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If large buy genuine kamagra chewable line erectile dysfunction yeast infection, or if there is appendicitis kamagra chewable 100mg erectile dysfunction pills new, although an ultrasound associated bleeding from the torn edges scan can be helpful cheap kamagra chewable 100 mg overnight delivery erectile dysfunction doctor miami. The pain is Treatment is surgery to remove the initially one-sided and then spreads to necrotic adnexa. Unruptured Ovarian Cyst Other surgical conditions which may While most of these cysts are without resemble a twisted ovarian cyst (such as symptoms, they can cause pain, bowel obstruction, appendicitis, ectopic particularly with strenuous physical pregnancy) may not have a good activity or intercourse. The cyst and ovary (and often a Gradual onset of mild bilateral pelvic portion of the fallopian tube) die and pain with purulent vaginal discharge is necrose. Since surgery may be required, Treatment consists of: transfer to a definitive surgical facility should be considered. In addition, they have palpable pelvic masses from dilated, abscessed Pregnancy-related problems fallopian tubes. With the antibiotics, the makes caring for these patients very patient will either improve and stabilize, simple. This surgery may be difficult because the Mechanical Causes of Abnormal considerable inflammation will obscure Bleeding anatomic landmarks and the edematous tissues will be friable and difficult to Uterine fibroids or endometrial polyps manipulate. In such a setting, are examples of mechanical problems supracervical hysterectomy may be a inside the uterus which may cause wise course even considering the leaving abnormal bleeding. Overview Hormonal Causes of Abnormal Bleeding Occasionally, abnormal bleeding will be due to a laceration of the vagina, a 17 Surgical Emergencies in Obstetrics & Gynecology Hormonal causes include anovulation With bedrest and hormonal treatment, leading to an unstable uterine lining, bleeding should be substantially breakthrough bleeding associated with improved within 24 hours. It should birth control pills, and spotting at continue to improve with additional days midcycle associated with ovulation. If hormonal control is not solution to all of these problems is to succeeding, then a D&C will be take control of the patient hormonally necessary. After a month Malignancy as a Cause of Abnormal or two, her bleeding should be well Bleeding under control. Abnormal bleeding can be a symptom of If the bleeding is heavy or her blood malignancy, from the vagina, cervix or count low, then it is best to have her lie uterus. Cancer of the cervix is several days to three a day, then two a more common but a normal Pap smear day, and then one a day. For those women with abnormal bleeding over age 40, an endometrial Since most (90%) of the non-pregnancy biopsy is a wise precaution during the bleeding is caused by hormonal factors, evaluation and treatment of abnormal your best bet is to: bleeding. These organs include the following: urethra, bladder, rectum, small intestine, uterus, and the vagina (vaginal vault) itself. The urethra and bladder are anatomically situated above the “roof”’ or top wall of the vagina, the cervix and uterus at the very deepest part of the vagina (the apex), and the rectum below the “foor” or bottom wall of the vagina. Thus, when prolapse develops, one or more of the following may occur: the urethra and bladder may descend into the vaginal roof, the cervix and uterus may descend into the vaginal canal, and the rectum may ascend into the vaginal foor. Pelvic relaxation can vary from minimal descent—causing few, if any, symptoms—to major descent— in which one or more of the pelvic organs literally prolapse outside the vagina at all times and cause signifcant symptoms. The degree of descent often varies with position and activity level, increasing with the assumption of the upright position and with exertional activities, and decreasing with lying down and resting. Pelvic relaxation usually results from a combination of factors including multiple pregnancies and vaginal deliveries (especially deliveries of large babies), menopause, hysterectomy, aging, weight gain, and any condition associated with chronic increases in abdominal pressure, such as asthma and bronchitis (chronic wheezing and coughing), seasonal allergies (chronic sneezing), or constipation (chronic straining). Passage of the large human head through the female pelvis causes tissue trauma, separation or weakness of connective tissue attachments, and alterations in the geometry of the pelvis. It is unusual for women who have not had children or who have delivered by elective caesarian section to develop signifcant pelvic relaxation. Because the female genital tract and urinary tract are intimately related (due to their anatomic proximity as well as a common embryological origin), pelvic relaxation can cause signifcant changes in normal urinary function. These range from stress urinary incontinence (a spurt-like leakage of urine from the urethra associated with an increase in abdominal