Alcohol and Alcoholism Vol. 35, No. 2, pp. 216-217, 2000
© 2000 Medical Council on Alcoholism
Book Reviews
New Treatments for Chemical Addictions (Review of Psychiatry, Series, Vol. 17).
This multi-author volume is one of six individually published sections which make up the 1998 American Psychiatric Association Review of Psychiatry, which is now in its seventeenth volume. The addictions volume has five chapters: Nicotine Dependence and Treatment, Alcohol Dependence in Women, Opiate Dependence Treatment, The Relationship Between Substance Misuse and HIV, and Contemporary Issues in Dual Diagnosis. The editors and lead authors are all North American psychiatrists, many from Yale University School of Medicine, which is the base of the two editors.
The editors' introduction sets out the aim of the volume clearly so as to assist current practising psychiatrists (including trainees) in their assessment and management of clinical problems. The introduction also indicates the North American orientation of the book. All of the epidemiological data are from the USA, and references to mental health legislation or to treatment organization are exclusively North American.
The chapter on Nicotine Dependence is excellent, taking a broad sweep through basic neuropharmacology, motivational theory, public health and policy, and clinical practice. The authors make an undeniable case that this is a sorely neglected area of clinical practice and of health service management. Psychiatric patients have smoking rates two to three times the population norm and the mental health system stands accused of providing a ‘smoking-enriched environment’, facilitating and promoting the behaviour. The point is made that people in treatment for alcohol dependence are more likely to die of illnesses related to smoking than to alcohol. The sections on intervention and management are clear and eclectic, and the authors convey a sense of considerable clinical experience. Attention is given to motivational enhancement strategies and to pharmacological interventions. A section on the difficult issues regarding smoking cessation in high priority groups such as pregnancy and vascular disease would, however, have been helpful. This contribution provides an invaluable starting point for those who know they ought to be doing something for their smoking clients, but don't know what.
The contribution on alcohol dependence in women sets out the intention of summarizing the available evidence to indicate that women need services which specifically address their unique needs, but the case is not made conclusively. Evidence is presented to suggest that sex differences in drinking over the past 50 years (in the USA) have not changed much, and that men continue to drink more with more problems and dependence. The physiological evidence is covered, including the relationship between alcohol and female sex hormones, with the conclusion that clinical implications of sex differences in metabolism are few at present. The exception to this is the compelling evidence of women's increased susceptibility to liver damage. Reviews of the evidence regarding sex issues in co-morbidity, outcome expectancies and use of treatment services are inconclusive. It is disappointing that not enough attention is paid to the relationship between sexual abuse and alcohol misuse. There is a helpful review of the authors' own work on the important issue of the under-representation of women in trials of pharmacological treatments, although reference to the stringent contraception criteria frequently in operation for drug trials would have helped to explain this. The case for the value of reporting sex differences in outcomes is well made. With regard to treatment provision, contrary to their preconceptions which the authors helpfully outline, the enduring impression is that services with a range of treatment setting options, and well-trained and adaptable therapists can meet the needs of both genders.
Opiate dependence and treatment is well covered with a good review of current physiological and pharmacological advances. The guidelines on the management of opiate intoxication and withdrawal are clear and the author's views on management, in particular the role of methadone maintenance and related practice issues are well argued. The author is firmly of the view that many methadone programmes use inadequate doses and presents evidence of less use of other opiates and cocaine with higher methadone doses. Reference is made to management issues in co-existing opiate and alcohol dependence. The case is made for the ‘added value’ of psychosocial interventions improving outcomes in methadone maintenance programmes. The North American enthusiasm for the use of buprenorphine (temgesic) in the treatment of opiate dependence based on its perceived limited abuse potential will, however, surprise those of us familiar with the Scottish drug scene in the 1980s.
The substance abuse and HIV chapter focuses mainly on the multiple factors which can prevent HIV-infected substance misusers obtaining appropriate treatment. These include social exclusion, prejudice regarding race or sexual behaviour, and hostile, morally based staff attitudes. The author feels strongly about this and these points are made repeatedly in the article. With regard to substance misuse treatment the author is a strong advocate of the helpfulness of an exclusively disease-based model and 12-step treatment. While the article is a powerful polemic and the author is clearly an advocate for this disenfranchised group, the article is disappointingly thin in new factual information.
The authors of the chapter on dual diagnosis summarize the epidemiological data showing substance misuse rates of 20–50% in psychiatric-treatment populations and the high incidence of mood disorder among patients in substance misuse treatment, particularly women. The authors note the paucity of good research on assessment and treatment outcomes, although there are a number of useful suggestions on clinical management issues. There was a sense that this subject was too broad to be done justice to in a single chapter and the main contribution is to outline the complexity of the issues under consideration.
The usefulness of this volume for any individual depends on the reader's area of interest. It is not a comprehensive review of current addiction interventions and treatments, and in that sense the book title is somewhat misleading. The exclusively North American orientation limits the book's value internationally, but there are some nuggets in here, particularly in the nicotine dependence contribution.
FOOTNOTES
Edited by F. Elinor McCance-Katz and Thomas R. Kosten. American Psychiatric Press, Washington, DC. 1998, £24.95. ISBN: 0-88048-838-7.
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