Alcohol and Alcoholism Vol. 35, No. 4, pp. 412, 2000
© 2000 Medical Council on Alcoholism
Book Reviews
Community Treatment of Drug Misuse: More Than Methadone.
Drug misuse is a more fashionable topic for concern than alcohol misuse. Yet the two conditions are intertwined in theory and practice. The conceptual interchanges rest in their causative reliance on similar psychological, social and partly identical neurochemical processes. In practice, the two disorders can occur in the same persons, simultaneously or successively, while their therapy is at times undertaken by a single agency and increasingly relies on identical psychological methods.
Treatment of drug misusers remains centred on opiate-dependent subjects and on the provision of oral methadone in courses of varying length. Methadone is the single most effective means in the armamentarium of drug dependence treatment, but few of its recipients wish to endure a life-long course of the drug. Dr Seivewright describes the various lengths of treatment with methadone and their respective indications, while recounting the differences between nations in currently favoured practices.
The text makes clear that the simple provision of methadone is unacceptable, as has occurred in the UK where the drug is often prescribed without the requisite degree of counselling and urine testing. Furthermore, in the UK, the preparation has been customarily dispensed and taken away by the subject without observation of its ingestion. The loose arrangements arouse misgivings because methadone obtained legally but sold illegally produces unacceptably high numbers of overdose deaths. This has led in the UK to recent government-sponsored recommendations on tighter prescribing, with the advice that methadone must initially be consumed under surveillance. Unfortunately the present book was completed too early to include these points, though unlike the official guidelines the volume notes that alcohol frequently contributes to fatal drug overdoses.
Drugs of misuse other than opiates lack a substitute preparation comparable to methadone. Therapy relies mainly on psychological measures which closely resemble those employed for problem drinking and indeed, as with relapse prevention and motivational enhancement, have been acquired from the field of alcohol treatment.
Hepatologists may know that hepatitis C has replaced HIV, at least in the UK, as the most common infective risk from the practice of injecting illegal drugs. Unlike hepatitis B, there is no prophylactic vaccination for the disease. Its prolonged course (which is aggravated by alcohol) leads to cirrhosis and liver carcinoma. Chemotherapy is only mildly effective. Hepatitis C provides another reason for engaging and retaining drug injectors in treatment.
Nicholas Seivewright explains that drug dependence is usually accompanied by tobacco dependence and that the latter is generally ignored by therapists. He pleads for a more-extensive treatment of tobacco dependence in attenders at the drug misuse services. The reader might well share the same hope for alcohol services. Would alcohol patients gain greater life expectancy if they stopped smoking rather than drinking?
Since alcohol misuse replaces, rather than accompanies, drug misuse, it is desirable to caution newly abstinent drug takers of the risk of interchange with alcohol. It is disappointing that the volume devotes little space to the treatment of problem drinking. In other respects, the text offers a wise account derived from the author's long experience as an academic who is also at the cutting edge of treatment provision.
FOOTNOTES
By Nicholas Seivewright. Cambridge University Press, Cambridge. 2000, 243 pp., £22.95 (paperback). ISBN: 0 521 665620.
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