NCAA wants Pa. gov's Penn State lawsuit dismissed

HARRISBURG, Pa. (AP) — The NCAA said Thursday a judge should throw out the federal antitrust lawsuit the governor filed against it over Penn State's $60 million fine and other penalties resulting from the Jerry Sandusky child molestation scandal.

College sports' governing body said in a filing that it disagrees with just about every allegation in the complaint against it initiated by Gov. Tom Corbett last month.

The NCAA said the penalties imposed under a July consent decree with the university are unrelated to regulation of economic activity, so antitrust law does not apply. It also argued Corbett lacks standing to sue and called his lawsuit "an inappropriate attempt to drag the federal courts into an intra-state political dispute."

"The remedial measures that Penn State agreed to were controversial, and have elicited strong feelings on all sides," the NCAA's lawyers wrote. "Some think they are too harsh, and some think they are too lenient. But none of those feelings have anything to do with the antitrust laws."

Corbett, a Republican, has said the NCAA overstepped its authority in punishing Penn State. His spokesman Nils Frederiksen said Thursday his lawyers will review the NCAA's filing "and respond as appropriate."

Corbett claimed in his lawsuit the NCAA "piled on" when it penalized Penn State over the Sandusky scandal. He asked that a federal judge throw out the sanctions, which include a four-year ban on bowl games, arguing that the measures have harmed students, business owners and others who had nothing to do with Sandusky's crimes.

The NCAA, in its federal court filing, disagreed.

"It is exceptionally unlikely that sanctions temporarily impairing one school's prowess on the football field would render any of these robust nationwide economic markets less competitive, such that Stanford suddenly could raise tuition, Michigan could offer fewer or less valuable football scholarships, or Notre Dame could charge more for branded football jerseys," the NCAA said in the new filing.

The case could define just how far the NCAA's authority extends. Up to now, the federal courts have allowed the organization broad powers to protect the integrity of college athletics.

Even if the factual claims in Corbett's lawsuit are true, the NCAA said, the matter involves Penn State, not the Pennsylvania residents on whose behalf the antitrust action was made.

Penn State said it had no role in the lawsuit. In fact, it agreed not to sue as part of the deal with the NCAA accepting the sanctions, which were imposed in July after an investigation found that football coach Joe Paterno and other top officials hushed up sexual-abuse allegations against Sandusky, a former member of Paterno's staff, for more than a decade for fear of bad publicity.

Sandusky, who's in his late 60s, was convicted in June of sexually abusing 10 boys, some of them on Penn State's campus. He is serving a 30- to 60-year prison sentence but insists he's innocent.

The penalties against Penn State include a cut in the number of football scholarships the university can award and a rewriting of the record books to erase 14 years of victories under Paterno, who was fired when the scandal broke in late 2011 and died of lung cancer shortly after.

The lawsuit represents a reversal by the governor. When Penn State's president consented to the sanctions last summer, Corbett, a member of the Board of Trustees, embraced them as part of the university's effort to repair the damage from the Sandusky scandal.

Corbett said he waited to sue over the penalties because he wanted to thoroughly research the legal issues and did not want to interfere with the football season.

Two Pennsylvania congressmen, Charlie Dent and Glenn Thompson, called for the NCAA to restore football scholarships taken away from Penn State, saying in a letter last month the sanctions unfairly punish innocent student-athletes for the child sex abuse scandal.

Penn State officials and Paterno's family deny there was a cover-up of allegations against Sandusky.

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Well: The 'Monday Morning' Medical Screaming Match

I did not think I would ever see another “morbidity and mortality” conference in which senior doctors publicly attacked their younger colleagues for making medical errors. These types of heated meetings were commonplace when I was a medical student but have largely been abandoned.

Yet here they were again on “Monday Mornings,” a new medical drama on the TNT network, based on a novel by Dr. Sanjay Gupta, CNN’s chief medical correspondent and one of the executive producers of the show. Such screaming matches may make for good television, but it is useful to review why new strategies have emerged for dealing with medical mistakes.

So-called M&M conferences emerged in the early 20th century as a way for physicians to review cases that had either surprising outcomes or had somehow gone wrong. Although the format varied among institutions and departments, surgery M&Ms were especially known for their confrontations, as more experienced surgeons often browbeat younger doctors into admitting their errors and promising to never make them again.

Such conferences were generally closed door — that is, attended only by physicians. Errors were a private matter not to be shared with other hospital staff, let alone patients and families.

But in the late 1970s, a sociology graduate student named Charles L. Bosk gained access to the surgery department at the University of Chicago. His resultant 1979 book, “Forgive and Remember,” was one of the earliest public discussions of how the medical profession addressed its mistakes.

Dr. Bosk developed a helpful terminology. Technical and judgment errors by surgeons could be forgiven, but only if they were remembered and subsequently prevented by those who committed them. Normative errors, which called into question the moral character of the culprit, were unacceptable and potentially jeopardized careers.

Although Dr. Bosk’s book was more observational than proscriptive, his depiction of M&M conferences was disturbing. I remember attending a urology M&M as a medical student in which several senior physicians berated a very well-meaning and competent intern for a perceived mistake. The intern seemed to take it very well, but my fellow students and I were shaken by the event, asking how such hostility could be conducive to learning.

There were lots of angry accusations in the surgical M&Ms in the pilot episode of “Monday Mornings.” In one case, a senior doctor excoriated a colleague who had given Tylenol to a woman with hip pain who turned out to have cancer. “You allowed metastatic cancer to run amok for four months!” he screamed.

If this was what Dr. Bosk would have called a judgment error, the next case raised moral issues. A neurosurgeon had operated on a boy’s brain tumor without doing a complete family history, which would have revealed a disorder of blood clotting. The boy bled to death on the operating table. “The boy died,” announced the head surgeon, “because of a doctor’s arrogance.”