pressure such as occurs with sneezing, coughing, etc. Non-operative treatment of pelvic relaxation is used when symptoms are minimal or when surgery cannot be performed because of infrmity and frailty. Such conservative treatment options include change of activities, management of constipation and other circumstances that increase abdominal pressure, pelvic foor exercises, hormone replacement, and pessaries. Pessaries are mechanical devices that are inserted into the vagina to act as a “strut” to help provide pelvic support. The side effects of pessaries are vaginitis (vaginal infection and discharge), extrusion (the inability to retain the pessary in proper position), and the “unmasking” of stress incontinence. You may wonder why a urologist is interested in female pelvic relaxation, since for many years urology was traditionally considered to be a male feld. In the late 1970’s, female urology emerged as a specialty branch of urology much as pediatric urology had done previously. Raz, a world-renowned physician and surgeon, developed the feld of female urology into a comprehensive surgical discipline. In addition to writing the textbook Atlas of Transvaginal Surgery and editing the textbook Female Urology, Dr. I was fortunate to be selected for one of these positions and after the completion of my urology residency at the University of Pennsylvania School of Medicine, spent the years 1987–1988 operating with Dr. Obviously, prolapse is an exclusively female feld, but incontinence and voiding dysfunction encompass both females and males. My practice is, in fact, almost equally divided between women and men, and I fnd that I enjoy this balance. Similarly, the gynecologist’s role in female pelvic relaxation was focused on prolapse of the bladder, uterus, and rectum, but ignored the urethral prolapse that is often responsible for stress urinary incontinence. Thus there was a division of labor, a “territoriality” within the realm of Figure 1 female pelvic surgery, as illustrated in this cartoon demonstrating the roles of the urologist, gynecologist, as well as the colon/rectal surgeon. Raz espoused the concept of a pelvic surgeon, one capable of dealing with any and all aspects of female pelvic relaxation, with a thorough knowledge of pelvic anatomy and plastic surgical reconstructive principles. Raz established became to train accomplished pelvic surgeons who could then obtain academic positions at University medical centers throughout the United States, the appropriate venue for further dissemination of the art and science of female urology and pelvic reconstructive surgery to medical students and residents in training. Thus, at Hackensack University Medical Center, one of my roles is to instruct urology residents and medical students from the University of Medicine and Dentistry of New Jersey in the principles and surgical techniques of Dr. Female pelvic reconstructive surgery incorporates principles of both urological, gynecological, and plastic surgery. A pelvic reconstruction for pelvic prolapse is not dissimilar to cosmetic facial surgical procedures performed by plastic surgeons for aging and sagging eyelids and jowels. Both pelvic reconstructive and plastic facial reconstructive surgery require some degree of creativity and artistic talent in addition to the requisite scientifc knowledge of anatomy and surgical principles. I personally fnd female reconstructive surgery to be particularly gratifying because of both the instant ability to assess the results before leaving the operating room as well as the great potential to improve the lifestyle and function of the person suffering with prolapse. Unlike facial cosmetic surgery, pelvic reconstruction, in addition to improving - 3 - cosmetic appearance, will result in functional improvement in terms of alleviation of incontinence, voiding dysfunction, sexual dysfunction, bowel dysfunction, and other symptoms associated with pelvic prolapse. Anatomy of The Female Pelvis A basic knowledge of pelvic anatomy will allow you to understand why prolapse occurs and how it can be corrected. The bony pelvis is the framework to which the support structures Uterus Bladder Sacrum Pubic Bone Rectum Urethra Vagina Levator Ani Figure 2 of the pelvis are attached.

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Pulmonary Circulation Recall that blood returning from the systemic circuit enters the right atrium (Figure 20 100mg kamagra chewable otc impotence quotes. This blood is relatively low in oxygen and relatively high in carbon dioxide order 100mg kamagra chewable amex erectile dysfunction consult doctor, since much of the oxygen has been extracted for use by the tissues and the waste gas carbon dioxide was picked up to be transported to the lungs for elimination order kamagra chewable 100 mg amex erectile dysfunction treatment nj. From the right atrium, blood moves into the right ventricle, which pumps it to the lungs for gas exchange. At the base of the pulmonary trunk is the pulmonary semilunar valve, which prevents backflow of blood into the right ventricle during ventricular diastole. As the pulmonary trunk