TIME
52
NO SPECIAL TIME REQUIRED

53. Motivational interviewing*
Motivational interviewing is an
EFFECTIVE way to talking to people
about change.
It is useful where you need a change in
behavior- obesity, diabetes, HT,
exercise, etc
*Miller and Rollnick
53

54. 1200 PUBLICATIONS
54

55. Role of Motivational interviewing
• MI helps resolve the AMBIVALENCE
• Elicits patients own motivation for change
55

56. Motivational interviewing
• Start “where the patient is”
• Try to see things from the patient’s point of
view
• Positive approaches are more effective than
confrontation or advisory approach
• “Be patient”
“Jism ki baat nahi, unke dil tak jaana hai.
Lambi doori tay karne mein waqt to lagta hai”
56

57. What exactly we do in motivational
interviewing?
• Win the confidence of the patient
• Make him/her realise that he/she has a
problem
• Help him find his/her own reason for
change
• Help him/her develop ability to change
57

58. Principles of Motivational interviewing
MI is founded on 4 basic principles:
 Express empathy
 Develop discrepancy
 Roll with resistance
 Support self-efficacy
These are basic counseling skills
58

59. EXPRESSING EMPATHY
• Empathy comprises an accepting, non-
judgmental approach that tries to
understand the patient’s point of view.
• We express empathy by our “accepting” body
language and reflective listening skill
• Avoid confrontation and blaming or criticism
of the patient. 59

60. EMPATHISE WITH THEIR REASONS
FOR DRUG USE
• “Zop laagat nahi manhun thodi gheta roj”
• “Handling irritant clients at call centre is the
reason for you using drugs to calm your nerves”
• “Ghanich kaam daaru ghetlya shiway hot nahi”
• “Bayko saarhki navin ghara sathi kit kit karte,
manhoon drinks gheto”
60

61. Develop discrepancy
Create and amplify in the patient’s mind a
discrepancy between their current behaviour
and their goals
What they want, and what will they get if they
continue the addictive behaviour
61

62. Why ask patient?
We can tell patients why they should
quit drugs
• “Cancer hoyil”
• “Liver kharab hoyil”
• “Tujhe aai wadil devsarhke- malkari ani tu
daaru ghetos?”
• “Daaru ghena tujhya sarkhya shiklelya
mansala ghena changala nahi”
62

63. Patients will find their own reason to quit drugs
• “Mula mothi zali and shikale aahe. Tyaana me mishri
khalela nahi aawadat”
• “My girlfriend hates me smoking”
• “I am applying for job in gulf and have to stop my
smoking”
• “People say one cannot “perform” if you smoke, so I want
to stop smoking
• “I am into marketing job and gutka stains my teeth. Its
affecting my performance”
• “We are planning for child and want to stop smoking”
63

64. DEVOLOPING DISCREPANCY HELPS…
“PATIENT express their own reasons
for change”
The best idea come from the patient
64

65. HINTS FOR NOT SO GOOD THINGS
Health – physical and mental;
Social – relationships with partner, family, friends,
work colleagues
Legal – accidents, driving while under the influence
of a substance
Financial – impact on personal budget
Occupational – difficulty with work, study, looking
after home and family
Spiritual – feelings of self worth, guilt.
65

66. HOW TO CREATE DISCREPANCY?
Asking open-ended questions to get patient
start thinking and talking about their substance
use
• “What are the good things about using drugs?”
• “What are the ‘less good things’ for you about
using drugs?
66

67. Patient may not be ready for change!!!!!!!!!!
• “Awadha samjhwun sudha tumhi sudharat nahi mahanje
kay?”
• “Tunhala tumchya gharchyanchi- mula balanchi kaljich
nahi”
• “Nahi sodhlis tar maroon jashil”
• “Tula sodhaychich nasel tar majhya kade yeyo nakoos”
• Addiction is a chronic disease with remissions
and relapses
67

68. Roll with resistance
• Avoid resistance or confrontation
• Shift perceptions
• Invite, but do not impose, new perspectives
• Value the patient as a resource for finding
solutions to problems
• Keep the doors open!!!!
68

