Search

The story of a profession can be told through an exploration of its history, language, values, rituals, symbols, and literature. This paper combines the expertise of an addictions librarian and an addictions treatment/recovery historian to describe the evolution of addiction/recovery-related periodicals (ARPs) over the past 150 years. It explores what the periodic rise, changing character, and fall of ARPs reveal about the larger history of addiction treatment and recovery in America. The alcohol and other drugs problems field is made up of diverse functions and institutions-formal prevention and treatment programs, informal mutual aid groups, scientific research institutes, personal growth movements, public policy bodies, education and advocacy agencies, and professional associations representing physicians, nurses, counselors, psychologists, and social workers. Addictions periodicals play an intregal part in linking these various constituency groups. We will examine the history of the addictions periodicals that have served to link these groups. This is not the first effort to step back and examine ARPs. Andrews and Cohen (1979) and Boxenbaum and Jaffe (1982) provided independent reviews of the emergence of addiction-- related periodicals that were birthed in the 1970s. These early review articles were followed by analyses of the evolving topical focus of articles in ARPs (Moll and Narin, 1977; Van Ruyven and Veenstra, 1993), analyses of the impact of particular ARPs via citation analysis within the broad arena of addiction literature (Jones, 1999), guides on where to publish addiction-related research manuscripts (Arciniega and Miller, 1997), and trend analyses of issues such as the rise of multiple authorship in ARPs (Jones, 1996; Howard, 1992; Howard and Walker, 1996). This paper is distinguished from these earlier efforts in three ways. First, it views this genre of literature within a much longer historical perspective. Second, it provides a widened perspective on ARPs by including-in addition to peerreviewed journals-professional trade journals, magazines, and newsletters for both professionals and general readers. Third, it suggests that trends in ARPs provide a subtle window of exploration into past and emerging trends in the alcohol and other drugs problems arena. I. Methodology We began this study by attempting to assemble a listing or chronology of all American ARP literature for the past 150 years. Collections utilized included the Illinois Addiction Studies Archive housed at Chestnut Health Systems in Bloomington, IL (http://www.chestnut.org), the Hazelden Library and Information Resources collection in Center City, MN (http:llwww.hazelden.org/library), and the online listing for the Alcohol and Drug Abuse Institute of Seattle, WA (http://depts.washington.edu/ada il). Also examined were Ulrichs International Periodicals Directory 2000, the Serials Directory: An International Reference Book 1999, the OCLC database, and serendipitous approaches such as word of mouth and advertisements. Our list of ARP titles continued to be expanded and updated until the paper was finalized in October 2001. "ARP" was defined to include journals, newsletters, and government items-anything produced in serial and periodical form rather than monographic form. We defined "addiction/ recovery-related" in the broadest sense, from publications that focused on the neurobiology of addiction to those that focused on treatment research and protocol to those written as mediums of personal support for persons in addiction recovery. When adding to the list, we focused on finding periodicals that were professional or non-professional in focus, regional or local or national in geographic scope, and published by any entity (private or public). The chronology of more than 200 collected titles was placed into a graph listing the title, publisher, date started, date ceased or still current (as appropriate), format, focus, and intended audience. …

Addiction counseling in the modern era has been practiced as an essentially clinical activity, but this has not always been the case. There have been key points in the history of addiction treatment when the functions of community organization and social activism competed with, or complemented, this clinical orientation. The first section of this paper draws on nine episodes in this history to explore the relationship between addiction recovery and the addict’s identification with, and participation in, a community of recovering addicts. The second section utilizes the work of John McKnight to explore how professionalized and institutionalized services can inadvertently undermine the development and vitality of indigenous community support systems. The third section outlines a series of recommendations that would shift the focus of addiction recovery from something that happens exclusively in the context of professionally-directed treatment to a process that unfolds within the larger community. It is argued that the professionalization (medicalization and psychologization) of addiction treatment needs to be balanced by a re-emphasis on recovery as a connection with indigenous resources and relationships beyond the self. The paper closes with a discussion of the potential pitfalls of this shift in focus from clinical technique to community resource mobilization.

Treatment researchers are increasingly advocating the use of evidenced-based treatment manuals. Here we describe therapist reactions to the use of manual-guided therapies in a multisite, randomized field experiment that evaluated five outpatient treatment protocols for adolescents who abuse or are dependent on marijuana. Data are summarized from qualitative interviews with 16 therapists and 3 case managers who provided the treatments. All of those interviewed felt that the manuals provided a structure to their therapeutic work, and the majority felt they were able to address individual patient needs. Therapists' reactions did vary depending on the type of manual they used (e.g., session-based, principle-based, or procedure-based). Recommendations for the development and use of manual-guided therapies to improve adolescent substance abuse treatment are discussed.

Resisting 12-Step Coercion: How to Fight Forced Participation in AA, NA, or 12-Step Treatment, by Stanton Peele and Charles Bufe with Archie Brodsky (Tucson, AZ: Sharp Press, 2000), 204 pp., $14.95 paper. Background Between 1930 and 1970 a multifactioned modern alcoholism movement sought and achieved a significant change in America's perception of alcoholism and the alcoholic (Johnson, 1973; Roizen, 1991). At the apex of this destigmatization campaign (perhaps the moment First Lady Betty Ford spoke to the nation about her addiction and recovery), the movement was eclipsed and subsequently colonized by a larger addiction-treatment movement. The burgeoning treatment industry shifted the focus of addiction recovery from indigenous support structures to more formal relationships that were institutional, professional and commercial. Once intertwined, these movements become something of a pop phenomenon in the 1980s, generating a legion of new recovery groups for every imaginable problem and a virtual explosion in addiction-treatment programs. For a brief moment it looked like everyone was addicted to something and that anyone of prominence was going to "rehab." It seemed like the whole culture had become enamored of recovery (White, 1998). The excesses of this treatment/recovery movement generated an ideological backlash against Alcoholics Anonymous (AA) and its perceived influence on the philosophical underpinnings of modern addiction treatment, as well as a financial backlash against the treatment industry. The diverse individuals and organizations that led this reaction slowly coalesced into a countermovement. Mirroring the movement it opposed, this anti-12-step movement generated its own organizations, its own stable of celebrity authors and public speakers, and its own cultural trappings (web sites, books, t-shirts, bumper stickers). The authors of Resisting 12-Step Coercion are among the vanguard of this countermovement, and their latest book reflects much of its evolving character. Resisting 12-Step Coercion is valuable in that it calls attention to the fact that addiction treatment in the United States is becoming increasingly coercive and intrusive. We agree that the growing emphasis on coercion raises serious ethical and legal questions and undermines the fundamental character of treatment and recovery. Despite our agreement with the authors on this basic point, however, we believe that they (1) misidentify the source of coercion as Alcoholics Anonymous; (2) fail in their promise to offer solutions to those being coerced into mutual aid or treatment; and (3) present their work with a stridency that serves only to quicken polarization among those concerned with alcohol and other drug problems. In our view, Resisting 12-Step Coercion misses the opportunity to explain the limitations of coercion and the forces that have contributed to our growing confidence in the use of threats. Premises and assumptions Resisting 12-Step Coercion is a series of topical essays that collectively provide an overview of the nature of the alcohol problem, of the dominance and (according to the authors) ineffectiveness of 12-step groups and 12-step treatment as a response to that problem, and of the ethical and legal issues involved in coerced participation in 12-step groups and 12-- step treatment. The book is based on the following nine propositions: 1. The AA philosophy is based on a "demonstrably false" premise: that alcoholism is a "disease" that completely overtakes the alcoholic's power of choice and requires complete surrender to outside help. 2. The AA program resembles a cult because its members are indoctrinated with what is essentially a rigid, intrusive religious doctrine. 3. The AA philosophy reflects a "one size fits all" approach that precludes viable alternatives. 4. AA and AA-oriented treatment are ineffective and potentially harmful. 5. As an institution, AA has actively solicited and encouraged "membership recruitment" by enlisting the courts, employers and correctional agencies as referral sources. …

