Our treatment approach is dedicated by simple principles ..

The treatment team at the Nirmal Hospital, Deaddiction & Rehabilitation Centre embraces a variety of medication treatment and behavioural approaches that are supported by strong scientific evidence and designed to improve outcomes for clients suffering from addictive disorders. We believe that individuals face several challenges in dealing with substance – related issues and accordingly we have designd a personalized treatment approach that has the best possibility of achieving the successful outcome of abstinence.

Medical Management:-

At Nirmal Hospital, Deaddiction & Rehabilitation Centre medical management is supervised by a licensed and qualified Psychiatrist to control distressing symptoms and improve the quality of life.
Medications are generally used with the following four goals:
1. Problems for acute and maintenance treatment of co-occurring psychiatric disorders.
2. For symptom – specific improvement (E.g. Withdrawal Symptoms, treatment of insomnia)
3. To achieve abstinence or reduction in use of alcohol and drugs.
4. To reduce relapse into alcohol or drug use.

Behaviour treatment approach:-

1. Cognitive behaviour therapy (CBT).
2. Motivational enhancement therapy (MET)
3. Relapse prevention therapy (RPT)
4. Group therapy
5. Twelve step facilitation (TSF)
6. Individual therapy
7. Rational Emotive Behaviour Therapy(REBT)

Psychiatric Illnesses treated at Nirmal Hospital, Deaddiction & Rehab Centre, Miraj

1. ANXITY / DEPRESSION / PHOBIA:- In this condition patient feels depressed Lonely, Feels like Crying, Reduced Appetite, Feeling sad, Weight loss, occasionally wait gain, Patient gets suicidal ideations, Lack of confidence, feels worthless, hopelessness, worthlessness etc.
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2. SCHIZOPHRENIA:- In this condition patient gets unknown fear, Suspiciousness towards peoples as talking about him planning something in food to kill him or her. Patients becomes aggressive / abusive / assaultive / gets hearing of voices in absence of anyone, mattering to self, smiles / weeps without reason. Sometimes patient becomes withdrawn, does not mix with others, Neglects personal care& hygiene, does not take bath In chronic stage, passes urine and stool at inappropriate places.
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3. SOMATO FORM DISORDER:- In this condition patient gets multiple physical complaints E.g. pain in chest / Abdomen, Headache, Low backache, pain in extremities, Heaviness of Head, Dryness of, mouth, Hyper acidity patients feels he has same major illness despite of all reports are normal, sexual symptoms, menstrual problems etc.
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4. OBSESSIVE COMPULSIVE DISORDER:- In this condition patients gets unwanted / un necessary repeated intrusive thoughts, Repeated checking doors, tap water, lights, locks etc. Repeated counting, Repeated hand washing, behaviour , Excessive cleanliness, Excessive use of water, taking long time for bath etc.
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5. HEADACHE:- Headache may be Local / diffused, dull or throbbing, episode or continuous, precipitated by sleep or particular food like ice – cream, chocolate etc. Relieved by sleep, Medicines, depending upon type of Headache. So Patient may need EEG/CT/MRI Brain like investigations.

6. EPILEPSY:- In this illness patient gets lock jaw, up rolling of eyeballs, tongue bite, frothing from mouth, voids urine in clothes, may get vomiting, Headache with total or partial lass of consciousness . To diagnose Epilepsy EEG Should be done May require MRI / CT Scan to know the exact cause.
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7. MANIA:- In this condition patient feels be feelsgreat, talks big things, feels happy, joyful, spending sprees,some patients becomes overactive / Aggressive, violent with Decreased need of sleep.May get grandiose ideas etc.

8. GERIATRIC ILLNESS / old age Problems / Dementia:- In this condition patients gets forgetfulness, unable to recall past events, unable to recognize peoples / places, poor orientation to time / places / person. Patients makes mistakes at work, repeatedly asks for tea, food even if he was already given etc.
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9. CHILD PROBLEMS:- Fear of going to School, fear of examination in student, poor scholastic performance, unable to concentrate at studies, stammering, speech, stuttering, bed wetting, Hyper activity , Mental Retardation , thumb sucking, pica etc....
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10. Sex Problems:- Patients gets complaints like...
1. Feels generalised weakness, Gets anxiety before performance
2. Difficulty in Maintaining Erection
3. Difficulty in initiation and Maintaining Erection
4. Lack of Erection
5. Feels as having small size genitalia
6. Curvature of penis Lt / Rt side
7. H/O Masturbation
8. Feeling guilty about Masturbation
9. H/O Night fall
10. Passing That through urine
11. H/O exposure

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Designated classes of pharmacological agents (i.e. Substance) :1) Alcohol 2) Anabolic steroids 3) Caffeine 4) Cannabis 5) Cocaine 6) Hallucinogens 7) Inhalants 8) Nicotine 9) Opioid 10) Drugs - Sedatives, Hypnotism and anxiolytics

* Physical Dependence - Refers to the physical (physiological) effects of multiple episodes of substance use. i.e. Ideas of tolerance or withdrawal appears in criteria for dependence.

