Health and Pills

Archive for the ‘Reviews & Views’ Category

The Facts about Drug Use

Dr Barry Stimmel, The Haworth Medical Press, 10 Alice St, Binghamton, NT 13904-1580, USA, 1993, 366pp

Family physicians often see patients who misuse drugs. This widespread problem is the source of much hidden morbidity and mortality for patients and much frustration for doctors.

Family doctors are likely to have had little formal training in identifying and intervening in this area. Their attitudes toward problem drug use probably differ little from those held by the public.

This book was written “to enable those with little or no background in science or health care to understand the often complex issues of drug use” and “is presented clearly, concisely, and without jargon.” It presents the facts about drug use with authority.

The book is divided into three parts: basic concepts, mood-altering drugs, and areas of special concern. Information is based on statistics from the United States. The regulations and laws quoted are American. Treatments discussed are based on the American system of privately funded health care.

In part 1 (basic concepts), the chapter titled “Habituation, Dependency and Addiction” is useful for defining terms and distinguishing misuse from abuse and dependency from addiction. This chapter briefly describes the neurophysiological basis for the ability of drugs to produce mood alteration, which can lead to dependency and addiction.

Part 2 discusses each different class of mood-altering drugs and provides lots of factual information. However, the chapter on opiates underemphasizes their importance as drugs of abuse in clinical practice while the chapter on heroin and on methadone maintenance is too long. In the chapter on nicotine, the nicotine patch is referred to only briefly.

In part 3 (areas of special concern), well written, factual chapters cover such topics as drugs and AIDS, drugs and pregnancy, and drugs and sports. The final chapter is one with a decidedly American slant entitled “Why has the War Against Drugs Failed?”

Three appendices covering sources for reporting drug use (American), drug testing technology, and common street names for drugs are followed by almost 400 references. This book is not written for family physicians. It does not develop skills for identifying problems or intervening in this area or even challenge attitudes. However, it would be useful for family doctors interested in the facts on drug use and as an addition to a hospital, school, or public library.

Essentials f Drug Therapy

Gordon E. Johnson, PHD W.B. Sounders Company, 55 Homer Ave, Toronto, ON M8Z 4X6, 1991, 425 pp

Essentials of Drug Therapy is a clearly written book, summarizing information on drugs that are commonly used. It is not a reference text in pharmacology or an exhaustive detailed volume, such as the Compendium of Pharmaceuticals and Specialties, but is a practical source of information for the medical student and practitioner.

The chapters are organized according to therapeutic categories and are introduced by a brief overview of the therapeutic rationale for use of pharmacologie agents. Most drug groups are included, even those used for symptomatic relief, such as antitussives and analgesics. It is somewhat surprising that laxatives are not included, but these have never been an attractive group of drugs for pharmacologists.

The text is clear and succinct. Paragraph headings facilitate rapid access to information, with paragraphs on mechanism of action and pharmacological effects, therapeutic uses, adverse effects, drug interactions, and doses.

The book should be a useful volume for the busy practitioner and the medical student.

Drug-induced hepatotoxicity

Ed by RG Cameron, G Feuer, FA de la Iglesia, 681 pp, ISBN 3 540 60201 1, Berlin: Springer Verlag 1996

The editors of this splendid volume have invited an international array of contributors to cover its 26 chapters on all aspects of hepatotoxicity due to drugs — adverse effects that mimic acute fulminant hepatitis, chronic active hepatitis, cirrhosis and even malignancy. Turn to one of these chapters for an update on molecular aspects of hepatic drug reactions, in vitro models, cytochrome P450, drug-induced cholestasis, choline deficiency, the fatty liver, immune mechanisms, encephalopathy, pregnancy, Reye syndrome, or hepatotoxicity in infants and the elderly; and, of course, for separate information on each individual drug, including one of the most important, alcohol.

This new Canadian text naturally invites comparison with an Australian text, Drug-induced Liver Disease, edited by GC Farrell (Churchill Livingstone), published in 1994. They are both very good and equally helpful when asked to solve a laboratory or clinical problem. Australian Ian Mackay contributes the immune mechanisms of drug hepatotoxicity in both books. To his credit they are in many respects different. In the earlier book he mentions the Th1 and Th2 subclasses of CD4 helper T cells. In the new Canadian book he advances his thoughts and forecasts that tipping towards Th1 or Th2 subsets influences the mode of expression of allergies and autoimmune diseases.

