stephen holt md-detoxificaton and the 911 distaster

THE WORLD TRADE CENTER COLLAPSE

&A REHABILITATIVE INTERVENTION

FOR RESCUE WORKERS USING A SAUNA DETOXIFICATION

METHOD

Stephen Holt, MD, LLD(Hon.) ChB., PhD, ND, FRCP (C)

MRCP (UK), FACP, FACG, FACN, FACAM, OSJ

Distinguished Professor of Medicine

Kathleen Kerr MD, Dip Env Health

Lecturer, Faculty of Medicine, University of Toronto

OBJECTIVES

1. To describe key aspects of the World Trade Center collapse, exposure and health effects

2. To describe a sauna detoxification intervention in use in rescue workers

3. To describe health outcomes after the intervention

World Trade Center Collapse Exposure

WORLD TRADE CENTER COLLAPSE EXPOSURE

ON THE MORNING OF SEPTEMBER 11, 2001, the destruction of New York City’s World Trade Center (WTC), two 110-story skyscrapers, generated tremendous forces which released large amounts of intermediate and large respirable particulates. 70% of the towers’ construction materials, office furnishings, computers, etc were pulverized.

• Long-lasting structural fires started with the ignition of 91,000 liters of aircraft fuel and spread to organic debris, transformer oil, heating and diesel oil, and fuel from several thousand automobiles. These processes generated predominantly small particles containing toxic combustion products, such as polycyclic aromatic hydrocarbons (PAHs).

• Rescue and cleanup workers, ~40,000, as well as volunteers and residents of the adjacent community, for the next 10 months, were exposed to the pollutants at or near ground zero, often without adequate respiratory protection which was unavailable or not used..


WTC DUST– coarse particles of pulverized cement (highly alkaline)– glass fibers, – asbestos, – lead, other metals. – phthalates,

COMBUSTION BY-PRODUCTS – many different polycyclic aromatic hydrocarbons & benzene– brominated diphenyl ethers,– polychlorinated biphenyls, – dibenzodioxins, and polychlorinated furans.


• Air quality monitoring during and early after the structural collapse was incomplete. Air sampling by EPA began day 12, thus remarkably little is known about initial PAH exposures (Pleil 2004). High levels of PAHs in soot indicated potential risk, particularly for reproductive effects.

• Exposure assessment models for NYFD are based on time of arrival: Group I= Day 1 AM (9/11), Group II =Day 1 PM and Day 2, Group III=after Day 2 (Prezant et al).

• Other exposure assessment models are based on 4 outdoor zones and 1 indoor zone (Lioy 2006).

• Dust samples were taken by day 5 & 6. (Lioy 2002, Landrigan 2004)

• Alkaline dust in particular has been shown to impair nasal clearance mechanisms.

• Window film analysis by a Canadian group found unique patterns of persistent bioaccumulative compounds such as PCDD/Fs, PCBs, PBDEs, PAHs on windows close to the site (Butt 2004, Rayne 2005 included Miriam Diamond, U of T).

World Trade Center Collapse Human Exposure

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(Banauch, Dhala, Prezant. Curr Opin Pulm Med. 2005)


BIOMONITORING• In 321 FDNY firefighters who had worked at the WTC site, serum

heptachlorodibenzodioxin and furan were higher 4 weeks after the collapse compared with those who had notworked there. PCBs were not elevated over control FDNY non-WTC exposed, except in 50 FF (Edelman 2003).

• Biomarkers of exposure (blood & urine) were measured in 187 women who were pregnant and were at or near the World Trade Center on or soon after September 11, 2001. Elevations of dioxin/furan in blood similar to firefighters were found along with elevated PAH-DNA adducts, lead, cobalt and PCBs, indicating

intense bystander exposure (Woolf 2005). • Ten months after the WTC collapse, induced sputum tests found

mineral particles characteristic of WTC debris in FDNY firefighters’ lower airway epithelial cells. (Fireman 2005)

WORLD TRADE CENTER COLLAPSE

HEALTH EFFECTS• Eye and skin irritation which has now largely resolved

• Upper respiratory symptoms such as nasal congestion persist 2- 4 yrs later in ~ 30% of NYFD rescue workers (RWs)

• Daily cough, shortness of breath, wheezing persist ~30%

• ~25 % highly exposed RWs have developed persistent airway hyperreactivity &/or RADS.

