Basic and Clinical Science of Opioid Addiction. Bibliotheca Psychiatrica No. 170

© 2003 Society for the Study of Addiction to Alcohol and Other Drugs

Addiction,

98

, 1637–1640

Blackwell Science, Ltd

Oxford, UK

ADDAddiction

1360-0443© 2003 Society for the Study of Addiction to Alcohol and Other Drugs

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Book Review

Book ReviewsBook Reviews

Book Reviews

Compiled by Susan Savva & Griffith Edwards

Treatment Matching in Alcoholism (an International Research Monograph in Addictions)

THOMAS F. BABOR & FRANCES K. DEL BOCA,

eds

Cambridge, UK, Cambridge University Press, 2003,275 pp.,

€

55, $75, ISBN 0521 65112 3

‘Less is more’ is a maxim that applies to many areas of life,including, it would seem, reporting results from a large-scale, complex research project. Project MATCH, fundedby the US National Institute on Alcohol Abuse and Alco-holism to study matching clients to alcohol treatments,was such a project. It had two separate arms (Outpatientand Aftercare), three treatment conditions [Twelve-StepFacilitation (TSF), Cognitive-Behavioral Treatment (CBT)and Motivational Enhancement Therapy (MET)] providedby 80 therapists, 10 primary matching variables, 10 sec-ondary matching variables, an additional potential(exploratory) matching variables, two primary outcomes[percentage days abstinent (PDA) and drinks per drinkingday (DDD)], several secondary outcomes, including acomposite outcome index, extensive baseline assessmentand repeated assessments during a 3-month treatmentperiod and a 1-year follow-up period, and, for the Outpa-tient arm, an additional assessment at a 3-year follow-uppoint. In addition to testing the main effects of the treat-ment conditions, the main (prognostic) effects of thematching and other client variables, therapist effects, siteeffects and the interactions of treatment and matchingvariables, the Project MATCH Research Group alsoprobed the causal chains presumed to underlie hypothe-sized matching effects. Prior to the publication of

Treat-ment Matching in Alcoholism

, more than 125 articles,chapters and monographs had been published to conveythe structure, methods and findings of this complexproject.

Treatment Matching in Alcoholism

describes theproject and its results in a concise, clear form and there-fore will be a very valuable reference work for alcoholtreatment researchers and providers who have somefamiliarity with the project, and an excellent source fromwhich to learn about the project for interested individualswho have not followed its progress over the past decade.

Consisting of 13 chapters written by different mem-bers of the Project MATCH Research Group and consult-ants, the book is divided into three parts: Part I describesthe background and design of the study; Part II presentsresults, including findings on the effects of therapists, thetherapeutic alliance, and participation in Alcoholics

Anonymous; and Part III provides conclusions and impli-cations. Chapters 7 and 8 convey results on the maineffects of treatment conditions and matching variables,and their interactions over time in relation to the two pri-mary drinking outcomes indices (PDA and DDD). In botharms, no significant main effects for treatment conditionswere found on PDA and DDD. As noted in the volume,these findings are important in two respects: first, theyindicate that a 12-Step-based treatment can achieve thesame outcomes as CBT (see also Ouimette

et al

. 1997;Morgenstern

et al

. 2001). In previous reviews of alcoholtreatment research findings, CBT was cited frequently ashaving empirical support, whereas no support was avail-able for 12-Step-based treatment. Secondly, the findingsindicate that MET, a less intensive treatment, whenspread out over a 12-week period, can achieve similaroutcomes to once-a-week treatments (TSF and CBT) pro-vided over the same period. Whether similar effects forMET would obtain among clients not undergoing 6–8hours of baseline assessment and not followed-up every 3months in the year after treatment ended remains to bedetermined. Intensity of assessment is cited as perhapsmasking matching effects; it also may have masked treat-ment intensity main effects.

Regarding findings on patient–treatment interactioneffects, the authors struck what I thought was an appro-priate balance between acknowledging the modest sup-port for matching overall (four of 21 primary/secondarymatching variables received some support—anger, socialsupport for drinking, severity of alcohol dependence, andpsychiatric severity) and considering the clinical implica-tions of the findings that achieved statistical significance.Enthusiasm for the clinical implications of the significantthe interaction effects was tempered, however, by recog-nition that ‘there is no clear way to determine a propermatch when the multiple matching criteria yield conflict-ing treatment assignments’ (p. 223).

