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Alcohol, Drugs and Tobacco

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Category: Alcohol, Drugs and Tobacco

Alcohol, Drugs and Tobacco
26/01/2019

Alcohol, Drugs and Tobacco

Psychiatry

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Alcohol, Drugs and Tobacco

abuse
  • Alcohol
  • Cannabis
  • Smoking Tobacco
  • Sleeping Pills

Consultation Charges

Adults:

First consultation Psychiatry – ₹ 1700

Follow up consultations– ₹ 1250

Overseas :

First consultation Psychiatry – ₹ 3750

Follow up consultations– ₹ 3750

Children :

First consultation Psychiatry – ₹ 1700
First consultation Psychiatry – ₹ 1700
Follow up consultations– ₹ 1250
Behaviour Therapy With videos (where applicable) – ₹ 2750 For Domestic patients (price for half an hour session)

Cognitive Behaviour Therapy – ₹ 3750
For overseas patients (price for half an hour session)

Marital therapy – ₹ 3000 price for half an hour therapy.
(Rs 1500 per person)

Biofeedback– ₹ 3000

Medical Specialists

Dr. Vijayakumar D.R

Consultant Psychiatrist
Dr. Vijayakumar D.R is a senior psychiatrist with more than 22 years of experience in handling mental health issues in India, Australia and the United Kingdom.

Dr. Madhu Shree Vijayakumar

Consultant Obstetrician and Gynaecologist
Dr. Madhu Shree Vijayakumar, Is an obstetrician and gynaecologist with about a decade experience in addressing women’s health problems from adolescence to post menopause.

Medical Specialists

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Consultation Days:

Mon, Tues,
Thurs & Friday10:00 am to 2:00 pm

Monday to
Saturday 4:00 pm to 9:00 pm

Sunday 9.00 – 15.00

Consultation by appointment only
Call : +91-82961-12250

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Doctors Timetable

No health without mental health.

VIEW TIMETABLE
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Emergency Cases

+91-82961-12250

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by Manasvi Specialistsin Alcohol, Drugs and Tobacco, Psychiatry0
Sleeping Pills
02/01/2019

Sleeping Pills

Psychiatry

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Sleeping Pills

Benzodiazepines.

What are benzodiazepines?

Benzodiazepine are a group of drugs which are commonly used as sleeping pills. This group contains about 20 specific drugs which vary in how long they work, how much sedation it provides and how much it helps to reduce anxiety symptoms.

What are they used for?

Benzodiazepines are classified as sedatives or anxiolytics (for relieving anxiety).

They are commonly used to reduce anxiety and for sedation. Sometimes they can also be used to treat seizures, alcohol withdrawal, aggression, and to relax the muscles.

Are benzodiazepines addictive?

Yes, benzodiazepine medications can cause dependence and hence should not be used for long term except under certain special circumstances and only by a specialist doctor.

It should never be used without prescription or as self medication.

Normally it is used up to 2-3 weeks and gradually tapered and stopped.

It is to be noted it is one of the most common prescription medications abused by patients.

What are the long term side effects of benzodiazepines?

Benzodiazepines can cause drowsiness, lack of motivation, memory impairment, and changes in emotional response, paradoxical anxiety, irritability, headaches, and aggression, increased risks of fall and accidents, confusion, lack of coordination, depression and slurred speech.

Benzodiazepine must always be taken under medical supervision.

What are the commonly used benzodiazepines in India?

Chemical nameBrand names
AlprazolamAnxit,restyl,trika,alprax
DiazepamCalmpose,valium
LorazepamAtivan,Lopez,Trapex
OxazepamSerepax
ChlordiazepoxideLibirium
ClobozamLobozam,frisium
ClonazepamPetril

What are the withdrawal symptoms of benzodiazepine?

If a person dependent on benzodiazepines or if they cut the dose drastically they will experience withdrawal symptoms as the body has to readjust to functioning without the drug. 

Withdrawal symptoms vary from person to person. It can last for weeks to months.

Withdrawal symptoms can include headache, sweating, tension, anxiety, confusion, dizziness, nausea, poor appetite, disturbed sleep, depression, delirium and at times seizures. Hence benzodiazepines must gradually withdrawn and not stopped or reduced suddenly.

Effects of benzodiazepines on pregnancy?