Part I of this article traced the history of recovered alcoholics as wounded healers from their roles in late 18 th century Native American cultural revitalization movements and the American temperance movement through their work as lay therapists and counselors within outpatient counseling clinics, Minnesota Model inpatient programs, industrial alcoholism programs and halfway houses. This article will focus on how the roles of the “paraprofessional” recovered alcoholic and ex-addict evolved into the professionalized role of the modern addiction counselor.

An elaborate network of inebriate homes, inebriate asylums, nationally franchised private addiction treatment institutes, and proprietary home cures for addiction arose on the American landscape between 1850 and 1900. The pinnacle of the movement to professionalize America's first addiction treatment field was the founding of the American Association for the Cure of Inebriety in 1870 and its publication of the first issue of the Journal of Inebriety in 1876. One of the most contentious issues among the various branches of this new professional field was the question of the use of "reformed men" as physicians, managers and attendants within treatment institutions. This article describes the employment of recovering physicians within one 19th century addiction treatment franchise--the Keeley Institutes--and documents the nature of the professional debate stirred by what was then a controversial practice.

BACKGROUND Testicular lymphoma is a rare extranodal presentation of non-Hodgkin lymphoma. The authors report long term follow-up information regarding a group of patients with testicular lymphoma evaluated at the Mayo Clinic and describe the outcome with special attention to patterns of recurrence. METHODS The medical records of patients with testicular lymphoma seen at the Mayo Clinic between January 1970 and March 1993 were reviewed. Patients were included if they had evidence of testicular involvement at the time of diagnosis of lymphoma. Pathology specimens were reviewed for confirmation of diagnosis. RESULTS Sixty-two patients with a diagnosis of testicular lymphoma were identified. Their median age was 68 years, and 60 patients underwent orchiectomy as the initial therapeutic and diagnostic procedure. Most of patients (79%) had localized or regional disease at the time of presentation. Other treatment modalities after diagnosis included radiotherapy (37%), combination chemotherapy (37%), and combination chemotherapy and radiotherapy (16%). Although 88% of patients had no residual disease after primary treatment, 80% subsequently experienced disease recurrence. There was no significant difference in the rate of recurrence, including Ann Arbor Stage I disease. Treatment did not appear to affect the recurrence rate. At a median follow-up of 2.7 years, 60% of patients had died of disease. Late recurrences were observed, and there appeared to be no plateau in the disease free survival curve. In half (51%) of the patients with disease recurrence, only extranodal locations were involved. Thirteen patients experienced recurrence in the central nervous system, 11 of whom had parenchymal lesions. In 8 of these 13 patients, the central nervous system was an isolated site of disease recurrence. CONCLUSIONS Testicular lymphoma is a unique and aggressive extranodal non-Hodgkin lymphoma. Better treatment strategies are needed to prevent recurrences. The risk of extranodal recurrence is high, especially in the central nervous system. Cancer 2000;88:154–61. © 2000 American Cancer Society.

America has a long fascination with the rise and fall (and resurrection) of some of her most affluent and celebrated citizens. The roles of addiction and recovery in such falls and resurrections ar...

Drunkard's Progress: Narratives of Addiction, Despair and Recovery, by John Crowley (Baltimore, MD, and London, England: The Johns Hopkins University Press, 1999), 202 pp., $15.95 (paper). Listening to Lazarus: the voices of America's first "reformed drunkards" There are historically obscure points where the fields of temperance history, alcohol studies, and addiction studies dramatically intersect. John Crowley has illuminated one of the earliest and most interesting of such intersections in his latest book, Drunkard's Progress: Narratives of Addiction, Despair and Recovery. This article reviews Crowley's latest contribution, analyzes the reform narratives presented in this work for their portrayal of the processes of addiction and recovery, and reflects on what these narratives tell us about the rise and fall of America's most celebrated 19th-century alcoholic mutual aid society. I. Context: the Washingtonian Movement Rising alcohol consumption and alcohol-related problems during the late 18th and early 19th centuries triggered abstinence-based cultural revitalization movements among Native American tribes and the emergence of the American temperance movement. Published stories of addiction and recovery that began to appear in the 1820s and 1830s challenged the belief that `"There was hope for our friend, if the yellow fever or even the plague was upon him; but none if he became a drunkard."1,2 Reform narratives emerged as something of a cultural phenomenon after six "hard cases" organized their own abstinence-based mutual aid society in Baltimore, Maryland, in 1840. This society was founded on the assumption that the reformed drunkard could reach his still-drinking brethren in ways that no one else could. For the reformed inebriate knows each avenue to his brother's heart; he highly (sic] touches the strings on which hang all his sorrow; no rebuke mingles with his invitation of welcome . . . The Washington Temperance Society that was launched in Baltimore spread rapidly through the United States and at its peak claimed a membership of same 600,000-of whom 150,000 were confirmed drunkards.3, 4 The Washingtonian Movement reached its zenith in 1843 and then entered a period of rapid decline. This decline has been attributed to many factors: conflict with existing religious and temperance groups, damaged credibility resulting from the relapse of prominent members, ineffective organization, failure to maintain the original closed (drunkards only) meeting structure, internal strife (particularly debates over the role of religion in personal reformation and the advisability of the legal prohibition of alcohol), and the lack of a clearly defined long-term program of recovery.5 The Washingtonian Temperance Society placed the reformed drunkard at the head of the temperance table and used the vivid portrayal of his own fall and rebirth as an invitation for others (drunkards and moderate tipplers) to pledge themselves to lifelong abstinence from all alcoholic drink. The Washingtonians placed "experience sharing" at the center of the process of personal reform. During the early 1840s, Washingtonian temperance missionaries carried a message of hope to the drunkard by reaching out to those still suffering (active recruitment), by serving as traveling temperance orators, and by telling their stories of personal decline and resurrection in newspaper articles, pamphlets and books.b The most fully developed of the temperance narratives that emerged within the Washingtonian Movement are the focus of John Crowley's Drunkard's Progress. II. A brief review John Crowley is not a newcomer to the study of the portrayal of alcoholism within American literature. His book The White Logic: Alcoholism and Gender in American Modernist Fiction was a significant contribution.' A more recent essay, comparing the narratives of John Gough and Frederick Douglass, is a remarkable piece of research that raised for the first time the question of whether Douglass should be classified as one who reformed himself from the excesses of drink and, as such, should be positioned historically as the first African American who framed abstinence within the context of cultural as well as personal survival. …

