SfoC ubr thlin se Aica tanssessl Pr ma cec Tpanrhodep mporraotnbioalengmesm aoenfn dpt s ioty fci hsS UoaaD cmst iaavjreoe rs o upbbuvsbitoalinuccs hley eu iamslethp do cirsotoanrncdtee, rbrnsu t(in StU hIeDnrdse)i a ihs. a Cas l wirneiiadcceah lv eaadsr sieaepbsiisdlmietyme niinct e Ument atice G sn clinical practice and deviance from evidence base. The members of the IPS Specialty edu Section on Substance Use Disorders felt that it would be a worthwhile venture to Mid Dae develop an updated set of Clinical Practice guidelines (CPGs) for assessment and nl management of SUDs. The present volume is the result of such endeavour. iagin see oms Talhceo hfoolll ouwsien gd iasoreradse rasr, eo cpoioveidre uds bey d tihsoersdee CrsP,G csa: nanssaebsissm uesen td oisfo SrUdeDrss ,i nse gdeanteivrael-, ren hypnotic use disorders, tobacco use disorders, inhalant use disorders, and dual dt o ef diagnosis. r s The development, refinement and finalization of these CPGs was the result of an arduous, long-drawn and rigorous process following a pre-defined iterative strategy involving progressively widening circles of peer review. The current Guidelines follow the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument. D e Each chapter begins with a clinically useful “Executive Summary” that summarizes b a the key recommendations and issues. Individual “Key Recommendations” are s i mentioned at the end of each major subsection of the chapters. sh The primary target audience for these CPGs is the practicing clinicians (especially BaEd psychiatrists but also non-psychiatric medical doctors and even non-medical suito professionals working in the area of SUDs). They should benefit from the Executive , rs Summary and Key Recommendations to be applied in their clinical practice. The P.K secondary, but very important, audiences include medical teachers, postgraduate . students, and researchers. These CPGs provide a comprehensive compendium of D updated knowledge that can be a rich resource for academic purposes of teaching, a l learning, and research. Finally, these might be of benefit to medical institutes and a l to policy makers to inform healthcare related decisions in the area of SUDs (e.g., the decision to fund and implement opioid substitution treatment programmes in an institute or in a state or even national basis). CPGs are meant to inform, assist and “guide” the clinician, not ask them to sacrifice their autonomy of clinical judgment, nor to be oblivious of the individual patient’s clinical situation and psychosocial context. With this caveat, if used for the correct purpose and in the correct manner, we hope that these CPGs should prove useful to An both their primary as well as secondary readerships. Official Publication - Debasish Basu, P.K. Dalal (Editors) of IPS CLINICAL PRACTICE GUIDELINES FOR THE ASSESSMENT AND MANAGEMENT OF SUBSTANCE USE DISORDERS Indian Psychiatric Society Speciality Section on Substance Use Disorders 2014 Editors: Debasish Basu P.K. Dalal Published by Indian Psychiatric Society INDIA An Official Publication of Indian Psychiatric SoCcliineitcyal Practice Guidelines - 2014 Clinical Practice Guidelines for the Assessment and Management of Substance Use Disorders Editors : Debasish Basu P.K. Dalal First Edition : January, 2014 Price : Rs.500/- Rs.100/- for IPS Members Editorial Office : Dr. Debasish Basu Professor of Psychiatry, Drug De-addiction & Treatment Centre, Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh-160012, India. Email : [email protected] Prepared by : Indian Psychiatric Society Speciality Section on Substance Use Disorders Website : http://www.ips-online.org For copies : Dr. M.S. Reddy Chair, IPS Publication Committee Asha Hospital, # 298, Road No.14. Banjara Hills, Hyderabad. Email : [email protected] Printed at : Aparna Graphics Kachiguda, Hyderabad. Email : [email protected] C All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, digital, recording or otherwise, without the prior permission of the publishers. ii Speciality Section on Substance Use Disorders IPS Executive Council Members (2013-14) Office Bearers President : Dr. Indira Sharma Vice-President : Dr. T.V.Asokan General Secretary : Asim Kumar Mallik Hon.Treasurer : Dr. Vinay Kumar Hon.Editor : Dr. T.S.S.Rao Immediate Past President : Dr. Roy Abraham Kallivayalil Immediate Past Secretary : Dr. U.C.Garg Executive Council Members (Direct) Dr. Sri Kumar Mukharhjee Dr. Rajeev Jain Dr. C.L.Narayan (Maj) Nand Kishore Dr. VSSR Ryali Dr. K.Sudarsan Dr. Mukesh Jagiwala Zonal Representatives Central Zone : Dr. Sarvesh Chandra, Dr.Sudhir Kumar East Zone: Dr. T. Sudhir, Dr. U.K.Sinha North Zone: Dr. Chander Mohan, Dr. R.K.Solanki South Zone : Dr. N.N.Raju, Dr. G.Prasad Rao West Zone : Dr. Kishor Gujar, Dr. Kaushik Gupte iii Clinical Practice Guidelines - 2014 INDIAN PSYCHIATRIC SOCIETY Speciality Section on Substance Use Disorders Chair: Dr. P. K. Dalal Convener: Dr. Debasish Basu Members: Dr. Atul Ambekar Dr. Kaustav Chakraborty Dr. Prabhat Chand Dr. Anju Dhawan Dr. Shubhmohan Singh Dr. B. N. Subodh IPS PUBLICATION COMMITTEE Chair: Dr. M.S. Reddy Convenor : Dr. Lalit Batra Advisory Board Members Dr. Indla Ram Subba Reddy Dr. E.Mohan Das Dr. P.K.Singh Dr. Ajit Avasthi Dr. Y.A. Matcheswalla Dr. Sudheer Kumar Editorial Board Members Dr. Avdesh Sharma Dr. Anand Dr. Eesha Sharma Dr. Arshad Dr. Uday Choudhury Dr. Tophan Pati Dr. Gowri Devi Dr. Guatam Saha Dr. Manaswi Gautham Dr. P.C.Shastri Dr. Sujata Sethi Dr. Nilesh Shah Dr. M.S. Bhatia Dr. Ruma Bhattacharya Dr. Prabhat Sitholey Dr. Rajkumar Dr. R.K. Gour Dr. Palaniappun Dr. B. Ram Dr. G.Swaminath Dr. Ajitha S. Nayak iv Speciality SecCtioLn I NonI CSuAbsLta