In one respect, it is good to see that the doctors in charge were so concerned. But as the study of medical errors expanded in the 1990s, researchers found that the likelihood of being blamed led physicians to conceal their errors. Meanwhile, although doctors who attended such conferences might indeed not make the exact same mistakes that had been discussed, it was far from clear that M&Ms were the best way to address the larger problem of medical errors, which, according to a 1999 study, killed close to 100,000 Americans annually.

Eventually, experts recommended a “systems approach” to medical errors, similar to what had been developed by the airline industry. The idea was to look at the root causes of errors and to devise systems to prevent them. Was there a way, for example, to ensure that the woman with the hip problem would return to medical care when the Tylenol did not help? Or could operations not be allowed to occur until a complete family history was in the chart? Increasingly, hospitals have put in systems, such as preoperative checklists and computer warnings, that successfully prevent medical errors.

Another key component of the systems approach is to reduce the emphasis on blame. Even the best doctors make mistakes. Impugning them publicly — or even privately — can make them clam up. But if errors are seen as resulting from inadequate systems, physicians and other health professionals should be more willing to speak up.

Of course, the systems approach is not perfect. Studies continue to show that physicians conceal their mistakes. And elaborate systems for preventing errors can at times interfere with getting things done in the hospital.

Finally, it is important not to entirely remove the issue of responsibility. Sad to say, there still are physicians who are careless and others who are arrogant. Even if today’s M&M conferences rarely involve screaming, supervising physicians need to let such colleagues know that these types of behaviors are unacceptable.

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Barron H. Lerner, M.D., professor of medicine at New York University Langone Medical Center, is the author, most recently, of “One for the Road: Drunk Driving Since 1900.”

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DealBook: 4 Years After Crisis, Ireland Strikes Deal to Ease a Huge Debt Load

LONDON — The Irish government, trying to lighten the staggering debt burden of bailing out some of its biggest banks four years ago, reached a deal on Thursday with the European Central Bank to give the country more time to repay some of those loans.

The agreement, which came after 18 months of negotiations with the central bank, will enable Ireland to swap 28 billion euros ($38 billion) of high-interest promissory notes — a form of i.o.u.’s — that were used to bail out Anglo Irish Bank in 2009 for long-term government debt.

Although crucial details of the agreement were not disclosed, it appeared to be another important milestone in Ireland’s slow emergence from a banking and real estate crisis that had cut living standards, caused unemployment to soar and left cities scarred by half-finished building projects.

The deal could also be an important step for the euro zone, showing that it is possible for a member to survive the painful financial adjustments needed to recover from the crisis without leaving the currency union. Besides Ireland, Greece and Portugal have borrowed huge sums from the central bank and other international organizations to bail out their governments, while Spain has done likewise to rescue its banks.

By exchanging the promissory notes for government debt, Enda Kenny, the Irish prime minister, and his governing party, Fine Gael, have secured more time for Ireland to put itself on a firmer financial footing.

They have also won a significant concession from the central bank, which had repeatedly rejected Ireland’s plans to restructure some of its debt. The central bank, based in Frankfurt, has been concerned that a refinancing deal for Ireland would set a precedent that could be followed by other countries that have also bailed out big lenders.

Mario Draghi, the central bank’s president, declined to comment on the Irish deal during a news conference Thursday, suggesting that reporters direct their questions to Irish officials.

Mr. Kenny was more than happy to trumpet the deal. “The promissory notes represent a highly onerous and unfair legacy of the banking crisis,” Mr. Kenny told the Irish Parliament on Thursday. “The legacy banking debt hoisted on the Irish taxpayer is a heavy burden.”

Analysts said the debt restructuring was an important step in Ireland’s recovery because the government could either repay existing debt faster than previously expected or pump the extra cash directly into the local economy.

“Ireland has been pushing hard for this deal,” said Jonathan Loynes, the chief European economist at Capital Economics in London. “It’s a victory for Ireland over the European Central Bank.”

After stepping in to save many lenders that made too many bad loans during the 2000s, Dublin eventually had to turn to the European Union and the International Monetary Fund in 2010, which provided a 67.5 billion euro rescue package.

One big part of that bailout, the nationalization of the giant bank Anglo Irish, had left Dublin with onerous annual interest payments of 3.1 billion euros. The figure is about the same amount that Irish politicians have said they need to make in additional cuts in yearly government spending to reduce the country’s debt levels. The hefty interest payments caused widespread anger across Ireland, whose population has already endured several years of tax increases and government spending reductions.

The interest rate on the new government debt is expected to average about 3 percent, instead of rates above 8 percent on the promissory notes. The restructuring also will cut the country’s budget deficit by one billion euros a year, according to a statement from the Irish Finance Ministry, though Ireland’s deficit as a percentage of its overall economy will still be one of the highest in the euro zone.

As part of the deal, the Irish government passed emergency legislation on Thursday to liquidate Anglo Irish Bank, which fell into trouble in the buildup to the financial crisis by lending billions of euros to real estate developers. Many of those loans went bad after Ireland’s real estate bubble burst. The bank had been renamed the Irish Bank Resolution Corporation after its failure and bailout.

Under the terms of the liquidation, Anglo Irish’s loans will be transferred to the National Asset Management Agency, the so-called bad bank set up by the local government. Other assets could be sold to outside investors.

Anglo Irish had been at the center of controversy since the beginning of the financial crisis. Three of its former executives, including its former chief executive, Sean FitzPatrick, are facing fraud charges in connection with loans that authorities have said were granted improperly.

The new legislation, which was signed into law after an all-night parliamentary session, had been rushed through because details of the debt-restructuring plan were leaked on Wednesday. Even as lawmakers were debating the Anglo Irish liquidation, the hashtag #promnight — in reference to the promissory notes — started to trend on Twitter as the Irish public eagerly awaited the outcome.

Politicians had hoped to wait to announce the liquidation after agreeing on new terms with the European Central Bank.

“I would have preferred to be introducing this bill in tandem with a finalized agreement with the European Central Bank,” the Irish finance minister, Michael Noonan, said in a statement.

