Diagnostic Considerations

Sepsis

Antisocial personality

Panic attack

Pontine infarct or hemorrhage

Depressed mood

Although GI symptoms of nausea, vomiting, and abdominal pain are predominant and common in opioid withdrawal, they may warrant consideration of gastroenteritis, pancreatitis, peptic ulcer disease, and intestinal obstruction.

Sympathetic overactivity must lead to consideration of panic attacks and CNS stimulants, such as amphetamines.

Because multi-drug abuse is common, investigate intoxication by drugs other than narcotics (benzodiazepines, barbiturates) in unconscious patients. A person who abuses opioids may conceal information about other abusive drugs. Because opioid intoxication generally does not cause tremulousness, delirium, and seizures, their presence should raise suspicion of alcohol and benzodiazepine dependence.

Small-sized pupils are observed in opioid intoxication, pontine lesions, and local cholinergic drops.

An antisocial personality may be mistaken as addictive behaviors (and vice versa), especially if confrontation with the law is involved.

Besides opioid-induced psychiatric disorders, a high prevalence of non–opioid-related psychiatric disorders exists. In Baltimore during the early 1990s, a study of people who were addicted and treated with methadone was performed, and the lifetime prevalence of comorbid mood and anxiety disorders was 19% and 8.2%, respectively. Lifetime rates of personality disorders in decreasing frequency were as follows:

Antisocial disorder (25.1%)
Avoidant disorder (5.2%)
Borderline disorder (5.2%)
Passive aggressive disorder (4.1%)
Paranoid disorder (3.2%)

In women, depression, anxiety disorders, and borderline personality disorder were considerably more common, and antisocial personality disorder was less common compared to males.

In the same study, comorbid dependence was also observed for cocaine (64.7%), cannabis (50.8%), alcohol (50%), and sedatives (46.6%).