reaches the superior surface of the heart, it curves posteriorly and rapidly bifurcates (divides) into two branches, a left and a right pulmonary artery. To prevent confusion between these vessels, it is important to refer to the vessel exiting the heart as the pulmonary trunk, rather than also calling it a pulmonary artery. The pulmonary arteries in turn branch many times within the lung, forming a series of smaller arteries and arterioles that eventually lead to the pulmonary capillaries. The pulmonary capillaries surround lung structures known as alveoli that are the sites of oxygen and carbon dioxide exchange. Once gas exchange is completed, oxygenated blood flows from the pulmonary capillaries into a series of pulmonary venules that eventually lead to a series of larger pulmonary veins. These vessels branch to supply blood to the pulmonary capillaries, where gas exchange occurs within the lung alveoli. Pulmonary Arteries and Veins Vessel Description Pulmonary Single large vessel exiting the right ventricle that divides to form the right and left pulmonary trunk arteries Pulmonary Left and right vessels that form from the pulmonary trunk and lead to smaller arterioles and arteries eventually to the pulmonary capillaries Pulmonary Two sets of paired vessels—one pair on each side—that are formed from the small venules, veins leading away from the pulmonary capillaries to flow into the left atrium Table 20. The aorta and its branches—the systemic arteries—send blood to virtually every organ of the body (Figure 20. It arises from the left ventricle and eventually descends to the abdominal region, where it bifurcates at the level of the fourth lumbar vertebra into the two common iliac arteries. The aorta consists of the ascending aorta, the aortic arch, and the descending aorta, which passes through the diaphragm and a landmark that divides into the superior thoracic and inferior abdominal components. At the base of the aorta is the aortic semilunar valve that prevents backflow of blood into the left ventricle while the heart is relaxing. After exiting the heart, the ascending aorta moves in a superior direction for approximately 5 cm and ends at the sternal angle. Following this ascent, it reverses direction, forming a graceful arc to the left, called the aortic arch. The aortic arch descends toward the inferior portions of the body and ends at the level of the intervertebral disk between the fourth and fifth thoracic vertebrae. Superior to the diaphragm, the aorta is called the thoracic aorta, and inferior to the diaphragm, it is called the abdominal aorta. The abdominal aorta terminates when it bifurcates into the two common iliac arteries at the level of the fourth lumbar vertebra. Components of the Aorta Vessel Description Largest artery in the body, originating from the left ventricle and descending to the abdominal region, where it bifurcates into the common iliac arteries at the level of the fourth Aorta lumbar vertebra; arteries originating from the aorta distribute blood to virtually all tissues of the body Initial portion of the aorta, rising superiorly from the left ventricle for a distance of Ascending aorta approximately 5 cm Graceful arc to the left that connects the ascending aorta to the descending aorta; ends at Aortic arch the intervertebral disk between the fourth and fifth thoracic vertebrae Descending Portion of the aorta that continues inferiorly past the end of the aortic arch; subdivided into aorta the thoracic aorta and the abdominal aorta Thoracic aorta Portion of the descending aorta superior to the aortic hiatus Abdominal aorta Portion of the aorta inferior to the aortic hiatus and superior to the common iliac arteries Table 20. These sinuses contain the aortic baroreceptors and chemoreceptors critical to maintain cardiac function. The coronary arteries encircle the heart, forming a ring-like structure that divides into the next level of branches that supplies blood to the heart tissues. As you would expect based upon proximity to the heart, each of these vessels is classified as an elastic artery. The brachiocephalic artery is located only on the right side of the body; there is no corresponding artery on the left. The brachiocephalic artery branches into the right subclavian artery and the right common carotid artery. The left subclavian and left common carotid arteries arise independently from the aortic arch but otherwise follow a similar pattern and distribution to the corresponding arteries on the right side (see Figure 20. Each subclavian artery supplies blood to the arms, chest, shoulders, back, and central nervous system. It then gives rise to three major branches: the internal thoracic artery, the vertebral artery, and the thyrocervical artery. The internal thoracic artery, or mammary artery, supplies blood to the thymus, the pericardium of the heart, and the anterior chest wall. The vertebral artery passes through the vertebral foramen in the cervical vertebrae and then through the foramen magnum into the cranial cavity to supply blood to the brain and spinal cord. The paired vertebral arteries join together to form