The Treatment of Drinking Problems: A Guide for the Helping Professions, by Griffith Edwards, E. Jane Marshall and Christopher C. Cook (Cambridge: Cambridge University Press, 1997), third edition, 368 pp., $85 cloth, $39.95 paper). I. REVIEWED BY William L. White A 1982 text by Griffith Edwards on the treatment of drinking problems was widely hailed and utilized. It went through a second edition (1987) and was eventually published in six languages. A new and significantly expanded edition of this text, titled The Treatment of Drinking Problems: A Guide for the Helping Professions, has been issued, with two coauthors, E. Jane Marshall and Christopher C. Cook. The critical praise heaped on the first two editions needs only be embellished for this latest edition. The Treatment of Drinking Problems is precisely what its title implies: a sweeping synthesis of the research and clinical literature on alcoholism and a highly useful manual for clinical practice. If anything, the authors are too humble in their statement of intent. Claimed to have been written for clinical practitioners, the book's utility easily extends to anyone who professionally encounters the personal and social consequences of excessive drinking. There are many quickly evident strengths to this book. First are its scope and objectivity. Edwards and his colleagues have presented a comprehensive survey of what we know about alcoholism and its treatment and have included balanced portrayals of some of the most controversial issues in alcoholism studies. Following a profusion of literature on addiction (much of questionable scientific merit), bringing into existence such a credible synthesis is no small feat. The text also rates high marks as a training manual. It is filled with prescriptive approaches to assessment and intervention that will be of great benefit to many helping professionals. The intent of this book is more one of helping alcoholics and their families than staking out ideological turf within the alcohol studies community. When the last page of The Treatment of Drinking Problems is turned, one is left with the clear impression that we are not only learning a great deal more about the potentially diverse and complex nature of alcohol problems but are also making significant strides in treating them. Having briefly added my own accolades to the praise that this book will surely receive as a training tool for professional helpers, it seems that this text might serve yet another purpose. The timing of this new edition offers something of a unique opportunity. Presenting itself as a comprehensive text on the treatment of alcoholism, and coming as it does at the end of the 20th century, this book affords a perfect vehicle to explore what we have learned about alcoholism and its treatment in this century. To conduct such a review requires that we define a baseline of knowledge by locating a comparable text written at the end of the l9th century. There are a number of late-19th-century texts that could serve this purpose, including Dr. Joseph Parrish's Alcoholic Inebriety (1883), Dr. T.L. Wright's Inebriism (1885), Dr. Norman Kerr's Inebriety (1894), or Dr. Charles Palmer's Inebriety: Its Source, Prevention and Cure (1898). The text I have chosen for this exercise is The Disease of Inebriety from Alcohol, Opium, and Other Narcotic Drugs (1893), compiled by Dr. T.D. Crothers. This choice is based on Crothers's international status as a late19th century addiction expert (a status comparable to that of Edwards today), the fact that Crothers's text was published by the American Association for the Study and Cure of Inebriety (an association analogous to today's American Society of Addiction Medicine), and that the text reflected the mainstream ideas of the association's central organ, The Journal of Inebriety. So, what does a comparison of these two widely acclaimed texts, written nearly 100 years apart, tell us about how the perception and treatment of alcohol-related problems have changed in the 20th century? …

The decrease in testosterone production associated with bilateral orchiectomy may result in normocytic anemia in men. We sought to determine the effect of orchiectomy on hemoglobin concentration. Patients were evaluated at the Mayo Clinic in 1993 and 1994 and underwent bilateral orchiectomy for prostate carcinoma. All patients were seen by one of the staff urologists. Patients were included if they had a normal preoperative complete blood cell count and serum levels of creatinine, if they remained without disease progression (suppressed prostate-specific antigen level and no evidence of clinical progression on review), and if they had normal serum levels of creatinine and mean corpuscular volume during the follow-up period. The patients could have no other cause of anemia. The complete blood cell count, prostate-specific antigen level, and serum level of creatinine were determined preoperatively and at least once (>90 days) after orchiectomy. Sixty-four patients were included in the analysis (median age, 68 years). The median decrease in hemoglobin concentration was 1.2 g/dL after orchiectomy. There was a statistically significant difference in the hemoglobin concentration before orchiectomy compared with postoperative values at all the intervals studied, both by the paired group t-test and the Kruskal-Wallis test. There is a clinically and statistically significant decrease in hemoglobin concentration after orchiectomy. Knowledge of this phenomenon may prevent unnecessary diagnostic work-up in men with normocytic anemia after bilateral orchiectomy.

To the best of our knowledge, the association of a medulloblastoma with a “dural-tail” sign has not been previously reported. A 24-year-old male developed severe headaches and right-sided dysmetria that worsened over 1 month. Magnetic resonance (MR) imaging of the brain demonstrated a heterogeneously enhancing lesion in the posterior fossa. The lesion appeared to be tentortally-based and exhibited a characteristic “dural-tail” sign, which is considered pathognothonic for meningioma. Cerebellar tonsil ectopia and hydrocephalus were also present. The presumptive diagnosis of tentorial meningioma was made. The lesion was resected by a posterior fossa approach. At surgery, the appearance of the tumor was inconsistent with the diagnosis of meningioma, and histopathologic evaluation yielded the diagnosis of medulloblastonia. This case and the literature demonstrate that malignant tumors can present with the characteristic MR imaging appearance of a meningioma. This possibility must be considered when treatment is planned, especially if a nonoperative course is favored.