Differential Diagnoses

Workup

Ahmad FB, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. Available at https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. 2021; Accessed: November 17, 2021.
Islam N, Jdanov DA, Shkolnikov VM, Khunti K, Kawachi I, White M, et al. Effects of covid-19 pandemic on life expectancy and premature mortality in 2020: time series analysis in 37 countries. BMJ. 2021 Nov 3. 375:e066768. [QxMD MEDLINE Link].
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2022. 608-15.
[Guideline] American Psychiatric Association. Practice guideline for the treatment of patients with substance use disorders, 2nd edition. In American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2006. Arlington, VA: American Psychiatric Association, 2006 (pp. 291–563). Available at http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1675010.
Younger JW, Chu LF, D'Arcy NT, et al. Prescription opioid analgesics rapidly change the human brain. Pain. 2011 Aug. 152(8):1803-10. [QxMD MEDLINE Link]. [Full Text].
Brooks M. FDA clears hydrocodone with abuse-deterrent properties. Medscape Medical News. November 20, 2014. [Full Text].
Lowes R. FDA Restricts Long-term Opioid Use to Combat Abuse. Medscape Medical News. Available at http://www.medscape.com/viewarticle/810732.. Accessed: September 18, 2013.
CDC. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm. March 15, 2016; Accessed: March 16, 2016.
Buprenorphine. Substance Abuse and Mental Health Services Administration (SAMHSA). Available at https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine. Accessed: 2/2/2017.
Wang J, Christo PJ. The influence of prescription monitoring programs on chronic pain management. Pain Physician. 2009 May-Jun. 12(3):507-15. [QxMD MEDLINE Link]. [Full Text].
Brooks M. Grim stats for opioid-related deaths, prescribing in US. Medscape Medical News. July 2, 2014. [Full Text].
Opioid painkiller prescribing: where you live makes a difference. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/vitalsigns/opioid-prescribing. Accessed: July 6, 2014.
Paulozzi LJ, Mack KA, Hockenberry JM. Vital signs: variation among States in prescribing of opioid pain relievers and benzodiazepines - United States, 2012. MMWR Morb Mortal Wkly Rep. 2014 Jul 4. 63(26):563-8. [QxMD MEDLINE Link].
Substance Abuse and Mental Health Services Administration. Results from the 2020 National Survey on Drug Use and Health. Available at https://www.samhsa.gov/data/sites/default/files/reports/rpt35319/2020NSDUHFFR1PDFW102121.pdf. 2021;
Hughes A, Williams MR, Lipari RN, et al. Prescription Drug Use and Misuse in the United States: Results from the 2015 National Survey on Drug Use and Health. Subtance Abuse and Mental Health Services Administration (SAMHSA). Available at https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR2-2015/NSDUH-FFR2-2015.htm#tabb-13.. September 2016; Accessed: February 2, 2017.
Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011 Apr 6. 305(13):1315-21. [QxMD MEDLINE Link].
[Guideline] Brooks M. New APS Guideline on Safe Use of Methadone. Medscape Medical News. May 22 2014. [Full Text].
[Guideline] Chou R, Cruciani RA, Fiellin DA, et al. Methadone safety: a clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. J Pain. 2014 Apr. 15(4):321-37. [QxMD MEDLINE Link].
Reimer J, Verthein U, Karow A, et al. Physical and mental health in severe opioid-dependent patients within a randomized controlled maintenance treatment trial. Addiction. 2011 Sep. 106(9):1647-55. [QxMD MEDLINE Link].
Melville, N. Three Key Factors Significantly Reduce Opioid-Related Deaths. Medscape Medical News. Available at http://www.medscape.com/viewarticle/882605. July 7, 2017; Accessed: July 13, 2017.
Watkins KE, Paddock SM, Hudson TJ, Ounpraseuth S, Schrader AM, Hepner KA, et al. Association between process measures and mortality in individuals with opioid use disorders. Drug Alcohol Depend. 2017 Jun 27. [QxMD MEDLINE Link].
Grella CE, Lovinger K. 30-Year trajectories of heroin and other drug use among men and women sampled from methadone treatment in California. Drug Alcohol Depend. 2011 Nov 1. 118(2-3):251-8. [QxMD MEDLINE Link]. [Full Text].
Frellick, M. More Children Entering EDs Are Addicted to Opioids. Medscape Medical News. Available at http://www.medscape.com/viewarticle/885793. September 17, 2017; Accessed: October 6, 2017.
Martin BC, Fan MY, Edlund MJ, et al. Long-term chronic opioid therapy discontinuation rates from the TROUP study. J Gen Intern Med. 2011 Dec. 26(12):1450-7. [QxMD MEDLINE Link].