the large basilar artery at the base of the medulla oblongata. The subclavian artery also gives rise to the thyrocervical artery that provides blood to the thyroid, the cervical region of the neck, and the upper back and shoulder. The right common carotid artery arises from the brachiocephalic artery and the left common carotid artery arises directly from the aortic arch. The external carotid artery supplies blood to numerous structures within the face, lower jaw, neck, esophagus, and larynx. The internal carotid artery initially forms an expansion known as the carotid sinus, containing the carotid baroreceptors and chemoreceptors. Like their counterparts in the aortic sinuses, the information provided by these receptors is critical to maintaining cardiovascular homeostasis (see Figure 20. The internal carotid arteries along with the vertebral arteries are the two primary suppliers of blood to the human brain. Given the central role and vital importance of the brain to life, it is critical that blood supply to this organ remains uninterrupted. Recall that blood flow to the brain is remarkably constant, with approximately 20 percent of blood flow directed to this organ at any given time. The locations of the arteries in the brain not only provide blood flow to the brain tissue but also prevent interruption in the flow of blood. Both the carotid and vertebral arteries branch once they enter the cranial cavity, and some of these branches form a structure known as the arterial circle (or circle of Willis), an anastomosis that is remarkably like a traffic circle that sends off branches (in this case, arterial branches to the brain). As a rule, branches to the anterior portion of the cerebrum are normally fed by the internal carotid arteries; the remainder of the brain receives blood flow from branches associated with the vertebral arteries. The internal carotid artery continues through the carotid canal of the temporal bone and enters the base of the brain through the carotid foramen where it gives rise to several branches (Figure 20. One of these branches is the anterior cerebral artery that supplies blood to the frontal lobe of the cerebrum. The right and left anterior cerebral arteries join together to form an anastomosis called the anterior communicating artery. The initial segments of the anterior cerebral arteries and the anterior communicating artery form the anterior portion of the arterial circle. The posterior portion of the arterial circle is formed by a left and a right posterior communicating artery that branches from the posterior cerebral artery, which arises from the basilar artery. The basilar artery is an anastomosis that begins at the junction of the two vertebral arteries and sends branches to the cerebellum and brain stem. The internal carotid artery first forms the carotid sinus and then reaches the brain via the carotid canal and carotid foramen, emerging into the cranium via the foramen lacerum. The vertebral artery branches from the subclavian artery and passes through the transverse foramen in the cervical vertebrae, entering the base of the skull at the vertebral foramen.

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Common indications for tracheal intubation •W here muscle relaxants are used to facilitate sur- gery (e order kamagra chewable cheap online erectile dysfunction caused by guilt. The equipment used will be determined by the cir- • Catheter mount: or ‘elbow’ to connect the tube to cumstances and by the preferences of the indivi- the anaesthetic system or ventilator tubing discount kamagra chewable 100mg impotence define. The following is a list of the basic • Suction: switched on and immediately to hand in needs for adult oral intubation kamagra chewable 100mg without a prescription erectile dysfunction lipitor. The technique of oral intubation The cuff is inflated by injecting air via a pilot tube, at the distal end of which is a one-way valve to pre- Preoxygenation vent deflation and a small ‘balloon’ to indicate when the cuff is inflated. A wide variety of All patients who are to be intubated are asked to specialized tubes have been developed, examples breathe 100% oxygen via a close-fitting facemask of which are shown in Fig. This provides a • Reinforced tubes are used to prevent kinking and reservoir of oxygen in the patient’s lungs, reducing subsequent obstruction as a result of the position- the risk of hypoxia if difficulty is encountered with ing of the patient’s head (Fig. Once this has been accomplished, the • Preformed tubes are used during surgery on the appropriate drugs will be administered to render head and neck, and are designed to take the con- the patient unconscious and abolish laryngeal nections away from the surgical field (Fig. Positioning Intubation The patient’s head is placed on a small pillow with The tracheal tube is introduced into the right side the neck flexed and the head extended at the of the mouth, advanced and seen to pass through the atlanto-occipital joint, the ‘sniffing the morning cords until the cuff lies just below the cords. The patient’s mouth is fully opened tube is