Despite persistent questioning at a Frankfurt news conference on Thursday, Mr. Draghi resolutely declined to offer any information about the central bank’s role, if any, in helping Ireland reduce its interest payments.

He said the bank’s governing council, which concluded its monthly meeting Thursday, merely “took note” of the Irish action. Mr. Draghi may have wanted to avoid any impression that the central bank was giving a financial break to the Irish government because its charter prohibits it from financing euro zone governments.

Ireland’s multibillion-euro lifeline in 2010 came with strings attached. International creditors demanded that Ireland adopt austerity measures that would cut public spending by $20 billion by 2015.

Salaries for many public sector workers, including nurses and teachers, have been reduced about 20 percent. Welfare programs like social protection and child benefits have been cut. And a series of new taxes has been introduced to refill the government’s coffers.

At first, the cuts plunged Ireland’s economy into recession, but the country’s gross domestic product is expected to grow 1.1 percent this year, much better than the mere 0.1 percent growth projected for the entire euro zone.

Despite the gradual recovery and now a reduction in the country’s debt burden, the Irish prime minister cautioned that more work had to be done to revive the country’s economy.

“Let there be no doubt, this is no silver bullet to end all our economic problems,” Mr. Kenny said on Thursday. “There is still a long way to travel in our country’s journey back to prosperity and full employment.”

Jack Ewing contributed reporting from Frankfurt

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Obama Orders Release of Drone Memos to Lawmakers

WASHINGTON — The White House on Wednesday directed the Justice Department to release classified documents discussing the legal justification for the use of drones in targeting American citizens abroad who are considered terrorist to the two Congressional intelligence committees, according to an administration official.

The White House announcement appears to refer to a long, detailed 2010 memo from the Justice Department’s Office of Legal Counsel justifying the killing of Anwar al-Awlaki, an American-born cleric who had joined Al Qaeda in Yemen. He was killed in a C.I.A. drone strike in September 2011. Members of Congress have long demanded access to the legal memorandum.

The decision to release the legal memos to the intelligence committees came under pressure, two days after a bipartisan group of 11 senators joined a growing chorus asking for more information about the legal justification for targeted killings, especially of Americans. The announcement also came on the eve of the confirmation hearing scheduled for Thursday for John O. Brennan, President Obama’s choice to be director of the C.I.A. As Mr. Obama’s counterterrorism adviser, Mr. Brennan has been the chief architect of the drone program, and he is expected to be closely questioned about it at the hearing of the Senate Intelligence Committee.

Critics noted that in 2009, Mr. Obama had ordered the public release of the classified memos governing C.I.A. interrogations under President George W. Bush and accused Mr. Obama of hypocrisy. Administration officials replied that the so-called enhanced interrogations had been stopped, while drone strikes continue.

Until Wednesday night, the administration had refused to even officially acknowledge the existence of the documents, which have been reported about in the press. This week, NBC News obtained an unclassified, shorter legal memo, described as a “white paper,” that officials said described the legal framework that officials follow in using the drones.

Administration officials said Mr. Obama had decided to take the action — which they described as extraordinary — out of a desire to involve Congress in the development of the legal framework for the use of drones. Aides noted that Mr. Obama had made a pledge to do that during an appearance on “The Daily Show” last year.

“Today, as part of the president’s ongoing commitment to consult with Congress on national security matters, the president directed the Department of Justice to provide the congressional Intelligence committees access to classified Office of Legal Counsel advice related to the subject of the Department of Justice White Paper,” the administration official said.

The official said that members of the intelligence committees would now get “access” to the documents. It remained unclear what kind of access that would be.

Christopher Anders, senior legislative counsel for the American Civil Liberties Union, called the president’s move “a small step in the right direction.” But he noted that the legal memo or memos were not being shared with either of the armed services committees, which have jurisdiction over Pentagon strikes, or the judiciary committees, which oversee the Justice Department.

The public should be permitted to see at least a redacted version of the relevant memos, Mr. Anders said. “Everyone has a right to know when the government believes it can kill Americans and others,” he said.

The Congressional intelligence committees were created in the late 1970s to exercise oversight after a series of scandals at the spy agencies. The law requires that the committees be kept informed of intelligence activities. But most administrations withhold at least some legal opinions, treating them as confidential legal advice to the president and agency officials.

Senator Dianne Feinstein, the California Democrat who leads the Senate Intelligence Committee, had proposed a clause for the annual intelligence authorization bill requiring that legal opinions on relevant matters be routinely shared with the committees. But the White House objected, and the measure was dropped from the bill.

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Signing Day: Ole Miss muscles in on power programs

Alabama. Ohio State. Michigan. Florida. Notre Dame. Mississippi?

Ole Miss muscled in on the powerhouses that usually dominate national signing day, landing some of the most sought-after prospects in the country on college football's annual first-Wednesday-in-February frenzy.

The Rebels, coming off a promising 7-6 season in their first season under coach Hugh Freeze, had the experts swooning by signing three of the bluest chips still on the board and building a well-rounded class otherwise.

"I do think (this class) has the possibility of being a program changer," Freeze said. "But it's all on paper right now.

The day started with defensive end Robert Nkemdiche from Loganville, Ga., rated the No. 1 recruit in the country by just about everyone who ranks them, deciding to join his brother, Denzel, in Oxford, Miss.

"I feel like it's the right place for me," Nkemdiche said after slipping on a red Ole Miss cap. "I feel like they can do special things and they're on the rise. I feel like going to play with my brother, we can do something special."

Nkemdiche originally committed to Clemson last year, then backed off that and narrowed his picks down to LSU, Florida and Mississippi — and the Rebels beat the big boys.

They weren't done. Coaches in the Ole Miss war room were exchanging hugs and high-fives again a couple hours later when Laremy Tunsil, a top-rated offensive tackle from Lake City, Fla., picked the Rebels over Florida State and Georgia.

"Tunsil to Ole Miss I think was the biggest surprise of the whole (recruiting season)," said JC Shurburtt, national recruiting director for 247Sports.com.