nPceR UAseC DTisIoCrdEer sGUIDELINES FOR THE ASSESSMENT AND MANAGEMENT OF SUBSTANCE USE DISORDERS INDIAN PSYCHIATRIC SOCIETY SPECIALTY SECTION ON SUBSTANCE USE DISORDERS 2014 Authors of the Chapters Atul Ambekar Additional Professor of Psychiatry National Drug Dependence Treatment Centre All India Institute of Medical Sciences (AIIMS), New Delhi 110029 Email : [email protected] Debasish Basu Professor of Psychiatry Drug De-addiction & Treatment Centre Department of Psychiatry Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh 160012 Email : [email protected] Kaustav Chakraborty Assistant Professor Department of Psychiatry College of Medicine and J.N.M. Hospital, Kalyani, West Bengal University of Health Sciences, West Bengal. Email : [email protected] Prabhat Chand Associate Professor of Psychiatry Centre for Addiction Medicine Department of Psychiatry National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore 560029 Email : [email protected] v Clinical Practice Guidelines - 2014 P.K. Dalal Professor and Head Department of Psychiatry King George’s Medical University, Lucknow 226003 Email : [email protected] Amitava Dan Assistant Professor Department of Psychiatry Calcutta National Medical College and Hospital, Kolkata Email : [email protected] Anju Dhawan Professor of Psychiatry National Drug Dependence Treatment Centre All India Institute of Medical Sciences (AIIMS), New Delhi 110029 Email : [email protected] Abhishek Ghosh Senior Resident Department of Psychiatry Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh 160012 Email : [email protected] Shrigopal Goyal Research Officer Department of Psychiatry & National Drug Dependence Treatment Centre, All India Institute of Medical Sciences (AIIMS), New Delhi 110029 Email : [email protected] Pratima Murthy Professor of Psychiatry Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore 560029 Email : [email protected] vi Speciality Section on Substance Use Disorders Subodh B.N. Assistant Professor of Psychiatry Drug De-addiction & Treatment Centre, Department of Psychiatry Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh 160012 Email : [email protected] Kavita Nagpal Senior Resident Drug De-addiction & Treatment Centre, Department of Psychiatry Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh 160012 Email : [email protected] Raman Deep Pattanayak Assistant Professor of Psychiatry National Drug Dependence Treatment Centre All India Institute of Medical Sciences (AIIMS), New Delhi 110029 Email : [email protected] Siddharth Sarkar Senior Resident Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry 605006 Email : [email protected] Shubh Mohan Singh Assistant Professor Department of Psychiatry Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh 160012 Email : [email protected] Umamaheswari Vanamoorthy Senior Resident, Department of Psychiatry National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore 560029 Email : [email protected] vii Clinical Practice Guidelines - 2014 CONTENTS Topics Pages IPS Committees ... iii-iv Authors ... v-viii Preface ... ix Foreword ... xi Overview ... 1-12 Assessment ... 13-96 Alcohol ... 97-156 Opioids ... 157-262 Cannabis ... 263-294 Sedative-hypnotics ... 297-344 Tobacco ... 345-382 Inhalants ... 383-466 Dual Diagnosis ... 469-513 viii Speciality Section on Substance Use Disorders PREFACE It gives me great pleasure to write the Preface of the book “Clinical Practice Guidelines for the Assessment and Management of Substance Use Disorders”, published by the Indian Psychiatric Society. Psychoactive substance use disorders take a heavy toll on the individuals, their families and the society at large. The situation has become very grim in India, with millions of people afflicted with these disorders. Along with the traditional substances like alcohol, opium and its derivatives, cannabis and tobacco, relatively newer substances like prescription drugs, injectable drugs, inhalants and others have made their entry in India and now pose a real threat. Management of these disorders, therefore, is an essential skill needed by all physicians and health professionals. Psychiatrists have to take leadership roles in this area. Substance use disorders are psychiatric disorders, and their management often requires a judicious combination of the right kind of knowledge, skills and attitude. Both pharmacological and non-pharmacological management, preceded by a comprehensive biopsychosocial assessment, are needed for this purpose. Herein lies the problem, because the clinical management of substance use disorders is far from uniform and consistent. Clinical practice varies widely from country to country, region to region, sector to sector, and even centre to centre. The evidence for various methods and modalities for management is large, changing, and at times inconsistent. In the face of such heterogeneity, it becomes difficult for the practicing clinician to choose the right approach of management. Clinical practice guidelines (CPGs) can be of substantial help in this situation. These are systematic statements, derived in a scientific manner, purported to assist and guide the clinicians in their decision making regarding management of specific clinical conditions. The previous CPGs developed by the IPS Task Force on substance use disorders were published in 2006. Things have changed since then, both in terms of prevalent patterns of use of substances and in terms of progress and clarifications made in their management. Thus it was imperative to update. In this regard, the IPS Specialty Section on Substance Use Disorders has done a commendable job of producing an entirely new set of comprehensive ix