Dr.Scott Buesing | American Addiction Centers

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Xanax, a brand name of alprazolam, belongs to a class of medications called benzodiazepines.1 Xanax is a relatively short-acting benzodiazepine used for treating generalized anxiety disorder or panic disorder in adults.1

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Xanax, and other benzodiazepines, are central nervous system (CNS) depressants; and therefore, act on the brain produce a sedative or calming effect.1,2 However, Xanax has potential for misuse and addiction, especially when taken at higher doses or combined with other substances such as opioids and alcohol.1,3

In relatively recent years, healthcare professionals have prescribed benzodiazepines to more than 5% of adults in the United States.4 In fact, alprazolam is one of the most widely prescribed drugs for anxiety disorder and panic disorder.5 Yet, in 2020, nearly 4.8 million people aged 12 and older reported misusing benzodiazepine prescriptions in the past year.6
<h2>How Addictive is Xanax?</h2>
<a href="https://americanaddictioncenters.org/xanax-treatment">Xanax</a> is classified as a Schedule IV controlled substance, meaning there is a recognized medical use for the drug, but there is also potential for abuse and addiction.7

Research indicates that individuals with a history of substance use disorder, a medical condition characterized by uncontrollable use of a substance despite its negative effects, are at particularly high risk for benzodiazepine misuse and addiction.5 Another study found that individuals with a history of alcohol or opioid use specifically preferred alprazolam because they found it to be more rewarding than other benzodiazepines.5

If any <a href="https://americanaddictioncenters.org/benzodiazepine">benzodiazepine</a> is taken long enough, physical dependence can develop. Once physical dependence develops to a benzodiazepine like Xanax, people may experience several characteristic withdrawal symptoms if they stop taking it.5 
<h2 class="faded">Xanax Withdrawal Timeline</h2>
Xanax withdrawal can begin within 24 hours after the last dose and symptoms may last between a few days to weeks.

The use of any benzodiazepine, even as directed, for as little as 3 to 6 weeks can result in dependence, including withdrawal upon discontinuation.8 When used for 6 months or more, research suggests that around 40% of people experience moderate to severe withdrawal symptoms when they stop taking the drug.8

Several researchers have described two distinct phases of benzodiazepine withdrawal—acute withdrawal, which lasts between 5 and 28 days after stopping benzodiazepines, and a more protracted withdrawal phase, which can last up to a year or more, in some cases.8
<h2>Xanax Withdrawal Symptoms</h2>
In general, symptoms of acute withdrawal from benzodiazepines can include:8
<ul>
 	<li>Anxiety.</li>
 	<li>Panic attacks.</li>
 	<li>Hyperventilation.</li>
 	<li>Tremors.</li>
 	<li>Sleep problems.</li>
 	<li>Muscle spasms.</li>
 	<li>Loss of appetite.</li>
 	<li>Sweating.</li>
 	<li>General discomfort.</li>
 	<li>Hypersensitivity to light, sound, or touch.</li>
 	<li>Abnormal sensations.</li>
 	<li>The sensation of being detached from your body.</li>
 	<li>Psychosis, including hallucinations, delusions, and delirium (a type of severe confusion).</li>
 	<li class="faded">Seizures.</li>
</ul>
Studies indicate that between 10% and 25% of chronic benzodiazepine users experience protracted withdrawal when they stop taking the drug.8 Symptoms typically include new or worsening anxiety and depression.8 

Additionally, benzodiazepines such as Xanax are associated with memory or cognition problems.1 Some research has suggested that benzodiazepine-related changes in cognitive function may persist to some degree, even after discontinuation.5
<h2 class="faded">Factors that Affect Xanax Withdrawal</h2>
Several factors can influence Xanax withdrawal. More severe acute benzodiazepine withdrawal is associated with the use of higher doses, concurrent use of multiple benzodiazepines, longer durations of use, and the use of shorter-acting benzos (e.g., Xanax).8 Additionally, research suggests that alprazolam withdrawal may be associated with higher instances of rebound anxiety compared to other benzodiazepines.5 These rebound symptoms are often more severe than they were before Xanax was initiated.5