Benzodiazepines taken during pregnancy can cross the placental barrier and can affect the growth and development of the foetus. If taking a prescription of benzodiazepines check with your doctor before altering the dosage.

Points to remember when on benzodiazepines.

  1. If concerned about the dosage, it is best to talk first with your prescribing doctor. Remember, there is no one set dosage suitable for everyone.
  2. If you haven’t seen your doctor for a while make an appointment to have the medication reviewed and to discuss alternatives.
  3. Consider if the medication is needed and discuss alternatives with your doctor.
  4. Consult a psychiatrist if you are dependent on benzodiazepines.

Consultation Charges

Adults:

First consultation Psychiatry – ₹ 1700

Follow up consultations– ₹ 1250

Overseas :

First consultation Psychiatry – ₹ 3750

Follow up consultations– ₹ 3750

Children :

First consultation Psychiatry – ₹ 1700
First consultation Psychiatry – ₹ 1700
Follow up consultations– ₹ 1250
Behaviour Therapy With videos (where applicable) – ₹ 2750 For Domestic patients (price for half an hour session)

Cognitive Behaviour Therapy – ₹ 3750
For overseas patients (price for half an hour session)

Marital therapy – ₹ 3000 price for half an hour therapy.
(Rs 1500 per person)

Biofeedback– ₹ 3000

Medical Specialists

Dr. Vijayakumar D.R

Consultant Psychiatrist
Dr. Vijayakumar D.R is a senior psychiatrist with more than 22 years of experience in handling mental health issues in India, Australia and the United Kingdom.

Dr. Madhu Shree Vijayakumar

Consultant Obstetrician and Gynaecologist
Dr. Madhu Shree Vijayakumar, Is an obstetrician and gynaecologist with about a decade experience in addressing women’s health problems from adolescence to post menopause.

Medical Specialists

tele_consultation2
purchase_book
online_counselling
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Consultation Days:

Mon, Tues,
Thurs & Friday10:00 am to 2:00 pm

Monday to
Saturday 4:00 pm to 9:00 pm

Sunday 9.00 – 15.00

Consultation by appointment only
Call : +91-82961-12250

icon-calendar.png

Doctors Timetable

No health without mental health.

VIEW TIMETABLE
icon-phone.png

Emergency Cases

+91-82961-12250

read more
by Manasvi Specialistsin Alcohol, Drugs and Tobacco, Psychiatry0
Smoking Tobacco
02/01/2019

Smoking Tobacco

Psychiatry

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Smoking Tobacco

Tobacco USE

What are the ingredients of tobacco smoke?

Cigarette smoke is a composition of gas and small particles. There are over 4000 chemicals in tobacco smoke many of which are poisonous and 43 known cancer causing chemicals.

  1. Nicotine: Nicotine is the drug in tobacco that causes addiction among smokers. It is one of the most addicting substance and more addicting than heroin. Nicotine is a poison; swallowing one drop of pure nicotine can kill an adult.
  2. Tar: When a cigarette burns tar is released. It can cause lung and throat cancer in smokers
  3. Carbon monoxide: it is a poisonous gas which is taken up more readily by the lung than oxygen. It is found in the exhaust gas of vehicles.
  4. Cancer causing chemicals include nitrosamines, cadmium, nickel etc
  5. Acetone which is found in nail polish remover
  6. Acetic acid found in vinegar
  7. Ammonia found in floor cleaners
  8. Arsenic a known poison
  9. Butane found in cigarette lighter fluid
  10. Formalin a tissue preservative
  11. Hydrogen cyanide a poison
  12. Methanol found in rocket fuel
  13. Naphthalene found in moth balls
  14. Toluene an industrial solvent

Point to ponder: a smoker who consumes an average of 20 cigarettes per day inhales these 4000 substances more than 70,000 times per year.

Next time you see or use a cigarette remember what is getting into your body.

What are the health related issues with tobacco usage?

Tobacco affects all the systems in the body. Some of the illness caused by tobacco smoking is

  1. Various types of cancers like lung, mouth, esophagus (food pipe), bladder, stomach etc
  2. Smoking is one of the major risk factor for coronary artery disease. It is responsible for at least 20% of deaths due to coronary artery disease.
  3. Arteriosclerosis
  4. Heart failure
  5. Strokes
  6. Decreases the blood supply to the tips of the toes and fingers leading to death of the tips and may lead to amputations. Buerger’s disease)
  7. Can cause sexual dysfunction
  8. Pregnant mothers smoking tobacco can low birth weight infants, higher risk of cleft palate and lip ( opening in the lip and palate due non fusion of the two separate parts )
  9. Lowers the sperm count in men
  10. Lowers the immune system

What are the effects of smoking?

