1. 1 Play file: 0 - Tequila

2. 2 The Medical Management of A LCOHOL W ITHDRAWAL John J. Stasinos, M.D. LTC(P), MC, USA Chief, Chemical Addictions Treatment Services Department of Psychiatry Tripler Army Medical Center

3. 3 Disclosures I have no affiliation or financial relationship with any pharmaceutical companies I have no affiliation or financial relationship with any pharmaceutical companies The opinions stated herein are my own The opinions stated herein are my own Off-label use of medications will be discussed Off-label use of medications will be discussed I am not on any medications or mood- altering substances... I am not on any medications or mood- altering substances...

4. 4 Outline Epidemiology Epidemiology Definitions Definitions Pathophysiology Pathophysiology Diagnosis Manifestations Management

5. 5 Objectives By the end of this briefing, you will be able to… By the end of this briefing, you will be able to… Identify, assess, & diagnose patients in acute EtOH withdrawal Identify, assess, & diagnose patients in acute EtOH withdrawal Determine the best setting for conducting management of withdrawal symptoms Determine the best setting for conducting management of withdrawal symptoms Manage patients with medically complicated EtOH withdrawal Manage patients with medically complicated EtOH withdrawal Grasp systemic & administrative issues that complicate care & put patients at unnecessary risk Grasp systemic & administrative issues that complicate care & put patients at unnecessary risk

6. 6 Why Are We Even Talking About This?... Joint Commission standards & policies have impacted our perceptions & decisions regarding medical management of EtOH withdrawal Joint Commission standards & policies have impacted our perceptions & decisions regarding medical management of EtOH withdrawal Disagreement persists among health care providers regarding how & where these patients are best cared for Disagreement persists among health care providers regarding how & where these patients are best cared for

7. 7 What Standards?... Joint Commission recently published new standards that specifically apply to procedure of “detoxification” Joint Commission recently published new standards that specifically apply to procedure of “detoxification” Standards require personnel, training, & equipment that represent considerable $ Standards require personnel, training, & equipment that represent considerable $ Some institutions sidestep the issue by declaring: Some institutions sidestep the issue by declaring: “W E D ON’T D O D ETOX ” “W E D ON’T D O D ETOX ”

8. 8 What Disagreement?...

9. 9 The Good Patient Acknowledges illness & need for treatment Acknowledges illness & need for treatment Seeks out medical care appropriately Seeks out medical care appropriately Communicates clearly & transparently with health care provider Communicates clearly & transparently with health care provider Complies with treatment Complies with treatment Responds to treatment Responds to treatment Thanks the M.D. (& pays their medical bills) Thanks the M.D. (& pays their medical bills) Goes away Goes away

10. 10 But these patients… Deny their illness Deny their illness Use up precious medical resources Use up precious medical resources Can’t be reasoned with Can’t be reasoned with Do not comply with treatment Do not comply with treatment Are unruly, agitated, uncooperative, & ungrateful Are unruly, agitated, uncooperative, & ungrateful Refuse potentially life- saving care Refuse potentially life- saving care And they keep coming back! And they keep coming back!

11. 11 H OT P OTATO ! =

12. 12 Clinical Vignette 22 y/o SWM AD/MC E4 c hx of EtOH Dependence 22 y/o SWM AD/MC E4 c hx of EtOH Dependence Brought to TAMC ER by Command escort after found to be intoxicated with EtOH Brought to TAMC ER by Command escort after found to be intoxicated with EtOH ER assessment: BAL & UDS negative ER assessment: BAL & UDS negative House staff: “We don’t do detox [at TAMC].” House staff: “We don’t do detox [at TAMC].” Pt has a grand mal seizure Pt has a grand mal seizure ICU course: seizures, delirium tremens, pneumonia, intubation & ventilation, management with iv benzos ICU course: seizures, delirium tremens, pneumonia, intubation & ventilation, management with iv benzos Discharged from hospital after 37 days Discharged from hospital after 37 days

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14. 14 Terminology Withdrawal Withdrawal Characteristic group of signs & symptoms that typically develop after rapid, marked decrease or discontinuation of a substance of dependence, which may or may not be clinically significantly or life threatening. Characteristic group of signs & symptoms that typically develop after rapid, marked decrease or discontinuation of a substance of dependence, which may or may not be clinically significantly or life threatening.