A site by treatment interaction was found in the Out-patient arm, indicating variation in treatment maineffects across sites. Indeed, ‘each of the three treatmentshad at least one site at which it did better than the othertwo, and at least one site at which its outcomes comparedunfavorably with the others’ (pp. 217–218). Such varia-tion in treatment main effects across sites rigorously fol-lowing a common protocol must give pause to anyonewho desires to synthesize the relative effects of the ‘same’treatment approaches as implemented and evaluated in

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varied ways across multiple single-site studies. The dis-cussion of the variation in treatment main effects acrossout-patient sites is just one way in which the volumeadmirably achieves one of its goals: to convey what waslearned in Project MATCH ‘about the limits of clinical sci-ence’ (p. xv), Overall,

Treatment Matching in Alcoholism

isa well-written, highly accessible record of the conduct of,and findings from, a landmark alcohol treatmentresearch project. The volume provides thoughtful, tem-pered consideration of the implications of ProjectMATCH’s findings for clinical practice and research. Asnoted in the volume’s final sentence: ‘If the findingsreported in this volume give an unexpected and notalways flattering answer to the matching question, so arethey likely to establish new insights, new standards, andnew questions to pursue’ (p. 237).

JOHN W. FINNEY

HSR&D Centre for Health EvaluationMenlo ParkCaliforniaUSA

DECLARATION OF INTEREST

Although the author was not involved directly in the con-duct of Project MATCH, he was asked by the US NationalInstitute on Alcohol Abuse and Alcoholism (NIAAA) toreview a draft Request for Applications for ProjectMATCH, he was a member of the NIAAA review commit-tee that evaluated Project MATCH applications and hewas a member of the Project MATCH Data and SafetyMonitoring Board.

REFERENCES

Morgenstern, J., Blanchard, K., Morgan, T. J., Labouvie, E. &Hayaki, J. (2001) Testing the effectiveness of cognitive behav-ioral treatment for substance abuse in a community setting:within treatment and posttreatment findings.

Journal of Con-sulting and Clinical Psychology

,

69

, 1007–1017.Ouimette, P. C., Finney, J. W. & Moos, R. H. (1997) Twelve step

and cognitive-behavioral treatment for substance abuse: acomparison of treatment effectiveness.

Journal of Consultingand Clinical Psychology

,

65

, 230–240.

98

11

Book Review


Basic and Clinical Science of Opioid Addiction. Bibliotheca Psychiatrica No. 170

MARCUS F. KUNTZE, F. MÜLLER-SPAHN, DIETERLADEWIG & ALEX H. BULLINGER, edsBasel, Karger, 2003, 71 pp., SwF88;

€

63, $76.50, ISBN3 8055 7504 1

This volume, from S. Karger AG Basel, Switzerland,sprang from symposia of the same name held in 1998and 2001 at the Psychiatric University Clinic of Basel,well known for scientific meetings regarding ‘opioid-assisted treatment’. The overall aim of this booklet, weare told, is to ‘shed some light on opiate-assisted treat-ment’ and this is achieved under different section head-ings. The first, ‘Treatment and Research’, details from avery Swiss perspective the availability of oral methadone,diacetyl morphine and buprenorphine on a supervisedbasis.

Opiate-assisted treatment paid for by health insuranceis offered based on the WHO framework for the classifica-tion of substance use disorders (ICD-10 F1). Programmesseem incredibly well structured, with mini-drug-czars(‘Kantonsarzt’) conducting annual treatment surveys.There is a ‘spontaneous notification system’ regardingundesired incidents during treatment, which has identi-fied anaphylaxis as occurring in 14/1000 cases; interest-ingly, the same rate as adverse events with respiratorydepression.

The Swiss have a well-documented heroin prescrip-tion treatment programme, which serves 4% of the esti-mated 30 000 opiate addicts in Switzerland. They have astructured system for evaluation called ‘PROVE 94–96’.This section of the booklet also houses two researchreports, a prospective follow-up study of the Geneva her-oin programme and a review of opiate detoxification by aDutch group from the University of Essen.