* Intoxication - Term is used for a reversible non dependent experience with a substance that produces impairment.

* Psychological dependence - also referred to as habituation, is characterized by a continuous or intermittent craving for the substance to avoid a dysphonic state.

Substance withdrawal - development of substance specific syndrome due to the cessation or reduction in substance use.

DSM IV Diagnostic criteria for substance Dependence

Manifested by three or more of the following occurring in any time in 12 months period
1) Tolerance - Markedly diminished effect with continued use of the same amount of substance a need for markedly increased amounts of substance to achieve intoxication or desired effect.
2) Withdrawal Symptoms - These symptoms are variable depending upon the substance.
3) Substance is often taken in larger amounts or over a longer period.
4) There is a persistent desire or unsuccessful efforts to cut down or control substance use.
5) Great deal of time is spent in activities necessary to obtain. The substances e.g. driving long distances.
6) Important social, occupational or recreational activities are given up or reduced because of a substance use.
7) Substance use is continued despite knowledge of having persistent or recurrent physical or psychological problem.

Diagnostic criteria for alcohol Intoxication:-

1) Recent injection of alcohol
2) One (or more) signs - slurred speech In coordination Unsteady gait Nystagmus (Antegrade grade amnesia) - Impairment in attention or memory Stupor or coma
3) Significant maladaptive behaviour or psychological changes. (i.e. inappropriate sexual or aggressive behaviour mood, liability, impaired judgment, impaired social or occupational functioning)

Alcohol withdrawal : -

1. Classical signs - tremulousness i.e. shakes or jitters (although spectrum of symptom may expand to psychotic and perceptual symptoms i.e. delusions and hallucinations)
2. Tremors - develops 6-8 hrs after cessation of drink
3. Delusion, hallucinations - begin in 8-12 hrs.
4. Delirium tremens during 72 hrs.
5. Conditions which can predispose to or aggravate withdrawal symptoms - include fatigue, malnutrition, physical illness and depression.
6. Seizures - Seizures (Rum fits) - begin in 12-24 hrs.
7. Seizures are stereotyped, generalized and tonic Clonic in character.
8. Patients often have more than one seizure 3-6 hrs after 1st seizure.
9. Status epileptics is relatively rare & occurs in less than 3 % of patients.
10. Rx of Rum fits - Usually anticonvulsant is not required for withdrawal seizures. Anticonvulsant if stated immediately - anticonvulsant should be discontinued once the cause of seizures is recognized.

Diagnostic criteria for alcohol withdrawal

A) Cessation or reduction in alcohol use B) Two or more of the following symptoms are seen -
1) Automatic hyper activity (e.g. sweating or pulse rate greater than 100)
2) Increased hand tremor
3) Insomnia
4) Nausea or vomiting
5) Transient visual, tactile or auditory hallucinations or illusions
6) Psychomotor agitation
7) Anxiety
8) Grand mal seizures

NICOTINE:- • Tobacco • Gutkha • Cigarette • Bidi • Mawa • Tapkir
Nicotine withdrawal : (A) Daily use of nicotine for at least several weeks. (B) Abrupt cessation of nicotine use or reduction in the amount of nicotine used, followed with in 24 hours by 4 or more of the following signs
1) Dysphonic or depressed mood
2) Insomnia
3) Anxiety
4) Difficulty in concentrating
5) Irritability, frustration or anger
6) Restlessness
7) Decreased heart rate
8) Increased appetite or weight gain

Phases of treatment for Alcohol Dependence:-

• Pre-Treatment :
1. Identification
2. Motivational Interviewing
3. Role of family members and physicians

• Detoxification :
1. Diazepam (20-60 mgs Per day) or Chlordiazepoxide (50-60 mgs. per day)/Lorazepam
2. Thiamine (or as part of Vitamin B-Complex) 50 mgs. Thrice a day orally or 100 mgs. IM daily
3. Supportive Measures viz fluids, electrolytes etc.