• The equivalent of a 12-year loss of pulmonary function in one year, in exposed firefighters has been found, affecting more exposed as well as other exposure groups. (Banauch 2005)

• Marked increase in “sarcoid-like” granulomatous pneumonitis cases (13 in 2002) and other rare pulmonary diseases including eosinophilic pneumonitis (2 cases), pulmonary fibrosis (4 cases, 1 died).

WORLD TRADE CENTER COLLAPSE HEALTH EFFECTS

WORLD TRADE CENTER COUGH • During the year following the WTC attack, Prezant et al. described a

syndrome of unrelenting airway inflammation in 332 New York City firefighters.

• The case definition specified a persistent cough severe enough to require at least 4 weeks of medical leave with onset during the 6 months following the WTC collapse.

• Clinical symptoms included rhinosinusitis, and bronchitis.• Also seen was a high (87%) rate of gastroesophageal complaints, such as

acid reflux (GERD). • The incidence of this syndrome was correlated with WTC dust exposure

intensity, estimated by initial arrival time at the WTC site.



(Banauch, Dhala, Prezant. Curr Opin Pulm Med. 2005)


PERSISTENCE OF SYMPTOMS• The range of contaminants present and the possible levels of each

contaminant is sufficiently unknown to make it impossible to arrive at an authoritative characterization of the incident or its possible health consequences.

• Initially, public health officials expected that the majority of the symptoms would reduce with the passage of time. Not only are complaints persisting, rescue workers who previously had not reported significant health problems are now falling ill (Kipen and Gochfeld 2002, Herbert and Levin

2003).

• Recent health surveillance data found that 70 percent of ~10,000 responders reported new or worsened respiratory symptoms while performing WTC work. Symptoms persisted to the time of examination (up to 2004) in 60% (Herbert 2006).

• Additionally persistent symptoms included– heartburn/reflux in 24% – severe headaches in 21%.


MENTAL HEALTH EFFECTS• 2-4 years follow-up of NYFD R/W found ~ 60% continued to have

sleep related problems such as getting a refreshing sleep.• Mood changes in ~50% similarly persisted at 2-4 years F/U such as

difficulty concentrating, irritable, angry, or anxious• Other persisting issues include detachment, flashbacks, numbness

which have continued unchanged in ~20-30%.RETIREMENT & DISABILITY• One third of the NYFD firefighters retired between 2001 and 2006.• More than 1500 FF diagnosed with respiratory disease, the most

severe are the retirees. • James Zadroga, an NYPD detective who spent hundreds of hours at

Ground Zero, later died at the age of 34 from respiratory failure.LATE EFFECTS• An unusual increase in leukemia and multiple myeloma is emerging in

younger exposed people (Herbert web interview 2007).


EFFECTIVE TREATMENT OPTIONS ARE URGENTLY NEEDED.

• While current medical screening programs continue, and long-term patterns of illness are identified, it is also essential to identify rehabilitative interventions that could restore function and quality of life to the greatest extent possible.

• Recognizing that they had had an unprecedented exposure from the WTC disaster, members of the Uniformed Firefighters Association contacted the Foundation for Science and Education in Los Angeles concerning assistance in making a specific intervention developed by Hubbard, aimed at enhancing detoxification of xenobiotics, available to exposed personnel.


SPECIFIC METHOD DEVELOPED BY HUBBARD, AIMED AT

ENHANCING DETOXIFICATION OF XENOBIOTICS • Following this request, an independent facility to provide the Hubbard

method, funded by private donations, was set up in September 2002 in lower Manhattan and later in a second facility on Long Island.

• Over 800 rescue workers and other exposed persons have since been treated without charge, with costs raised through bi-annual fundraising drives, & NY city grant of $330,000 to treat exposed sanitation workers.

METHOD AIMED AT ENHANCING DETOXIFICATION OF XENOBIOTICS

DETOXIFICATION• The word “detoxification” is often used medically to describe the stage of

withdrawal from alcohol or illicit drugs.This is not the above meaning• Physiologically the word refers to the biotransformation and elimination

of byproducts of metabolism or xenobiotics. Older textbooks use the term “detoxication”, but detoxification is more common now.

• There are inherited genetic polymorphisms of several enzymes involved in detoxification which may affect individual risk (Kelada 2003).