15. 15 Terminology Detoxification: Detoxification: Interventions aimed at managing acute intoxication & withdrawal in order to clear toxins from body & minimize physical harm from substance use. Interventions aimed at managing acute intoxication & withdrawal in order to clear toxins from body & minimize physical harm from substance use. Generic Marine (has he been drinking?...)  Generic Marine (has he been drinking?...) 

16. 16 Terminology Detoxification: Detoxification: Caveat #1: The acute medical management of life-threatening intoxication & related medical problems is NOT included within the term detoxification. Caveat #1: The acute medical management of life-threatening intoxication & related medical problems is NOT included within the term detoxification. Caveat #2: Detox does NOT constitute substance abuse treatment for dependence but is only one part of a continuum of care for substance use disorders. Caveat #2: Detox does NOT constitute substance abuse treatment for dependence but is only one part of a continuum of care for substance use disorders. Substance Abuse & Mental Health Services Administration (SAMHSA), TIP 45: Detoxification & Substance Abuse Treatment

17. 17 Do we do inpatient detox?... Patients ARE NOT hospitalized on an elective basis for detox purposes if… Patients ARE NOT hospitalized on an elective basis for detox purposes if… patient’s withdrawal symptoms can be managed in a less restrictive setting; patient’s withdrawal symptoms can be managed in a less restrictive setting; patient has access to outpatient resources; patient has access to outpatient resources; patient has the benefit of family or other supports to monitor & provide support during detox process. patient has the benefit of family or other supports to monitor & provide support during detox process. We DO hospitalize patients for the clinical management of Medically Complicated Withdrawal. We DO hospitalize patients for the clinical management of Medically Complicated Withdrawal.

18. 18 Do we do inpatient detox?... Medical complications of substance withdrawal may be benign or life-threatening, depending on… Medical complications of substance withdrawal may be benign or life-threatening, depending on… Substance used: e.g., EtOH, Benzodiazepines, etc. Substance used: e.g., EtOH, Benzodiazepines, etc. Patient’s hx of prior withdrawals Patient’s hx of prior withdrawals Patient’s age: older  more severe Patient’s age: older  more severe Number & severity of medical problems Number & severity of medical problems Severe or high risk withdrawal requires inpatient medical treatment Severe or high risk withdrawal requires inpatient medical treatment

19. 19 Management of EtOH Withdrawal Consists of 3 essential components: Consists of 3 essential components: Clinical assessment Clinical assessment Management of medical complications of withdrawal Management of medical complications of withdrawal Transition of patient into substance abuse treatment (REHAB) Transition of patient into substance abuse treatment (REHAB) Intervention that does not incorporate all 3 components is incomplete & inadequate Intervention that does not incorporate all 3 components is incomplete & inadequate

20. 20 EtOH Intoxication Diagnostic Criteria Recent Ingestion of EtOH Clinically significant maladaptive behavioral or psychological changes One or more of the following signs, following EtOH use: Slurred speech Incoordination Unsteady gait Nystagmus Impairment in attention or memory Stupor or coma Symptoms are not due to a general medical condition or another mental disorder

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23. 23 Blood EtOH Levels BAL =effect on function BAL =effect on function 0.1%motor coordination is impaired 0.1%motor coordination is impaired 0.2%user is obviously intoxicated 0.2%user is obviously intoxicated 0.3%physical & mental activity decreases 0.3%physical & mental activity decreases 0.35%anesthesia is present 0.35%anesthesia is present 0.4%respiratory drive is critically affected; some die 0.4%respiratory drive is critically affected; some die 0.6%most die 0.6%most die

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25. 25 EtOH Withdrawal Diagnostic Criteria Cessation of (or reduction in) EtOH use that has been heavy & prolonged Cessation of (or reduction in) EtOH use that has been heavy & prolonged Two (or more) of the following, developing within several hours to a few days later: Two (or more) of the following, developing within several hours to a few days later: Autonomic hyperactivity (sweating, tachycardia) Autonomic hyperactivity (sweating, tachycardia) Increased hand tremor Increased hand tremor Insomnia Insomnia Nausea or vomiting Nausea or vomiting Transient visual, tactile, or auditory hallucinations Transient visual, tactile, or auditory hallucinations Psychomotor agitation Psychomotor agitation Anxiety Anxiety Grand mal seizures Grand mal seizures Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning Symptoms are not due to a general medical condition or another mental disorder