Both books will undoubtedly achieve new editions, so that each will leapfrog the other effectively in different segments of the Commonwealth in the long-term future. It is true to say that clinicians and pathologists have combined admirably to cover the whole gamut of adverse reactions in a single volume which is authoritative, academic and readable.

Complete Guide To Women's Health

Author: American Medical Association
Random House of Canada, Ltd, 1265 Aerowood Dr, Mississauga, ON L4W1B9
1996/759 pp

Good starter guide to women’s health

Strengths

Well formatted, easy to read, practical approaches to common problems, focus on wellness and preventive health

Audience

General public

This comprehensive reference volume for women contains common-sense approaches to a number of important health issues. Its target audience is middle-class American women with a moderately high level of literacy. The book aims to provide women with up-to-date medical information to guide decision making and to facilitate communication with their physicians.

Its four main sections cover health maintenance, sexual and reproductive health, pregnancy, and the common health concerns of women. It is well laid out with useful summaries, flow charts, sidebars containing helpful hints, questions women often ask, and narrative vignettes that lend a dynamic and personal tone to the main text.

I found the chapters on nutrition, fitness, avoiding risky behaviour, and stress management refreshingly frank and practical. The sections on pregnancy and childbirth are well illustrated and cover many of the issues women enquire about in my own practice. Although there are excellent chapters on family violence, sexual assault, and bereavement, the social context of women’s health is not explored in sufficient depth. The short section on sexual abuse, for example, makes only passing mention of the health consequences that an adult survivor of abuse might experience. In contrast, the 19 pages on elective cosmetic surgery seemed excessive.

The book is written with a specialty focus, emphasizing early referral. Very little is said about family physicians and their potential for providing comprehensive care and building health partnerships with women over time. There are no references or suggestions for further reading for women who wish to pursue controversial or rapidly changing issues, such as prevention guidelines. It is also unclear how consultants evaluated the evidence behind their recommendations. I found it surprising, for example, to see episiotomy presented as a procedure to prevent excessive tears during childbirth when there is evidence in the literature to the contrary.

The overall strength of this publication is its range, its detail, and its attention to the prevention of illness, making it a good starting place for many women to access health information and to consider dialogue with their physicians. In this regard, it fulfils the authors’ objectives. Because of its expense and likelihood of dating quickly, I would recommend it as a resource volume for a public library or community health clinic.

Atlas Of Clinical Diagnosis

M. Afzal Mir
W.B. Saunders Company, 55 Horner Ave, Toronto, ON M8Z 4X6
1995/266 pp

Strengths

Practical, excellent illustrations

Audience

Medical students and practitioners

This book aims to provide medical students and practitioners with a comprehensive survey of clinical signs organized by external body parts. The underlying assumption is that most diagnoses from clinical signs are based on pattern recognition, so the book is a rich collection of colour illustrations of common, rare, and esoteric conditions. Using arrows to highlight the more subtle signs would help readers, like me, who need more guidance.

The organization of the book is excellent with a logical approach to each external body part; for example, the chapter on the external eye deals with eyelids and orbit and the conjunctiva. Some interesting clinical tips include listening to a patient’s breathing by putting the stethoscope bell in front of the patient’s mouth.

The focus at times is esoteric with eight pages on various porphyrias, something I was taught in great detail in medical school and have yet to see in practice. Useful diagrams for such conditions as acromegaly or Cushing’s disease illustrate that clinical signs from each anatomical area are only part of the overall picture. Suggestions for further investigation of these major conditions are given but are brief and superficial. Common conditions seen in family practice, such as viral exanthemas, otitis media, and pharyngitis, are given less coverage, and there is a paucity of penile or vulval lesions.

The book is a good reference for unusual conditions and has excellent chapters on fundi, nail disorders, and hands. But the high price of the book could limit how widely it is used.