And, as if the Ole Miss needed more good news, highly touted defensive back Antonio Conner from nearby Batesville, Miss., chose the Rebels over national champion Alabama.

Ole Miss also landed Laquon Treadwell from Crete, Ill., one of the best receiver prospects in the country. He made a verbal commitment to the Rebels back in December, and sealed the deal Wednesday, the first day high school players can sign binding letters of intent.

The end result was a class good enough to even catch the attention of LeBron James.

"Ole Miss ain't messing around today! Big time recruits coming in. SEC is crazy," the NBA MVP posted on his Twitter account.

Crazy good. While the Rebels racked up, it's important to remember they still have plenty of ground to gain on the rest of their conference.

Nick Saban reloaded the Crimson Tide with a class that Rivals.com ranked No. 1 in the country.

SEC powers Florida, LSU and Georgia pulled in typically impressive classes. SEC newcomer Texas A&M cracked the top 10 of several rankings. Even Vanderbilt, coming off a nine-win season, broke into the top 25.

It's the cycle of life in the SEC, which has won seven straight BCS championships. Stock up on signing day and scoop up those crystal footballs at season's end.

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SLIPPING AWAY FROM USC

Signing day didn't do much to soothe the scars left from a difficult season for Southern California.

NCAA sanctions limited the number of scholarships coach Lane Kiffin and the Trojans could hand out this year, and then as signing day approached USC had several players who had given verbal commitments change their minds.

The most notable defection on signing day was five-star defensive back Jalen Ramsey of Brentwood, Tenn., who flipped to Florida State. Defensive end Jason Hatcher from Louisville, Ky., bailed on USC and signed with Kentucky, and defensive end Torrodney Prevot from Houston not only reneged on his USC commitment, but he landed at Pac-12-rival Oregon.

"People expected (Prevot) to flip from USC, but they thought it would be to Texas A&M," Shurburtt said.

USC's class won't be lacking blue chippers. Quarterback Max Browne from Washington is considered the next in a long line of topflight Trojans quarterbacks, and Kenny Bigelow from Maryland is rated among the best defensive linemen in the nation.

Kiffin will be banking on quality to make up for the lack of quantity, but that's a precarious way to play a game as uncertain as recruiting.

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IF MOMMA'S NOT HAPPY ...

Alex Collins, a top running back prospect out of Plantation, Fla., announced on Monday night that he was going to Arkansas instead of Miami.

It was considered a huge victory for new Razorbacks coach Bret Bielema.

But on Wednesday morning, when it was time to make it official, Collins' letter of intent didn't come spinning through the fax machine in Fayetteville, Ark.

There were some odd reports about Collins' mother not being happy with her son's decision to go so far from home.

College coaches aren't allowed to talk about specific players before they sign, but Bielema did acknowledge during his signing day news conference that Arkansas' class of 22 players could "grow by one."

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THE BIG TWO

Ohio State and Michigan received two thumbs up from experts on their signing day classes. They all had the Buckeyes and Wolverines around top five in the country.

After that, there was a drop off. Nebraska received solid grades and Penn State, despite NCAA sanctions that limited its class to 17 signees, held up pretty well.

"That's a tribute to the job (Penn State coach) Bill O'Brien and the staff did," Shurburtt said.

But signing day 2013 signaled that Urban Meyer's Buckeyes and Brady Hoke's Wolverines are primed to pull away from most of the Big Ten, and maybe — just maybe — give the league a team or two that can challenge those SEC teams for a national title.

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BUILT TO LAST

Notre Dame followed up its best season in more than two decades with a recruiting class that coach Brian Kelly hopes can keep the Fighting Irish contending for more national titles.

The class includes a famous name in Torii Hunter Jr., the son of the All-Star outfielder. Hunter Jr. is a top-notch receiver prospect, though he broke his leg during an All-Star game and it could be a while before he's back on the football field.

Linebacker Jaylon Smith from Fort Wayne, Ind., is generally regarded as the jewel of a class that experts have ranked among the best in the country.

"I love agreeing with experts," Kelly said.

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BASEBALL OR FOOTBALL?

Oklahoma hopes it has found the next Sam Bradford in Cody Thomas, a pocket passer from Colleyville, Texas.

One small problem. Thomas is also a big-time baseball player who could draw interest in the major league draft this summer.

"We wouldn't have pursued him if we didn't feel there was a great chance he'd be playing football," Oklahoma coach Bob Stoops said.

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QUOTABLE

South Carolina coach Steve Spurrier said recruiting classes "don't always pan out. Of course, they always seem to pan out at Alabama."

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AP Sports Writer David Brandt in Oxford, Miss., and Associated Press Writer Tom Coyne in South Bend, Ind., contributed.

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Follow Ralph D. Russo at www.Twitter.com/ralphdrussoap

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Personal Health: Effective Addiction Treatment

Countless people addicted to drugs, alcohol or both have managed to get clean and stay clean with the help of organizations like Alcoholics Anonymous or the thousands of residential and outpatient clinics devoted to treating addiction.

But if you have failed one or more times to achieve lasting sobriety after rehab, perhaps after spending tens of thousands of dollars, you’re not alone. And chances are, it’s not your fault.

Of the 23.5 million teenagers and adults addicted to alcohol or drugs, only about 1 in 10 gets treatment, which too often fails to keep them drug-free. Many of these programs fail to use proven methods to deal with the factors that underlie addiction and set off relapse.

According to recent examinations of treatment programs, most are rooted in outdated methods rather than newer approaches shown in scientific studies to be more effective in helping people achieve and maintain addiction-free lives. People typically do more research when shopping for a new car than when seeking treatment for addiction.

A groundbreaking report published last year by the National Center on Addiction and Substance Abuse at Columbia University concluded that “the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.” The report added, “Only a small fraction of individuals receive interventions or treatment consistent with scientific knowledge about what works.”