69. NOT READY TO QUIT- USE
• Relevance
• Risk
• Rewards
• Roadblocks
• Repetition
69

70. Support self-efficacy
The patient’s belief in the ability to change
is an important motivator
Optimistic empowerment
Restoring their self esteem
Thomas Edison
70

71. Skills we need to develop for MI
• Ask open ended questions
• Affirmation
• Reflective listening
• Summarizing
71

72. Open or closed?
• Are u having pain?
• How are you feeling?
• Don’t you feel like quitting drugs?
• What do you think about your drug habit?
• So are you ready to quit alcohol?
• What do you thing about setting a quit date?
• Does the wife gets mad at you?
• What is your wife’s reaction ?
72

73. ASK OPEN ENDED QUESTIONS
What do you enjoy about your drug use?
What’s about the drug use that you don’t like ?
You seem to have some concerns about your substance
use; tell me more about them
What concerns you about that?
How do you feel about ……..?
What would you like to do about that?”
What do you know about ….?
73

74. OPEN Vs CLOSED
• OPEN ENDED QUESTIONS GETS US TO
KNOW WHAT’S IN THE PATIENT’S MIND
• CLOSED ENDED QUESTIONS REFLECTS
WHAT’S IN THE DOCTOR’S MIND
74

75. Affirmation
Statements of acknowledgement about anything
positive about the patient
To boost confidence
To build up self-efficacy
NO ONE TRUST THEM AND THEIR ABILITY
WE NEED TO …
75

76. Affirmation
– “I think it is great that you want to do
something positive for yourself.”
– “That must have been very difficult for you.”
– “That is a good suggestion.”
– “I appreciate that you are willing to talk with
me about your substance use.”
– You really care about your children
– It great to know that you had quit smoking
almost for a week.
76
(Source: McGree, 2005)

77. REFLECTIVE LISTENING
• Understanding what the patient is thinking and
feeling and then saying it back to the patient.
• Using reflective listening is like being a mirror for
our patient
• Reflective listening shows the patient that the we
understand what has been said and it can be used
to clarify what the patient means.
• It conveys our empathy 77

78. REFLECIVE LISTENING
• “I do not want to upset
my family.”
• Hmmm… I don’t know.
Not sure…. I mean…
• Am I drinking so much?
 “It is really important to
you to keep your
relationship with your
family.”
 “You are not
comfortable talking
about this.”
 “You are surprised that
your score shows you
are at risk for problems.”
78

79. REFLECIVE LISTENING
79

80. Summarising
It is an important way of gathering together
what has already been said.
Summarizing is used to highlight the patient’s
ambivalence- it’s a long reflection
You can be selective to use your hidden
agenda in summary to make a positive change
in patient
80

81. Summarising
“On the one hand, you enjoy drinking at parties and
you are not using any more than your friends.
On the other hand, your wife is not happy with your
drinking habit and fights with you.
Also it is now affecting your health that worries you”
81(Source: McGree, 2005)

82. 82
Brief intervention
Brief intervention is low-intensity, short-duration
counselling for those who screen positive
 Uses motivational interviewing style
 Incorporates readiness to change model
 Includes feedback and advice
(Source: McGree, 2005)

83. 83
Rationale for brief intervention
• Studies show brief interventions (BIs) in
primary care settings are beneficial for alcohol
and other drug problems
• Brief advice (3 minutes) is just as good as 20
minutes of counselling, making it very cost
effective*
• BIs extend services to individuals who need
help, but may not seek it.
(*Source: WHO Brief Intervention Study Group, 1996)

84. Components of brief intervention
“FRAMES”
• Feedback is given to the individual about personal
risk
• Responsibility for change is placed on the patient
• Advice to change is given
• Menu of treatment options is offered to patient
• Empathic style
• Self-efficacy or optimistic empowerment

85. PRECONTEMPLETION
• Offering factual information about the risks of
substance use
• Providing clear , strong and personalized
feedback about harm because of their drug
use
• Eliciting the patient's perceptions of the
problem
• Exploring the pros and cons of substance use
• Express concern and keep the door open.
• Roll with resistance
85

86. CONTEMPLATION STAGE
• Eliciting and weighing pros and cons of
substance use
• Evoking self-motivational statements for
change from the patient.
• Summarize self-motivational statements.
• Emphasizing the patient's free choice,
responsibility, and self-efficacy for
change .
86

