Abstract
This is a very timely and refreshing book on the treatment of people with drug problems, written by ‘one of the UK's leading specialists in drug misuse’. The book combines a highly practical approach with scientific rigour, beginning from the position that the drug treatment scene has become so dominated by methadone substitution treatment that other treatment endeavours are being overlooked. Two key areas highlighted as neglected are the use of alternative pharmacotherapies in opioid substitution treatment and treatment for people with drug problems other than opioid dependence, and in both specialist and primary care settings.
The eight main chapters of the book are organized into two main parts, which follow an introduction setting the scene in a wide social context. Emphasis is given to delivering treatment to the maximum number of people with drug problems necessitating the efficient utilization of scarce resources such as inpatient treatment. Part 1, ‘Treatment’, deals firstly with methadone maintenance and then other substitute drugs, including diamorphine, dipipanone, cyclimorphine, morphine, levo-alpha-acetyl-methadol (LAAM), buprenorphine, dihydrocodeine, as well as consideration of amphetamine and benzodiazepine substitution treatment. Highly informative chapters on detoxification and treatment of non-opioid mis-use completes this first part. Part 2 titled ‘Providing clinical services’ deals with a range of topics including community drug services, treatment of drug misuse in primary care, balancing security with accessiblity, and coexisting psychiatric disorders in drug misusers. A future directions epilogue briefly documents a pot-pourri of relevant issues. The book is very well referenced and indexed and each chapter ends with an excellent summary. There are numerous highly informative tables throughout and several appendices offering treatment protocols and helpful clinical information.
In reading this book, we are challenged to consider the potential limitations of methadone treatment, while the undoubted great value of methadone as an intervention is emphasized. For instance, the author suggests there has not been the same rigorous testing of contemporary ‘low-threshold’, high access methadone treatment initiated by the HIV epidemic, as occurred in early times of methadone treatment, which involved higher doses and more stringent monitoring.
The use of diamorphine is suggested as being appropriately reserved for committed long-term injectors for whom other treatments have been unsuccessful and who are not likely to be engaged into other alternatives, for example injectable methadone. These suggestions, along with the practical discussion of alternative opioid pharmacotherapies, certainly highlight the straitjacket nature of opioid substitution treatment in this country, although would not be as relevant in Australia where cutting edge research and clinical practice in the area of alternative opioid pharmacotherapies have been occurring for a number of years.
I really liked the various references to the importance of expert drug counselling as the fundamental basis of working with drug-dependent people. Although exciting new treatments are likely to occur in the future, therapeutic relationships with drug misusers will continue to be crucial in the delivery of treatment. I also really liked the discussion about risks. We are reminded that there is always going to be a high degree of risk involved in the treatment of drug misusers. This risk needs to be recognized by not only the front-line clinicians, but also employers and legal advisors, to prevent restrictive practice undermining significant benefits of treatment, which at times may be suboptimal.
Who should read this book? It is clearly a must-read for all dedicated alcohol and drug clinicians and is now on the recommended reading list for our national, multidisciplinary postgraduate papers here in New Zealand. However, I would particularly recommend it to all psychiatrists and psychiatric trainees. Drug misuse continues to be a seriously neglected area of contemporary psychiatry in Australasia by our profession. Here is an easy-to-read, practically written, evidence-based book authored by an esteemed colleague, which will certainly help fill some of the gaps in knowledge. It is also likely to inspire us all to take a more appropriately leading role in the treatment of people with these disorders in this part of the world.