The Columbia report found that most addiction treatment providers are not medical professionals and are not equipped with the knowledge, skills or credentials needed to provide the full range of evidence-based services, including medication and psychosocial therapy. The authors suggested that such insufficient care could be considered “a form of medical malpractice.”

The failings of many treatment programs — and the comprehensive therapies that have been scientifically validated but remain vastly underused — are described in an eye-opening new book, “Inside Rehab,” by Anne M. Fletcher, a science writer whose previous books include the highly acclaimed “Sober for Good.”

“There are exceptions, but of the many thousands of treatment programs out there, most use exactly the same kind of treatment you would have received in 1950, not modern scientific approaches,” A. Thomas McLellan, co-founder of the Treatment Research Institute in Philadelphia, told Ms. Fletcher.

Ms. Fletcher’s book, replete with the experiences of treated addicts, offers myriad suggestions to help patients find addiction treatments with the highest probability of success.

Often, Ms. Fletcher found, low-cost, publicly funded clinics have better-qualified therapists and better outcomes than the high-end residential centers typically used by celebrities like Britney Spears and Lindsay Lohan. Indeed, their revolving-door experiences with treatment helped prompt Ms. Fletcher’s exhaustive exploration in the first place.

In an interview, Ms. Fletcher said she wanted to inform consumers “about science-based practices that should form the basis of addiction treatment” and explode some of the myths surrounding it.

One such myth is the belief that most addicts need to go to a rehab center.

“The truth is that most people recover (1) completely on their own, (2) by attending self-help groups, and/or (3) by seeing a counselor or therapist individually,” she wrote.

Contrary to the 30-day stint typical of inpatient rehab, “people with serious substance abuse disorders commonly require care for months or even years,” she wrote. “The short-term fix mentality partially explains why so many people go back to their old habits.”

Dr. Mark Willenbring, a former director of treatment and recovery research at the National Institute for Alcohol Abuse and Alcoholism, said in an interview, “You don’t treat a chronic illness for four weeks and then send the patient to a support group. People with a chronic form of addiction need multimodal treatment that is individualized and offered continuously or intermittently for as long as they need it.”

Dr. Willenbring now practices in St. Paul, where he is creating a clinic called Alltyr “to serve as a model to demonstrate what comprehensive 21st century treatment should look like.”

“While some people are helped by one intensive round of treatment, the majority of addicts continue to need services,” Dr. Willenbring said. He cited the case of a 43-year-old woman “who has been in and out of rehab 42 times” because she never got the full range of medical and support services she needed.

Dr. Willenbring is especially distressed about patients who are treated for opioid addiction, then relapse in part because they are not given maintenance therapy with the drug Suboxone.

“We have some pretty good drugs to help people with addiction problems, but doctors don’t know how to use them,” he said. “The 12-step community doesn’t want to use relapse-prevention medication because they view it as a crutch.”

Before committing to a treatment program, Ms. Fletcher urges prospective clients or their families to do their homework. The first step, she said, is to get an independent assessment of the need for treatment, as well as the kind of treatment needed, by an expert who is not affiliated with the program you are considering.

Check on the credentials of the program’s personnel, who should have “at least a master’s degree,” Ms. Fletcher said. If the therapist is a physician, he or she should be certified by the American Board of Addiction Medicine.

Does the facility’s approach to treatment fit with your beliefs and values? If a 12-step program like A.A. is not right for you, don’t choose it just because it’s the best known approach.

Meet with the therapist who will treat you and ask what your treatment plan will be. “It should be more than movies, lectures or three-hour classes three times a week,” Ms. Fletcher said. “You should be treated by a licensed addiction counselor who will see you one-on-one. Treatment should be individualized. One size does not fit all.”

Find out if you will receive therapy for any underlying condition, like depression, or a social problem that could sabotage recovery. The National Institute on Drug Abuse states in its Principles of Drug Addiction Treatment, “To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems.”

Look for programs using research-validated techniques, like cognitive behavioral therapy, which helps addicts recognize what prompts them to use drugs or alcohol, and learn to redirect their thoughts and reactions away from the abused substance.

Other validated treatment methods include Community Reinforcement and Family Training, or Craft, an approach developed by Robert J. Meyers and described in his book, “Get Your Loved One Sober,” with co-author Brenda L. Wolfe. It helps addicts adopt a lifestyle more rewarding than one filled with drugs and alcohol.

This is the first of two articles on addiction treatment.

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Postal Service Plans to End Saturday Delivery

Christopher Gregory/The New York Times

Patrick R. Donahoe, the postmaster general, announcing the planned service change.

WASHINGTON — Faced with billions of dollars in losses, the Postal Service announced on Wednesday that it would seek to stop Saturday delivery of letters, a sweeping change in mail delivery that immediately drew criticism from postal unions, some businesses and lawmakers.

Jim Wilson/The New York Times

Grinje Fernandez, a letter carrier for the Postal Service, delivered mail in San Francisco's Richmond District on Wednesday.

The post office said a five-day mail delivery schedule would begin in August and would shave about $2 billion a year from its losses, which were $15.9 billion last year. The Postal Service would continue to deliver packages six days a week, and post offices would still be open on Saturdays. Reducing Saturday delivery is in line with mail services in several other industrialized countries like Australia, Canada and Sweden, which deliver five days a week.

The move raised immediate legal questions on Capitol Hill, where some lawmakers claimed that the Postal Service could not change its delivery schedules without Congressional approval. The post office has made earlier attempts to change the law, only to meet with objections or delays in Congress. Now, seizing a moment when the post office believes the law no longer applies, it moved on its own to shut down Saturday letter delivery.

Whether it will succeed is difficult to predict. Many lawmakers view the Postal Service as the quintessential government service that touches constituents almost every day, and rigidly oppose any changes. Also, postal worker unions hold sway over some lawmakers who are influential in writing legislation that governs the agency.

Whether the post office is ultimately blocked by an act of Congress or it tries to move ahead with ending letter delivery on Saturdays, the announcement on Wednesday moves postal overhaul legislation — which had stalled for many months — up the Congressional agenda.