87. Preparation Stage
• Offer a menu of options for treatment and expert
advice
• Evaluate “ability” to change and empower
• Elicit from the patient what has worked in the past
• Negotiate a treatment plan
• Help the patient enlist social support.
• Have the patient publicly announce plans to
change.
87

88. MENU OF OPTIONS
• Keeping a diary of substance use (where, when, how much,
who with, why)
• Helping patients to prepare substance use guidelines for
themselves
• Identifying high risk situations and strategies to avoid
them
• Identifying other activities instead of drug use – hobbies,
sports, clubs, gymnasium, etc.
• Encouraging the patient to identify people who could
provide support and help for the changes they want to
make
• Providing information about other self help resources and
written information 88

89. MENU OF OPTIONS
• Inviting the patient to return for regular
sessions to review their substance use and to
• work through the “substance users guide to
cutting down or stopping” together
• Providing information about other groups or
counsellors that specialise in drug and
• alcohol problems
• Putting aside the money they would normally
spend on substances for something else
89

90. STAR
• S: SET A QUIT DATE
• T: TELL YOUR CLOSE PEOPLE
• A: AWARENESS ABOUT WITHDRAWALS
AND COPING SKILLS TO PREVENT
• R: RE-INFORCERS, REPLASE
PREVENTION, REARRANGE FOLLOW UP
90

91. ACTION STAGE
• Acknowledge difficulties for the patient in early
stages of change.
• Help the patient identify high-risk situations and
develop appropriate coping and problem
strategies to overcome these.
• AVOID-COPE-ESCAPE
• Assist the patient in finding new re-inforcers of
positive change.
• Help the patient find strong family and social
support.
• Focusing on the benefits of change
91

92. MAINTENANCE STAGE
• Help the patient identify and maintain drug-
free sources of pleasure (i.e., new re-inforcers).
• Support lifestyle changes.
• Affirm the patient's resolve and self-efficacy.
• Help the patient practice and use new coping
strategies to avoid a return to use.
92

93. Relapse/Recurrence
• Relapse is not a failure
• If relapse occurs, identify what stage the
individual cycled back to and move forward
from there.
• Help the patient re-enter the change cycle.
• Assist the patient in finding alternative
coping strategies.
• Maintain supportive contact.
93

94. 94
If only tool you have is hammer then
every problem looks like a nail

95. CHARGE FOR YOUR COUNSELLING TIME
95

96. Thank you
Dr Madhu Nimesh Thakkar
Muktaa Charitable Foundation
www.mcf.org.in
Email: madhu.oswal@mcf.org.in
MOB: 9890044477
9/4/2016 MUKTAA CHARITABLE OUNDATION-SAMVAD HELPLINE-020-26381234

97. CASE 1
Yash, a software engineer, came with his wife
who is in her 1st tri of pregnancy.
Yash complains of headache, increased cough
with postnasal drip, sore throat. He feels very
restless, irritable and found that he is not able
to concentrate in his work.
97

98. ASK and ASSESS
• Tumhala cigarrette, daru kinwa iter kuthly
savay ahe ka kinwa hoti ka?
• If yes, how much, how long, how severe is
the dependence?
• What stage of change the patient is in?
• Any past quit attempts and its experience?
98

99. WHAT’S YOUR DIAGNOSIS?
• Fagerstrom score is 8, he used to smoke
more 2 packs a day: Heavy user
• Now in Nicotine withdrawals
• Stage of Change: Action
• Intervention: Assist and Arrange
• Score more than 6: Need BI and
Pharmacological help
99

100. Action stage: Trying to quit
• Help them to set a quit date in the next two
weeks- done.
• Let him declare to every one that he is quitting.
• Getting tobacco out of sight- THINGS AND
PLACES AND PERSONS
• Educate them about withdrawal symptoms and
simple ways of handling them.
• Advise them to plan on how to handle situations
that set off urges to use in ways other than by
using tobacco.
100

101. CASE 2
• A 50 year old male comes for early morning
headache for last 1 month.
• BP: 180/94 NOT ON ANY ANTI-
HYPERTENSIVE DRUGS
• He is a business man
101

