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Reviews, Notes, and Listings: Practical Guide for the Treatment of Substance Abuse

Practical Guide for the Treatment of Substance Abuse Michael F. Fleming and Kristen Lawton Barry; eds. 439 pages. St. Louis: Mosby-Year Book; 1992. $39.95. Chemical dependency has emerged as a growing concern for primary health care providers; however, few reference sources exist to meet practitioners' needs. This multiauthor text aims to serve primary care clinicians who care for patients with addictive disorders. Here, addictions are defined broadly to include dependency on illicit drugs, alcohol, tobacco, and gambling, as well as eating disorders. Special populations such as women, adolescents, athletes, the elderly, the disabled, and the mentally ill are also addressed in separate chapters. The chapters are brief but comprehensive, and the text is organized in a readable outline format. The many case examples throughout the book effectively emphasize important clinical points in the text. Also useful is an appended list of street names for substances. The text is generally well presented to meet the needs of clinicians. Some unevenness is inevitable in a multiauthor text that deals with the relatively young science of addictive disorders. The chapter on pharmacologic management of drug dependence recommends a low methadone maintenance dose during pregnancy ( 30 mg/d) to minimize the severity of neonatal withdrawal. A later chapter on perinatal management presents both high- and low-dose alternatives. Because continued uncontrolled drug use and its sequelae are associated with low-dose methadone maintenance in pregnancy and because neonatal methadone withdrawal is quite manageable, high-dose therapy in pregnancy deserves more consideration. The chapter on drug testing fails to discuss the risks of testing to patients. Women or newborns tested in the perinatal period may risk postpartum social sanctions, including lengthy separations. Clinical drug testing programs with criminal or civil penalties attendant to positive test results may drive people away from medical care. Benefits of testing must be balanced with risks, particularly in the highly charged area of illicit substance use. This chapter also includes a disturbing endorsement of adolescent drug screening without the patient's knowledge, providing that parents consent. Such a policy is contrary to sound clinical practice and ethical consent guidelines. Despite these limitations, this book offers useful reviews of the clinical management of addictive disorders in primary care and would be a helpful addition to the library of any primary health care provider.