– cytochromes P450, – N-acetyltransferase, – glutathione S-transferases, peroxidase.– microsomal epoxide hydrolase, – NAD(P)H:quinone oxidoreductase,

• Nutritional status affects detoxification at numerous points


ENHANCING DETOXIFICATION • For contaminants which undergo biotransformation, elimination can

be enhanced via – mobilization from stores, – inducing hepatic biotransformation pathways, along with nutrient

cofactor support

• For persistent contaminants which resist biotransformation, elimination can theoretically be enhanced via – starvation- mobilizes too fast– lactation - passes to infant – diffusion into GI tract- EFA in diet, olestra, – bile sequestrant- cholestyramine – chelation methods- heavy metals– sweat- sweat lodges, Finnish sauna, infra red sauna– Hubbard method- exercise, oils, niacin, sauna


BRIEF BACKGROUND OF METHOD

• Research and development was by L. Ron Hubbard, whose educational background was in engineering and atomic physics. His main research was in resolving philosophical questions concerning the life force.

• In the sixties and seventies Hubbard was finding that students of his, who had been using various street drugs, were having mental blanks and flashbacks. The original purpose of this method was to help former LSD users, who even years later could report “flashbacks”, and had difficulties with learning and perception.

• Early participants reported apparent exudation of other chemical

odours such as pesticides.


USES FOR OCCUPATIONAL EXPOSURES • Some researchers began to study the Hubbard method for occupational

exposures. A number of case reports, preliminary studies and small controlled trials of exposed cohorts treated with the method have been published or presented.

• These cohorts include electrical workers, painters, pesticide applicators, police, radiation liquidators, firefighters and Gulf war veterans.

• Some studies have measured serum and/or adipose tissue body burden of fat soluble xenobiotics including organohalides such as DDT/DDE, HCB, PCBs and PBBs.

• Some studies have used symptom based questionnaires, psychometric or neurobehavioural testing.

• These have shown consistent improvements.


USES FOR OCCUPATIONAL EXPOSURES • In 1984, pilot before-after trial of the Hubbard method was published

in the peer reviewed journal Ambio. (Schnare et al 1984)

– 7 participants with an accidental exposure to PBBs had adipose levels of several organohalides determined before and after the regimen.

– There were statistically significant reductions in many of the chemicals at the end of the program and further reductions at post treatment follow-up 4 months later.

– This demonstrated body burden reductions were actual, not

compartment shift.


USES FOR OCCUPATIONAL EXPOSURES

• In 1986 a small non-randomized, controlled study (n=10) was published in WHO, IARC, Scientific Publication Series.

• Electrical workers with ongoing exposure to PCBs and HCB were studied.

• Controls’ adipose levels increased while participants’ HCB body burdens were reduced by 30% at post-treatment and 28% three months post-treatment, adjusted for re-exposure as represented in the control group (f<0.001).

• During the treatment, serum levels of the chemicals did not increase which demonstrated that mobilization from tissue stores was

keeping pace with the enhanced excretion (Schnare 1986).


USES FOR OCCUPATIONAL EXPOSURES

• In 1989, Kilburn et al published a neurobehavioral study of 14 firemen in the peer reviewed Archives of Environmental Health. The firemen had been exposed to PCBs and combustion byproducts at a transformer fire and explosion.

– They had poorer neurocognitive tests than control firemen from the same city.

• Following the Hubbard protocol detoxification program there were significantly improved neurocognitive scores on:

– 3 memory tests

– Block design

– Trails B

– Embedded figures


USES FOR OCCUPATIONAL EXPOSURES • In 1991, a case was reported in Human and Experimental Toxicology

of a female capacitor factory worker in Slovenia with PCB exposure and high body burden. (Tretjak 1991)

• She had multiple symptoms, cloracne and a bluish-green daily nipple discharge. PCB levels pre- and post treatment:– Adipose 102 ppm reduced to 37 ppm– Serum 512 ppm reduced to 261 ppm– Skin lipids measured 66 ppm– Nipple discharge 712 ppm - ceased during treatment– PCBs measured in sebum increased up to five-fold during sauna

sweating, demonstrating the body’s enhancement of this route of excretion during treatment.