The second section focuses on methodology andcontains a theoretical piece covering general therapeu-tic strategies. There is a useful critique of the ‘Random-ized Controlled Clinical Trial’ for opioid-assistedtreatments which would make good reading for theaspiring addiction researcher. Similarly, p. 37 has a tre-mendously useful short section entitled ‘Indicators ofeffectiveness’.

A fascinating section on neuroscience follows and arefreshingly honest review of ‘Brain imaging in opiateaddiction’ by a German group (Heinz, Smolka & Mann).This article neatly covers the major techniques but ownsup to the fact that the ‘current database is not withoutcontradictions’. The considerable variance in individualresponses to psychoactive substances being noted as amajor problem.

I enjoyed the description of the neurological sequelaeof substance misuse by Stohler which were listed as sixdiscrete entities and wonder whether the knowledge thathypercapnia and hypoxia are significant risk factors forsuch sequelae should be advertised more widely or thatspongiform leukoencephalopathy is particularly associ-ated with chasing-the-dragon.

Finally, the inclusion of the case by the psychothera-pist Nicola was a mystery. Not that it was not interesting;

Book Reviews

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it was—but the point of its inclusion in this ratherscientific-research led booklet was lost on me.

In summary, a good book with interesting materialand a useful resource for policy makers and practitionersalike.

KIM WOLF F

National Addiction CentreLondonUK

[email protected]

98

11

Book Reviews


Reefer Madness: Sex, Drugs, and Cheap Labor in the American Black Market

ERIC SCHLOSSERBoston, Houghton Mifflin, 2003, 320 pp; $23 cloth,ISBN 0 618 33466 1

Despite moments of compelling reportage,

Reefer Madness

is an uneven book, one that never quite reconciles twodifferent objectives. Schlosser’s first aim is descriptive, toexamine the underside of the American economy. Whathe finds there is predictably unflattering: a nation of hyp-ocrites who indulge pot, porn and cheap fruit, the lattercourtesy of illegal immigrant labor. His second aim isevaluative, to judge attempts to suppress or regulate theseactivities. Are we better off when the government inter-venes in the working of the market?

Schlosser thinks those who exploit illegal labor shouldbe prosecuted. He concedes that marijuana can be harm-ful for teenagers who experience enough social and emo-tional confusion without the added handicap ofconstantly being stoned, but he finds the criminal justiceresponse grotesquely disproportionate to the marijuanaproblem. Statutory changes since the 1980s have meantlengthy, sometimes life-long sentences for marijuana traf-fickers, notably those with prior convictions who refuse toname other offenders. (Professional informers will evensell incriminating information to defendants so they canreduce their sentences by cooperating with prosecutors.)Evoking Bentham’s dictum that excessive punishment isjust so much misery run to waste, Schlosser calls fordecriminalization of personal marijuana possession andreform of sentencing and forfeiture laws as they apply tothose caught with large amounts. What constitutes alarge amount, or what to do about harder drugs, he doesnot say.

Schlosser makes some telling points. Suppression hasnot made much of a dent in marijuana use. Cannabis hasbecome a huge cash crop in the American heartland,while other cultivators have taken advantage of grow-lights and hydroponics to expand indoor production. Themarijuana crusade is as much about politics as publichealth. Schlosser is on the mark in his criticism of the

Clinton administration, which acquiesced to the contin-uation of the Drug War while curtailing federal obscenityprosecutions. Tolerating pornography entailed fewerpolitical risks than marijuana smoking by the young.

A logician would fault Schlosser for relying on

ad hor-rendum

stories and failing to consider what offsetting ben-efits, intended and unintended, marijuana laws may haveproduced. Legal pressure can compel compulsive users toenter treatment. Pressure on drug-trafficking suspectscan lead to breaks in other criminal investigations. UScrime rates have declined since the early 1990s, partlybecause incarcerated drug traffickers could not commitstreet crimes. Historically, the ranks of drug traffickersand pornographers have included some dangerous socio-paths. Suppose that assassin James Earl Ray, who dabbledin both occupations, had been jailed on a smuggling orobscenity conviction in early 1968. Martin Luther KingJr might still be alive. Selective example? Certainly. Emo-tionally manipulative? Of course. But so is Schlosser’sunbroken parade of harmless-guys-doing-hard-time.His conclusion—rationalize the marijuana laws-—issounder than his one-sided case. Anyone making a con-sequentialist argument should consider all the conse-quences, not just those that appeal to readers’ sense offairness.

