Book Review

Pathways of Addiction: Opportunities in drug abuse research

N Engl J Med 1997; 337:646-647August 28, 1997

Article

Pathways of Addiction: Opportunities in drug abuse research
By the Committee on Opportunities in Drug Abuse Research. 310 pp. Washington, D.C., National Academy Press, 1996. $49.95. ISBN: 0-309-05533-4

The contributors to this book present a thoughtful and scholarly evaluation of biomedical and psychosocial factors of major importance in the process of addiction. Comprehensive yet succinct reviews of recent advances in behavioral research and research in the areas of neuroscience, epidemiology, etiology, prevention, and consequences persuasively illustrate current achievements and prospects for future discoveries. The book concludes with a perceptive review and critique of managed care and drug-control procedures that influence approaches to the prevention and treatment of drug dependence.

Most physicians will find this book valuable in understanding drug abuse and dependence. The process of addiction has many behavioral and psychosocial antecedents and consequences, but the perception of addiction as an illness that can be treated effectively is of paramount importance for medical practice. Research on the clinical pharmacology of opioids, carried out within the context of drug-abuse research, has provided new and important data on pain management, a matter of substantial concern in medicine. The editors note:

The investigation of the potency, metabolism, analgesic effects, and side effects of opioid drugs has been a major research target of the drug abuse field since its inception. The National Institute on Drug Abuse (NIDA)-supported research has revealed the range of plasma opioid concentrations required for effective pain relief. Based on this research, clinicians have developed new methods of drug administration that maintain optimal levels of analgesic, including sustained-release tablets, transdermal patches, continuous drug infusions, and patient-controlled analgesic pumps. Those methods have now made it possible to keep more than 90% of cancer patients relatively comfortable for their entire course.

These advances flow from the discovery of the opiate receptor and of receptors for subtypes of opiates (mu, kappa, delta) and will facilitate the development of the next generation of useful analgesics.

Another example is naltrexone, originally developed for the treatment of opiate abuse and dependence. Recently, naltrexone has been found to be safe and effective for the treatment of alcohol abuse and dependence, and the Food and Drug Administration has approved it for this purpose. The discovery that endogenous opioid systems are involved in both opiate and alcohol dependence has stimulated the search for new medications for the treatment of cocaine abuse and dependence. The discovery of promising new drugs in this area has encompassed the evaluation of endogenous opioid systems in the brain, the activation of the nervous system by antibodies, and the use of glycoprotein hormones in blood that may bind cocaine and prevent transport of the drug across the blood–brain barrier.

The book concludes with a sensitive and perceptive evaluation of the role of managed care in the treatment of addiction. A pivotal issue relates to patients' freedom to choose their physicians and health care services. The concern about managed care and addiction emphasizes that “treatment outcomes are still unknown due to the current lack of research on the effectiveness and cost-effectiveness of managed care treatment.” Physicians will find in this book a comprehensive presentation of research that has transformed the perception of addiction from deviancy to preventable disease. Enhanced research will not only provide more humane treatment of the afflicted, but also contribute to improved medical practice generally.

Jack H. Mendelson, M.D.
Harvard Medical School, Boston, MA 02115