• Intensive Treatment :
1. Brief Intervention / Simple advice
2. Disulfiram (only with consent) Anti craving drugs (NTX, Acamprosate)
3. Group Therapy
4. Family Therapy
5. Behaviour Therapy

• Posttreatment / Aftercare:
1. Treatment contact
2. Relapse Prevention
3. Social Rehabilitation
4. Occupational Rehabilitation
5. Continued Supervision

* Chlordiazepoxide orally every 6h for 3d (50-100 mg per dose day 1, then 25-50 mg per dose)
* Diazepam 5-20 mg orally every 2h while symptomatic until resolution
* For delirium tremens Diazepam 10 mg intravenously, then 5 mg every 5 min until calm but awake.
* If unable to take oral medication or in the presence of hepatic synthetic dysfunction (hypoalbuminemia, elevated prothrombin time), intramuscular, sublingual, oral or intravenous (for delirium tremens only) lorazepam 1-4 mg may be substituted. Oral oxazepam 30-60 mg or lorazepam may be substituted in the elderly and those at risk of excessive sedation or its complications.
* All patients should receive thiamine 50-100 mg daily.
* Treatment of Alcohol Withdrawal Seizures
* The seizure generally resolves spontaneously. Benzodiazepines, carbamazepine, and probably Phenobarbital prevent seizures, but phenytoin is ineffective preferably diazepam, chlordiazepoxide, or lorazepam, all shown to prevent initial and recurrent seizures.
* Treatment of Delirium Tremens - 20-50 % of patients die eventually if not treated, there is 5-10 % mortality even with treatment .
* It requires immediate hospitalization in untreated cases.
* Treatment of choice is intra venous diazepam (10 mg every 20 minutes till patient is sedated or signs and symptoms of withdrawal subsides) * Or IV lorazepam 2-8 mg

Treatment for alcohol dependence continues

* Anti craving agents – * Topiramate- 50-200 mg,
* Acamprosate - 333 mg 2 tab TID
* Carbamazepine - 300 - 1000
* Naltrexone - An analogue of naloxone, is a relatively pure opioid antagonist - with highest affinity of for the mu-opiate receptor type.
* Naltrexone reduced alcohol craving, days of drinking per week, and the rate of relapse among those who drank.
When administered at 50 mg/day for 3 months.

Treatment For Alcohol Dependence Continues

* Selective Serotonergic Reuptake Inhibitors- Fluoxetine 20 mg, Escitalopram 10,20 mg. Sertraline 25,50 mg Fluoxamine-50 mg
* Topiramate - Antiepileptic and adjuvant mood stabilizer. It inhibits release of dopamine in meso-cortico-limbic pathway by augmenting GABA and inhibiting specific glutaminergic pathway. It also inhibits carbonic anhydrase enzyme Dose is 25 to 300 mg. per day.
* Ondansetron - a selective 5HT3 receptor antagonist. It reduces urge to intake
* Combinations of above drugs can be used.


* Alcoholic patients with major depression.
* Alcoholic patients with anxiety depression. PDF Download
* Alcoholic patients with Somatoform disorders.
* Alcoholic patients with Obsessive compulsive disorder.
* Alcoholic patients with Dissociative disorder.
* Alcoholic patients with Mood disorders/Swings- mania and depression.
* Alcoholic patients with Personality disorders.
* Alcoholic patients with Schizophrenia / other psychotic disorder. PDF Download
* Alcoholic patients with other substance dependence PDF Download

A] Pharmacotherapy For Nicotine Dependence

* The nicotine gum : is usually used during the first few months of a quit attempt.
* Nicotine gum is available in 2 and 4 mg.
* Most patients can start reducing use of gum after 3-4 weeks.

B] Nicotine Therapy:-

* Bupropion : The mechanism of action is unknown
* Action- Enhancing dopamine levels in the mesolimbic system

C] Other Pharmacotherapies For Nicotine Dependence

Includes agents that make smoking aversive (e.g. silver acetate) clonidine, blocking agents (e.g. mecamylamine, naltrexone) and medications to decrease withdrawal problem or replace the positive effects of nicotine (e.g. anxiolytics, antidepressants, stimulants, anorectics)

Management of Opioid Abuse and Dependence:-

* Opioid Agonist Pharmacotherapy
* Methadone : Methadone is a m opioid receptor agonist and produces the typical morphine like effects in people, including euphoria, drowsiness, analgesia, respiratory depression nausea, vomiting. constipation, itching and constriction of pupils. Methadone is 20-30 mg, with 5 to 10 mg increases every other day as tolerated. usual dose of ranges from 30-100 mg.

* Levomenthol acetate (LAAM) - - is derivative of methadone. Its long duration of action (48-72 hrs) allows dosing at 48-72 hr interval for opioid maintenance treatment.

* Buprenorphine : buprenorphine, is a partial m opioid against and a weak k opioid antagonist . Buprenorphine formulated as a sublingual tablet is available alone or in a combination tablet containing Buprenorphine and Naloxone in a ratio of 4:1

* Opioid antagonist pharmacotherapy Naltrexone, an opioid antagonist blocks opioid receptors competitively. Single daily dose of 50 mg, doses of 100-150 mg can block opioid effects for 48-72 hrs.

* Psychotherapy- Cognitive-behavioural therapy, relapse prevention and psychotherapy (individual, family and group therapy)