Book Review

Cocaine

N Engl J Med 1994; 330:723-724March 10, 1994

Article

Cocaine
(Drugs of Abuse: A Comprehensive Series for Clinicians. Vol. 3.) By Mark S. Gold. 238 pp. New York, Plenum, 1993. $39.50. ISBN: 0-306-44386-4

The medical sequelae of cocaine use, including addiction, now challenge health professionals in nearly every major specialty. There is a growing consensus that much can be done in the primary care setting to facilitate public health efforts to reduce the prevalence of cocaine use and to treat those with cocaine-related disorders. Thus, there is a strong need for an authoritative work on the topic. Unfortunately, clinicians may be disappointed if they expect Cocaine to be useful as either a clinical handbook or a bibliographic resource.

This book will provide clinicians and lay audiences with some generally interesting historical and scientific information about cocaine. Gold also gives a strong argument for increasing the involvement of health care professionals in reducing cocaine use and the medical care of the cocaine user.

One of the best chapters is “The Neurobiology of Cocaine.” It is not generally understood that self-administration of cocaine can become chronic, in part because of previous exposure to the drug. This lack of understanding undoubtedly contributes to the belief that cocaine use is a problem of self-control and a lack of awareness of the dangers of its use, as opposed to a behavioral syndrome no less biologically determined than depression or panic. This mini-review convincingly demonstrates that the cellular mechanisms underlying the pathophysiology of cocaine addiction are at least as well understood as the pathophysiologic consequences of cocaine use, such as myocardial infarction.

Cocaine also makes a compelling case that the fundamental strategies for treating cocaine dependence encompass the following triad: diagnosis, accompanied by objective testing of blood samples or other specimens; implementation of structured therapy tailored to the individual patient; and follow-up. The discussion of potential benefits with respect to health care and costs is timely in view of the national debate over services for treating drug addiction.

Other treatment issues are not adequately discussed, however. For example, the chapter on pharmacotherapy might lead clinicians to assume, wrongly, that there are more than a dozen medications that can be appropriately used to treat cocaine abuse. But the rationale for using these medications rests largely on theoretical extensions of findings from basic research, with little support from clinical data. Furthermore, the absence of a discussion of probable contraindications and side effects of pharmacologic agents could lead to misapplications. This chapter might best be considered a summary of medications to watch for in the literature or to evaluate in research, but not a list for use in general clinical practice.

The chapter entitled “Eating Disorders and Substance Abuse” could be more appropriately condensed and presented as an interesting but speculative analysis of the causes of cocaine use. There is simply little information provided that is either substantive or of proved clinical value. Similarly, the final chapter, “Physicians, the Elderly, Adolescents, and Substance Abuse,” is a miscellany of interesting observations with little of substantive importance for the practicing clinician.

In summary, for the clinician with a general interest in the effects of cocaine and the role of the health professional, Cocaine should provide interesting general reading. If it were not presented as part of a “Comprehensive Series for Clinicians,” there would be little to criticize. As part of this series, however, the book shows that this particular gap on the clinician's shelf has yet to be filled.

Jack E. Henningfield, Ph.D.
National Institute on Drug Abuse, Baltimore, MD 21224