The effects of smoking will vary from person to person and depends on,

  1. The number of cigarettes smoked per day
  2. The age when the person began smoking
  3. The number of years of smoking
  4. A person’s susceptibility to chemicals in the tobacco

Immediate effects

  1. Smoking one cigarette immediately raises the blood pressure and heart rate. It decreases the blood flow to the body extremities like the figure and toes
  2. stimulates the brain for a short time and then reduces
  3. causes dizziness,nausea,watery eyes and acidity in the stomach
  4. appetite ,taste and smell are altered

Other effects

  1. they can experience shortness of breadth, persistent coughs, reduced fitness, yellow stains of the teeth a
  2. Lowers the immune system and they are more prone to infections
  3. Facial wrinkles appear much earlier

What are the withdrawal symptoms of nicotine (tobacco)?

People who stop smoking suddenly can experience irritability, drowsiness, difficulty in concentrating, anxiety, impaired task functioning, hunger, weight gain, craving, slowing of heart rate.

What is passive smoking?

Passive smoking is the smoke inhaled by others who are around a smoker it is also called environmental tobacco smoke. Passive smoking can be dangerous and can cause

  1. Sudden infant death syndrome
  2. Respiratory infections
  3. Asthmatic attacks
  4. Reduced growth
  5. Chronic obstructive airway disease
  6. Cancer

Point to ponder: Smoking tobacco not only harms the smoker but also causes damage to his near and dear ones especially children.

What is the treatment for nicotine dependence?

Nicotine dependence is treated with medications as well as therapy

Medications

Smokers who want to stop are offered a range of medications like nicotine replacement therapy, bupropion and varenicline tatrate.

Non pharmacological approach also helps smokers quit smoking and it is usually best to combine both.

Consultation Charges

Adults:

First consultation Psychiatry – ₹ 1700

Follow up consultations– ₹ 1250

Overseas :

First consultation Psychiatry – ₹ 3750

Follow up consultations– ₹ 3750

Children :

First consultation Psychiatry – ₹ 1700
First consultation Psychiatry – ₹ 1700
Follow up consultations– ₹ 1250
Behaviour Therapy With videos (where applicable) – ₹ 2750 For Domestic patients (price for half an hour session)

Cognitive Behaviour Therapy – ₹ 3750
For overseas patients (price for half an hour session)

Marital therapy – ₹ 3000 price for half an hour therapy.
(Rs 1500 per person)

Biofeedback– ₹ 3000

Medical Specialists

Dr. Vijayakumar D.R

Consultant Psychiatrist
Dr. Vijayakumar D.R is a senior psychiatrist with more than 22 years of experience in handling mental health issues in India, Australia and the United Kingdom.

Dr. Madhu Shree Vijayakumar

Consultant Obstetrician and Gynaecologist
Dr. Madhu Shree Vijayakumar, Is an obstetrician and gynaecologist with about a decade experience in addressing women’s health problems from adolescence to post menopause.

Medical Specialists

tele_consultation2
purchase_book
online_counselling
icon-clock.png

Consultation Days:

Mon, Tues,
Thurs & Friday10:00 am to 2:00 pm

Monday to
Saturday 4:00 pm to 9:00 pm

Sunday 9.00 – 15.00

Consultation by appointment only
Call : +91-82961-12250

icon-calendar.png

Doctors Timetable

No health without mental health.

VIEW TIMETABLE
icon-phone.png

Emergency Cases

+91-82961-12250

read more
by Manasvi Specialistsin Alcohol, Drugs and Tobacco, Psychiatry0
Cannabis
02/01/2019

Cannabis

Psychiatry

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Cannabis

  • What is cannabis?

Cannabis is a drug that comes from the cannabis sativa plant. The active ingredient is called Delta -9 tetrahydrocannabinol.

  • What are the forms of cannabis?

Marijuana: most common and powerful form of cannabis. It is the dried leaves and flowers of the plant.

Hashish: It is small blocks of dried cannabis resin. It is added to tobacco and smoked or baked and eaten in foods.