102. ASK
• Using tobacco ( Gutkha) since 15 years
• 12 -13 pouches a day
• Tried to quit many times as teeth are
stained and does not look nice when in
business meetings.
• “Khup prayatne kele, pay sutat nahi”
• Now has given up the hope of quitting
because of previous failed attempts
102

103. Assess
• Fagerstrom score: 7
• Stage of change: Contemplation
• Failed in previous attempts as had a very
strong craving and his friend circle all uses
Gutkha
103

104. Feedback
• “Your score shows you have a high nicotine
dependence
• Your BP is high and even if we treat BP, it
wont help unless the tobacco use stops
• Chances of cardiac complications increases
when tobacco use is along with diabetes or
HT.
104

105. Responsibility: Tumcha nirnay….
• Now that you know the risks, what do you
think you should be doing about your
Gutkha habit?
• HE SAYS HE WANTS TO QUIT: Moved
from Contemplation to Preparation stage
105

106. Preparation Stage
• Offer a menu of options for treatment and
provide expert advice
• Negotiate a treatment plan
• Help the patient enlist social support.
• Elicit from the patient what has worked in the
past
• Have the patient publicly announce plans to
change.
• Follow up when prepared to take action
106

107. Case 3
• Mahesh, 23 years old, labor comes for URTI
• O/e: Leucoplakia
107

108. Ask
• “Kya tumhe bidi, cigarrate, gutka daro ya
aur kisi cheej ki aadat hai ya thi?”
• Kab se?
• Kitna?
• Kabhi chodne ka prayas kiya?
108

109. Ask
• Taking Gutkha since childhood when he was 8
year old
• Now he takes 8 to 10 sachets a day as its costly
• Never attempted to quit otherwise cannot do
the hard hamali kaam
• But he had severe restlessness, anxiety when
there was a sudden gutkha ban and availability
was a problem
• Has to take Gutkha first thing in the morning
109

110. Assess
• Fagestrom score: 7
• Stage of change: Precontemplation
• No quit attempt in past
110

111. Feedback
• Your have a lesion in your mouth which
could be precancerous- Show him mirror
• Its because of your years of Gutkha use
• If you stop Gutkha at this stage, the lesion
may not progress.
111

112. Responsibilty: Tumhe sochna hai
• He says he cannot do the hamali work
without Gutkha
• And he has to feed a family of 6
112

113. USE MOTIVATION ENHANCEMENT TECHNIQUE
• Express empathy by reflective listening
“ Tumhe bahut kathin kaam karna hota hai
aur bina gutkha wo karna mushkil hai
• Develop discrepancy: “Aap ko che logo ka
khayal rakhna padta hai aur koi kamana wala
nahi. To aap ka swasth rehna jarori hai”
• Roll with resistance: Don’t argue if he is not
yet ready to give up Gutkha at this stage.
113

114. USE MOTIVATION ENHANCEMENT TECHNIQUE
• Self efficacy: “aap ko kam karne ke liye
gutkha jarori kagta hai par aap ko swasth
rehana bhi aap ke pariwar ke liye bahut
zarori hai”Aap ko sochna hai aap ko kya
karna hai
• Give him some reading material or ask him
to see the posters in your waiting room.
• Assure him of help when he wants to quit
114

115. NOT READY TO QUIT- USE
• Relevance
• Risk
• Rewards
• Roadblocks
• Repetition
115

116. Case 4
• Rohan wants to go to Saudi Arabia and has
come to you to get rid of his alcohol habit.
116

117. ASK AND ASSESS
• How much you drink?- 4 -5 drinks( whisky) 2 to 3
times a week . Weekends 6 to 7 drinks
• Cage questionnaire: GUILT, wife is Annoyed
• Audit: Score is 15
• Tried to quit in past during Shravan, but suffered from
severe craving.
• Stage of Change: Preparation with motivation to stay
abstinent.
• No H/o suggesting of cardiac disease
• Clinically NAD except tremors.
• LFT, RFT normal.
117

118. ADVICE and assist
• Avoid high risk situations
– times,
– places,
– occasions,
– people,
– thoughts and emotions
Use problem solving approach.
118