Concerns also exist surrounding certain populations and Xanax use. Changes in how the body is able to absorb, metabolize, and eliminate active forms of the drug can influence its pharmacological effects. Studies indicate that Xanax may be more slowly metabolized in older adults, individuals with liver disease, and those who are obese.10 Research suggests that Asian individuals may experience relatively higher peak serum concentrations and longer elimination times for Xanax compared to Caucasians.10
<h2>How Much Xanax Causes Withdrawal?</h2>
There appears to be an increased risk of physiological dependence and severe withdrawal in patients that consume more than 4 mg of Xanax per day for 12 weeks or more.10 However, people taking lower doses, especially for longer periods of time, may still have withdrawal symptoms when the medication is discontinued. Keeping Xanax dosing under 4 mg per day does not necessarily remove the risk of withdrawal.10 One study estimates that a third of people who use benzodiazepines for 6 months or longer experience withdrawal.3
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<h2 class="faded">Is it Safe to Detox from Xanax Naturally or at Home?</h2>
The abrupt discontinuation of Xanax can result in life-threatening withdrawal reactions. If an individual stops taking the medication cold turkey—without appropriate tapering—it can result in seizures, severe confusion and disorientation, and death.11 <a href="https://americanaddictioncenters.org/drug-detox" target="_blank" rel="noopener">Medically managed detoxification</a> allows medical professionals to supervise and support an individual as their body rids itself of the drug and other toxins safely and as comfortably as possible.

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<h2>Medications Used to Treat Xanax Withdrawal Symptoms</h2>
Many withdrawal management protocols involve administering benzodiazepines in gradually decreasing amounts. In some instances, a switch to a relatively longer-acting benzodiazepine—such as chlordiazepoxide, clonazepam, or diazepam—will take place to stabilize the patient in withdrawal prior to proceeding with a gradual dose reduction.12,13

There is some preliminary evidence that flumazenil, a medication which blocks the activity of benzodiazepines at specific receptor sites, could help to alleviate both acute symptoms for those actively going through withdrawal and more protracted withdrawal symptoms that persist after discontinuing benzodiazepines.8 One study found that individuals who took flumazenil experienced fewer withdrawal symptoms, had less cravings, completed withdrawal at better rates, and relapsed less.8

Additionally, studies show that anticonvulsants, antidepressants, and beta blockers have some efficacy in treating <a href="https://americanaddictioncenters.org/benzodiazepine/length-of-withdrawal">benzodiazepine withdrawal symptoms</a>.8

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<h2>Xanax Withdrawal Treatment</h2>
Due to the challenges associated with benzodiazepine withdrawal and discontinuation, the World Health Organization (WHO) recommends that healthcare professionals use a schedule to help individuals taper benzodiazepines safely.12 As mentioned, clinicians may use a relatively long-acting medication such as Valium (diazepam) to help stabilize individuals experiencing benzodiazepine withdrawal and then gradually decrease the dose over a period of days or weeks to keep the individual safe and as comfortable as possible.12

While detox is an effective first step in the journey to recovery, it is typically not enough to support an individual’s long-term recovery from a drug addiction.14 Medical detox can serve as an ideal entry point for more comprehensive treatment, where evidence-based <a href="https://americanaddictioncenters.org/therapy-treatment">behavioral therapies</a> and counseling can help people to better prevent relapse and achieve long-term abstinence.14
<h2>Take Our Substance Abuse Self-Assessment</h2>
Take our free, 5-minute substance abuse self-assessment below if you think you or someone you love might be struggling with drug addiction. The evaluation consists of 11 yes or no questions that are intended to be used as an informational tool to assess the severity and probability of a substance use disorder. The test is free, confidential, and no personal information is needed to receive the result.