26. 26 Pathophysiology of EtOH Withdrawal GABA (Gama amino butyric acid) GABA (Gama amino butyric acid) Major inhibitory neurotransmitter Major inhibitory neurotransmitter Chronic EtOH exposure  decrease in GABA A alpha 1 receptor activity Chronic EtOH exposure  decrease in GABA A alpha 1 receptor activity NMDA (N-methyl-D-aspartate) NMDA (N-methyl-D-aspartate) Major excitatory neurotransmitter Major excitatory neurotransmitter Chronic EtOH exposure  increase in NMDA receptor concentration  neuron hyper excitability Chronic EtOH exposure  increase in NMDA receptor concentration  neuron hyper excitability

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28. 28 Pathophysiology of EtOH Withdrawal In short… In short… GABA receptor is the brake GABA receptor is the brake NMDA receptor is the accelerator NMDA receptor is the accelerator EtOH Withdrawal is the brain accelerating without brakes... EtOH Withdrawal is the brain accelerating without brakes...

29. 29 Factors affecting Course of Withdrawal S everity & duration of withdrawal depend on: 1. Nature of substance 2. Half-life & duration of action 3. Length of time substance used 4. Amount used 5. Use of other substances 6. Presence of other medical & psychiatric conditions 7. Individual biopsychosocial variables

30. 30 Blood EtOH Levels during Withdrawal

31. 31 Course of EtOH Withdrawal

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33. 33 Course of EtOH Withdrawal SymptomOnset after last drink Tremulousness6 – 36 hours Hallucinations12 – 48 hours Seizures6 – 48 hours Delirium Tremens48 - 96 hours

34. 34 Tremulousness occurs within 6 – 36 hours 2ndary to autonomic hyperactivity Symptoms Symptoms Tremor Tremor Anxiety Anxiety Agitation Agitation Insomnia Insomnia Anorexia Anorexia Nausea Nausea Palpitations Palpitations Signs Tachycardia Hypertension Hyper-reflexia Hyperthermia Diaphoresis

35. 35 Hallucinations Occurs within 12 – 48 hours of last drink Occurs within 12 – 48 hours of last drink 3 – 10% of cases develop hallucinations 3 – 10% of cases develop hallucinations Duration is variable Duration is variable Usually visual (e.g., pink elephants) Usually visual (e.g., pink elephants) Occasionally auditory, tactile, or olfactory Occasionally auditory, tactile, or olfactory EtOH Hallucinosis: reality testing is intact EtOH Hallucinosis: reality testing is intact

36. 36 Seizures Occur within 6 – 48 hours of last drink Occur within 6 – 48 hours of last drink 11-35% of patients develop seizures in hospital setting 11-35% of patients develop seizures in hospital setting Risk correlates with duration EtOH use Risk correlates with duration EtOH use Manifests as grand mal tonic-clonic activity Manifests as grand mal tonic-clonic activity Always rule out other causes Always rule out other causes 40% are single episodes 40% are single episodes 30% of untreated patients go on to develop delirium tremens 30% of untreated patients go on to develop delirium tremens

37. 37 Stephen KC. “Alcohol Consumption & Withdrawal in New-Onset Seizures.” NEJM, 1988 Seizures EtOH is an independent risk factor for seizures EtOH is an independent risk factor for seizures Retrospective study of 308 patients in a city hospital with new onset of seizures during EtOH withdrawal Retrospective study of 308 patients in a city hospital with new onset of seizures during EtOH withdrawal EtOH (gm/day)Risk EtOH (gm/day)Risk 51 – 1003x 51 – 1003x 101 – 2008x 101 – 2008x 201 – 30020x 201 – 30020x 10 gm = 1 beer 10 gm = 1 beer

38. 38 Delirium Tremens Begins 3 to 5 days after last drink Begins 3 to 5 days after last drink Occurs in less than 5% of withdrawal patients Occurs in less than 5% of withdrawal patients Not always predictable or preventable Not always predictable or preventable Usually lasts 2-3 days, but can last up to 30 days Usually lasts 2-3 days, but can last up to 30 days Delirium can occur with/without “tremens” Delirium can occur with/without “tremens” Risk factors Risk factors Acute concurrent medical illness Acute concurrent medical illness History of seizures or delirium tremens History of seizures or delirium tremens Heavier & longer EtOH history Heavier & longer EtOH history Age > 60 Age > 60 Elevated BAL on admission (greater than 300 mg/dl) Elevated BAL on admission (greater than 300 mg/dl)