HUBBARD METHOD MAIN POINTS• Following medical examination and determination of fitness for

participation the daily regimen includes: – daily monitoring of vital signs, weight (which is kept constant throughout

the regimen) and recording of all treatment events;

– aerobic exercise 20-30 minutes; – sauna at 60–82 C (140–180 F) ~ 4 hrs; – vitamins, calcium, magnesium and trace minerals, centered around

gradually increasing doses of crystalline niacin; – polyunsaturated oil; – water and salts taken as needed to avert dehydration or salt

depletion due to sweating; and – an orderly daily schedule, balanced meals and adequate sleep.

• No alcohol or illegal drugs are permitted during the period of the regimen. Concurrent use of medications is only as approved by the program physician.

• The regimen length is participant specific, averaging 33 days.

METHOD AIMED AT ENHANCING DETOXIFICATION OF XENOBIOTICS SAUNA COMPONENT One of the first written descriptions of the Finnish

Sauna was in 1112.


SAUNA COMPONENT: HISTORICAL USES

• Sweat related activities appear to have been practiced in some form by many cultures

– The Romans 2000 years ago used their steam baths

– The ancient Russian bania continues to be utilized in Europe

– Mayan ruins uncovered ancient sweat houses some over 1200 years old

– Many North and Central American Indian tribes have traditionally used the sweat lodge

• Ramazzini, in his 1713 work, Diseases of Workers, noted that writers of works on poisons at that time

– “advise, in general, remedies that have the power of setting the spirits and blood mass in motion and of provoking sweat”.

– (Ramazzini B. Diseases of Workers. Translated from De Morbis Artificum of 1713 by Wilmer Cave Wright. New York: Haffner, 1964.)


TABLE 1. Physiologic Effects of Sauna Bathing

From: Nguyen: Cardiol Rev, Volume 12(6).November/December 2004.321-324Copyright (c) 2000-2007 Ovid Technologies, Inc.

Version: rel10.5.1, SourceID 1.13281.2.2


TABLE 2. Benefits and Risks of Sauna Bathing


SAUNA COMPONENT SUMMARY

• Widespread and long term use by human cultures. Sauna per se, probably has health benefits exclusive of detoxification, such as reduced pain, improved cardiac output and possibly respiratory function.

• Physiologic effects and safety well described.

• Hubbard protocol is not just sauna, but is a more complex, specific regimen, including exercise, niacin, multiple vitamin/minerals, oils.

• Hubbard method stipulates a cooler temperature about 60 - 80 C (most health clubs are at 100 C or higher). Short periods in sauna with breaks

for cooling showers as needed.


SAUNA LIMITATIONS. • Pharmacokinetics of drugs are not much affected by sauna per se

(Vanakowski 1998).

• Lipophilic contaminants such as PCBs and dioxins have been identified in sebum (Sasaki 1991, Ohgami 1993, Watabi 1999) and numerous xenobiotics have been identified in sweat including antibiotics (Hoiby 2000), codeine (Schwilke 2006), cocaine and heroin (Levisky 2000), and

other drugs of abuse (Huestis 1999). • Some loss of xenobiotics via sweat is thus probable, given a

sufficient quantity of sweat, long enough, and if these can be mobilized from tissue storage compartments.

• The biggest problem of detoxification is concerned with mobilizing and excreting two types of persistent lipophilic xenobiotics:

– molecules which persist because of disposition to adipose tissue, – molecules which are essentially not metabolizable such as certain

PCBs and dioxins.


ADIPOSE BODY BURDEN: • Over 700 compounds were found in human adipose tissue US EPA

National Human Adipose Tissue Survey: a biomonitoring program for toxic substances in the adipose tissue of the general U.S. population. In fiscal year 1982 , analyzed as composites for volatile and semivolatile organic compounds, :– saturated and unsaturated hydrocarbons, – aldehydes, – ketones, – steroids,– heterocyclic compounds, – drugs, – aliphatic and phthalate esters, – phenols, – halocarbons, and – methyl-substituted organosiloxanes.


ADIPOSE BODY BURDEN• Drugs such as morphine, oxycodone, methadone, amitryptiline, (Levisky

2000), cocaine (Weiss 1988, Cone 1989), marijuana (Leighty 1976, Mason 1985, Nahas 2001), diazepam (Freidman 1985), LSD (Axelrod 1957), PCP (James 1976, Martin 1982) and their metabolites have been identified in fat and other organs. Postmortem analyses of adipose tissues disclosed cocaine and methamphetamine, morphine and temazepam (Levisky 2001) .