DAVID COUR TWRIGHT

University of North FloridaUSA

[email protected]

98

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Original Article


Cross-National Drug Policy (Annals of the American Academy of Political and Social Science, Vol. 582, July 2002)

ROBERT MACCOUN & PETER REUTER, edsThousand Oaks, CA, USA, Sage Publications, 230 pp.,$32, ISBN 07619 2744 1; ISSN 0002 7162

Drug policies vary sharply from country to country, evenbetween countries otherwise seemingly quite similar, andsometimes a given country will abruptly change direc-tions; nor are the policies easily arrayed along a one-dimensional soft-to-tough spectrum.

Those observations suggest a political-science puzzle:what explains the variations in drug policies across coun-tries and over time? International and intertemporal vari-ations also offer a tantalizing research strategy formeasuring the impacts of drug policy on the drug prob-lem, where ‘drug problem’ means not only the extent ofdrug abuse but also the damage drug abuse does to thosewho abuse drugs and, through them, to others, and thedamage done by the control policies themselves.

As MacCoun & Reuter note in their preface, four bar-riers stand between us and being able, for example, to

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learn from Dutch experience what the impact would be ifsome other country carried out a semiformal legalizationof the sale of retail quantities of cannabis.

First, the data are scarce so many of the results ofinterest have never been measured, in the Netherlands orelsewhere. Secondly, the data of are poor quality, so evenmeasured outcomes may be measured with so muchnoise as to drown out any signal. Thirdly, any causalinferences are shaky, because observing the coexistenceof a given policy and a given condition is no assurancethat the condition resulted from the policy rather thanfrom some other factor. Fourthly, generalizations are dan-gerous, because even if we knew how Dutch policies hadinfluenced Dutch cannabis use rates we would have noassurance that similar policies in the United Kingdom orthe United States would have comparable effects on userates in those countries, given their very different socialsettings. (I would add a fifth factor: if the discussionrestricts itself to illicit drugs, rather than consideringalcohol as well, it ignores about four-fifths of the total vol-ume of intoxication and of problem intoxicant use. Acountry with a relatively small amount of ‘drug’ use anda relatively large alcohol problem has been less successfulin dealing with its intoxicant problem than a countrywhere the reverse is true, but a focus on ‘drugs’ wouldonly conceal that fact.)

Nevertheless, the temptation to reason by analogy isvirtually impossible to resist. After all, what else is thereto substitute for the raw assertion that makes up so muchof the drug policy debate in virtually every country?

Cross-National Drug Policy

stands as a kind of compan-ion volume to

Drug War Heresies,

MacCoun & Reuter’smasterful essay on comparative drug policy (MacCoun &Reuter 2001). The current volume provides tantalizing

hints of answers to both analytical questions, as well as awealth of material about the actual processes and detailsof drug policy in France, Portugal, Sweden, Denmark,Canada, Australia, Colombia, Jamaica, Mexico, Iran andRussia. Reading it will reward not only those concernedwith drug policy specifically, but those who want to knowabout an important but ill-studied aspect of social policyand social conditions in the countries involved. The qual-ity of the essays is higher and less uneven than that of theaverage journal special issue or edited volume, but theskill of the chapter authors cannot overcome fully thesheer difficulty of establishing what is going on and why.

For example, having read the essay by Leif Lenke &Boerje Olsson, the reader will be able to formulate moreprecisely the question of whether Sweden’s success inachieving both lower rates of illicit drug use and lowerdrug-related imprisonment than Switzerland means thatits notoriously inflexible and punitive policies have suc-ceeded, or rather that only a country without much of adrug problem can maintain such policies; but, alas, for-mulating such questions precisely is one thing, answer-ing them convincingly quite another.

MARK KLEIMAN

School of Public Policy and Social ResearchUniversity College of Los AngelesCaliforniaUSA

REFERENCE

MacCoun, R. J. & Reuter, P. (2001)

Drug War Heresies

. Cam-bridge: Cambridge University Press.

Documents

Basic and Clinical Science of Opioid Addiction. Bibliotheca Psychiatrica No. 170