Book Review

Drug Addiction and Its Treatment: Nexus of neuroscience and behavior

N Engl J Med 1997; 337:1094-1095October 9, 1997

Article

Drug Addiction and Its Treatment: Nexus of neuroscience and behavior
Edited by Bankole A. Johnson and John D. Roache. 448 pp., illustrated. Philadelphia, Lippincott–Raven, 1997. $125. ISBN: 0-397-51764-5

The impetus for this book grew out of the editors' concern that the behavioral and neuroscience disciplines have developed independently of one another; in research on drug abuse, therefore, a mutual understanding of each other's technology was in order. Johnson and Roache propose that the nexus of neuroscience and behavior is on the cutting edge of current technology and that clinicians familiar with the fundamentals of these disciplines will be better prepared to “integrate pharmacological, behavioral, and social work technologies into a comprehensive treatment plan.”

The book has four sections, entitled “Behavioral Processes,” “Neurobiological Processes,” “New Horizons in Neuroscience,” and “Treatment Application.”

The first section, on behavioral processes, relies heavily on behavioral analysis in animals and humans concerning drugs as reinforcers, drug-dosing limits, and contingency relationships. The authors address difficult concepts such as craving, relapse, interoceptive stimuli, tolerance, and sensitization from the perspective of behavioral science.

The second section highlights a valuable feature of the book: consideration of the neurobiologic mechanisms involved in several drugs of abuse. This overview provides an integrated perspective, whereas most chapters in other books focus on a single drug category such as psychostimulants or alcohol. The chapter on the neurobiologic basis of drug reinforcement includes an up-to-date discussion of various techniques of assessing reinforcement, mechanisms such as self-administration, and the use of in vivo microdialysis and voltammetry. Drug-abuse-induced tolerance and dependence are well characterized, in terms of the interplay of the two phenomena and the ability to separate them. The contribution of genetics to susceptibility to drug abuse and the effects of drugs on development are well covered.

In the third section, “New Horizons in Neuroscience,” there is a lucid chapter about exciting developments in our understanding of gene expression after drug administration. There is insightful discussion of the sequence of events in early gene expression, including the accumulation of fos-related antigen after long-term drug administration, and of the ability of molecular procedures to disable genes or their transcripts to elucidate biologic mechanisms. There are two solid chapters on imaging and electroencephalographic mapping in humans and animals, but one could have hoped for a more extensive discussion of magnetic resonance imaging, positron-emission tomography, and functional magnetic resonance imaging studies, especially those related to craving and damage to the central nervous system.

In the fourth section, “Treatment Application,” the chapter on clinical efficacy of pharmacotherapy carefully describes and distinguishes between acute withdrawal and maintenance pharmacotherapies, a distinction that is often lost in reviews. Indeed, drugs that may work well during the first two weeks of withdrawal may actually provoke recidivism during the relapse-prevention phase. The therapeutic efficacy as well as the dosing problems and side effects of an extensive list of drugs are critically reviewed. In another chapter, the concepts involved in treating alcoholism (e.g., aversive treatments and treatment of depression) and the various drugs that have proved useful are covered in reasonable detail.

Finally, the chapter on integrated behavioral and pharmacologic treatments illustrates how the “complete clinician” uses behavioral techniques to increase compliance with medication and how medications can help reduce dropout rates long enough to engage the patient in behavioral treatment. The chapter delineates both behavioral strategies and pharmacologic strategies for altering drug-use antecedents, increasing alternative responses, and altering the consequences of drug use. The section on treatment, although quite short given the title of the book, provides an excellent overview for the clinician who is either involved in treatment or refers patients to treatment programs.

To some extent, the integrative nature of most of the chapters belies one of the premises of the book: that the behavioral disciplines and neuroscience disciplines had developed independently for the most part and that each could benefit from understanding the other's technology. This refrain appears throughout the book; for example, “Most standard pharmacology texts give scant, if any, consideration to the importance of conditioning.” This is certainly not the case for major pharmacology textbooks such as Goodman and Gilman's (Essentials of Pharmacology. New York: McGraw-Hill, 1995). In summary, the book is an excellent review for both basic and clinical researchers in the field of drug abuse and its treatment. It provides a perspective on the integrative neurobiologic and behavioral aspects of much of the research on drug abuse.

Everett H. Ellinwood, Jr., M.D.
Duke University Medical Center, Durham, NC 27710