39. 39 Delirium Tremens Symptoms Symptoms Confusion & disorientation Confusion & disorientation Hallucinations Hallucinations Hyper-responsiveness Hyper-responsiveness Signs Hypertension Tachycardia Fever

40. 40 Delirium Tremens Mortality Mortality: Mortality: without treatment = 20% without treatment = 20% with treatment = 2 – 10% with treatment = 2 – 10% Temperature > 104  45% mortality Temperature > 104  45% mortality Seizures & DTs  24% mortality Seizures & DTs  24% mortality Cause of death Cause of death Pneumonia Pneumonia Liver disease Liver disease Hypotension Hypotension Trauma Trauma

41. 41 Clinical Assessment History History Presentation Presentation Intake: amount, type, time of last drink, etc.? Intake: amount, type, time of last drink, etc.? Hx of complicated withdrawal? Hx of complicated withdrawal? Use of other substances? Use of other substances? Medical & psychiatric history Medical & psychiatric history Mental Status Examination Mental Status Examination Cognitive impairment? Cognitive impairment? Hallucinations? Hallucinations? Impulsivity? Impulsivity? Suicide/homicide risk? Suicide/homicide risk?

42. 42 Clinical Assessment Physical Examination Physical Examination Vital Signs Vital Signs Neurological exam Neurological exam Cardiovascular exam Cardiovascular exam Abdominal exam Abdominal exam Stigmata of liver disease Stigmata of liver disease Evidence of trauma, etc. Evidence of trauma, etc.

43. 43 Clinical Assessment Laboratory studies Laboratory studies Blood EtOH level Blood EtOH level Urine Drug Screen Urine Drug Screen Urinalysis Urinalysis Blood chemistries Blood chemistries Complete Blood Count Complete Blood Count Liver function tests & GGT Liver function tests & GGT PT/PTT PT/PTT B12 & folate assays B12 & folate assays Laboratory studies Thyroid Function Tests Beta-HCG RPR, HIV, STD screens Other studies (if clinically indicated) EKG CXray CT scan

44. 44 EtOH Withdrawal Differential Diagnosis Acute stimulant intoxication Acute stimulant intoxication cocaine, methamphetamine, caffeine cocaine, methamphetamine, caffeine Sepsis Sepsis Thyrotoxicosis Thyrotoxicosis Heat stroke Heat stroke Hypoglycemia Hypoglycemia Intracranial processes (e.g., trauma, CVA) Intracranial processes (e.g., trauma, CVA) Encephalitis/encephalopathy Encephalitis/encephalopathy

45. 45 EtOH Withdrawal Treatment Setting Severity of withdrawal dictates level of care: Social Detoxification: 24 hour care, non- hospital/residential setting without professional medical staff Social Detoxification: 24 hour care, non- hospital/residential setting without professional medical staff Medically Supported Detoxification: 24 hour care, non-hospital/residential setting with profession medical staff Medically Supported Detoxification: 24 hour care, non-hospital/residential setting with profession medical staff Medical Detoxification: 24-hour care, hospital setting Medical Detoxification: 24-hour care, hospital setting

46. 46 Treatment Setting ASAM Criteria Level I-D: Ambulatory Detoxification Without Extended Onsite Monitoring Level I-D: Ambulatory Detoxification Without Extended Onsite Monitoring Level II-D: Ambulatory Detoxification With Extended Onsite Monitoring Level II-D: Ambulatory Detoxification With Extended Onsite Monitoring Level II.2-D: Clinically Managed Residential Detoxification Level II.2-D: Clinically Managed Residential Detoxification Level III.7-D: Medically Monitored Inpatient Detoxification (hospital ward) Level III.7-D: Medically Monitored Inpatient Detoxification (hospital ward) Level IV-D: Medically Managed Intensive Inpatient Detoxification (ICU) Level IV-D: Medically Managed Intensive Inpatient Detoxification (ICU)