In America the issue of occupational vulnerability to alchol and other drug-related problems has been a subject of observation and study for more than 200 years. Dr. Benjamin Rush raised this question in 1777, when he expressed concerns about increased consumption of distilled spirits by soldiers and called into question the use of daily "grog rations" in the United States Army.1 Literature from the inebriates' asylum era was filled with observations that particular occupational groups seemed to be prone to alcoholism and other drug addictions. For example, Dr. R. P. Harris suggested that shoemakers were "especially difficult to reform, as they incite each other to drink, and club together and send out for beer and whiskey."2 There was particular concern about addicted physicians during the l9th century and early 20th century. In 1883, Dr. J. B. Mattison attributed the high incidence of morphine addiction among physicians to their access to narcotics, their intimate knowledge of the hypodermic, and the weary days and sleepless nights that so typified their lives.3 Nineteenth-century autobiographical accounts of morphine dependency also underscored how easy it was for physicians to become addicted.4 Dr. T. D. Crothers suggested that the professional classes were particularly vulnerable to addiction and estimated that 10% of American physicians were addicted to narcotics.5 In 1911 Dr. Benjamin Burley set forth a theory of occupational vulnerability to alcoholism. In explaining the particular susceptibility of horse-keepers to inebriety, he noted: "I believe here we are dealing with a peculiar animal-loving but unstable temperament which is naturally susceptible to intoxication." Burley also believed merchants and salespeople were vulnerable to inebriety due to the custom of drinking at business meetings and dinners.6 Most of this concern and this literature faded from history with the collapse of inebriates' homes and asylums. While some attention to exploring alcoholism as an "occupational disease" was sparked in the 1940s in tandem with the rise of what has been called the modern alcoholism movement,7 this was only a warm-up for the intense focus on addicted professionals that grew out of the addiction treatment industry's more recent interest in "special populations." That interest generated a large body of literature, to which Robert Holman Coombs has added a new and significant contribution in Drug-Impaired Professionals. II. The growing array of literature on impaired professionals has emerged as a genre within the larger body of addiction literature. Subjects that have become mandatory in articles and texts addressing this issue include: literature reviews of problem prevalence; overviews of the signs, symptoms and stages of addiction; overviews of treatment modalities and mutual aid societies; and discussions of the specialty groups that exist specifically to aid addicted professionals. Even though Coombs's text covers these required discussions with greater depth and insight than many earlier texts, its strengths lie in another area. Coombs's first contribution is his recognition that addicted and recovering professionals are not a homogeneous group to be easily depicted in sweeping generalizations. The addiction of "pedestal professionals" is portrayed as springing from multiple etiological pathways that unfold in diverse drug choices and patterns of use and consequence and that follow different pathways of recovery. Typical of this subtlety is Coombs's classification of professionals across a continuum of drug-involvement intensity: abstention (Type 1), those who use socially (Type 2), those who abuse drugs but are not chemically dependent (Type 3), those who are physically but not psychologically dependent (Type 4), and those who are physically and psychologically dependent (Type 5). Coombs makes particular note of how Type 4 and Type 5 differ in their response to treatment and styles of recovery; for example, Type 4 individuals share a greater capacity for self-initiated "solo recovery" (recovery without benefit of formal treatment or affiliation with a mutual aid society). …

The alcohol and other drug (AOD) problems arena is extending its organizing center from knowledge drawn from the study of addiction-related pathologies and clinical and social interventions to knowledge drawn from the lived experience of long-term addiction recovery. A distinctive element within this shift is the increased use of non-clinical, peer recovery support services as an adjunct or alternative to specialized, professionally directed addiction treatment. This paper reviews the context of this shift, notes the evolution from competing to integrated service models, and outlines a decade of experience integrating peer recovery support services within the City of Philadelphia’s behavioral healthcare system. Integrated models of peer-professional addiction recovery support have the potential of capitalizing on the respective strengths of clinical and environmental interventions into severe AOD problems.

Patient-reported quality-of-life (QOL) end points are becoming increasingly important health care metrics. To date, no nasal morbidity instrument specifically designed for patients undergoing endonasal skull base surgery has been developed. In this study, the authors describe the development and validation of a site-specific nasal morbidity instrument to assess patient-reported rhinological outcomes following endonasal skull base surgery.Eligible patients included those with planned endonasal transsphenoidal surgery for sellar pathology identified in outpatient neurosurgical clinics of 3 skull base centers from October 2011 to July 2012. An initial 23-question pool was developed by subject matter experts, review of the literature, and from the results of a previous validation study to assess for common rhinological complaints. Symptoms were ranked by patients from "No Problem" to "Severe Problem" on a 6-point Likert scale. Exploratory factor analysis, change scores, and importance rank were calculated to define the final instrument consisting of 12 items (The Anterior Skull Base Nasal Inventory-12, or ASK Nasal-12). Psychometric validation of the final instrument was performed using standard statistical techniques.One hundred four patients enrolled in the study. All patients completed the preoperative survey and 100 patients (96%) completed the survey 2-4 weeks after surgery. Internal consistency of the final instrument was 0.88. Concurrent validity measures demonstrated a strong correlation between overall nasal functioning and total scores (p0.001). Test-retest reliability measures demonstrated a significant intraclass correlation between responses (p0.001). Effect size as calculated by standardized response mean suggested a large effect (0.84). Discriminant validity calculations demonstrated that the instrument was able to discriminate between preoperative and postoperative patients (p0.001).This prospective study demonstrates that the ASK Nasal-12 is a validated, site-specific, unidimensional rhinological outcomes tool sensitive to clinical change. It can be used in conjunction with multidimensional QOL instruments to assess patient-reported nasal perceptions in endonasal skull base surgery. This instrument is being used as a primary outcome measure in an ongoing multicenter nasal morbidity study. Clinical trial registration no.: NCT01504399 (ClinicalTrials.gov).

