Journal ofSubstance Abuse Treatment, Vol. 7, pp. 269-274, 1990 Printed in the USA. All rights reserved.

BOOK REVIEWS

Cocaine Addiction: Treatment, Recovery and Relapse Prevention

Arnold M. Washton New York: W.W. Norton & Company, 1989,

$22.95, 243 pages.

The need for dissemination of new information about the epidemic use of cocaine in this country and the is- sues related to the scientific knowledge about cocaine, including assessment, diagnosis, treatment, and re- search, is acute. Current estimates of the cocaine abuse proportions are as high as 24 million Americans who have experimented and tried it at least once and as many as 2 to 3 million individuals may be depen- dent on the drug.

With the tremendous increase in the prevalence of cocaine abuse, the psychological, medical, and social consequences associated with its use have become quite evident. The escalation of cocaine use in the last few years has forced providers in the health care sys- tem to confront new challenges. Treatment strategies must be adopted to accommodate the needs of these individuals and to address their drug related medical and psychiatric problems.

In this book, Dr. Washton presents the major is- sues related to cocaine and its abuse in such a way that it enhances one’s understanding of the addictive na- ture of the substance. It provides the reader with a practical guide to clinical assessment and treatment of cocaine addiction, emphasizing outpatient treatment and relapse prevention.

The first two chapters address the basics which are needed to fully understand the particulars of cocaine use. Information is provided about the pharmacologic actions, routes of administration, and the rituals in- volved in the actual preparation and use of the drug. In his chapter, “Why Do People Use Cocaine?,” the main reason given is “to alter one’s mood and change their mental state.” He then presents factors that pro- mote the compulsive use of cocaine. There is reference to the late Dr. Sidney Cohen’s “pharmacologic imper- atives,” which foster this compulsion. These include the reinforcement in and the rapid delivery to the brain, the short lived emphoria, the “crash,” toler- ance, and physical dependence. In addition to these pharmacologic factors, the psychiatric vulnerability, societal or cultural forces, and the availability of the drug, to mention just a few, are addressed. Dr. Wash- ton then elaborates on the adverse effects from med- ical complications to behavioral, psychosocial and psychiatric consequences.

0740-5472190 $3.00 + .OO Copyright 0 1990 Pergamon Press plc

Chapters 2 and 3 address the issues of addiction. He openly states that there is still more to be learned about “The Addicted Brain.” However, what is known is that the chronic use of a mood-altering drug such as cocaine will effect changes in the biochemical functioning of the brain. As Dr. Washton points out, “these chronic changes may give rise to compulsive cravings for the drug, impaired cognitive abilities, and negative mood states,” and it is clear that these crav- ings have a physiological basis. The author then re- views the process of addiction and the basic chemistry of the brain, including cocaine’s effect on dopamine. The stages of addiction, namely, experimental, regu- lar, and addictive, are described in his chapter on “Understanding Addictive Disease.”

His approach is basically the disease model, which he feels is essential to understand so that the formu- lation of effective treatment is enhanced, since one would be accepting the fact that anyone is vulnerable to this addiction. He then discusses factors related to being prone to the addiction, including physical pre- disposition, psychological vulnerability, and access to cocaine.

The next five chapters are basically concerned with treatment and assessment, goals of treatment, and group therapy. As for the treatment issues, he ad- dresses several points: one’s need for treatment and one’s actually entering into treatment, cocaine addic- tion compared with other chemical dependencies, guidelines for successful treatment, outpatient com- pared with inpatient or residential treatment, and aftercare.

Obviously in order to provide effective treatment, there must be a thorough clinical assessment, begin- ning with the initial interview. It is at this time that the clinician attempts to establish a therapeutic alliance and obtain needed information for a treatment plan. Dr. Washton indicates that there is a wide range of issues to be examined and that the assessment of the individual is an ongoing process. He also utilizes as- sessment questionnaires focusing on severity of the addiction, sexual compulsions, gambling, and eating disorders.

The author’s chapter, “Achieving Abstinence,” makes the point very clearly that he means cessation of all mood-altering substances, including alcohol. He proceeds to discuss the identification of external and internal (feeling states) cues that can trigger cravings, avoidance strategies, and establishing controls and a support system. The issue of retention in treatment or

269

270 Book Reviews

“premature dropout” and the reason for this occur- rence were covered, including the factor of early “slips.”

