Book Review

Textbook of Substance Abuse Treatment

N Engl J Med 1994; 331:1780-1781December 29, 1994

Article

Textbook of Substance Abuse Treatment
Edited by Marc Galanter and Herbert D. Kleber. 475 pp. Washington, D.C., American Psychiatric Press, 1994. $71.55. ISBN: 0-88048-532-9

Physicians caring for patients with substance abuse or dependence have to overcome the obstacle of the underemphasis on addictions in the curriculum at most medical schools. Given the high prevalence and often devastating nature of these syndromes, too little literature of good quality is easily available to the practitioner. The textbook edited by Galanter and Kleber is a solid addition to a relatively small number of textbooks to which the generalist may turn for aid in addressing these difficult, chronic, and multifactorial problems.

This book is a reworking of the substance-abuse and dependence sections of The Treatment of Psychiatric Disorders: Revised for the DSM-III-R (William H. Reid. New York: Brunner/Mazel, 1989). In this new textbook, the work of dozens of authors is organized into three sections. The first is an overview. The second is a series of chapters, each on a different class of substances that have the potential for abuse, which cover detoxification and treatment of the addictions themselves. The final section, which makes up roughly half the book, contains chapters on different treatment methods, such as individual therapy, group therapy, and other approaches, such as therapeutic communities.

The Textbook of Substance Abuse Treatment is full of good and useful information, but it suffers from unevenness and lack of focus; some chapters are appropriate for the generalist, whereas others will be useful only to a psychiatrist specializing in the treatment of addictions. One author, for instance, assumes the reader's practice includes the possibility of weekly appointments for therapy. Nevertheless, most chapters are accessible and useful.

Throughout this book we sense the tension between the urgent need to care for patients (who are often in crisis) and the desire to base care on treatments proved to be effective. For instance, the 12 steps of Alcoholics Anonymous (AA) have become central to many methods of treatment. In a chapter by Galanter, we are told, “The use of AA is desirable whenever possible.” Yet the separate chapter devoted to AA takes a skeptical view, emphasizing how little we actually know about the organization's effectiveness and even warning that it may do more harm than good. Similarly, Galanter exhorts us to prescribe disulfiram “when seeing an alcoholic patient for the first time... as soon as possible.” Yet a chapter on outcomes states that only “fair” evidence supports the use of this drug. Though these tensions may appear to be merely disturbing inconsistencies, they are characteristic of the field, where practice needs rigorous evaluation.

The book has some omissions. There is no chapter on inhalants or anabolic steroids. The chapter on the management of alcohol withdrawal describes and recommends objective scales to rate severity, but none are included in the book. The book does not spell out the 12 steps of AA -- an illustration of its orientation toward specialists.

This book has some outstanding chapters. Those on cocaine, tobacco, opiates, methadone, and alcohol are all informative and clear. The chapter on the prevention of relapse contains important information for any physician treating patients in recovery from active addiction (that is, for all internists). The chapter on psychodynamics is a welcome and exciting introduction for the generalist, illustrating some relations among the abuse of substances and psychological processes. This chapter contains one of the pearls of the book, which is worth repeating here: “We have found that even very damaged, impaired individuals in inner city settings often had a dream in their lives that they have buried. Rekindled dreams can foster renewed hope and self-esteem.” Indeed, in holistically addressing all areas of patients' lives, working toward health, and permitting our patients to rekindle their dreams, we may accomplish some of the most important work of physicians. This textbook is a substantial aid in this task.

Michael Bierer, M.D.
Massachusetts General Hospital, Boston, MA 02114