Graft survival is prolonged by pretransplant transfusion of the graft recipient. It has been postulated that graft rejection is associated with Th1-like cytokines. We tested whether transfusion shifts cytokine production from a Th1-type (gamma-IFN production) to a Th2-type (IL-4 production). Transfusion prolonged cardiac allograft (C3H/HeN donor to a C57BL/6 recipient) survival (10.4+/-0.5 versus 7.2+/-0.2 days for controls, P

Purpose: Extranodal marginal zone B-cell lymphoma (low-grade B-cell lymphoma of mucosa-associated lymphoid tissue [MALT] type) is a distinctive type of lymphoma that usually arises in association with mucosa or other epithelial structures and has an indolent clinical course. The frequency and clinical features of MALT lymphomas in the ocular adnexa have not been well studied. Methods: The authors examined the clinicopathologic features of ocular adnexal lymphoma, identified a subset of cases with MALT characteristics, and determined patient outcome. Results: The 42 patients, 16 men and 26 women age 35-89 years (mean, 64) were followed an average of 4.8 years. Thirty-two patients had ocular adnexal involvement at presentation (primary ocular adnexal lymphoma) and 10 had a history of lymphoma that relapsed in the orbit (secondary ocular adnexal lymphoma). In the primary group, 23 patients had lymphoma confined to the ocular adnexa, 3 had a single lesion that invaded adjacent structures, and 6 had distant spread at the time of presentation. Twenty-five patients achieved a complete remission. Nine patients, including 6 patients whose disease was localized initially, had progression or relapse of disease in distant sites. At last follow-up, 21 patients were free of disease, 9 were alive with disease and 2 had died of lymphoma. In the secondary group, at last follow-up, 1 patient had died of other causes, free of lymphoma, 3 patients were alive with disease and 5 had died of lymphoma (outcome not known in 1 case). Using the recently described revised European-American lymphoma classification, we found 16 MALT lymphomas, 8 diffuse large B cell, 12 follicular center, 3 mantle cell, 1 B-small lymphocytic lymphoma, and 2 unclassifiable low-grade lymphomas. The most common type of primary lymphoma was MALT type (15 of 30 classifiable cases), and the most common secondary lymphoma was follicular center (6 of 10). No increased frequency of conjunctival or lacrimal gland involvement by MALT lymphomas was found. All 33 lymphomas with immunophenotyping were of B lineage. Conclusions: Ocular adnexal lymphomas are 8-cell tumors that develop in older adults, predominantly among women. Primary orbital lymphomas have a favorable prognosis; a high proportion of them have MALT characteristics.

Introduction Coeliac disease (CD) is a chronic inflammatory enteropathy treated with a gluten free diet (GFD). Clinical symptoms and complications of CD are thought to be associated with ongoing duodenal inflammation due to continued gluten exposure, hence the optimal assessment of response to a GFD is histological remission. However, there is little consensus in the UK on routine re-biopsy during follow up. Duodenal biopsy requires a gastroscopy which is invasive and can be poorly tolerated. Coeliac serology and dietetic evaluation have been used as surrogate markers for histological remission, but the correlation has been shown to be poor. We aimed to assess the role of an IgA/G-deamidated gliadin peptide (DGP) based point of care test (POCT), Simtomax, in predicting histological remission in CD. Methods We prospectively recruited patients with known CD attending for a gastroscopy with duodenal biopsy for the assessment of disease remission. All patients underwent a blood test for IgA-endomysial antibodies (EMA), IgA-tissue transglutaminase antibodies (TTG), total IgA levels and Simtomax at the point of endoscopy. They also completed a validated GFD adherence questionnaire (Biagi) which gives a 5 point score (0–4), with the highest score indicating strict adherence to a GFD. Patients with an adherence score of 3 or 4 were considered to follow a strict GFD. A gastroscopy was then performed with quadrantic biopsies taken from the second part of the duodenum and one biopsy taken from the duodenal bulb. We compared all surrogate markers to the gold standard of duodenal histology. Results 145 (74% female, median age 53) patients with CD on a GFD were recruited from 2013–2015. 52 (36%) patients had persistent villous atrophy. Simtomax was the most sensitive in predicting villous atrophy (78.8%). The sensitivities of EMA, TTG and the GFD adherence score were significantly lower than that of Simtomax. Simtomax had the best negative predictive value (NPV) for villous atrophy at 82.5%. Conclusion Simtomax exceeds all other available surrogate markers in predicting the presence of villous atrophy. Simtomax could be used to aid informed decision making in patients who require but are reluctant to undertake a gastroscopy for duodenal biopsy to assess for disease remission. It could also act as a useful adjunct to identify patients who may require further dietetic support. Disclosure of Interest M. Lau: None Declared, P. Mooney: None Declared, W. White: None Declared, M. Burden: None Declared, S. Wong: None Declared, M. Kurien: None Declared, D. Sanders Grant/research support from: Tillotts Pharma for investigator led studies in coeliac disease. None of the funding sources had any input in the study design, access to study data, interpretation of the findings or drafting of the abstract.

Introduction Non coeliac gluten sensitivity (NCGS) is an emerging clinical entity with a prevalence of 0.5–13%. It is characterised by gluten related symptoms with a negative coeliac serology and no villous atrophy (VA). It is currently a diagnosis based on exclusion of coeliac disease (CD). We aimed to assess the role of Simtomax, an IgA/G deamidated gliadin peptide (DGP) based point of care test (POCT), in differentiating between NCGS and CD. Methods Group 1: we compared the sensitivities of 3 POCTs: Simtomax, Biocard [IgA-tissue transglutaminase (TTG)] and Celiac Quick Test (IgA/G/M-TTG). We prospectively recruited 100 patients referred with a positive endomysial antibody (EMA) attending for a gastroscopy. All patients undertook the 3 POCTs, EMA, TTG, and all underwent a gastroscopy with 5 duodenal biopsies. Sensitivities were measured based on their histology. Group 2: the sensitivity of Simtomax in the general population was evaluated by prospectively recruiting 667 patients with gastrointestinal symptoms or ataxia attending for a gastroscopy. To reduce positive ascertainment bias, we excluded patients referred with a positive EMA, previous VA, known CD, self-reported gluten sensitivity, and those on a gluten free diet. All patients undertook Simtomax, EMA, TTG and a gastroscopy with 5 duodenal biopsies. Sensitivities were measured based on their histology. Group 3: we demonstrated the sensitivities of Simtomax in a gluten sensitive population. 35 patients with self-reported gluten sensitivity attending for a gastroscopy were prospectively recruited. All patients undertook Simtomax, EMA, TTG and a gastroscopy with 5 duodenal biopsies. Sensitivities were measured based on their histology. Results Group 1 showed that Simtomax was the best POCT in detecting CD. The CD prevalence was 85%. In group 2, the sensitivity and negative predictive value (NPV) of Simtomax were comparable to that of EMA and TTG. The prevalence of CD was 4.95%. In group 3, Simtomax had 100% sensitivity and NPV in differentiating between CD and NCGS. 4 patients (11.4%) were diagnosed with CD, 4 (11.4%) with potential CD (positive serology but no VA) and 27 (77.1%) with NCGS (negative serology and no VA). Conclusion Simtomax was the most accurate POCT for detecting CD. In a lower CD prevalence group 2 cohort, its sensitivity remained comparable to TTG and EMA. Simtomax had 100% sensitivity in detecting CD in patients with self-reported gluten sensitivity, and 100% NPV in identifying patients with NCGS. Disclosure of Interest M. Lau: None Declared, P. Mooney: None Declared, W. White: None Declared, M. Burden: None Declared, S. Wong: None Declared, M. Kurien: None Declared, D. Sanders Grant/research support from: Tillotts Pharma for investigator led studies in coeliac disease. None of the funding sources had any input in the study design, access to study data, interpretation of the findings or drafting of the abstract.