then held firmly and the laryngoscope is using the index finger and thumb of the right hand carefully removed, and the cuff is inflated suffi- in a scissor action. Laryngoscopy For nasotracheal intubation a well-lubricated The laryngoscope is held in the left hand and the tube is introduced, usually via the right nostril blade introduced into the mouth along the right- along the floor of the nose with the bevel pointing hand side of the tongue, displacing it to the left. It is ad- The blade is advanced until the tip lies in the gap vanced into the oropharynx, where it is usually between the base of the tongue and the epiglottis, visualized using a laryngoscope in the manner de- the vallecula. The rectly into the larynx by pushing on the proximal effort comes from the upper arm not the wrist, to end, or the tip picked up with Magill’s forceps lift the tongue and epiglottis to expose the larynx, (which are designed not to impair the view of the seen as a triangular opening with the apex anteri- larynx) and directed into the larynx. The proce- orly and the whitish coloured true cords laterally dure then continues as for oral intubation. It is inserted by holding the handle rather Due to: than using one’s index finger as a guide, and sits • Unrecognized oesophageal intubation If there is opposite the laryngeal opening. A specially de- any doubt about the position of the tube it should signed reinforced, cuffed, tracheal tube can then be be removed and the patient ventilated via a inserted, and, due to the shape and position of the facemask. Confirming the position of the • Aspiration Regurgitated gastric contents can tracheal tube cause blockage of the airways directly, or secondary This can be achieved using a number of to laryngeal spasm and bronchospasm. Cricoid techniques: pressure can be used to reduce the risk of regurgita- • Measuring the carbon dioxide in expired gas (capnog- tion prior to intubation (see below). Trauma • Oesophageal detector: a 50mL syringe is attached to the tracheal tube and the plunger rapidly with- • Direct During laryngoscopy and insertion of the drawn. If the tracheal tube is in the oesophagus, re- tube, damage to lips, teeth, tongue, pharynx, lar- sistance is felt and air cannot be aspirated; if it is in ynx, trachea, and nose and nasopharynx during the trachea, air is easily aspirated. Complications of tracheal intubation • Vomiting This may be stimulated when laryn- The following complications are the more com- goscopy is attempted in patients who are inade- mon ones, not an attempt to cover all occurrences. It is more frequent when there is material in the stomach; for example in emergencies when the patient is not starved, in 25 Chapter 2 Anaesthesia patients with intestinal obstruction, or when gas- Cricoid pressure (Sellick’s manoeuvre) tric emptying is delayed, as after opiate analgesics or following trauma. Regurgitation and aspiration of gastric contents are • Laryngeal spasm Reflex adduction of the vocal life-threatening complications of anaesthesia and cords as a result of stimulation of the epiglottis or every effort must be made to minimize the risk. Preoperatively, patients are starved to reduce gas- tric volume and drugs may be given to increase pH. At induction of anaesthesia, cricoid pressure pro- Difficult intubation vides a physical barrier to regurgitation. As the Occasionally, intubation of the trachea is made cricoid cartilage is the only complete ring of carti- difficult because of an inability to visualize the lage in the larynx, pressure on it, anteroposteriorly, larynx. This may have been predicted at the forces the whole ring posteriorly, compressing the preoperative assessment or may be unexpected. A oesophagus against the body of the sixth cervical variety of techniques have been described to help vertebra, thereby preventing regurgitation. An as- solve this problem and include the following: sistant, using the thumb and index finger, applies •M anipulation of the thyroid cartilage by back- pressure whilst the other hand is behind the pa- wards and upwards pressure by an assistant to try tient’s neck to stabilize it (Fig. Pressure is and bring the larynx or its posterior aspect into applied as the patient loses consciousness and view. It long, is inserted blindly into the trachea, over should be maintained even if the patient starts to which the tracheal tube is ‘railroaded’ into place. If trachea via the mouth or nose, and is used as a vomiting does occur, the patient should be turned guide over which a tube can be passed into the tra- onto his or her side to minimize aspiration. Consciousness is lost rapidly as sort to one of the emergency techniques described the concentration of the drug in the brain rises below. The drug is then redistributed to other tissues and the plasma concentration falls; this is followed by a fall in brain concentration and Emergency airway techniques the patient recovers consciousness. Despite a short These must only be used when all other techniques duration of action, complete elimination, usually have failed to maintain oxygenation. Consequently, brane is identified