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American Addiction Centers (AAC) is the nationwide leader in addiction treatment. If you’re struggling with Xanax dependence, we’re here to help. Quitting can be scary and challenging; but, quitting abruptly can be dangerous. AAC has the medical team and treatment staff to safely manage benzodiazepine withdrawal through medical detox. Don’t trust your life to chance. Achieve long-term sobriety with the professional support of a recovery program that offers medical detoxification and tailored rehabilitation treatment. Call our <a href="https://americanaddictioncenters.org/rehab-guide/alcohol-drug-hotline" target="_blank" rel="noopener">drug abuse hotline</a> at [phone]
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<h2 class="faded">Coping with Xanax Withdrawal Symptoms</h2>
Withdrawing from Xanax can be challenging. If you are coping with Xanax withdrawal symptoms, know that they will subside with time. Consider the following coping strategies:15-17
<ul>
 	<li>Access counseling support. Research suggests that psychological support coupled with a medically managed dose reduction schedule may be better than tapering alone.</li>
 	<li>Utilize relaxation therapies. Early evidence indicates that mindfulness meditation may help individuals with a substance use disorder, although additional research is necessary.</li>
 	<li>Don’t skip appointments. During the medication taper, regular doctor visits that include benzodiazepine education, the problems that they can cause, and information on withdrawal can be helpful.</li>
 	<li>Celebrate your progress. When combined with positive reinforcement, celebrating the successes may improve outcomes.</li>
</ul>
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[sources]
<ol>
 	<li>DailyMed. (2021, September 29). <a href="https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=388e249d-b9b6-44c3-9f8f-880eced0239f&amp;audience=consumer" target="_blank" rel="noopener">Label: Xanax-alprazolam tablet.</a></li>
 	<li>Griffin, C. E., 3rd, Kaye, A. M., Bueno, F. R., &amp; Kaye, A. D. (2013). <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684331/" target="_blank" rel="noopener">Benzodiazepine pharmacology and central nervous system-mediated effects</a>. The Ochsner journal, 13(2), 214–223.</li>
 	<li>Lader, M. (2014). <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4014015/" target="_blank" rel="noopener">Benzodiazepine harm: how can it be reduced?</a> British journal of clinical pharmacology, 77(2), 295–301.</li>
 	<li>Maust, D. T., Lin, L. A., &amp; Blow, F. C. (2019). <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6358464/" target="_blank" rel="noopener">Benzodiazepine use and misuse among adults in the United States</a>. Psychiatric services, 70(2), 97–106.</li>
 	<li>Ait-Daoud, N., Hamby, A. S., Sharma, S., &amp; Blevins, D. (2018). <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5846112/" target="_blank" rel="noopener">A review of alprazolam use, misuse, and withdrawal</a>. Journal of addiction medicine, 12(1), 4–10.</li>
 	<li>Substance Abuse and Mental Health Services Administration. (2020). <a href="https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf" target="_blank" rel="noopener">Key Substance Use and Mental Health Indicators in the United States: Results from the National Survey on Drug Use and Health</a>.</li>
 	<li>United States Drug Enforcement Administration. (n.d.) <a href="https://www.dea.gov/drug-information/drug-scheduling" target="_blank" rel="noopener">Drug Scheduling</a>. </li>
 	<li>Hood, S. D., Norman, A., Hince, D. A., Melichar, J. K., &amp; Hulse, G. K. (2014). <a href="https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bcp.12023" target="_blank" rel="noopener">Benzodiazepine dependence and its treatment with low dose flumazenil</a>. British journal of clinical pharmacology, 77(2), 285–294.</li>
 	<li>Tan, K. R., Rudolph, U., &amp; Lüscher, C. (2011). <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4020178/" target="_blank" rel="noopener">Hooked on benzodiazepines: GABAA receptor subtypes and addiction</a>. Trends in neurosciences, 34(4), 188–197.</li>
 	<li>Federal Drug Administration. (2011, March). <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/018276s044,021434s006lbl.pdf" target="_blank" rel="noopener">Xanax.</a></li>
 	<li>Fluyau, D., Revadigar, N., &amp; Manobianco, B. E. (2018). <a href="https://journals.sagepub.com/doi/full/10.1177/2045125317753340" target="_blank" rel="noopener">Challenges of the pharmacological management of benzodiazepine withdrawal, dependence, and discontinuation</a>. Paton, C. <a href="https://www.cambridge.org/core/journals/psychiatric-bulletin/article/benzodiazepines-and-disinhibition-a-review/421AF197362B55EDF004700452BF3BC6" target="_blank" rel="noopener">Benzodiazepines and disinhibition: a review</a>. Psychiatric Bulletin, 26(12), 460-462.</li>
 	<li>World Health Organization. (2009). <a href="https://www.ncbi.nlm.nih.gov/books/NBK310652/" target="_blank" rel="noopener">Clinical guidelines for withdrawal management and treatment of drug dependence in closed settings</a>.</li>
 	<li>Substance Abuse and Mental Health Services Administration. (2015). <a href="https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4131.pdf" target="_blank" rel="noopener">Treatment Improvement Protocol—TIP 45: Detoxification and Substance Abuse Treatment</a>.</li>
 	<li>National Institute on Drug Abuse. (2018). <a href="https://nida.nih.gov/sites/default/files/675-principles-of-drug-addiction-treatment-a-research-based-guide-third-edition.pdf" target="_blank" rel="noopener">Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition).</a></li>
 	<li>Brett, J., &amp; Murnion, B. (2015). <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4657308/" target="_blank" rel="noopener">Management of benzodiazepine misuse and dependence</a>. Australian prescriber, 38(5), 152–155.</li>
 	<li>Barros, V. V., Opaleye, E. S., Demarzo, M., Curado, D. F., Bowen, S., Hachul, H., &amp; Noto, A. R. (2021). <a href="https://pubmed.ncbi.nlm.nih.gov/34013489/" target="_blank" rel="noopener">Effects of mindfulness-based relapse prevention on the chronic use of hypnotics in treatment-seeking women with insomnia: a randomized controlled trial.</a> International journal of behavioral medicine, 10.1007/s12529-021-10002-4. Advance online publication.</li>
 	<li>Vicens, C., Fiol, F., Llobera, J., Campoamor, F., Mateu, C., Alegret, S., &amp; Socías, I. (2006). <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1934057/" target="_blank" rel="noopener">Withdrawal from long-term benzodiazepine use: randomised trial in family practice</a>. The British journal of general practice:the journal of the Royal College of General Practitioners, 56(533), 958–963.</li>
</ol>
[/sources]