“Our financial condition is urgent,” said Patrick R. Donahoe, the postmaster general, at a news conference announcing the change. “This is too big of a cost savings for us to ignore.”

Mr. Donahoe said the move to end Saturday delivery was part of a long-term plan to return the agency to profitability. Since 2010, the agency has continued to close post offices, reduce hours at many small, rural offices and cut staff. It also announced plans to sharply reduce the number of its regional processing plants. Last month, the agency raised the price of a first-class stamp to 46 cents, the latest in a series of generally annual postage increases.

But post office officials say the cuts, rate increases and staff reductions are not enough to make up for the two reasons it is losing money. One is a requirement that it pay nearly $5.5 billion a year for health benefits to future retirees, a mandate imposed on no other government agency. Second, since 2007, first-class mail volume has declined by 37 percent as use of e-mail and online payment services has soared.

The agency said eliminating Saturday mail service represented a substantial cost savings because of fewer staff hours and less equipment needed to maintain the deliveries.  

The Postal Service also said the rise in online retail purchases and other e-commerce was contributing to its increase in that area and was why it would continue to deliver packages on Saturdays.

Since 1981, a Congressional mandate has required the Postal Service to deliver mail six days a week. But on Wednesday the agency argued that since the current stopgap budget measure for the entire government, known as a continuing resolution, did not contain language explicitly mandating six-day delivery, the agency could make the changes without Congressional approval.

But some members of Congress immediately questioned the Postal Service’s claim.

“The passage of the continuing resolution did not suspend that language, as they claim, but in fact extended it,” said Representative José E. Serrano, Democrat of New York and ranking member on the appropriations subcommittee on financial services and general government, which has jurisdiction over the post office. “Rather than use very dubious legal arguments to end Saturday delivery, the U.S.P.S. should work hand in hand with Congress to come up with a successful restructuring and reform package that allows them to become more efficient while maintaining vital services like Saturday delivery.”

This article has been revised to reflect the following correction:

Correction: February 6, 2013

An earlier version of this article misstated the news organization that first reported the Postal Service’s plans to end Saturday service. It was CBS News, not The Associated Press.

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Obama to Visit Israel in Spring

WASHINGTON — President Obama plans to travel to Israel this spring for the first time since taking office, as he and Prime Minister Benjamin Netanyahu try to move past the friction of the last four years now that both have won re-election.

By making Israel a stop on the first overseas trip of his new term, Mr. Obama hopes to demonstrate support for the Jewish state despite doubts among some of its backers. But the trip also seems designed to signal a desire to restart what has been a fraught relationship, and not to be seen as an ambitious effort to revive a stalled peace process.

“The start of the president’s second term and the formation of a new Israeli government offer the opportunity to reaffirm the deep and enduring bonds between the United States and Israel,” Jay Carney, the White House spokesman, said Tuesday, “and to discuss the way forward on a broad range of issues of mutual concern, including, of course, Iran and Syria.”

Mr. Carney said Mr. Obama would also travel to Jordan and the West Bank. The Israeli news media reported that Mr. Obama would arrive on March 20, but the White House would not discuss any dates for the trip.

Mr. Netanyahu’s office said a visit by the president would be “an important opportunity to underscore the friendship and strong partnership between Israel and the United States.”

The relationship between the two leaders has been edgy for years over issues like Israel’s settlements in the West Bank and ways to stop Iran’s nuclear program.

While Mr. Obama won a clear victory in November, Mr. Netanyahu emerged from elections last month in a weakened state, winning enough seats to retain office but forced to recruit centrist lawmakers for a coalition that might temper his policies. He has until March 16 to present his new government.

Mr. Obama is not expected to unveil concrete proposals for bringing Israelis and Palestinians together during his visit or initiate a specific new peace process. But advisers hope that just by showing up and talking about these issues, Mr. Obama will show that he is not walking away from them.

Dennis Ross, a former Middle East adviser to Mr. Obama, attributed the trip to “a desire to connect with the Israeli public at a time when he can go and not have high expectations about having to produce something.”

The president “can create a new beginning with the same prime minister but with a new Israeli government,” Mr. Ross said.

Some peace advocates welcomed the trip but said it should go beyond atmospherics. “The key is, they’ve got to use this as a real substantive jumping off point for a serious diplomatic initiative,” said Jeremy Ben-Ami, the president of J Street, a Washington advocacy group. “This has to be more than a photo op to show that he cares.”

A former Israeli defense official said the trip’s announcement might have been timed to send a message to Israelis and even influence the composition of the next government amid talk of restarting the peace effort. The former official said a more centrist government would allow the sides more room to maneuver.

Also on the agenda this trip will be Iran and the continuing strife in Syria that threatens to descend into a wider regional conflict. Israel last week struck a convoy of antiaircraft weapons inside Syria that it feared was being moved to Hezbollah forces.

“The United States can put an end to the Iranian threat,” President Shimon Peres of Israel said in an address to Parliament on Tuesday, “and I believe that the president of the United States is determined to do it.”

While Mr. Obama visited Israel in 2008 as a candidate, he did not travel there during his first term, a fact that became fodder on the campaign trail last year. A television commercial from a group called the Emergency Committee for Israel said Mr. Obama had “traveled all over the Middle East but he hasn’t found time to visit our ally and friend, Israel.” Mitt Romney, the Republican presidential nominee, ran his own advertisement criticizing the president for not going to Israel.

Only four sitting presidents have visited Israel: Richard M. Nixon and Jimmy Carter each went once, George W. Bush twice, and Bill Clinton four times. Mr. Bush, considered one of the strongest friends Israel has had in the Oval Office, did not visit until 2008, near the end of his presidency.

Isabel Kershner contributed reporting from Jerusalem.

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Her knee shredded, Lindsey Vonn done for season

SCHLADMING, Austria (AP) — All it took was a moment. Lindsey Vonn landed hard and tumbled face first with a piercing shriek.

Just like that, the star American skier was on the ground with two torn ligaments in her right knee and a broken bone in her lower leg.