Pituitary adenomas are common brain tumors, comprising nearly 10% of all intracranial lesions. Although classically treated with transsphenoidal surgery, other methods of treatment that minimize damage to eloquent tissue need to be used as adjuncts to surgery when the tumor encases vital structures, such as the optic nerve and carotid arteries. Over the past 10 years, the literature increasingly has supported the efficacy and safety of fractionated radiosurgery for the treatment of patients with pituitary adenomas. In this chapter we review this literature and describe the method used at our institution for the treatment of pituitary adenomas.

In 2009, approximately four million adults ages 18 and older received addiction treatment in the US (Substance Abuse and Mental Health Services Administration, 2010a). Although we do not know how many of these adults are parents or are raising children, based on general population data, we know that approximately 38% of males and 45% of females live with a child under the age of 18 (Halle, 2002), and likely many more might be responsible for at least one child that does not live with them in the same household. Studies of adults in substance abuse treatment that have queried parenting status generally find that anywhere from 19% to 53% live with children under 18 prior to entering treatment. These estimates vary greatly by gender and type of treatment entered (Gerstein et al., 1994; Grella et al., 2003; McMahon et al., 2005; Wechsberg et al., 1998). Children of parents with substance use disorders (SUD) have increased risk for a variety of adverse consequences including early conduct problems (Kuperman and Schlosser, 1999), lower academic achievement, and adolescent and young adult drug involvement (Walden et al., 2007; Clark and Winters, 2002). Maladaptive parenting behaviors appear to be an important mediator of the intergenerational transmission of SUD risk and other psychiatric symptoms (Johnson et al., 2001) and parental SUD may play a critical role in this. For example, research has demonstrated that parental SUD is associated with impaired parent-infant interactions (Burns et al., 1997; Eiden, 2001; Eiden & Leonard, 2000; Mayes et al., 1997; Tronick et al., 2005) harsh parenting and child abuse potential (Hien et al., 2010; Kim et al., 2010), child neglect (Dunn et al., 2002; Chaffin et al., 1996), decreased levels of monitoring and supervision (Chassin et al., 1993), parent-child conflict (El-Sheikh and Flanagan, 2001), perception of less parental warmth (Barnow et al., 2002), inconsistent discipline (Dishion et al., 1999), as well as destructive marital conflict (Keller et al., 2008). Moreover, external factors such as financial stressors due to unemployment might also influence the quality of parenting, and be exacerbated in a family where one or both parents has an SUD. In contrast, several aspects of parenting behavior have been shown to reduce or mitigate the risk for adolescent substance involvement, including adequate levels of parental monitoring and supervision, parent disapproval of underage drinking, high quality parent-child interactions, low family conflict, and general communication. These parental influences have been studied in relation to adolescent substance use involvement using both general population samples (Brook et al., 2009; Cohen et al., 1994; Latendresse et al., 2008; Tobler and Komro, 2010) and as described above, in families affected by parental SUD. Research studies have demonstrated that parenting skills among substance-abusing parents can be improved by using standardized methods. For example, in their study of 170 women in residential addiction treatment who were participating in the Nurturing Program for Parents of Children From Birth to Five Years Old, Camp and Finkelstein (1997) found that women who received a specialized parenting component during treatment made improvements in self-esteem and showed significant increases in parenting knowledge and attitudes. Similarly positive results have been demonstrated among mothers in substance abuse treatment participating in the Mothers and Toddlers Program (MTP; Suchman et al., 2010) as well as the Relational Psychotherapy Mothers’ Group (RPMG; Luthar and Suchman, 2000), a developmentally informed, supportive psychotherapy group designed for mothers with heroin addiction who have children up to 16 years of age. Further, preliminary results examining the effectiveness of the Partners in Parenting (PIP; Bartholomew et al., 2000) curriculum indicate that substance-abusing mothers who participated in PIP described better attitudes toward parenting strategies as well as reduced family conflict (Knight et al., 2007). Moreover, it turns out that clients in addiction treatment are interested in receiving such services when they are offered. McMahon et al. (2007) found that 84% of fathers in a drug treatment sample stated that they would be interested in counseling to help them become more effective parents. In addition to these interventions developed specifically for substance-abusing parents, a variety of other evidence-based parent training curricula are currently available to reduce children’s aggression and behavior problems and increase social competence (e.g., the Incredible Years, see Webster-Stratton et al., 2010 for description) as well as to reduce risks and enhance protection against early substance use initiation in children and early adolescents (e.g., Preparing for the Drug Free Years, see Haggerty et al., 1999). These sorts of interventions may also be useful for increasing parental competence and decreasing the risk for problems among offspring of substance abusing parents, although much more research is needed to examine how these interventions may need to be modified for parents with an SUD (Bromberg et al., 2010; Suchman et al., 2004). Unfortunately, however, we know very little about the extent to which parenting skills are addressed during the course of addiction treatment for adults who are caregivers of children, and if so, what kinds of curricula are offered. Most of our knowledge about services provided in addiction treatment facilities comes from the National Survey of Substance Abuse Treatment Services (N-SSATS), which annually collects information from all facilities in the US; both public and private that provide addiction treatment. The survey includes questions on whether facilities offer childcare or residential beds for clients’ children, whether or not family counseling is offered, and whether services are provided to pregnant or post-partum women. However, it does not specifically query whether parent training or parenting skills services are offered, nor does it ask respondents to estimate the number of clients served by their facility that are parents or actively raising children. To begin to address gaps in our knowledge regarding whether parenting skills education or interventions are integrated into adult addiction treatment programs, we surveyed a convenience sample of addiction treatment facilities in the US. Specifically, we wanted to learn more about the types of parenting skills development services offered at each facility, to assess the relative priority treatment programs place on parenting skills, and to explore program characteristics associated with the delivery of specialized parenting services.

Recovery is being used as a conceptual fulcrum for the redesign of addiction treatment and related support services in the United States. Efforts by policy, research, and clinical leaders to define recovery and calls for assertive models of long-term recovery management raise critical questions about how transformation efforts of recovery-focused systems will affect the pharmacotherapeutic treatment of opioid addiction and the status of patients participating in such treatment. This article highlights recent work advocating a recovery-oriented approach to medication-assisted treatment.