47. 47 Indications for Admission (Level III) Hx of severe withdrawal symptoms Hx of severe withdrawal symptoms Hx of withdrawal seizures or delirium tremens Hx of withdrawal seizures or delirium tremens Hx of heavy prolonged EtOH use with a high degree of tolerance Hx of heavy prolonged EtOH use with a high degree of tolerance Abuse of multiple substances Abuse of multiple substances Concomitant psychiatric or medical illness Concomitant psychiatric or medical illness Pregnancy Pregnancy Lack of reliable support network Lack of reliable support network

48. 48 Who goes to the ICU?... (Level IV) Age > 65 Age > 65 Significant cardiac disease Significant cardiac disease Hemodynamic instability Hemodynamic instability Marked acid-base disturbances Marked acid-base disturbances Severe respiratory disease Severe respiratory disease Serious infection Serious infection Active delirium tremens Active delirium tremens

49. 49 Who goes to the ICU?... (Level IV) Serious GI pathology Serious GI pathology Temp > 103 F Temp > 103 F Rhabdomyolysis Rhabdomyolysis Acute renal failure Acute renal failure Hx of recurrent withdrawal seizures Hx of recurrent withdrawal seizures Hx of delirium tremens Hx of delirium tremens IV benzodiazepine drip (Ativan 12+ mg/day) IV benzodiazepine drip (Ativan 12+ mg/day)

50. 50 Treatment Strategy Reduce symptoms Reduce symptoms Prevent seizures Prevent seizures Prevent delirium tremens Prevent delirium tremens Prevent &/or manage medical complications & co- morbidities Prevent &/or manage medical complications & co- morbidities

51. 51 Supportive Care Ensure ABCs!... Ensure ABCs!... Secure patient in safe environment Secure patient in safe environment Provide IV hydration Provide IV hydration Correct electrolyte imbalances Correct electrolyte imbalances Provide nutritional support Provide nutritional support

52. 52 Supportive Care Nursing care: reassurance, orientation Nursing care: reassurance, orientation Monitor for signs & symptoms of withdrawal Monitor for signs & symptoms of withdrawal Involve Psychiatrist on Duty (PsoD) if patient c/o suicidal/ homicidal ideation &/or psychotic symptoms Involve Psychiatrist on Duty (PsoD) if patient c/o suicidal/ homicidal ideation &/or psychotic symptoms

53. 53 Role of Pharmacotherapy Stabilize psychological or physiological withdrawal symptoms Stabilize psychological or physiological withdrawal symptoms Manage medical emergencies Manage medical emergencies Remediate non-life threatening, relapse- triggering symptoms Remediate non-life threatening, relapse- triggering symptoms Stabilize co-morbid conditions Stabilize co-morbid conditions

54. 54 Thiamine & Multivitamins 30-80% of patients are deficient 30-80% of patients are deficient Thiamine does not reduce risk of seizures or delirium tremens Thiamine does not reduce risk of seizures or delirium tremens Thiamine does reduce risk of Wernicke’s encephalopathy Thiamine does reduce risk of Wernicke’s encephalopathy Give thiamine 50 – 100 mg IV or IM x 1, then po qd Give thiamine 50 – 100 mg IV or IM x 1, then po qd Administer thiamine before glucose Administer thiamine before glucose Add MV 1 tab po qd Add MV 1 tab po qd

55. 55 Benzodiazepines Ideal for management of EtOH withdrawal symptoms Ideal for management of EtOH withdrawal symptoms Cross-tolerance with EtOH Cross-tolerance with EtOH Fairly wide therapeutic window (compared to barbiturates) Fairly wide therapeutic window (compared to barbiturates) Short- vs. long-acting Short- vs. long-acting Liver disease limits use to short acting benzos Liver disease limits use to short acting benzos

56. 56 Benzodiazepines Short-acting Oxazepam & Lorazepam Oxazepam & Lorazepam Advantages Advantages They can be administered IM or IV (in monitored settings) They can be administered IM or IV (in monitored settings) They have no significant active metabolites They have no significant active metabolites They are metabolized & excreted principally through kidneys (& do not jeopardize already-damaged liver) They are metabolized & excreted principally through kidneys (& do not jeopardize already-damaged liver) Disadvantages Disadvantages They need to be administered more frequently. They need to be administered more frequently.