National Institutes of Health (NIH) National Center for Complementary and Integrative Health (NCCIH). In the News: Kratom (Mitragyna speciosa). Available at https://nccih.nih.gov/news/kratom. February 23, 2018; Accessed: March 14, 2018.
Swogger MT. Is concern around kratom ‘drug hysteria’?. Medscape Medical News. Available at https://www.medscape.com/viewarticle/893709. March 12, 2018; Accessed: March 14, 2018.
Remarks from FDA Commissioner Scott Gottlieb, M.D., as prepared for delivery at the FDA OCI Meeting, November 14, 2017. US Food & Drug Administration. Available at https://www.fda.gov/newsevents/speeches/ucm584978.htm. November 14, 2017; Accessed: March 14, 2018.
Rech MA, Donahey E, Cappiello Dziedzic JM, Oh L, Greenhalgh E. New drugs of abuse. Pharmacotherapy. 2015 Feb. 35 (2):189-97. [QxMD MEDLINE Link].
DEA announces intent to schedule kratom. United States Drug Enforcement Administration. Available at https://www.dea.gov/divisions/hq/2016/hq083016.shtml. August 30, 2016; Accessed: March 14, 2018.
Drugs of Abuse. 2017 Edition. United States Drug Enforcement Administration. Available at https://www.dea.gov/pr/multimedia-library/publications/drug_of_abuse.pdf. 2017; Accessed: March 14, 2018.
Henningfield JE, Fant RV, Wang DW. The abuse potential of kratom according the 8 factors of the controlled substances act: implications for regulation and research. Psychopharmacology (Berl). 2018 Feb. 235 (2):573-589. [QxMD MEDLINE Link].
Statement from FDA Commissioner Scott Gottlieb, M.D., on the agency’s scientific evidence on the presence of opioid compounds in kratom, underscoring its potential for abuse. US Food & Drug Administration. Available at https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm595622.htm. February 6, 2018; Accessed: March 14, 2018.
What's Kratom, and Why Are States Banning It?. Governing the States and Localities. Available at http://www.governing.com/topics/health-human-services/sl-kratom-state-ban.html. December 4, 2017; Accessed: March 14, 2018.
Richardson LP, Russo JE, Katon W, McCarty CA, Devries A, Edlund MJ, et al. Mental Health Disorders and Long-term Opioid Use Among Adolescents and Young Adults With Chronic Pain. J Adolesc Health. 2012 Jun. 50(6):553-8. [QxMD MEDLINE Link]. [Full Text].
Saxon AJ, Oreskovich MR, Brkanac Z. Genetic determinants of addiction to opioids and cocaine. Harv Rev Psychiatry. 2005 Jul-Aug. 13(4):218-32. [QxMD MEDLINE Link].
Narcan Nasal Spray (naloxone intranasal) [package insert]. Radnor, PA: Adapt Pharma, Inc. November, 2015. Available at [Full Text].
FDA News Release. FDA moves quickly to approve easy-to-use nasal spray to treat opioid overdose. U.S. Food and Drug Administration. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm473505.htm. 2015 Nov 18; Accessed: November 18, 2015.
Zimhi (naloxone HCl injection) [package insert]. San Diego, CA: Adamis Pharmaceuticals. October 2021. Available at [Full Text].
Community-based opioid overdose prevention programs providing naloxone - United States, 2010. MMWR Morb Mortal Wkly Rep. 2012 Feb 17. 61:101-5. [QxMD MEDLINE Link].
Amato L, Davoli M, A Perucci C, et al. An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research. J Subst Abuse Treat. 2005 Jun. 28(4):321-9. [QxMD MEDLINE Link].
Simoens S, Matheson C, Bond C, et al. The effectiveness of community maintenance with methadone or buprenorphine for treating opiate dependence. Br J Gen Pract. 2005 Feb. 55(511):139-46. [QxMD MEDLINE Link].
Ling W, Amass L, Shoptaw S, et al. A multi-center randomized trial of buprenorphine-naloxone versus clonidine for opioid detoxification: findings from the National Institute on Drug Abuse Clinical Trials Network. Addiction. 2005 Aug. 100(8):1090-100. [QxMD MEDLINE Link].
Sigmon SC, Dunn KE, Saulsgiver K, Patrick ME, Badger GJ, Heil SH, et al. A Randomized, Double-blind Evaluation of Buprenorphine Taper Duration in Primary Prescription Opioid Abusers. JAMA Psychiatry. 2013 Oct 23. [QxMD MEDLINE Link].
Cassels C. Longer Taper May Boost Abstinence Rates in Opioid Abusers. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/813231. Accessed: November 4, 2013.
Fiellin DA, Schottenfeld RS, Cutter CJ, et al. Primary Care-Based Buprenorphine Taper vs Maintenance Therapy for Prescription Opioid Dependence: A Randomized Clinical Trial. JAMA Intern Med. 2014 Oct 20. [QxMD MEDLINE Link].