and punctured using a large bore most drugs are not given repeatedly to maintain cannula (12–14 gauge) attached to a syringe. Currently, the only exception to this ration of air confirms that the tip of the cannula is propofol (see below). The cannula is then angled the dose required to induce anaesthesia will be to about 45° caudally and advanced off the needle dramatically reduced in those patients who into the trachea (Fig. A high-flow oxygen sup- are elderly, frail, have compromise of their ply is then attached to the cannula and insufflated cardiovascular system or are hypovolaemic. Breathing an inhalational anaesthetic in oxygen or • Surgical cricothyroidotomy This involves making in a mixture of oxygen and nitrous oxide can be an incision through the cricothyroid membrane to used to induce anaesthesia. However, is assessed (and overdose avoided) using clinical once a tube has been inserted the patient can be signs or ‘stages of anaesthesia’; the original ventilated, ensuring oxygenation, elimination of description was based on using ether, but the main carbon dioxide and suction of the airway to re- features can still be seen using modern drugs. Currently, sevoflurane is the most popular anaesthetic used for Drugs used during general this technique. As well as the above, the anaesthetic will have ef- The stages of anaesthesia fects on all of the other body systems, which will need appropriate monitoring. The pupils Maintenance of anaesthesia will be normal in size and reactive, muscle tone is normal and breathing uses intercostal mus- This can be achieved either by using one of a vari- cles and the diaphragm. Second stage In this period there may be breath-holding, Inhalational anaesthesia struggling and coughing. The pupils will be di- Inhalational anaesthetics are a group of halogena- lated and there is loss of the eyelash reflex. There is inspired concentration of all of these compounds reduction in respiratory activity, with progres- is expressed as the percentage by volume. The pupils There are two concepts that will help in under- start by being slightly constricted and gradually standing the use of inhalational anaesthetics: dilate. This is the concentration required to prevent 29 Chapter 2 Anaesthesia 30 Anaesthesia Chapter 2 31 Chapter 2 Anaesthesia Table 2. It is the partial pressure in the brain that is responsible for the anaesthetic ef- Nitrous oxide (N2O) is a colourless, sweet-smelling, fect and this follows closely the partial pressure in non-irritant gas with moderate analgesic proper- the alveoli. As pressure can be changed determines the rate of the maximum safe concentration that can be ad- change in brain partial pressure, and hence speed ministered without the risk of hypoxia is approxi- of induction, change in depth of, and recovery mately 70%, unconsciousness or anaesthesia from anaesthesia. Con- One of the main determinants of alveolar partial sequently, it is usually given in conjunction with pressure is how soluble the inhalational anaesthe- one of the other vapours.

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Readmissions can be seen treatment intervention can compromise as evidence that treatment is not working and otherwise effective treatment plans cheap 100mg kamagra chewable erectile dysfunction drugs prostate cancer. While the baseline would improve the patient’s condition cheap kamagra chewable 100mg overnight delivery erectile dysfunction drugs medicare, or level of addiction-related services offered to the documents why the initial treatment was 135 general population is inadequate buy line kamagra chewable erectile dysfunction pills in malaysia, the deficiency insufficient. Given that addiction often is a in tailored services offered to populations with chronic disease and that relapse is possible, 127 special treatment needs is even more glaring. For many individuals, addiction manifests as a chronic disease, requiring disease and symptom 128 management over the long term. In recent years, there has been growing recognition of the importance of comprehensive disease management in the treatment of chronic health conditions for which there is no known cure, where relapse episodes are considered an expected part of the disease course and where long-term symptom management is considered routine care. While this approach increasingly has been adopted for diseases such as 129 130 131 diabetes, hypertension and asthma, addiction treatment largely remains stuck in the 132 acute-care model. While most of these approaches have been discredited with time, some have proven to be prescient in their foreshadowing of current treatment approaches, both those that are evidence based and those that continue to profit from claims about being able to treat or even cure addiction in manners that largely are not based on scientific evidence. Benjamin Rush, the “father of American psychiatry,” was the first American doctor to say 136 137 th that “habitual drunkenness should be regarded not as a bad habit but as a disease” that should be treated. In the late 19 century, medically-based addiction treatment mostly involved