Hash oil: It is a thick oily liquid that can be extracted from hashish.

  • What are the other names of cannabis?

The street names of cannabis are grass, hash, weed, dope, ganga, joint etc.

  • What are the effects of cannabis?

Immediate effects

It can have effects that last 2-3 hours

a. Relaxation and loss of inhibition.

b. Increases appetite

c. Increased awareness and perception of colour, sound and other sensations.

d. Coordination impaired: dangerous to drive or operate machinery.

e. Affects memory and the ability to think logically

f. In large quantity it can cause confusion, restlessness, excitement, hallucinations, anxiety, decreased reaction time, paranoia.

Long term effects

a. Respiratory problems

b. Less motivation

c. Concentration and memory impaired

d. Lower sex drive

e. Psychosis

  • What are the withdrawal symptoms of cannabis?

Abrupt withdrawal of cannabis can cause mild withdrawal syndrome. Sleep disturbance, irritability, decreased appetite, anxiety symptoms, loss of weight and increased sweating can be present.

  • How is cannabis dependence treated?

Cannabis dependence is treated by a combination of methods which include medications to control the withdrawal symptoms, counseling and cognitive behaviour therapy.

The chances of success depend on how motivated the patient is.

Consultation Charges

Adults:

First consultation Psychiatry – ₹ 1700

Follow up consultations– ₹ 1250

Overseas :

First consultation Psychiatry – ₹ 3750

Follow up consultations– ₹ 3750

Children :

First consultation Psychiatry – ₹ 1700
First consultation Psychiatry – ₹ 1700
Follow up consultations– ₹ 1250
Behaviour Therapy With videos (where applicable) – ₹ 2750 For Domestic patients (price for half an hour session)

Cognitive Behaviour Therapy – ₹ 3750
For overseas patients (price for half an hour session)

Marital therapy – ₹ 3000 price for half an hour therapy.
(Rs 1500 per person)

Biofeedback– ₹ 3000

Medical Specialists

Dr. Vijayakumar D.R

Consultant Psychiatrist
Dr. Vijayakumar D.R is a senior psychiatrist with more than 22 years of experience in handling mental health issues in India, Australia and the United Kingdom.

Dr. Madhu Shree Vijayakumar

Consultant Obstetrician and Gynaecologist
Dr. Madhu Shree Vijayakumar, Is an obstetrician and gynaecologist with about a decade experience in addressing women’s health problems from adolescence to post menopause.

Medical Specialists

tele_consultation2
purchase_book
online_counselling
icon-clock.png

Consultation Days:

Mon, Tues,
Thurs & Friday10:00 am to 2:00 pm

Monday to
Saturday 4:00 pm to 9:00 pm

Sunday 9.00 – 15.00

Consultation by appointment only
Call : +91-82961-12250

icon-calendar.png

Doctors Timetable

No health without mental health.

VIEW TIMETABLE
icon-phone.png

Emergency Cases

+91-82961-12250

read more
by Manasvi Specialistsin Alcohol, Drugs and Tobacco, Psychiatry0
Alcohol
02/01/2019

Alcohol

Psychiatry

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stress-management-workshop
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Alcohol

What is alcohol?

Alcohol is produced by fermentation of liquids containing sugar and starch. Alcoholic drinks vary in colour and taste because of the ingredients used in them. The alcohol we drink is called ethyl alcohol.

Why do effects of alcohol vary from person to person?

Alcohol is directly absorbed into the blood stream through the stomach and small intestine. Food in the stomach slows down the rate at which alcohol is absorbed but does not prevent intoxication or drunkenness. Alcohol is distributed throughout the water in the body and not into fatty tissue.

The effects of alcohol vary from person to person. It depends upon many factors like

  1. How much you drink (more you drink, higher the effects)
  2. How quickly you drink (faster you drink more the effects)
  3. If alcohol is consumed along with other drugs both illicit and prescription drugs.
Age health status
weightMood
Gender How used the person is to drinking alcohol

Effects of alcohol on the body?

Contrary to common beliefs alcohol is a depressant drug and not a stimulant. It slows down the activity of the brain and affects concentration and coordination. 

Immediate effects

  1. First few drinks, feel happy and more relaxed, less concentration and reflexes slowed.
  2. Few more , less inhibitions, more confidence, less coordination, speech is slurred, mood fluctuates
  3. Few more – confusion ,blurred vision, poor muscle control
  4. More- nausea, vomiting ,sleep
  5. It can cause coma or death if drinking continues.