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Xanax Withdrawal Symptoms, Timeline & Detox Treatment

[content-overview]Nausea and vomiting accompanied by stomach cramping or pain is a common set of symptoms present in many conditions, including the stomach flu and food poisoning. However, cyclical vomiting syndrome (CVS) or psychogenic vomiting, repeated episodes of severe nausea and vomiting without any indication of infection or illness, is not. CVS is more common in children than adults, and it is sometimes associated with behavioral problems. Some research suggests that it may be a variant of migraine headache or abdominal migraine.1,2[/content-overview]

In 2004, doctors in South Australia first described episodes of cyclical vomiting of unknown origin in adult patients who were regular marijuana users.3 Additional case reports and research on the condition, cannabinoid hyperemesis syndrome (CHS), continue to be published and CHS is still not fully understood nearly 20 years later. Thus, the condition may go unrecognized and undiagnosed as a result.3

Therefore, the prevalence of CHS is difficult to gauge though one study out of Colorado found that after the legalization of cannabis, emergency room visits for CVS increased.2,4 A separate study evaluating people who had a history of smoking cannabis 20 days or more per month found that approximately one-third exhibited the symptoms of CHS.5 Consequently, marijuana was also the most prevalent federally illicit drug used in 2020—with more than 49 million individuals reporting past-year marijuana use.6

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<h2>What Is Cannabinoid Hyperemesis Syndrome (CHS)?</h2>
CHS is a rare condition associated with long-term, regular (daily or weekly) cannabis use that’s characterized by severe nausea, vomiting, and stomach pain that run in cycles.7 Individuals with CHS commonly find relief from frequent or long-lasting hot showers.7