trying to cure individuals of their addiction, often with the use 138 of other addictive substances. By 1910, private sanitariums in the United States offered specialized treatment for addicted individuals--but only for those who could afford the expense. Similar to today, many of the “treatment experts” opening facilities were savvy businessmen or enterprising physicians, including Harvey Kellogg (later of cereal fame) and Dr. Between 1892 and 139 1893, almost 15,000 people with addiction were treated at the famous, yet controversial Keeley Institutes. Keeley’s treatment for addiction involved bichloride of gold remedies, a substance purportedly containing gold that would cure addiction involving alcohol and opioids. Although Keeley’s treatments were later discredited, his position that addiction was decidedly a disease rather than a religious or moral failing was ahead of its time. His use of “shot treatments” or hypodermic treatments that induced vomiting was a precursor to later aversion therapies and his introduction of clubs for addicted individuals to receive social support to maintain sobriety was a precursor to the mutual support programs that remain prominent today. His focus on helping people 141 quit smoking in the 1920s was prescient in its characterization of nicotine as a harmful and addicting drug. Addiction treatment tactics that are based more on the personal charisma of the founders, catchy phrases and simplistic approaches than on the science of what works in addiction continue to proliferate and show no sign of waning. A simple Google search produces an abundance of “rehabilitation” approaches and facilities with slogans such as: Learn how to heal 142 the underlying causes of dependency--and be free of addiction forever! A recent study examining treatments that a panel * of experts believes qualifies as quackery in addiction treatment found such treatments as electrical stimulation of the head, past-life therapy, electric shock therapy, psychedelic medication and neuro-linguistic programming to be “certainly 143 discredited. In the late 1930s and early 1940s, many hospitals would not admit patients for the treatment of addiction involving alcohol, 144 so lay approaches became an important option. While the mutual support/self-help approach maintained the perspective of addiction as a disease--formalized in the development of the principles underlying the Minnesota Model in the 1950s--the “rehabilitative model” of treatment was seen as distinct from “the medical model. Yet, its limitations and failure to address addiction the way other diseases are addressed have led to a call to integrate addiction treatment into mainstream medical care. And a lot or qualifications to implement the existing of medical people like and want it that way; they range of evidence-based practices and face do not want to deal with addiction; they do not many organizational and structural barriers like to deal with the people and they do not feel 148 to providing services; effective addressing the problem. Other highly-trained and intervention, treatment and disease credentialed health professionals may be part of management is inadequate. Motivated and experienced non-professionals Because of the vast chasm between the health may serve additional vital functions--such as care system and approaches to preventing risky providing social support to encourage adherence substance use or treating addiction, medical to a treatment plan and help patients maintain professionals fail to address risky substance use important lifestyle changes that can reduce the or addiction or take responsibility for risk of relapse--but their roles and services do intervention or treatment, risky substance use is not supersede or replace those of the medical addressed primarily in terms of its consequences team. Degree * Among those who responded that the educational qualification is "very Further, most treatment providers see important". Program Staff Directors Providers Despite this variability in perceptions regarding High volume of paperwork/reporting what the treatment system should look like, requirements 76. While limited education and training of most providers and a provide treatment for co-morbid conditions treatment culture largely steeped in the self-help Insufficient number of trained master’s- 28. We haven’t inadequate education and training of treatment 161 effectively brought practical research results to providers in evidence-based practices, the 168 individual providers…so they can use it. Janes implementing many evidence-based practices Former Director and the qualifications that the majority of the Florida Office of Drug Control 162 treatment workforce currently possesses. Office of the Governor Because most treatment providers are not adequately trained, they are not capable of Evidence from research findings is not generally performing health assessments, prescribing accessible and understandable to providers; 169 we’re failing miserably at that. National Association of Lesbian and Gay Most also are not trained in the scientific method Addiction Professionals or clinical