• A number of highly lipophilic environmental contaminants or pharmaceutical drugs, such as dioxins, PCBs, DDE, and amiodarone, are eventually accumulated at high levels in white adipose tissue with long

half-lives in the body of months to years (Bickel, 1984; Latini et al., 1984; Muhlebach et al., 1985; Flesch-Janys et al., 1996; Michalek et al., 1996).

• Their direct effects on adipose tissue remain unclear. Adipose is not only a lipid store but also an important endocrine organ secreting a large number of cytokines and hormones (Ahima and Flier, 2000; Large et al., 2004).

These…can activate AhR pathways, increasing the tissue's detoxifying capability, and raising the possibility that these compounds dysregulate

the gene expression profile in adipose, causing unexpected effects on the tissue (Yoshinari 2006).


HUBBARD PROTOCOL: NIACIN • Niacin causes rebound lipolysis about 1 - 2 hours after taking it (Carlson 2005).

It has also been found to stimulate cholesterol mobilization from macrophages, linking it to a regression in atherosclerosis (Rubic 2004)

• During the lipolysis rebound and cholesterol mobilization from macrophages we have the opportunity for fat stored xenobiotics to exit the adipocyte or other cells, associated with FFAs or other lipids.

• Mobilization of free fatty acidshas been shown in animal studies to mobilize fat stored halogenated xenobiotics (Findlay 1971, de Freitas 1974, Mitlavila 1981).

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HUBBARD PROTOCOL: COMBINATION OF STEPS • To accomplish any significant body burden reduction, must if

mobilizing, be excreting xenobiotics at the same pace, thus must exploit all detoxification pathways. Regulated by graduated doses of niacin and other cofactors as well as by time in the sauna.– Increase lipolysis via exercise and niacin to mobilize xenobiotics. – Provide for enzymatic biotransformation pathways via high

intake of niacin and balanced with other micronutrients. (NAD is depleted by xenobiotics).

– High PUFAs encourage diffusion across intestinal wall (non metabolized xenobiotics) and/or prevent enterohepatic recirculation (metobolized, excreted in bile then reabsorbed) to excrete via fecal route.

– Greatly increased sweat and sebum utilized as excretory route.


HUBBARD PROTOCOL: EXERCISE/LIPOLYSIS• Aerobic exercise results in doubling of adipose blood flow and a

substantial post exercise lipolysis and lipid mobilization from adipose tisssue beginning ~ 1 hr post exercise and continuing ~ 3 hrs.(Mulla et al, J Physiol 2000)

• Plasma PCB, DDE levels were found to significantly rise in response to weight reduction in obese individuals. This was related to increase in basal lipolysis of subcutaneous abdominal and femoral adipocytes, especially in men. (Imbeault et al, Int J Obes, 2001)




HUBBARD PROTOCOL: HIGH MICRONUTRIENT INTAKE

– Vitamins and minerals are lost in sweat.

– Many metabolic steps are highly vitamin and mineral dependent. Factors controlling xenobiotic metabolism include availability of cofactors required for biotransformation steps such as niacin for NADPH and regeneration of glutathione (GSH), antioxidants, B complex vitamins, EFAs.

– Drugs and or toxins may induce specific deficiencies.

• Overall metabolic condition influences NADPH supply as there will be competition for its use.(Timbrell, 2000)


HUBBARD PROTOCOL: POLYUNSATURATED OILS • A mix of n6 and n3 EFAs and phosphatidylcholine. Oils have two roles:

– Early animal trials with mineral oil (Rozman 1885), liquid paraffins (Rozman 1984), and later human trials with sucrose-polyester olestra (Moser

1999) and colestemide (Saturai 2004), enhanced gut excretion of lipophilic toxins. Polyunsaturated oils present in the gut can act to

1. prevent re-uptake of xenobiotics being eliminated through bile (which may be reabsorbed via enterohepatic recirculation) as well as

2. enhance passive diffusion across the intestinal mucosa.(Birnbaum 1985)

– Diet-induced modifications in membrane lipid composition are associated with changes in the rates of membrane-linked cellular

processes. (Hulbert et al, 2005)


HUBBARD PROTOCOL: SUFFICIENT TIME SWEATING • “The relationship between PCB concentrations in the skin surface

lipids and blood was investigated in 22 patients with Yusho PCB poisoning and 9 control subjects. PCB levels in the skin surface lipids were higher than those in the blood. – These findings suggests that cutaneous sebaceous system is one

of the excretory systems of polyhalogenated chemicals, such as PCBs or PCQs..” (Tanaka et al, 1995)

• Sweating and sebum production are greatly increased by 2 to 4.5 hours of sauna induced sweating, promoting enhanced elimination of the mobilized xenobiotics.