Cassels C. FDA Approves New Treatment for Opioid Dependence. Available at http://www.medscape.com/viewarticle/807379. Accessed: July 19, 2013.
Cassels C. FDA approves Bunavail for opioid addiction. Medscape Medical News. June 10, 2014. [Full Text].
Kowalczyk WJ, Phillips KA, Jobes ML, Kennedy AP, Ghitza UE, Agage DA, et al. Clonidine Maintenance Prolongs Opioid Abstinence and Decouples Stress From Craving in Daily Life: A Randomized Controlled Trial With Ecological Momentary Assessment. Am J Psychiatry. 2015 Aug 1. 172 (8):760-7. [QxMD MEDLINE Link].
McCance-Katz EF. Office-based buprenorphine treatment for opioid-dependent patients. Harv Rev Psychiatry. 2004 Nov-Dec. 12(6):321-38. [QxMD MEDLINE Link].
Understanding the Final Rule for a Patient Limit of 275. Substance Abuse and Mental Health Services Administration (SAMHSA). Available at http://www.samhsa.gov/sites/default/files/programs_campaigns/medication_assisted/understanding-patient-limit275.pdf. Accessed: February 2, 2017.
FDA. FDA approves first buprenorphine implant for treatment of opioid dependence. U.S. Food and Drug Administration. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm503719.htm. May 26, 2016; Accessed: June 7, 2016.
Ling W, Casadonte P, Bigelow G, Kampman KM, Patkar A, Bailey GL, et al. Buprenorphine implants for treatment of opioid dependence: a randomized controlled trial. JAMA. 2010 Oct 13. 304(14):1576-83. [QxMD MEDLINE Link].
Sublocade (buprenorphine extended-release injection) [package insert]. North Chesterfield, VA: Indivior, Inc. November, 2017. Available at [Full Text].
Gowing L, Farrell M, Bornemann R. Substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev. 2004. [QxMD MEDLINE Link].
Tsui JI, Herman DS, Kettavong M, Anderson BJ, Stein MD. Escitalopram is associated with reductions in pain severity and pain interference in opioid dependent patients with depressive symptoms. Pain. 2011 Nov. 152(11):2640-4. [QxMD MEDLINE Link]. [Full Text].
Comer SD, Sullivan MA, Yu E, et al. Injectable, sustained-release naltrexone for the treatment of opioid dependence: a randomized, placebo-controlled trial. Arch Gen Psychiatry. 2006 Feb. 63(2):210-8. [QxMD MEDLINE Link].
Sullivan M, Bisaga A, Pavlicova M, Choi CJ, Mishlen K, Carpenter KM, et al. Long-Acting Injectable Naltrexone Induction: A Randomized Trial of Outpatient Opioid Detoxification With Naltrexone Versus Buprenorphine. Am J Psychiatry. 2017 Jan 10. appiajp201616050548. [QxMD MEDLINE Link].
Krupitsky E, Nunes EV, Ling W, et al. Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial. Lancet. 2011 Apr 30. 377(9776):1506-13. [QxMD MEDLINE Link].
Tiihonen J, Krupitsky E, Verbitskaya E, et al. Naltrexone Implant for the Treatment of Polydrug Dependence: A Randomized Controlled Trial. Am J Psychiatry. 2012 Feb 17 [Epub ahead of print].
Rosenthal RN, Ling W, Casadonte P, Vocci F, Bailey GL, Kampman K, et al. Buprenorphine implants for treatment of opioid dependence: randomized comparison to placebo and sublingual buprenorphine/naloxone. Addiction. 2013 Dec. 108 (12):2141-9. [QxMD MEDLINE Link]. [Full Text].
Melville N. COMT Inhibitors Up Adherence to Opioid Maintenance Treatment. Medscape Medical News. Available at http://www.medscape.com/viewarticle/817481. Accessed: December 16, 2013.
Zhang XL, Shi J, Zhao LY, Sun LL, Wang J, Wang GB. Effects of stress on decision-making deficits in formerly heroin-dependent patients after different durations of abstinence. Am J Psychiatry. 2011 Jun. 168(6):610-6. [QxMD MEDLINE Link].
Passetti F, Clark L, Davis P, et al. Risky decision-making predicts short-term outcome of community but not residential treatment for opiate addiction. Implications for case management. Drug Alcohol Depend. 2011 Oct 1. 118(1):12-8. [QxMD MEDLINE Link].
Gorodetzky CW, Walsh SL, Martin PR, Saxon AJ, Gullo KL, Biswas K. A phase III, randomized, multi-center, double blind, placebo controlled study of safety and efficacy of lofexidine for relief of symptoms in individuals undergoing inpatient opioid withdrawal. Drug Alcohol Depend. 2017 Jul 1. 176:79-88. [QxMD MEDLINE Link].
Law FD, Diaper AM, Melichar JK, Coulton S, Nutt DJ, Myles JS. Buprenorphine/naloxone versus methadone and lofexidine in community stabilisation and detoxification: A randomised controlled trial of low dose short-term opiate-dependent individuals. J Psychopharmacol. 2017 Aug. 31 (8):1046-1055. [QxMD MEDLINE Link].
Brooks, M. FDA Clears First Device to Help Curb Opioid Cravings. Medscape Medical News. Available at https://www.medscape.com/viewarticle/888662. November 15, 2017; Accessed: November 25, 2017.