57. 57 Other Medications Beta-blockers & Clonidine Beta-blockers & Clonidine Reduce autonomic hyper- arousal (tachycardia, hypertension) Reduce autonomic hyper- arousal (tachycardia, hypertension) May reduce total dosage of benzos & result in less sedation May reduce total dosage of benzos & result in less sedation Do not reduce risk of seizures or delirium tremens Do not reduce risk of seizures or delirium tremens

58. 58 Other Medications Carbamazepine Carbamazepine Reduces risk of seizure activity Reduces risk of seizure activity Does little for autonomic hyper-arousal Does little for autonomic hyper-arousal Requires monitoring of CBC, LFTs, & serum levels Requires monitoring of CBC, LFTs, & serum levels Risks include liver & bone marrow toxicity Risks include liver & bone marrow toxicity

59. 59 Other Medications Antipsychotic agents Antipsychotic agents Can be used for management of agitation, aggression, & psychotic symptoms Can be used for management of agitation, aggression, & psychotic symptoms CAUTION: Can also lower seizure threshold CAUTION: Can also lower seizure threshold Bottom line: other medications are best used as adjuncts instead of substitutes for benzos Bottom line: other medications are best used as adjuncts instead of substitutes for benzos

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61. 61 Routine vs. Symptom-driven Protocols Study: 100 VA patients in EtOH withdrawal Study: 100 VA patients in EtOH withdrawal Outcomes Outcomes Treatment time = 68 hrs vs. 9 hrs. Treatment time = 68 hrs vs. 9 hrs. Total dose Librium = 425 mg vs. 100 mg Total dose Librium = 425 mg vs. 100 mg Advantages Advantages Reduced hospital length of stay Reduced hospital length of stay Reduced total dosage of medication Reduced total dosage of medication Reduced cost of care Reduced cost of care Less sedation Less sedation

62. 62 Sullivan, JT. British Journal of Addiction, 1989; 84: 1353-7 Symptom-driven Protocols Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA) Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA) 10-item clinical rating system for EtOH withdrawal assessment 10-item clinical rating system for EtOH withdrawal assessment Patient is assessed q 4 hours (while awake) Patient is assessed q 4 hours (while awake) CIWA can be administered in under 2 minutes CIWA can be administered in under 2 minutes Each item (but one) is scored on a scale of 0 – 7 Each item (but one) is scored on a scale of 0 – 7 Maximum score of 67 points Maximum score of 67 points Medicate for scores > 8-10 Medicate for scores > 8-10

63. 63 Clinical Institute Withdrawal Assessment for Alcohol Scale Nausea & vomiting Nausea & vomiting Tremor Tremor Sweating Sweating Anxiety Anxiety Agitation Agitation Tactile disturbances Auditory disturbances Visual disturbances Headache or head fullness Disorientation

64. 64 CIWA

65. 65 FREE EtOH Detox Guide! Double Click Document to Open

66. 66 Discharge Criteria Neurologically stable for last 24 hrs Neurologically stable for last 24 hrs No withdrawal symptoms; CIWA scores < 10 for last 24 hrs No withdrawal symptoms; CIWA scores < 10 for last 24 hrs Vital signs are stable & within normal limits Vital signs are stable & within normal limits No c/o of suicidal/homicidal thoughts or behavior No c/o of suicidal/homicidal thoughts or behavior Detox protocol/taper must be completed; seizures are controlled Detox protocol/taper must be completed; seizures are controlled Enrollment in rehab program, ideally within 24 hrs of discharge Enrollment in rehab program, ideally within 24 hrs of discharge

67. 67 P r o t r a c t e d Withdrawal Syndrome Duration Duration 6 – 12 MONTHS 6 – 12 MONTHS Features Insomnia Depression Anxiety Irritability Mood swings Cognitive deficits

68. 68 TAMC Process Action Team EtOH Withdrawal Protocols Membership Membership Psychiatry Psychiatry Internal Medicine Internal Medicine Family Medicine Family Medicine Emergency Medicine Emergency Medicine Process Process Literature review Literature review Discussion & collaboration Discussion & collaboration

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72. 72 Contact Information John J. Stasinos, M.D. LTC(P), MC, USA Chief, Chemical Addictions Treatment Services, TAMC Director, Addiction Psychiatry Fellowship Program (808) 433-6566 john.j.stasinos@us.army.mil