As the author points out, once the individual has achieved abstinence, the focus of treatment is to pre- vent relapse. Dr. Washton’s chapter on this topic deals with seven myths about relapse behaviors. The strate- gies for preventing relapse are also presented, but the author points out that lasting recovery must include changes in “lifestyle, behavior, attitude, values, and personality.”

The following chapter, “Group Therapy,” is pre- sented to the reader as the most pertinent and central aspect of outpatient treatment for cocaine addicts. This is a rather thorough examination of the benefits of group activities, therapeutic functions and needs met by groups, composition of membership, and roles of group leaders. What is helpful in this chapter is the discussion of such problem areas as lateness, fees, at- tendance, and problem group members.

The chapter, “Cocaine and the Family,” provides a number of clinical vignettes to illustrate several points. One of these areas is the denial and enabling behaviors of family members. Unfortunately for both the ad- dicted individual and the family member(s), this re- sponse of enabling can lead to codependency. An aspect also covered in this chapter is the need for a family assessment. This proves to be helpful in the de- velopment of treatment goals for both the patient and the family.

The last chapter focuses on the special popula- tions often in need of treatment, namely, adolescents, women, health-care professionals, and athletes. Dr. Washton mentions that the treatment techniques al- ready outlined in the text are applicable with these populations. However, in these four categories there are a few extra considerations. A few areas of focus would be for adolescents- their reasons for seeking treatment, family involvement, and developmental ar- rest; for women-male supply sources, dual addic- tions such as eating disorders, couples issues, and pregnancy; for healthcare professionals -confidenti- ality versus protection of consumers and role reversal of being a patient; and for professional athletes-their celebrity status and the obstacle of their schedules.

Dr. Washton’s book is written in a straightforward style and is concise and practical. He provides the reader with up-to-date information on the neurochem- ical, psychological, and environmental factors contrib- uting to cocaine addiction. His organization of the material is good, and the goals established by him are achieved. He wanted to present the basic information about cocaine, necessity for intensive counseling, and the need for long-term changes in behavior, attitude, and lifestyle.

This text has the potential for being a reliable re- source for substance abuse centers in establishing

treatment programs for individuals addicted to co- caine as well as other substances. It can provide guide- lines to clinicians on all levels on how to deliver care and treatment to these patients. Dr. Washton’s book should be considered as a contribution to the field where so much new information is being accumulated and should be read by treatment professionals. In ad- dition, this book can be read by and can help addicted individuals and their families in gaining an under- standing of this problem and its process.

Raymond F: Hanbury, Jr., PhD JFK Johnson Rehabilitation Institute

Edison, New Jersey Mount Sinai School of Medicine

Department of Psychiatry New York, New York

Alcohol and the Writer Donald W. Goodwin New York: Penguin Books, 1990, $7.95

(paperback), 208 pages.

Donald W. Goodwin, M.D., has written a concise 210 page book on the “epidemic of alcoholism in Ameri- can writers” in the first half of the 20th century. He has chosen six American writers (four of whom were Nobel laureates in literature): Edgar Allen Poe, F. Scott Fitzgerald, Ernest Hemingway, John Steinbeck, William Faulkner, and Eugene O’Neill; the seventh writer is a Belgian novelist, George Simenson; the eighth is an English novelist, Malcolm Lowry. All of the writers, including others who are lesser known, meet current diagnostic criteria for alcoholism. Dr. Goodwin has written eight minibiographies and much of the material has been skillfully crystallized out of more comprehensive biographies, which are included as references. The author writes as an astute observer, as a clinical psychiatrist (who uses very little jargon), and as a psychobiosocial historian with a family inter- active orientation. There is a good deal of demo- graphic, clinical, social, and family data, and, although the volume can be utilized for case study histories, I did not have the feeling I was reading a case vignette with the usually experienced soporific effect.

Dr. Goodwin, who is professor and chairman of the Department of Psychiatry at the University of Kansas Medical Center, has written extensively on al- coholism and other psychiatric disorders. He does not write as a traditional psychiatrist, yet he is clinically and phenomenologically selective and astute in his ob- servations and in all of what he reports as relevant. His background as an English major in a small Meth- odist college, a graduate student at Columbia Univer- sity, a psychiatric social worker in the U.S. Army, and