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<h2>Symptoms of Cannabinoid Hyperemesis Syndrome</h2>
Symptoms of CHS and their severity depend on the phase of the syndrome. Common symptoms of CHS may include:7
<ul>
 	<li>Morning sickness.</li>
 	<li>A fear of throwing up.</li>
 	<li>Intense abdominal discomfort or pain.</li>
 	<li>Persistent nausea.</li>
 	<li>Repeated vomiting and retching (i.e., making the sound and movement of vomiting).</li>
 	<li>Loss of appetite.</li>
 	<li>Weight loss.</li>
</ul>
Those with CHS may also feel compelled to take hot showers or baths. This may be due to the soothing effects of hotter temperatures, which temporarily alleviate the symptoms.7
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<h2>CHS Phases and Timeline</h2>
It can take years of cannabis use to develop CHS. A 2011 report published in Current Drug Abuse Reviews noted that “in nearly all cases, there is a delay of several years” from the time marijuana smoking started to when the first CHS symptoms are experienced.8

Research suggests there are 3 phases of CHS, including:7
<ol>
 	<li>The prodromal phase. Individuals experience general morning sickness and abdominal discomfort or pain during this phase. Since these symptoms are relatively mild and can occur after years of cannabis use, many people continue to smoke marijuana or even increase their consumption due to the belief that cannabis will settle their stomachs. Thus, this phase can last for months or years.</li>
 	<li>The hyperemetic phase. This is the acute phase of CHS. During this phase, CHS’ effects intensify. Individuals experience intense and persistent nausea and vomiting. There is typically a persistent mild abdominal pain as well. Due to the severity of the symptoms, individuals may struggle with weight loss and dehydration.</li>
 	<li>The recovery phase. Individuals get to this phase when they abstain from cannabinoid use and symptoms begin to fade. However, if a patient starts using cannabis again, symptoms tend to recur.</li>
</ol>
<h2>What Are the Possible Complications of CHS?</h2>
Frequent vomiting can lead to complications, including:9,10
<ul>
 	<li>Dehydration and electrolyte imbalances, which can result in nutritional deficiencies and renal failure.</li>
 	<li>Aspiration, which can result in inflammation of lung tissue (pneumonitis) and aspiration pneumonia (when vomit is breathed into the lungs or airway).</li>
 	<li>Esophagus rupture and other esophageal injury such as tears in the tissue.</li>
 	<li>Low potassium (hypokalemia).</li>
 	<li>Low levels of phosphorous in the blood (hypophosphatemia).</li>
 	<li>Air trapped in the chest cavity between the lungs (pneumomediastium).</li>
</ul>
<h2>What Might Cause CHS?</h2>
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Researchers have several theories on the causes of CHS—none of which is strongly supported by evidence. Some of these theories include:3,7 
<ul>
 	<li>Genetics. Some individuals might be more susceptible to cannabis toxicity due to genetic variations.</li>
 	<li>Dysregulation of certain receptors. Researchers identified two receptors—CB1 and CB2 located in the brain, gastrointestinal tract, nervous system, and immune system—to which marijuana binds. These receptors respond to specific stimuli or changes in the environment. CB1 receptors, specifically, regulate the effects of marijuana on the gastrointestinal tract. In the short term, marijuana can help decrease nausea and vomiting by activating these CB1 receptors. However, chronic stimulation of these receptors might decrease their activity, leading to CHS.</li>
 	<li>Slowed digestion. Stimulation of these receptors in the gut may slow digestion enough to cause nausea and vomiting.</li>
 	<li>Toxic buildup. Long-term marijuana use might lead to an accumulation of cannabinoid components in the brain and fatty tissues of the body that cause a toxic effect.</li>
 	<li>Enlarged blood vessels. Marijuana may cause an increased dilation of blood vessels in the gastrointestinal tract, leading to CHS.</li>
 	<li>A stress response. Long-term marijuana use might dysregulate the hypothalamic-pituitary-adrenal axis, which is a physiological arm of the stress response, leading the CHS symptoms.</li>
 	<li>Disruption of temperature control. Cannabis might disrupt the body’s ability to regulate temperature, which could contribute to symptoms, especially those temporarily alleviated by hot showers and bathing.</li>
</ul>
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<h2>Risk Factors for Developing Cannabinoid Hyperemesis Syndrome </h2>
Not every person who uses marijuana—even long term—develops CHS. While it is certain that individuals who use marijuana frequently (on a daily or weekly basis for at least a year) or in prolonged high doses are at an increased risk of getting CHS, not much is understood beyond that. Additional evidence is needed to better understand or identify factors that may contribute to an individual’s overall risk of developing CHS, including the potency of marijuana, <a href="https://americanaddictioncenters.org/co-occurring-disorders">co-occurring</a> physical or mental health conditions, ethnicity, or socioeconomic environmental factors.7
<h2>How Is CHS Diagnosed?</h2>
For a number of reasons, CHS is often missed as a diagnosis. Individuals with CHS may not disclose their drug use or they may not seek medical care. It’s an emerging diagnosis that may be overlooked in the emergency department, where many individuals go to seek help.7