The cascading fall down the slope during the super-G at the world championships Tuesday knocked out the four-time World Cup champion for the rest of the season, the latest and most serious in a string of injuries for Vonn at skiing's biggest events.

The U.S. team said in a statement it expects her back for the next World Cup season and the 2014 Sochi Olympics, which start a year from this week.

The harrowing accident came after Vonn was lifted into the air off a jump in the opening race at the championships. As she hit the ground, her right leg gave way and she spun down face first, throwing an arm out to protect herself. She ended up on her back as she smashed through a gate.

On the television feed, Vonn was clearly heard screaming an expletive as she landed, then a despairing "Yes, yes," when someone asked, "Are you hurt?"

Race leader and eventual champion Tina Maze watched with her mouth agape. The concern also was obvious on the face of Vonn's sister, Laura Kildow, who has been traveling with her full time this season.

For 12 minutes, Vonn lay on the snow getting medical treatment before being airlifted by helicopter to a hospital in Schladming.

Vonn tore her anterior cruciate ligament and medial collateral ligament in her right knee, U.S. ski team medical director Kyle Wilkens said in a statement. The broken bone was described as a "lateral tibial plateau fracture."

Christian Kaulfersch, the assistant medical director at the worlds, said Vonn left the Schladming hospital on Tuesday afternoon and will have surgery in another hospital. "She first wanted to go back to the team hotel to mentally deal with all what has happened," Kaulfersch said.

Vonn's father, Alan Kildow, spoke with her by phone and said that she's, "mad at the way things turned out." His daughter told him that she landed in a clump of sugar snow, or ice crystals, that caused her to fall forward, he said.

"She's a tough character. A very determined and tough character," Kildow told The Associated Press in a phone interview. "She will be back."

Kildow said that surgery could take place as soon as this weekend, likely at the Steadman Clinic, in Vail, Colo. Recovery time varies, according to Dr. Tom Hackett, an orthopedic surgeon at the clinic and the team physician for the U.S. snowboard squad.

But Vonn could be looking at six-to-eight months before she's back on skis.

"It's not like at six months you say, 'OK, you can get back on a super-G course," Hackett said. "There's a progression to getting back on skis, getting back to taking some easy runs, getting back to some gates, and working your way back to some steeper terrain. There's a whole return to snow progression that we've developed over many years."

Time enough to get back for Sochi?

"I think so," Hackett said. "I would be very optimistic she could come back strong. She's a fierce competitor. She's a fighter and chances are that she will — I would think — essentially take all of that athletic energy and put it into her rehabilitation. There's a really good chance she could come back as strong as ever."

Comebacks are nothing new for Vonn, who has also been afflicted by injuries at her last six major championships — from a thumb she sliced on a champagne bottle at the 2009 worlds in Val d'Isere, France, to a bruised shin that she cured with Austrian cheese at the Vancouver Olympics.

This one, however, could prove the biggest test yet for the 28-year-old who won the downhill at the 2010 Vancouver Olympics.

Vonn took a month off this season after being hospitalized for an intestinal illness in November, and had just regained her form with two wins last month.

That was evident at the start of her Tuesday's run. She led Maze by 0.04 seconds at the first checkpoint and was just 0.12 back at the second interval and seemingly on her way to a medal, if not victory.

Exactly what went wrong was debated by competitors and officials at the championships.

The start of the race was delayed by 3½ hours because of fog hanging over the course and it began in waning light at 2:30 p.m local time. Even before Vonn's crash, a course worker fell and also had to be airlifted. He was reported to have broken his nose.

All the delays made for what skiers call flat light — overcast and dreary conditions — when Vonn raced.

"Lindsey did a great job on top and Lindsey has won a lot of races in flat light so the flat light was definitely not a problem," U.S. Alpine director Patrick Riml told the AP.

"We are upset obviously with what happened but if you don't know the facts and why they decided to start and what the weather forecast was it's hard to say without any reasoning," Riml said. "And they probably had a reason, otherwise they wouldn't have started."

Atle Skaardal, women's race director for the International Ski Federation, defended the decision to go ahead with the event.

"I can confirm that the visibility was great, there were no problems, and the course was also in good shape," he said. "I don't see that any outside factors played a role in this accident. ... The other factors were like they were supposed to be for ski racing."

Vonn's list of injuries at major championships is long.

Two years ago, she pulled out midway through the last worlds in Garmisch-Partenkirchen, Germany, because of a mild concussion. At the 2010 Vancouver Olympics, Vonn skied despite a severely bruised shin to win the downhill and take bronze in the super-G.

At the 2009 worlds in Val d'Isere, she sliced her thumb on a champagne bottle after sweeping gold in the downhill and super-G, forcing her out of the giant slalom. At the 2007 worlds in Are, Sweden, Vonn injured her knee in training and missed her final two events.

And at the 2006 Turin Olympics, she had a horrific crash in downhill training and went directly from her hospital room to the mountain to compete in four of her five events.

The conditions Tuesday varied from racer to racer, and as the light began to fade even more, organizers stopped the race after only 36 of the 59 skiers had come down.

Maze skied immediately before Vonn.

"I saw it was a very high jump, so I knew I had to take the right line to make the next gate," she said. "World championship races often have special conditions and the mistakes from the girls were not because of the slope."

The two racers who started immediately after Vonn, former overall winner Maria Hoefl-Riesch of Germany and local favorite Anna Fenninger of Austria, each skied off course. In all, six women who started the course failed to finish. Still, Skaardal said he never thought about stopping the race.

"It's not a very difficult course but in some parts you couldn't see anything," said Fabienne Suter of Switzerland, who finished fifth.

Vonn's teammate Julia Mancuso also thrived in the difficult conditions and won the bronze medal.

"It's the same for everybody," U.S. speed coach Chip White said. "Everyone had to wait for a long time and that's always difficult. And the holds were every 15 minutes so it really doesn't give you a chance to go and do something else. You're always kind of on edge at the ready. It's a difficult situation but everybody had the same difficult situation."