REHABILITATIVE TREATMENT OF RESCUE WORKERS AND

OTHER INDIVIDUALS EXPOSED TO THE WORLD TRADE

CENTER COLLAPSE~

NEW YORK RESCUE WORKERS' DETOXIFICATION PROJECT

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NEW YORK RESCUE WORKERS' PROJECT INTAKE• Individuals are referred to the project because of persistent symptoms

following WTC exposure. Many individuals self-refer through word of mouth from co-workers.

• The project’s rehabilitative goal emphasizes restored quality of life (“wellness”).

• The project includes an ongoing evaluation component to assess the full range of WTC associated health effects experienced by each participant and outcomes following the detoxification regimen. All participants in this evaluation signed informed consent.

• The evaluation includes a structured medical examination plus a comprehensive exposure history, health history and symptom survey developed specifically for this project.

WORLD TRADE CENTER COLLAPSE NEW YORK RESCUE WORKERS' PROJECT

COMPREHENSIVE QUESTIONNAIRE – basic demographic information– employment history and relevant work exposure questions– recent symptomatology focusing on the cluster of symptoms

common to environmental exposures including the WTC– medications – the number of lost workdays.

LABORATORY TESTS – panel of standard laboratory tests including CBC, comprehensive

metabolic panel, thyroid panel, lipid panel, – ECG, spirometry and urinalysis.– SF-36 and CDC Health-related Quality of Life scoring. – Neurocognitive testing including IQ, choice reaction time,

calibrated postural sway.


NEW YORK RESCUE WORKERS' PROJECT DEMOGRAPHICS (compiled from systematically collected chart review data)

• First 3 years: 484 completions

– 402 men and 82 women completed the Hubbard detoxification protocol

– 273 Firefighters

– 52 Sanitation Workers

– 19 Paramedics

– 23 Police Officers

– 117 citizens

• As of September 2007: 822 completions – 678 Men and 144 Women

– 305 firefighters– 77 police officers

– average program 34 days , 47% of patients complete within a month


NEW YORK RESCUE WORKERS' PROJECT SUMMARY OF RESULTS (compiled from systematically collected chart

review data) • Persistent symptoms greatly diminished such as

– cough, shortness of breath, sinus/nasal– gastroesophageal reflux, – rashes, – neurocognitive problems– fatigue

• Improved job performance, social and family relationships, mood, perception of health.

• Elimination of need for many respiratory medications. • Considerable reductions in days of work missed, leading to reduced

concerns about forced retirement.


MEDICATION REQUIREMENTS• 84% of those clients requiring medications to manage symptoms

related to WTC exposure were able to discontinue their use. Over half the clients required multiple pulmonary medications on entry to achieve near-normal spirometry (measured as FVC & FEV1). On completion of detoxification, 72% of these individuals were free of pulmonary medication yet had improved spirometry tests (data not shown).

LABORATORY• 30 % had abnormal levels of thyroid-related hormones at start of

treatment. Following treatment, 66% of these patients had normal thyroid levels with the remaining third improved.

• Choice Reaction Time improved (p<0.01)• Postural Sway Test improved (p =0.012)


NEW YORK RESCUE WORKERS' PROJECT




IMPROVED QUALITY OF LIFE

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• Pre/post detoxification balance testing (sway) was completed on a random cohort of firefighters. P=0.012.




CONCLUSIONS• A large proportion of exposed WTC collapse survivors, rescue

workers, residents, etc have persistent respiratory and mental health effects.

• Comprehensive screening programs and monitoring for long term effects have been established.

• The New York Rescue Workers’ Detoxification Project, an independent facility, has treated over 800 exposed persons at no cost, with systematically collected chart review data showing impressive reduction in previously persistent respiratory symptoms, medication requirements, and improved overall function.

• It is important to develop increased collaboration and independent research into this method in order to substantiate the reported outcomes and increase access to the program as warranted.

• Specific case reports will be presented in the workshop.

stephen holt md-detoxificaton and the 911 distaster

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