In order to be diagnosed with CHS, certain criteria must be present, including:7,11
<ul>
 	<li>Long-term, frequent marijuana use—at least more than 1 year.</li>
 	<li>Severe cyclic vomiting episodes after prolonged, high-dose cannabis use.</li>
 	<li>Stabbing abdominal pain.</li>
 	<li>Symptoms stop when the individual sustains abstinence from marijuana use.</li>
 	<li>May be associated with compulsive bathing in hot water.</li>
</ul>
To further complicate the diagnosis, CHS bears a strong resemblance to another condition called cyclic vomiting syndrome (CVS).12 While CVS presents the same way, the triggers that cause CVS are different, including lack of sleep, stress, certain foods, but not marijuana.2
<h2>Tips for Dealing with CHS Symptoms</h2>
It’s well documented that individuals with CHS find temporary relief by taking hot showers or baths. One case study found capsaicin—the chemical found in chili peppers that makes your mouth burn—in a cream form eased painful abdominal pain for an individual with CHS.13 In some cases, anti-anxiety medication helped provide relief for individuals with CHS.14 However, the only sustainable solution to resolve CHS symptoms is to stop marijuana use.14
<h2>Cannabinoid Hyperemesis Syndrome Treatment &amp; Outlook</h2>
While there is no standard for treating CHS, there are options to treat the symptoms, but all of them lack robust research pointing to their effectiveness. For instance, some research suggests that <a href="https://americanaddictioncenters.org/benzodiazepine" target="_blank" rel="noopener">benzodiazepines</a>—specifically lorazepam—showed a positive response in the treatment of CHS.15 Other studies indicate that the antipsychotic medication haloperidol, given intravenously to individuals with CHS, has been effective in symptom relief.15 However, after alleviating the symptoms associated with CHS with medications and/or creams, treatment includes patient education and counseling to help the individual stop their marijuana use since research suggests that’s the most likely way to resolve CHS in most patients.14 In fact, one study found about 84% of the patients who received treatment for CHS reported abstinence from marijuana use. Of those, more than 86% reported resolution of their CHS symptoms.15

If you or a loved one have a marijuana use disorder and struggle to quit, professional treatment can help. While research is virtually nonexistent on the efficacy of addiction treatment for individuals with CHS, drug rehab treatment for marijuana use can help you achieve lasting abstinence, which studies suggest may likely resolve the symptoms associated with CHS.
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 	<li><a href="https://americanaddictioncenters.org/rehab-guide/free" target="_blank" rel="noopener">Free Drug Rehabs</a></li>
 	<li><a href="https://americanaddictioncenters.org/rehab-guide/inpatient" target="_blank" rel="noopener">Inpatient Drug Treatment</a></li>
 	<li><a href="https://americanaddictioncenters.org/drug-detox/same-day-admittance" target="_blank" rel="noopener">Same Day Detox Centers</a></li>
 	<li><a href="https://americanaddictioncenters.org/rehab-guide/outpatient-treatment" target="_blank" rel="noopener">Outpatient Drug Treatment</a></li>
</ul>
[/link-bank]

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Cannabinoid Hyperemesis Syndrome (CHS): Symptoms and Treatment

Scott Buesing, ND is a licensed naturopathic doctor with a background in both mental health conditions and chronic pain treatment. His experience includes working in a multidisciplinary, partial-hospitalization program for individuals struggling with mental health conditions and addiction. In addition, he also has significant experience working in a multidisciplinary pain clinic. The clinic focused on [&hellip;]

Scott Buesing | American Addiction Centers

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