Brauser D. FDA Okays Wearable Device for Opioid Withdrawal. Medscape Medical News. Available at https://www.medscape.com/viewarticle/898043. June 13, 2018; Accessed: June 21, 2018.
Kleber HD, Gold MS, Riordan CE. The use of clonidine in detoxification from opiates. Bull Narc. 1980. 32(2):1-10. [QxMD MEDLINE Link].
Gowing L, Ali R, White J. Buprenorphine for the management of opioid withdrawal. Cochrane Database Syst Rev. 2004. [QxMD MEDLINE Link].
Gowing L, Farrell M, Ali R. Alpha2 adrenergic agonists for the management of opioid withdrawal. Cochrane Database Syst Rev. 2004. [QxMD MEDLINE Link].
Kunoe N, Lobmaier P, Vederhus JK, Hjerkinn B, Hegstad S, Gossop M, et al. Naltrexone implants after in-patient treatment for opioid dependence: randomised controlled trial. Br J Psychiatry. 2009 Jun. 194(6):541-6. [QxMD MEDLINE Link].
Hulse GK, Morris N, Arnold-Reed D, Tait RJ. Improving clinical outcomes in treating heroin dependence: randomized, controlled trial of oral or implant naltrexone. Arch Gen Psychiatry. 2009 Oct. 66(10):1108-15. [QxMD MEDLINE Link].
Marsch LA, Bickel WK, Badger GJ, et al. Comparison of pharmacological treatments for opioid-dependent adolescents: a randomized controlled trial. Arch Gen Psychiatry. 2005 Oct. 62(10):1157-64. [QxMD MEDLINE Link].
Amato L, Minozzi S, Davoli M, Vecchi S. Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. Cochrane Database Syst Rev. 2011 Sep 7. 9:CD005031. [QxMD MEDLINE Link].
Morasco BJ, Gritzner S, Lewis L, et al. Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. Pain. 2010 Dec 22. [QxMD MEDLINE Link].
Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006 Jan 17. 144(2):127-34. [QxMD MEDLINE Link].
Brooks M. New CDC Guidance on Prescribing Opioids for Pain. Medscape Medical News. Available at https://www.medscape.com/viewarticle/983488. Nov 3, 2022; Accessed: Dec 6, 2022.
Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep. 2022 Nov 4. 71 (3):1-95. [QxMD MEDLINE Link].
Substance Abuse and Mental Health Services Administration. Considerations for the Care and Treatment of Mental and Substance Use Disorders in the COVID-19 Epidemic. Substance Abuse and Mental Health Services Administration. Available at https://www.samhsa.gov/sites/default/files/considerations-care-treatment-mental-substance-use-disorders-covid19.pdf. March 20, 2020; Accessed: March 23, 2020.
[Guideline] Substance Abuse and Mental Health Services Administration. Opioid Treatment Program (OTP) Guidance. Substance Abuse and Mental Health Services Administration. Available at https://www.samhsa.gov/sites/default/files/otp-guidance-20200316.pdf. March 19, 2020; Accessed: March 23, 2020.
Brooks, M. COVID-19 Prompts 'Lifesaving' Policy Change for Opioid Addiction. Medscape Medical News. Available at https://www.medscape.com/viewarticle/927248. March 21, 2020; Accessed: March 23, 2020.
[Guideline] American Society of Addiction Medicine. The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder 2020 Focused Update. American Society of Addiction Medicine. Available at https://www.asam.org/Quality-Science/quality/2020-national-practice-guideline. Accessed: March 23, 2020.
Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016 Dec 30. 65 (5051):1445-1452. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention (CDC). Vital Signs: Risk for overdose from methadone used for pain relief – United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2012 Jul. 3;61:[Full Text].
Cassels C. Illicit Use of Pain Meds a Gateway to Heroin Abuse. Medscape Medical News. Available at http://www.medscape.com/viewarticle/809812.. Accessed: August 27, 2013.
Cicero TJ, Inciardi JA, Munoz A. Trends in abuse of Oxycontin and other opioid analgesics in the United States: 2002-2004. J Pain. 2005 Oct. 6(10):662-72. [QxMD MEDLINE Link].
Davenport L. Avoid Buprenorphine Detox for Prescription Opioid Addiction. Medscape Medical News. Oct 23 2014. [Full Text].
Fischer B, Rehm J, Kim G, Kirst M. Eyes wide shut?--A conceptual and empirical critique of methadone maintenance treatment. Eur Addict Res. 2005. 11(1):1-9; discussion 10-4. [QxMD MEDLINE Link].
Muhuri PK, Gfroerer JC, Davies MC. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. The Substance Abuse and Mental Health Services Administration (SAMHSA). Available at http://www.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-reliever-use-2013.pdf.. Accessed: August 27, 2013.