Not long after Vonn was injured, NBC hosted a news conference in New York to discuss its coverage of the Sochi Games. A poster of a smiling Vonn hung in the room next to one of snowboarder Shaun White, evidence of the network's unsurprising expectations that she would be one of the biggest stars in Sochi.

The network's executives chose to put a positive spin on the injury.

"We expect her to be the comeback Olympian of the year," NBC Sports Group Chairman Mark Lazarus said.

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Associated Press writer Eric Willemsen in Schladming and AP Sports Writers Pat Graham and Rachel Cohen contributed to this report.

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Well: Warning Too Late for Some Babies

Six weeks after Jack Mahoney was born prematurely on Feb. 3, 2011, the neonatal staff at WakeMed Hospital in Raleigh, N.C., noticed that his heart rate slowed slightly when he ate. They figured he was having difficulty feeding, and they added a thickener to help.

When Jack was discharged, his parents were given the thickener, SimplyThick, to mix into his formula. Two weeks later, Jack was back in the hospital, with a swollen belly and in inconsolable pain. By then, most of his small intestine had stopped working. He died soon after, at 66 days old.

A month later, the Food and Drug Administration issued a caution that SimplyThick should not be fed to premature infants because it may cause necrotizing enterocolitis, or NEC, a life-threatening condition that damages intestinal tissue.

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Catherine Saint Louis speaks about using SimplyThick in premature infants.

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Experts do not know how the product may be linked to the condition, but Jack is not the only child to die after receiving SimplyThick. An F.D.A. investigation of 84 cases, published in The Journal of Pediatrics in 2012, found a “distinct illness pattern” in 22 instances that suggested a possible link between SimplyThick and NEC. Seven deaths were cited; 14 infants required surgery.

Last September, after more adverse events were reported, the F.D.A. warned that the thickener should not be given to any infants. But the fact that SimplyThick was widely used at all in neonatal intensive care units has spawned a spate of lawsuits and raised questions about regulatory oversight of food additives for infants.

SimplyThick is made from xanthan gum, a widely-used food additive on the F.D.A.’s list of substances “generally recognized as safe.” SimplyThick is classified as a food and the F.D.A. did not assess it for safety.

John Holahan, president of SimplyThick, which is based in St. Louis, acknowledged that the company marketed the product to speech language pathologists who in turn recommended it to infants. The patent touted its effectiveness in breast milk.

However, Mr. Holahan said, “There was no need to conduct studies, as the use of thickeners overall was already well established. In addition, the safety of xanthan gum was already well established.”

Since 2001, SimplyThick has been widely used by adults with swallowing difficulties. A liquid thickened to about the consistency of honey allows the drinker more time to close his airway and prevent aspiration.

Doctors in newborn intensive care units often ask non-physician colleagues like speech pathologists to determine whether an infant has a swallowing problem. And those auxiliary feeding specialists often recommended SimplyThick for neonates with swallowing troubles or acid reflux.

The thickener became popular because it was easy to mix, could be used with breast milk, and maintained its consistency, unlike alternatives like rice cereal.

“It was word of mouth, then neonatologists got used to using it. It became adopted,” said Dr. Steven Abrams, a neonatologist at Texas Children’s Hospital in Houston. “At any given time, several babies in our nursery — and in any neonatal unit — would be on it.”

But in early 2011, Dr. Benson Silverman, the director of the F.D.A.’s infant formula section, was alerted to an online forum where doctors had reported 15 cases of NEC among infants given SimplyThick. The agency issued its first warning about its use in babies that May. “We can only do something with the information we are provided with,” he said. “If information is not provided, how would we know?”

Most infants who took SimplyThick did not fall ill, and NEC is not uncommon in premature infants. But most who develop NEC do so while still in the hospital. Some premature infants given SimplyThick developed NEC later than usual, a few after they went home, a pattern the F.D.A. found unusually worrisome.

Even now it is not known how the thickener might have contributed to the infant deaths. One possibility is that xanthan gum itself is not suitable for the fragile digestive systems of newborns. The intestines of premature babies are “much more likely to have bacterial overgrowth” than adults’, said Dr. Jeffrey Pietz, the chief of newborn medicine at Children’s Hospital Central California in Madera.

“You try not to put anything in a baby’s intestine that’s not natural.” If you do, he added, “you’ve got to have a good reason.”

A second possibility is that batches of the thickener were contaminated with harmful bacteria. In late May 2011, the F.D.A. inspected the plants that make SimplyThick and found violations at one in Stone Mountain, Ga., including a failure to “thermally process” the product to destroy bacteria of a “public health significance.”

The company, Thermo Pac, voluntarily withdrew certain batches. But it appears some children may have ingested potentially contaminated batches.

The parents of Jaden Santos, a preemie who died of NEC while on SimplyThick, still have unused packets of recalled lots, according to their lawyer, Joe Taraska.

The authors of the F.D.A. report theorized that the infants’ intestinal membranes could have been damaged by bacteria breaking down the xanthan gum into too many toxic byproducts.

Dr. Qing Yang, a neonatologist at Wake Forest University, is a co-author of a case series in the Journal of Perinatology about three premature infants who took SimplyThick, developed NEC and were treated. The paper speculates that NEC was “most likely caused by the stimulation of the immature gut by xanthan gum.”

Dr. Yang said she only belatedly realized “there’s a lack of data” on xanthan gum’s use in preemies. “The lesson I learned is not to be totally dependent on the speech pathologist.”

Julie Mueller’s daughter Addison was born full-term and given SimplyThick after a swallow test showed she was at risk of choking. It was recommended by a speech pathologist at the hospital.

Less than a month later, Addison was dead with multiple holes in her small intestine. “It was a nightmare,” said Ms. Mueller, who has filed a lawsuit against SimplyThick. “I was astounded how a hospital and manufacturer was gearing this toward newborns when they never had to prove it would be safe for them. Basically we just did a research trial for the manufacturer.”

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