Antioxidants in Nutrition, Health, and Disease

John M.C. Gutteridge, Barry Halliwell
Oxford University Press, 70 Wynford Dr, Don Mills, ON M3C 1J9
1994/143 pp

Strengths

Summarizes current thought on free radicals and antioxidants. A clear, pithy, scientific, informative text

Audience

Physicians, medical students, nurses, biologists, nutritionists, and chemists

The authors have written a short textbook introducing antioxidants to clinical practice. They also refresh readers with a review of the basic clinical sciences.

A short, informative preface asks succinct questions on using antioxidants for treating heart disease, cancer, and degenerative illnesses. The authors answer their questions with sufficient information on free radicals, cholesterol, and oxidative stress for readers to use in laboratories and practices.

A historical discussion of oxygen, oxidation-reduction definitions, and electron transport is followed by scientific information on the Krebs cycle, vitamins, and nutrients and a timely presentation of free radicals as contributing to cardiovascular and degenerative disease.

Later, epidemiologic and pathologic evidence on nutrient use is presented. This evidence allows us to understand information applicable to a scientific study of tissue damage and regeneration. Clearly, interest in the effects of nutrition and vitamins on health has increased. This short text will help practitioners upgrade current knowledge and share the information with patients.

The authors acknowledge the brevity of their text. They have challenged readers to examine modern concepts that might be discussed with our patients in the office. They also give us sufficient information to provide our patients and colleagues with current thinking on the activity of essential vitamins A, E, and C.

The style of this book flows well with diagrams, bold headings, illustrations, and informative tables. I enjoyed the quotations from The Beatles and Butch Cassidy and the Sundance Kid mixed with Paracelsus and Francis Bacon, which set the tone for the discussion in each of the seven chapters.

Appendices supplementing chapters 1, 4, and 5 provide further information on cholesterol, saturated and unsaturated fats, and their effect on the cardiovascular system. The authors raise questions not only for academics, but also for the less scientific. Skillfully, they then lead us through a historical discussion of the building blocks of life: carbon, hydrogen, oxygen, and nitrogen. Are antioxidants elixirs or media hype? Are human phagocytes useful? Does oxidative stress help or hinder our health? Should vitamins and minerals be used as supplements? What is the window of optimum activity of antioxidants?

Although the jury is still out on the results of antioxidant research, the authors present much food for thought. This book is valuable, and a few nights’ perusal should give readers sufficient vital information on antioxidant therapy to guide application.

James McCormack, Glen Brown, Marc Levine, Robert Rangno, John Ruedy
W.B. Saunders Company, 55 Horner Ave, Toronto, ON M8Z 4X6
1996/550

Strengths

Evidence-based approach for making drug therapy decisions

Weaknesses

Missing key information

Audience

Any clinician who prescribes drug therapy, particularly useful for teaching practices

This book is not just another multi-authored reference book. It is designed to wean clinicians away from “habitual or intuitive solutions” and to encourage decisions based on explicit factors. To achieve these goals, the book has a section on drug therapy for disease states to help readers make therapeutic choices that are reasonable if not optimal and to provide information on initiating, altering, or terminating a drug.

For each clinical condition a set of questions is asked. For example, in treating depression, before choosing a therapeutic agent you are asked to consider treatment goals, evidence to support drug therapy, when to consider drug therapy, initial treatment, dosage, the length of the initial treatment regimen, the efficacy parameters and patient assessment interval, when to add an additional drug if initial therapy fails, and the length of drug therapy.

This is good medicine. The process reinforces a framework for making therapeutic decisions and subsequently managing patients appropriately. The text also has sections on common drug-induced adverse reactions and drug monographs. Both these sections use questions to develop rational therapeutic decisions.

No text is perfect. Inevitably some key information is missing. I could not find a specific therapeutic approach to necrotizing fasciitis. Also, the book does not provide advice on how to switch from one group of antidepressants to another. Nevertheless, once I got used to the directed format, I found it is easy to use and helpful in making reasonable if not optimal drug therapy decisions.

Handbook of Substance Abuse: Neurobehavioral Pharmacology.
Robert T. Ammerman, Ralph E. Tarter, Peggy J. Ott (eds).
1998. (602 pp).
ISBN 0306458845 (hard).