Media Gallery

of 0

Author

David W Dixon, DO Psychiatrist, 2nd Chance Treatment Center, Gilbert, AZ

David W Dixon, DO is a member of the following medical societies: American Medical Association, American Psychiatric Association

Disclosure: Nothing to disclose.

Coauthor(s)

Ryan P Peirson, MD Aerospace Psychiatry Consultant, Aeromedical Consultation Service, Neuropsychiatry Branch (FECN), US Air Force School of Aerospace Medicine; Assistant Professor of Psychiatry, Chief of Forensic Psychiatry, Assistant Training Director, General Psychiatry Residency, Wright State University, Boonshoft School of Medicine

Ryan P Peirson, MD is a member of the following medical societies: Aerospace Medical Association, American Academy of Psychiatry and the Law, American Psychiatric Association, Ohio Psychiatric Physicians Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Glen L Xiong, MD Associate Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California, Davis, School of Medicine; Medical Director, Sacramento County Mental Health Treatment Center

Glen L Xiong, MD is a member of the following medical societies: AMDA - The Society for Post-Acute and Long-Term Care Medicine, American College of Physicians, American Psychiatric Association, Central California Psychiatric Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: SafelyYou, Blue Cross Blue Shield<br/>book co-editor for: Wolter Kluwer, American Psychiatric Publishing Inc.

Additional Contributors

Barry I Liskow, MD Professor of Psychiatry, Vice Chairman, Psychiatry Department, Director, Psychiatric Outpatient Clinic, The University of Kansas Medical Center

Disclosure: Nothing to disclose.

Adrian Preda, MD Professor of Clinical Psychiatry and Human Behavior, University of California, Irvine, School of Medicine

Adrian Preda, MD is a member of the following medical societies: American Association for the Advancement of Science, American Psychiatric Association, International College of Neuropsychopharmacology, International Congress of Schizophrenia Research, Schizophrenia International Research Society, Society of Biological Psychiatry

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors Ziaur Rehman, MD, Suzan Khoromi, MD, James E Douglas, MD, Steven A Adelman, MD, and William J Meehan, MD, PhD to the development and writing of this article.