It will make you unfit for driving and using machinery.

Long term effects

If you drink heavily for a long period of time alcohol can cause damage to various parts of the body. It can affect every system of the body.
Nervous system

  1. Memory disturbances
  2. Tingling and numbness in the palms and feet
  3. Confusion
  4. Psychological problems

Like depression, psychosis, suicide rates are higher

Liver

  1. Liver becomes enlarged
  2. Hepatitis
  3. Liver failure
  4. liver cancer

Heart

  1. Enlarged heart
  2. high blood pressure

Lungs

  1. Higher chances of infection like tuberculosis

Pancreas

Inflamed pancreas causing pain

Sex Organs

Male:

  1. Impotency
  2. Testis becomes smaller
  3. Damaged or less sperms

Female: damage to the foetus if pregnant

Blood

Changes to the red blood cells

Stomach

Ulcers

  1. Bleeding

Intestines

Ulcers

Symptoms of alcohol dependence?

Symptoms of alcohol dependence are

  1. If your hands and limbs start to shake and have tremors
  2. If you have to drink more and more to get the desired effect
  3. If you start spending a lot of your time thinking about alcohol and how to get it
  4. If you have withdrawal symptoms like loss of appetite, nausea, anxiety , disturbed sleep, irritability, at times convulsions , hallucinations etc
  5. Your work and relationships start to suffer
  6. You carry on drinking in spite of the problem it causes
    You start to drink earlier and earlier
  7. Other things become less important than alcohol

What is a standard drink?

A standard drink is defined as one that contains 10 grams of pure alcohol.

The following are all equal to approximately to one standard drink.

  1. Low alcohol beer (3.5 %) – 375 ml
  2. Beer 4.9 % -285 ml
  3. Wine 12% — 100 ml
  4. Spirits (40%) – 30ml

What is low risk drinking?

Drinking alcohol will affect your body irrespective of how little you drink. However research has shown that the risk increases if the quantity of alcohol consumption increases.

Standard drinks per day

Scale of risk LowHarmfulHazardous
FemaleUp to 2 SD3-4 SD>4  SD
MaleUp to 4 SD4-6 SD>6 SD

SD= Standard drink

Remember drinking is harmful to the body IF YOU DO NOT START YOU WILL NOT HAVE TO QUIT. So say no to alcohol every time.

What are the differences between men and women drinking alcohol?

Research has shown that alcohol affects men and women differently.

If a man and women drink exactly the same amount of alcohol the women will have a higher blood alcohol level concentration (BAC). A women body contains more fat tissue and less water than a man’s body and they are often smaller than men. Hence the alcohol will be more concentrated in women’s body, producing a higher BAC. Women also breakdown alcohol more slowly than men.

Women may develop liver damage and other health problems at lower levels of alcohol consumption than men.

Women who take the contraceptive pill may take longer to get rid of alcohol in their bodies than women who are not taking the pill.

What is the effect of alcohol on pregnancy?

Alcohol crosses the placenta to the baby. It can cause problems in pregnancy such as bleeding, miscarriage, stillborn and premature birth. It is not known whether or not there is a safe level of alcohol in pregnancy.

Babies who are born to mothers heavily dependent on alcohol can have withdrawal symptoms after birth like tremors, irritability, fits and bloated abdomen.

Remember in pregnancy no alcohol is the safest approach.

How to drink less?

A few techniques to reduce drinking are as follows

  1. Start with a soft drink : you will drink much faster if you are thirsty so quench your thirst before you start drinking alcohol
  2. Use standard drinks : monitor how much you drink by converting everything you drink into standard drink, it helps in keeping track
  3. Drink slowly: take sips and not gulps. Put your glass down between sips
  4. Eat before or while drinking: eating fills you up and slows your drinking pace the absorption of alcohol also slows down. 
  5. Avoid salty snacks : salty snacks like chips or nuts make you thirsty so you drink more
  6. Do not get involved in drinking contests
  7. Drink at your own pace and not someone else pace.
  8. One drink at a time. Do not let someone top up your drinks. It is hard to keep track of how much alcohol is drunk.
  9. Take a non alcoholic drink every alternative drink. Pace yourself.
  10. Do something between drinks if possible –don’t just sit and drink.
  11. Try the low alcohol alternatives.
  12. Have alcohol free days.  At least 2-3 days a week.        
    Like how lot of people have no non vegetarian days.
  13. Keep a diary and maintain how much you drink every day.
  14. Be assertive do not be pressured into drinking more. Learn to say no.