research, further impeding their (now Vice President, and association now called ability to integrate clinical research findings into The Association of Lesbian, Gay, Bisexual, 164 Transgender Addiction Professionals treatment practice. They also were more likely to have * Evidence-based practice involves the use of current staff with advanced degrees and less likely to have evidence in making decisions about patient care. The authors of this study speculate Evidence-based practices aim to combine the best that programs with managed care contracts might be available research and clinical judgment while taking likelier than those without such contracts to be into account patient characteristics and needs. For example, based practices tended to be more highly while numerous guidelines have been produced 172 †† 178 educated. In contrast, specialists is essential to help educate and train providers with a strong 12-step orientation to other physicians, serve as equal partners in treatment tend to perceive evidence-based regular medical practice and provide specialty 175 183 practices as less acceptable. For many recovering paraprofessional Efforts also must be made to translate physician counselors, their counseling “trump card” is training into practice. A lack of time and that their personal experience is exemplary of resources make it difficult for physicians to 177 how recovery works. Poor training in the care of patients fourth-year medical students in New York City with addiction relates to low confidence among found that the majority (85 percent) did not physicians in their ability or competence to treat know of local smoking cessation programs to 193 such patients, negative attitudes toward patients which to refer patients. Curriculum time and the number of faculty with Only a small proportion of primary care expertise in addiction education pale in physicians feel “very prepared” to detect comparison to curriculum time and the number particular types of risky use (alcohol--19. A students and I feel that too many of our attending state-based 2006 survey of primary care physicians have not demonstrated to us that they physicians found that the vast majority (88 believe that addiction can and should be percent) screen for diabetes in adults with risk addressed and that attitude affects patient care factors such as obesity, hypertension and a 198 189 for the worse. Another national study found that 199 established, yet there often are more addiction only half of psychiatry residency programs offer -217- 205 psychiatry residency positions available than ability to provide psychosocial therapies. For example, overwhelming evidence has percent); and “smoking patients are not proven that smoking cessation interventions are interested in smoking cessation counseling” 206 clinically effective and cost effective and that a (19. Yet many medical schools do not training in caring for patients with risky 202 207 require clinical training in smoking cessation. Only about half of dental * schools and dental hygienist programs have My relapse was in part due to ignorance in the tobacco cessation clinical activities integrated in medical profession and lack of medical 210 their student clinics. Yet, nurses are not clinical psychologists are highly trained in adequately prepared to perform these services, psychosocial therapies, many of which can be particularly tobacco cessation for which applied effectively to addressing addiction in the research indicates they can be particularly 215 significant proportion of their patient population effective. Barriers to the implementation of that has co-occurring addiction and mental smoking interventions include a reported lack of 204 motivation, self- efficacy, institutional support, health disorders. Nursing school curricula screening and intervention for risky substance have little tobacco control content; there is a users and in diagnosing, treating or referring lack of tested curricula, nurse educators are not patients with addiction, some fail to identify * risky use or addiction or lack confidence in their Forty-seven percent of dental schools and 55 percent of dental hygienist programs. Specifically, cessation interventions are effective in providing although it is well understood that dosages 218 those services, and despite the important role between 60-100 mg per day promote retention in 225 pharmacists can play in preventing the misuse of treatment and reduction of opioid use, 34 219 controlled prescription drugs, most are not percent of patients are given doses of less than well trained to perform these functions, have 60 mg per day and 17 percent are given doses of * 226 little confidence to do so and believe that most less than 40 mg per day. Treatment patients are not interested in having them programs more likely to give suboptimal doses 220 intervene. The underutilization of pharmaceutical therapies in addiction treatment is another example of the Furthermore, despite the potentially vast market disconnect between addiction treatment services for pharmaceutical treatments for addiction, the and medical care.