To help illuminate the causes and natural history of substance abuse disorders, and given increasing interest in drug therapy for the treatment of addiction, this reference volume provides a comprehensive technical review of the pharmacology of each type of drug known to induce abuse or dependence.

Sections correspond to drug classes listed in the American Psychiatric Association’s 1994 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV): alcohol; caffeine; cannabis; cocaine; hallucinogens; inhalants; nicotine; opiates; sedatives, hypnotics, and anxiolytics; and amphetamines. A final section addresses other substances of abuse, including anabolic steroids, ecstasy, and phencyclidine.

In an attempt to integrate neurological, behavioral, and clinical material, each section provides separate chapters on pharmacology, behavioral pharmacology, and psychological and psychiatric consequences. Presentations review human and animal studies (including conflicting or indeterminate data), mechanisms of action, variables related to dose and drug interactions, different effects of closely related specific drugs, and voluminous additional information to provide a panoramic neurobehavioral view. The book has many contributors, numerous tables, extensive references, and a detailed index.

An introduction notes that no common feature has been found for all drugs that lead to abuse or dependence. Drugs’ capacity to produce intoxication, tolerance, and physical dependence and the severity of withdrawal symptoms vary widely. Abusable drugs may provide positive reinforcement, such as enhancing energy, arousal, or euphoria; or negative reinforcement, relieving fatigue, stress, or depression. This ability to alter emotions, cognition, or behavior is not unique to abusable drugs.

Although definitions vary, like DSM-IV this book distinguishes drug abuse from dependence. Abuse criteria include consumption in difficult or dangerous circumstances and interference with normal activities. Dependence may involve tolerance, withdrawal symptoms, loss of control, relinquishing of personal and social roles, and extensive efforts to maintain use.

The editors acknowledge that understanding substance abuse disorders requires examining the contributions of genetic, developmental, neurobiological, behavioral, and social policy factors, as well as the pharmacological properties of drugs. There has been little research on individual and gender differences in drug response and vulnerability to abuse disorders and dependence.

Introduction to Psychosexual Medicine.
For doctors, nurses, students, and other health professionals

R L Skrine (ed)

Montana Press, Carlisle

1989, 211 pages

If a woman patient innocently remarked, ‘I would not have your job for anything’, just as her doctor was about to perform a vaginal examination, then she may be in need of psychosexual counselling. If you accept this concept then Introduction to psychosexual medicine will be of service as it is predominently Freudian in content. It discusses how a general practitioner can be aware of patients’ hidden sexual problems during routine consultations. It certainly cannot be regarded as a good reference book for non-Freudians.

The field of psychosexual counselling is highly specialized, and any attempt to teach it to a wider audience should be met with caution. As such, it is doubtful whether this book will be of value to all doctors, nurses, students, and other health professionals as is suggested by its subtitle. It should be placed beside volumes that express alternative points of view in psychosexual medicine.

Health, Happiness and Security
The creation of the National Health Service

Frank Honigsbaum

Routledge, London

1989, 286 pages

Health, happiness and security describes in detail the ideas and events which led to the founding of the National Health Service in 1948. The author intends that the part played by civil servants should form the central thread of a narrative which begins in 1911. But, seen through the eyes of a doctor, this is an account of the medical profession’s movement towards the same goal of a comprehensive service and the struggles which this movement entailed — struggles to avoid the control, in turn, of the friendly societies, the approved societies, local authorities and finally, but with less determination, the Department of Health. Almost hidden within this movement towards the major goal was another of comparable importance — to enlarge and develop a specialist service which would take over the extensive work done by general practitioners in hospitals and establish for specialists a commanding role in medical care. This proved to be a crucial step in the division of British medicine into primary and secondary care, which is now the most distinctive feature of our system. In both movements the figure of Charles Wilson, Lord Moran, looms large.

This book appears at a time when an upheaval comparable to that of 1945-48 is taking place in the health service. Was this the reason for writing the book? The evidence suggests rather that the reason was the recent availability of crucial documents. In addition, it would have been impossible to write in such detail, with such careful referencing and so little bias without long preparation. Indeed the author’s interest goes back 30 years. This is historical writing, not journalism — and it is not for the casual reader.