How to help a person to seek help from doctors for drinking problems?

This is a common problem family members and carers face when dealing with people who are dependent on alcohol.

  1. 1 Get the person to a doctor in context of the problem and defocus from his problem
    Eg: marital issue in context of alcohol dependence, try to get the person to see a doctor for the marital issue and not the alcohol issue. The doctor will try and work on the alcohol problem when he sees him.
    Eg: tell him to see the doctor for his sexual problem and the doctor will work on his alcohol problem also.
  2. Get a person who has some influence on the patient to talk to him.
  3. Ask the person to consider one appointment with the doctor and leave the person to decide regarding future appointments.

Remember for the treatment to work we need to have a person motivated to stop drinking alcohol. 

What is the CAGE questionnaire?

This is a questionnaire to screen persons for alcoholism. The questionnaire asks the following questions

  1. Have you ever felt you need to Cutdown on your drinking?
  2. Have people annoyed you for criticizing you about your drinking?
  3. Have you ever felt guilty about your drinking?
  4. Have you ever felt you needed a drink first thing in the morning (eye-opener) to steady your nerves or to get rid of your hangover?

If you have 2 yes to the above questions, you must be investigated for alcohol dependence.

What is the treatment for alcohol dependence?

Alcohol dependence is treated in two stages.

Stage 1: medications will be given to reduce the withdrawal symptoms and the medications will gradually be tapered off.

Injections will be given to replenish the loss of vitamins due to drinking.

Stage 2 :  medications will be given to reduce the craving for alcohol and if the patient is suitable medication will be given which causes an unpleasant reaction if the patient drinks alcohol while on the medications.

During this stage cognitive behaviour therapy will be adviced which will help patient to stay away from alcohol and also handle the issues that lead to the person drinking alcohol.

Remember many people have gone through the treatment and have stopped alcohol permanently, you also can.

Can alcohol dependence be treated on outpatient basis?

Alcohol dependence can be treated on outpatient basis and it is as effective as in patient care. The patient must be motivated to stop alcohol and he must have a good support system.

Who should be admitted to a rehabilitation centre?

If a person has tried numerous times to stop drinking alcohol by himself, with medical supervision both outpatient and inpatient then it would be worth to try a rehabilitation center were the patient can stay for a few months.

Remember to admit the patient to a centre which has a psychiatrist supervising the treatment process and always do your research regarding the rehabilitation center before admitting the patient there.

Consultation Charges

Adults:

First consultation Psychiatry – ₹ 1700

Follow up consultations– ₹ 1250

Overseas :

First consultation Psychiatry – ₹ 3750

Follow up consultations– ₹ 3750

Children :

First consultation Psychiatry – ₹ 1700
First consultation Psychiatry – ₹ 1700
Follow up consultations– ₹ 1250
Behaviour Therapy With videos (where applicable) – ₹ 2750 For Domestic patients (price for half an hour session)

Cognitive Behaviour Therapy – ₹ 3750
For overseas patients (price for half an hour session)

Marital therapy – ₹ 3000 price for half an hour therapy.
(Rs 1500 per person)

Biofeedback– ₹ 3000

Medical Specialists

Dr. Vijayakumar D.R

Consultant Psychiatrist
Dr. Vijayakumar D.R is a senior psychiatrist with more than 22 years of experience in handling mental health issues in India, Australia and the United Kingdom.

Dr. Madhu Shree Vijayakumar

Consultant Obstetrician and Gynaecologist
Dr. Madhu Shree Vijayakumar, Is an obstetrician and gynaecologist with about a decade experience in addressing women’s health problems from adolescence to post menopause.

Medical Specialists

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Consultation Days:

Mon, Tues,
Thurs & Friday10:00 am to 2:00 pm

Monday to
Saturday 4:00 pm to 9:00 pm

Sunday 9.00 – 15.00

Consultation by appointment only
Call : +91-82961-12250

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by Manasvi Specialistsin Alcohol, Drugs and Tobacco, Psychiatry0
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