The development of the pituitary gland is not well understood, but duplication of the gland, a rare embryonic anomaly, may shed some light on the process. Since 1880 only about 40 cases have been described. A 56-year-old woman complained of chronic bilateral upper extremity paresthesia and numbness along her first three fingers relieved by rest and exacerbated by increased activity. Magnetic resonance imaging of her head and neck showed an incidental discovery of a duplication of the pituitary infundibulum and pituitary fossa. Computed tomography of the neck showed congenital fusion of C2 with C3, C4 with C5, C1 with the occipital bone, and a duplication of the odontoid process. Her physical examination and all laboratory data were negative. Only seven patients with a pituitary duplication have ever survived beyond puberty. While all of these patients had normal mental capabilities, they also all had obvious craniofacial malformations. Unlike our patient, all other reported cases of duplicated pituitaries have been associated with abnormalities of the face or brain. Previously proposed theories for duplicated pituitary glands include failed twinning, teratogens, and an extreme form of the median cleft face syndrome. We feel that the cleft theory developed by Morton et al. best describes the cause of our patient's malformations. Such anomalous presentations will improve our understanding of how the pituitary gland develops and the order in which cranial structures develop to cause these cranial malformations.

Hematopoietic progenitors obtained from the bone marrow of healthy adults fail to undergo clonogenic maturation in vitro if a source of hematopoietic growth factors is not included in the culture dishes. In contrast, a fraction of similarly purified progenitors obtained from umbilical cord blood undergo clonogenic maturation even in the absence of added growth factors. We postulated that production of hematopoietic growth factors within the culture dishes containing the progenitors of umbilical cord blood origin might be responsible. We postulated further, that this production might be by non-progenitor cells co- plated along with the progenitors, or alternatively by CD34+ cells themselves, or by cells clonally derived from CD34+ cells. To test these possibilities we first assessed the effect of including in the cultures neutralizing antibody directed against various growth factors. Inclusion of anti-granulocyte macrophage colony-stimulating factor (GM- CSF) and anti-interleukin-3 (IL-3) (but not anti-IL-2) significantly reduced the growth factor independence of cord blood progenitors (P > .005 and P > .01). Inclusion of both anti-GM-CSF and anti-IL-3 almost completely ablated the spontaneous colony growth (P > .001). Inclusion of IL-10 also reduced, in a concentration-dependent fashion, the spontaneous generation of umbilical cord blood-derived colonies. Transcripts for GM-CSF and IL-3 were detected, by reverse transcriptase- polymerase chain reaction (RT-PCR), in the CD34+ cells from cord blood and from adult marrow. When plated without added growth factors, however, the CD34+ cells of adult marrow origin failed to produce colonies, whereas 6% of cord blood CD34+ cells similarly cultured did so. When these growth factor independent colonies were plucked from culture, transcripts for GM-CSF and IL-3 were identified in all. We conclude that production of GM-CSF and IL-3 occurs within culture dishes containing hematopoietic progenitors of umbilical cord origin, and that this explains some of their apparently unique features of in vitro growth.

Ocular and periocular burns continue to be very complicated problems to manage clinically. Significant contributions have been made over the last year regarding the care and rehabilitation of the patient with this type of injury. N-acetylglucose aminidase activity in burned corneoscleral tissues may prove to be a good clinical indicator to assess the severity of ocular burns. Tenonplasty and split-thickness dermal grafts offer alternatives to conjunctival flaps when the latter is not practical or possible. Split-thickness dermal grafts are useful for treating persistent corneoscleral defects when an environment conducive to free grafts exists. Tenonplasty is a useful procedure in patients with persistent corneoscleral defects in whom no conjunctiva is available and a free graft is not advisable. Oversized soft contact lenses may prove useful in the care of the burn patient predisposed to forniceal foreshortening. An algorithm has been presented to aid in the management of the patient with periocular burns. High-density porous polyethylene can be successfully utilized in the reconstruction of the facial skeleton in burn patients. Useful guidelines have been proposed for the use of tissue expanders in the lower face and neck in pediatric burn patients.

(1994). Management of Periorbital Burns. Seminars in Ophthalmology: Vol. 9, No. 3, pp. 152-164.

The goal of this project was to develop a prospectively-validated, site-specific patient quality of life survey for assessing nasal outcomes following endonasal pituitary and skull base surgery. (ClinicalTrials.gov #NCT01322945) An 9-item patient survey (the ASK Nasal Inventory) focusing on the most common postoperative complaints, such as crusting, sinusitis, pain, and ease of breathing, was developed by the anterior skull base team at the Barrow Neurological Institute. Content was validated in structured patient interviews and by four subject matter experts. This survey was self-administered before and 3 months after surgery to 94 patients (52 endonasal surgery and 42 controls) between October 2010 and June 2011. Standard methods for psychometric evaluation were applied. Cronbach’s alpha was 0.83 indicating good internal consistency. Test–retest reliability was excellent in both groups (r = 0.87 and 0.95; P < 0.001). Discriminant validity was determined by comparing mean scores at 3 months in the endonasal and control groups and the difference was significant (13.5 vs. 17.2, P = 0.001). Standardized response mean was 0.17 suggesting that the scale was sensitive to clinical change. Concurrent validity was determined by mean ASK Nasal score for each level of self-reported overall functioning at 3 months (P = 0.001). Preliminary psychometric evaluation of the performance of the ASK Nasal Inventory suggests that it meets criteria as a clinical and research instrument in endonasal surgery. This study also suggests modifications to the instrument, which will serve as key quality of life endpoint in an ongoing multicenter nasal outcomes study.

