Reviewed by Darlene H. Moak, MD
The goal of this well-intentioned and mostly well-written, small book is to present an "integrated pharmacopsychosocial approach to treatment" of substance addictions and behavioral addictions, such as pathological gambling, eating disorders, and compulsive sexuality. A unified framework for the treatment of addictive disorders has great clinical appeal, given that most people seeking treatment will have multiple addictions as well as co-occurring psychiatric symptoms and disorders. The authors offer valuable advice on principles that increase the likelihood of successful treatment, such as "Less is more--simplification of pharmacotherapy" and "Importance of accurate diagnosis as the basis for treatment." They also correctly emphasize that addiction is a chronic disorder requiring a long-term approach to treatment.
Unfortunately, this book suffers as a result of its ambitious focus. Although it is intended for health professionals--that is, psychiatrists, other physicians, and therapists--the information offered is, for the most part, very basic and seems more appropriate for a lay audience. Chapters on substances are very short: "Marijuana and Tobacco" devotes only 3 paragraphs to nicotine(Drug information on nicotine). Discussion of pharmacological treatment is limited to "tried and true" standards; newer treatments for which evidence has been published are neglected. Examples are anticonvulsants (carbamazepine [Carbatrol, Tegretol], valproate(Drug information on valproate) [Depakene, Depakote], and gabapentin(Drug information on gabapentin) [Gabarone, Neurontin]) for alcohol and benzodiazepine detoxification and maintenance treatment, the possible role of modafinil(Drug information on modafinil) (Provigil) and topiramate(Drug information on topiramate) (Topamax) in the treatment of cocaine dependence, and naltrexone(Drug information on naltrexone) (Depade, ReVia) and antidepressants for the treatment of pathological gambling.
There are also more than a few inaccurate and unsubstantiated statements. For example, in the chapter on alcohol(Drug information on alcohol), the reader is told, "about 95% of alcoholics eventually die from complications resulting from the disease." Without a reference, it is impossible to know which alcohol abusers have this dire prognosis (ie, anyone who has ever abused alcohol, alcoholics who continue to drink until the end of their lives, or alcoholics with severe medical consequences). In fact, it has been shown that nicotine dependence causes more mortality among persons who are alcohol dependent than does alcohol itself. Elsewhere the authors state, "when addiction is the secondary problem and another disorder is the primary problem . . . treatment for the underlying condition must come first." An example is given of a woman with depression who uses heroin to feel better. While treating depression in this person is essential, it is unlikely that this treatment could succeed in the setting of active heroin abuse.
I wanted to like this book. As both a researcher and clinician, I would welcome a short, well-written text that would help clinicians understand the common neurobiological bases for addictive disorders and how to deliver better treatment to patients who often present with multiple conditions. Unfortunately, this is not the book. For now, I would advise colleagues to rely on slightly older books such as that by Marc Schuckit (Drug and Alcohol Abuse: A Clinical Guide to Diagnosis and Treatment, Springer, 2005) and peer-reviewed journal articles for newer information on pharmacological and psychosocial treatments for these common disorders.
Dr Moak is an addiction psychiatrist in private practice in Charleston, SC, and is adjunct clinical assistant professor in the department of psychiatry, Medical University of South Carolina, Charleston. *