Addiction recovery management , Addiction recovery management , کتابخانه مرکزی دانشگاه علوم پزشکی تهران

We postulated that defective generation of granulocyte colony- stimulating factor (G-CSF) by cells of newborn infants might underlie their deficiencies in upregulating neutrophil production and function during bacterial infection. To test this, we isolated monocytes from the blood of preterm neonates, term neonates, and adults and, after stimulation with various concentrations of interleukin-1 alpha (IL-1 alpha) or lipopolysaccharide (LPS), quantified G-CSF concentrations in cell supernatants and G-CSF mRNA in cell lysates. When stimulated with plateau concentrations of IL-1 alpha for 24 hours, G-CSF concentrations were higher in supernatants of adult cells (8,699 +/- 5,529 pg/10(6) monocytes) than in those from term infants (2,557 +/- 442 pg, P < .05) or from preterm infants (879 +/- 348 pg, P < .05 v adults). When stimulated with plateau concentrations of LPS, supernatants of monocytes from preterm neonates had less G-CSF than did those from term neonates or adults. G-CSF mRNA content was low in cells from preterm infants, higher in those from term infants, and highest in those from adults. On the basis of the in vitro studies, we speculated that serum G-CSF concentrations might be less elevated in neutropenic neonates than in neutropenic adults. Indeed, serum concentrations were relatively low in all nonneutropenic subjects; 92 +/- 34 pg/mL (mean +/- SEM) in 10 preterm neonates, 114 +/- 21 pg/mL in 16 term neonates, and 45 +/- 13 pg/mL in 11 healthy adults. Serum concentrations were not elevated in 7 neutropenic neonates (39 +/- 17 pg/mL) but were in 8 neutropenic adults (2101 +/- 942 pg/mL, P < .05 v healthy adults). Other studies suggested that the lower G-CSF production in neonates is not counterbalanced by a heightened sensitivity of G-CSF--responsive progenitors to G-CSF. Therefore, we speculate that newborn infants, particularly those delivered prematurely, generate comparatively low quantities of G-CSF after inflammatory stimulation, and that this might constitute part of the explanation for their defective upregulation of neutrophil production and function during infection.

This new executive compensation paradigm for the 1990s is dominated by an awareness of the need to compete globally and to create value through core competencies while paying attention to the Securities and Exchange Commission's demanding executive pay disclosure rules.

Purpose To report a series of lacrimal complications associated with a specific type of lacrimal plug (Herrick Lacrimal Plug; Lacrimedics Incorporated, Rialto, CA.) Design Retrospective, noncomparative case series and survey. Methods Members of the American Society of Ophthalmic Plastic and Reconstructive Surgery were asked to submit personally treated cases of patients referred for treatment of complications after placement of a Herrick Lacrimal Plug. Main outcome measures Failure of the device to be removed by simple lacrimal irrigation. Results The clinical courses of 41 patients were analyzed. Patients ranged in age from 19 to 81 years, and all had symptomatic epiphora related to the presence of the lacrimal plug. Several interventions were used to treat lacrimal obstruction. Nasolacrimal duct probing with irrigation was used in 15 lacrimal systems, whereas six systems were probed and subsequently stented with silicone tubing. Eyelid margin cutdown was used in eight cases. Balloon dacryoplasty was performed in three systems, dacryocystorhinostomy in 18 instances, and conjunctivodacryocystorhinostomy in two patients. Conclusions The Herrick lacrimal occlusion device sometimes cannot be removed by simple irrigation and is capable of inducing permanent, irreversible, symptomatic lacrimal drainage system obstruction.

Purpose: To report on the usage of a thermoplastic material in eyelid reconstruction. Methods: Retrospective single-surgeon case review. Results: Thirty-eight full-thickness skin grafts in 37 patients are reported. No major complications were encountered. All outcomes with the use of this technique yielded satisfactory results. Conclusions: The use of thermoplastic materials in eyelid reconstruction appears to achieve results equal to those seen with traditional materials. This technique in eyelid surgery may save operative time and be less expensive than traditional methods.

An efficient pathway for the preparation of m-hydroxycocaine (6) and m-hydroxybenzoylecgonine (7) is described.

Ten patients complaining of visual impairment, proptosis or ocular pain, were selected for transnasal transsphenoid microsurgical approach to address cavernous haemangiomas located at inferomedial part of orbital apex. Via this approach, the contents of orbital apex were clearly illuminated and exposed as large as the surgical removal required. All tumours were identified under frameless image-guided neuronavigation and removed completely without any complications and recurrence in a mean of 12.2 months follow-up. It is concluded that a transnasal transsphenoid microsurgical approach is a minimally invasive surgery for cavernous haemangiomas located at inferomedial part of orbital apex.

Recovery capital—the quantity and quality of internal and external resources to initiate and maintain recovery—is explored with suggestions for how recovery support services (RSS) (nontraditional, and often nonprofessional support) can be utilized within a context of comprehensive addiction services. This article includes a brief history of RSS, conceptual and operational definitions of RSS, a framework for evaluating RSS, along with a review of recent empirical evidence that suggests that rather than enabling continued addiction, recovery supports are effective at engaging people into care, especially those who have little recovery capital, and/or who otherwise would likely have little to no “access to recovery.”

Scientific understanding of addiction as a chronic disorder has increased substantially in the past 15 years stemming from the results of several retrospective and prospective studies. This research has revealed that among individuals with severe alcohol and other drug problems periods of relapse and poor functioning are common over many years and even decades, despite the receipt of intermittent interventions. Because these interventions typically occur only following acute substance-related crises, treatment typically takes the form of acute biopsychosocial stabilization and is delivered in discrete, self-contained, programs that typically end the service relationship shortly after discharge with little focus on providing adequate linkage to continuing care or recovery support. The predominant acute care paradigm is insufficient and mismatched to the realities of the chronic illness of substance dependence. In this chapter, we provide an overview of recovery management (RM) and recovery-oriented systems of care (ROSC) as new guiding paradigms for the future treatment of, and recovery from, severe alcohol and other drug problems. We also summarize notable examples of RM and ROSC implementation efforts at the program, system, city, and state, levels. Results from these efforts provide a foundation for confident optimism that a cost-effective system of care can be successfully established that is well suited to managing the undulating and enduring risks associated with the chronic illness of substance dependence.

Severe alcohol and other drug problems typically take a chronic course and often require multiple episodes of intervention before stable recovery is achieved. The conceptualization of addiction as a chronic disorder has critical implications for the design, delivery, evaluation, and funding of addiction treatment. Yet, despite widespread acknowledgement that the nature and long-term course of addiction is similar to other chronic illnesses, such as hypertension and diabetes, it is still treated almost universally as an acute condition. This acute care model has been shaped by a number of influences, including the commercialization of addiction treatment and a system of managed behavioral health care, which have forced treatment into discrete, and ever-briefer, episodes of care. In this chapter, we address the shortfalls of the acute care model and contrast it with a model of sustained recovery management, which aims to remedy the mismatch between the chronic nature of addiction and the approaches designed to treat it. The nature of Recovery Management as a philosophy of organizing addiction treatment and recovery support services to enhance early prerecovery engagement, recovery initiation, long-term recovery maintenance, and the quality of personal/family life in long-term recovery is described. The shift to a model of sustained recovery management includes changes in treatment practices related to the timing of service initiation, service access and engagement, assessment and service planning, service menu, service relationship, locus of service delivery, assertive linkage to indigenous recovery support resources, and the duration of posttreatment monitoring and support.